Cementless femoral fixation has become widely adopted throughout the United States for primary total hip arthroplasty (THA). However, femoral fixation in conversion THA (convTHA) presents unique challenges, and optimal strategies have not been extensively studied. This study investigated differences in outcomes for cemented versus cementless femoral fixation in convTHA for patients with failed osteosynthesis after proximal femur fracture.

Data was retrospectively collected for 75 patients who underwent convTHA after previous proximal femur fracture. Based on type of femoral fixation type at time of conversion, patients were sorted into two cohorts, cemented (n=19) or cementless (n=56). Demographic, surgical, and outcome variables, including revision and complication rates, were collected and compared between the cemented and cementless cohorts. Statistical analyses were performed using multivariate regression analyses.

As compared to the cemented cohort, patients for whom cementless implants were chosen tended to be younger (P<0.01), male (P=0.03), and non-white (P<0.01). The cementless cohort had shorter surgical time (149.64 minutes vs. 197.16 minutes, P=0.01). No differences were noted in anesthesia type (P=0.93), surgical approach (P=0.84), or use of dual mobility implants (P=0.93). Multivariable logistic regression analysis revealed that there was no difference in length of stay (LOS), revision rate, complication rate, or discharge disposition between the cemented and cementless cohorts.

Our results revealed shorter operative times with cementless femoral fixation in convTHA, but no significant difference in LOS, discharge disposition, revision rate, or complication rate when compared with cemented fixation.

Total hip arthroplasty (THA) after prior hip or acetabular fracture fixation is considered higher risk than primary THA, as studies have shown reduced implant survival and higher infection rates. The anterior-based muscle-sparing (ABMS) approach can potentially reduce some of these risks by utilizing a new surgical interval. The goal of this study is to analyze the efficacy of the ABMS approach for conversion to hip arthroplasty surgery after previous fracture fixation with comparison to posterior approach.

This retrospective cohort study included patients with prior hip surgical intervention requiring hardware then converted to a THA using the ABMS or posterior approach at 1 institution between 2013 and 2020. Outcomes studied included postoperative complications, 30-day emergency department visits, 90-day readmission rates, any reoperation and patient-reported outcome measures.

A total of 85 patients (51 male and 34 female) in the ABMS group and 17 patients (9 male and 8 female) in the posterior group were included. Within the ABMS group, the mean age was 65.6 years (±16.2) with a mean body mass index of 27.5 kg/m2 (±5.4). The average operative time was 85 minutes (±35) and estimated blood loss was 178 mL (±183). There was 1 postoperative complication (dislocation) within 90 days, 1 patient made an emergency department visit within 30 days, and there were 3 readmissions within 90 days; only 1 readmission was orthopaedic in nature. One patient required reoperation (1.2%) over the study period of 5.0 years (±2.1). Patient-reported outcome measures indicate successful return of function. Operative, hospital, and outcome data were similar between patients receiving the ABMS and posterior approach.

This study is the first to evaluate outcomes of conversion THA using the ABMS approach, when compared to the posterior approach. Our institution's experience demonstrates that the ABMS approach is safe and effective for conversion THA after prior fracture fixation.

Conversion total hip arthroplasty (cTHA) is commonly used for patients with persistent osteoarthritis or failed fixation following femoral neck fracture (FNF). There are limited data comparing patient-reported outcomes between patients undergoing cTHA after FNF and primary THA (pTHA) patients. This study aimed to compare the time to reach the minimal clinically important difference for improvement (MCID) for the Hip Disability and Osteoarthritis Outcomes Score-Physical Function Short Form, Patient-Reported Outcomes Measurement Information System (PROMIS) Global Physical, and PROMIS Physical Function short form 10a (PF-10a).

Patients undergoing cTHA for FNF between 2016 and 2022 were identified from an institutional database and propensity score matched 1:4 to pTHA patients by age, sex, body mass index, and Charlson Comorbidity Index. Demographic and MCID achievement rates were compared. To assess the time to achieve MCID, survival curves with and without interval censoring were used.

A total of 258 THAs (52 FNF cTHA and 206 pTHA) were analyzed. All FNFs were managed surgically. The rate of achieving MCID was similar between the FNF cTHA and pTHA cohorts for all three PROMs. For PROMIS PF-10a, FNF cTHA had a markedly longer median time to MCID at 9.8 months (95% confidence interval [CI], 6.5 to 12.1) compared with 4.2 months (95% CI, 3.3 to 6.0) for pTHA (P < 0.001). Interval censoring revealed that FNF cTHA achieved MCID for PROMIS PF-10a between 5.07 and 5.34 months, whereas pTHA achieved MCID between 1.37 and 1.37 months (P < 0.001).

The time to achieve MCID was markedly slower for FNF cTHA patients compared with pTHA patients. This delay in achieving MCID should be factored into shared decision-making discussions to enhance preoperative expectation management and patient education. Future research is needed to identify modifiable factors that could improve recovery outcomes for FNF cTHA patients.

Previous studies have shown that conversion total hip arthroplasty (cTHA) is associated with worse clinical outcomes, increased complications, and higher costs than primary total hip arthroplasty (pTHA). An underinvestigated factor that may vary between cTHA and pTHA is patient postoperative clinical improvement timelines. This study compared the median time to achieve minimal clinically important difference (MCID) between cTHA and pTHA patients.

We conducted a retrospective analysis comparing 175 cTHA and 523 propensity score-matched pTHA patients. Patient-reported outcomes were evaluated using preoperative and postoperative scores of Patient-Reported Outcomes Measurement Information System (PROMIS) Global Physical, PROMIS Physical Function-10a, and Hip disability and Osteoarthritis Outcome Score Physical Function Shortform. Time to achieve MCID was assessed using survival curves with and without interval-censoring, and statistical comparisons were performed using log-rank and weighted log-rank tests.

Using interval censoring to more precisely determine the exact time to achieve MCID, cTHA patients had a statistically delayed time to MCID for the PROMIS Physical Function-10a (3.03 to 3.04 versus 1.63 to 1.63; P = 0.011) and PROMIS Global Physical (0.73 to 0.74 versus 0.67 to 0.67; P = 0.049) as compared to pTHA patients. Time to MCID for the Hip disability and Osteoarthritis Outcome Score Physical Function Shortform was similar between cohorts (1.43 to 1.44 versus 1.33 to 1.34; P = 0.40).

Patients undergoing cTHA may have delayed improvement timelines as compared to pTHA. This finding is possibly related to the increased medical and surgical complexity of cTHA. Conversion total hip arthroplasty remains a safe and effective treatment choice to improve patient hip pain and function in many settings. Yet arthroplasty surgeons can counsel cTHA patients that it may take approximately 3 months for the median patient to experience clinically relevant improvement. The same improvement timeline may be experienced by the median pTHA patient in only 1.6 months.

Total hip arthroplasty (THA) is an increasingly popular option for pediatric end-stage hip disease. However, data regarding implant longevity and functional outcomes remain limited. This case series evaluated complication and revision rates, patient-reported outcome measures (PROMs), and implant survivorship in consecutive pediatric THA patients from a single surgeon. We hypothesized that pediatric patients would have low revision rates and excellent functional outcomes at 5-year follow-up.

Following institutional review board approval, 74 patients under age 21 years who underwent 92 THAs between 2013 and 2023 were identified. Age, etiology, follow-up interval, complications, revisions, and preoperative and postoperative PROMs were recorded. The mean follow-up was 5.3 years (range, one to 11.2) and mean age at surgery was 16 years (range, 11 to 21). All patients underwent THA by the senior surgeon through a posterior (92.4%) or anterior (7.6%) approach; 90.2% received a ceramic on a highly cross-linked polyethylene bearing, with the remaining 9.8% receiving a metal femoral head. All patients received a cementless stem based on femoral morphology. No patients were lost to follow-up.

The most common etiologies were Perthes disease and corticosteroid-induced osteonecrosis (15.2% each). A patient (1.1%) with Mucopolysaccharidosis type IV required a femoral revision for aseptic loosening; no other patients were revised. All average postoperative PROMs improved significantly (P < 0.00001): Hip Disability and Osteoarthritis Outcome Score, Joint Replacement 53.4 (interquartile range [IQR], 46.7 to 70.4) to 89.9 (IQR, 85.3 to 100), EQ-5D 0.5 (IQR, 0.2 to 0.7) to 0.8 (IQR, 0.7 to 1), and EQ visual analog scale 81 (IQR, 70 to 95) to 85 (IQR, 80 to 100). Revision-free Kaplan-Meier survivorship at 5 and 10 years was 98.9%.

Total hip arthroplasty (THA) in patients under age 21 years yields substantial improvements in 5-year functional outcomes, regardless of etiology, with extremely low revision rates and excellent implant survivorship.

Prior open reduction and internal fixation (ORIF) of tibial plateau fracture (TPF) adds complexity to subsequent total knee arthroplasty (TKA). The purpose of this study was to compare the outcomes of patients undergoing a TKA following prior ORIF of TPF to patients undergoing a primary TKA for osteoarthritis and an aseptic revision TKA.

There were 52 patients who underwent primary TKA following prior ORIF of TPF between January 2009 and June 2021, who were included and matched in a 1:4 ratio to 208 patients undergoing primary TKA. A second 1:1 matched comparison to 52 aseptic revision TKA patients was also included. The Knee injury and Osteoarthritis Outcome Score for Joint Replacement scores were obtained preoperatively and at two years postoperatively. Independent t-tests and Chi-square tests were used for statistical comparisons.

The TPF patients were significantly younger than both primary and revision cohorts (55 ± 14.0 versus 63 ± 16.3 versus 64 ± 9.5, P < 0.001). Compared to primary TKA patients, the TPF group had worse Knee injury and Osteoarthritis Outcome Score for Joint Replacement scores at two years (46.9 ± 18.5 versus 66.2 ± 17.8, P = 0.0152), higher rates of wound complications (15.4 versus 3.9%, P = 0.0020), and increased operative times (140.2 ± 45.3 versus 95.2 ± 25.7, P < 0.0001). Additionally, TPF patients were more likely to require a manipulation under anesthesia than both primary and revision patients (21.2 versus 5.8 versus 5.8%, P = 0.001).

The TKAs following ORIF of TPF are more like revision TKAs than primary TKAs in terms of patient-reported outcomes, operative times, and wound complications. The rate of manipulation under anesthesia was higher than in both matched groups. These findings provide valuable information that can affect preoperative patient education and postoperative management regimens. They also emphasize the need for a conversion TKA code due to increased complexity and complications seen in this more difficult subset of TKAs.

Socioeconomic factors have been implicated in delayed presentation for compressive neuropathies of the upper extremity. Our article seeks to elucidate the effect of socioeconomic factors on self-reported symptom duration and objective disease severity at presentation for cubital tunnel syndrome.

This retrospective cohort study included 207 patients with surgical management of cubital tunnel syndrome at 2 institutions between June 1, 2015, and March 1, 2020. Exclusion criteria included age under 18 years, revision surgery, lack of preoperative electrodiagnostic studies, and concurrent additional surgeries. Response variables were self-reported symptom duration, time from presentation to surgery, McGowan grade, and electrodiagnostic measures. Explanatory variables included age, sex, white race, diabetes mellitus, depression, anxiety, and the Distressed Communities Index.

Symptom duration was associated with nonwhite race, and time from presentation to surgery was associated with insurance provider. More clinically severe disease was associated with older age, male sex, and not having carpal tunnel syndrome. Nonrecordable sensory nerve action potential latency was associated with older age, higher body mass index, male sex, diabetes mellitus, and unemployment. Nonrecordable conduction velocities were associated with older age, and having fibrillations at presentation was associated with older age, male sex, and unemployment.

Economic distress is not associated with self-reported symptom duration, time from presentation to surgery, or presenting severity of cubital tunnel syndrome. White patients presented with shorter self-reported symptom duration. Insurance type was associated with delay from presentation to surgery. Older age and male sex were risk factors for more clinically severe disease at presentation.

The conversion of previous hip fracture surgery to total hip arthroplasty (CTHA) can be surgically challenging with unpredictable outcomes; reported complication rates vary significantly. This study aimed to establish the medium-term survival and outcomes of CTHA performed following a previous hip fracture surgery.

All CTHAs performed at our tertiary orthopaedic institution between January 2008 and January 2020 following previous ipsilateral hip fracture surgery were included. Patients were followed up clinically using Oxford Hip Scores (OHS), and radiologically until death or revision surgery. Postoperative complications, radiological implant failure, and indications for revision surgery were reviewed.

A total of 166 patients (167 hips) were included in the study, with a mean age of 71 years (42 to 99). Of these, 113 patients (67.7%) were female. CTHA followed cannulated screw fixation in 75 cases, hemiarthroplasty in 18, dynamic hip screw fixation in 47, and cephalomedullary nail in 27 cases. Patients were followed up for a mean of four years (0.1 to 9.3). During the follow-up period, 32 patients (19.2%) died. Overall, 14 patients (8.4%) suffered a complication of surgery, with intraoperative fractures (4.2%) and dislocations (3.6%) predominating. The survival probability was 96% at 9.53 years in the cemented group and 88% at 9.42 years in the uncemented group (p = 0.317). The median OHS improved from 13 (IQR 7.75 to 21.25) preoperatively to 39 (IQR 31 to 45) postoperatively in the uncemented group, and from 14 (IQR 10.5 to 22) to 38 (IQR 27 to 45) in the cemented group.

This study highlights that CTHA from hip fracture surgery is associated with higher complication rates than conventional THA, but good medium-term results can be achieved. Their classification within the NJR requires review, acknowledging the increased potential for complications.

Background/Objectives: Stress concentration around distal screw-removal holes confers a major risk for periprosthetic fractures following conversion total hip arthroplasty (cTHA) for intertrochanteric femoral fractures. Optimal stem-selection criteria and guidelines for cTHA can improve clinical outcomes. We determined the influence of the cementless stem length on the stress distribution around distal screw-removal holes. Methods: For the finite element analysis, institutional data from preoperative CT scans of contralateral femurs of patients who underwent THA were used. To replicate the post-nail-removal state, we used 3D registration of standard triangulated language data of the intramedullary nail as an unused material to simulate distal screw-removal holes, located 135 mm from the proximal end of the intramedullary nail. Cementless stems of 130, 140, 150, and 160 mm were individually registered using STL data, and cTHA models were constructed accordingly. Using simulations under load conditions representing normal walking and stair climbing, the mean and maximum equivalent stress values around the distal screw-removal holes were calculated. For multiple comparisons, repeated-measures ANOVA with Bonferroni correction was employed. Results: Compared to the 130 mm stem, the 150 mm and 160 mm stems similarly reduced the maximum equivalent stress around the distal screw-removal holes, although the 140 mm stem showed no significant difference with other stems. Conclusions: A ≥150 mm stem length reliably mitigated stress concentration around distal screw-removal holes post-cTHA; it is the optimal choice for balancing effectiveness and risk of complications and may contribute to improved long-term clinical outcomes. This study provides practical evidence for stem selection in cTHA and offers valuable insights for future treatment guidelines.

Hip fractures are prevalent orthopaedic injuries with substantial morbidity and mortality. Failed primary treatments of these fractures often necessitate conversion to total hip arthroplasty (THA), a complex procedure requiring extensive exposure and hardware removal. It poses major challenges and is associated with high rates of complications such as infection, dislocation, and periprosthetic fractures. Despite the documented risks, there are limited data comparing complication rates between early (within 1 year) and late (after 1 year) conversion THA (CTHA). This study aimed to compare early and late CTHA and hypothesized that early CTHA was associated with higher complication rates than late CTHA.

A retrospective cohort study was conducted using an administrative claims database. The time from primary fixation of the proximal femur fracture to CTHA was used to identify patients who underwent early (n = 1,205) and late (n = 6,455) CTHA. Rates of joint complications within 2 years and medical complications within 90 days postoperatively were compared using multivariable logistic regressions.

Early CTHA patients exhibited significantly higher rates of reoperation (8.3 versus 5.1%; odds ratio [OR]: 1.72), periprosthetic infections (7.1 versus 5.2%; OR: 1.50), periprosthetic fractures (5.4 versus 2.6%; OR: 1.73), mechanical complications (5.2 versus 3.1%; OR: 1.60), and dislocations (7.7 versus 3.9%; OR: 1.97). Overall, 19.4% of early conversion patients experience an orthopaedic complication, compared to 12.4% of late conversions. Medical complications within 90 days included higher rates of deep vein thrombosis in early CTHA patients (1.7 versus 0.8%; OR: 1.99), transfusions (5.6 versus 3.1%; OR: 1.50), and hospital readmission (13.9 versus 9.3%; OR: 1.39).

Early CTHA was associated with higher rates of complications compared to late conversion. Understanding these risks allows surgeons to better prepare patients for the surgery and ensure that patients have a realistic understanding of their prognosis and are adequately prepared for the challenges of recovery.

Background/Objectives: Proximal femoral fractures are particularly common in older adults, and cases requiring conversion to total hip arthroplasty may arise because of treatment failure or osteoarthritis. Fractures around the distal screw removal holes can be problematic. This study aimed to analyze the relationship between stem length and femoral stress distribution to determine the optimal stem length. Methods: A finite element analysis simulation was conducted using pre-existing femoral computed tomography data, an intramedullary nail, and three types of stems of varying lengths. Loads simulating normal walking and stair climbing were applied, and the average and maximum equivalent stresses were measured on both the medial and lateral sides of the distal screw removal hole for each stem length. Statistical analysis was then performed to evaluate the stress distributions. Results: The average stress around the distal screw removal hole tended to decrease as stem length increased. The maximum stress was significantly lower with the 160-mm stem, which provides a 40-mm bridging length, compared to the 120-mm and 130-mm stems, where the stem tip aligned with or only slightly extended past the distal screw removal hole (bridging lengths of 0 mm and 10 mm, respectively). Conclusions: In conversion hip total arthroplasty following proximal femoral fractures, using a sufficiently long stem can help avoid stress concentration around the distal screw removal hole, thereby potentially reducing the risk of periprosthetic fractures.

Conversion total hip arthroplasty (THA) is associated with higher rates of complications compared with primary THA, with prior surgical fixation of fractures in the ipsilateral hip shown to further increase these rates. There is a scarcity of literature on the effect of timing of conversion THA on complication rates. In this study, we evaluated early (≤6 months of index surgery) and late (>6 months of index surgery) conversion to THA following prior fixation of the proximal femur or acetabulum.

Ninety-one patients who underwent conversion THA following prior surgical fixation of either the proximal femur or acetabulum were identified. Index surgery, fracture characteristics, time, and cause of failure were obtained. Postoperative complications evaluated following the conversion THA included infection, revision surgery rates, dislocation, and revision rates.

A total of 91 patients were included, of which 22 underwent early conversion to THA. In the early conversion group, 22.7% of patients had a complication versus 11.6% of patients in the late conversion group (P = 0.194). The most common complications were deep infection (18.2% vs. 5.8%), revision surgery (22.7% vs. 10.1%), and revision THA (18.2% vs. 5.8%). The early conversion group had a markedly higher rate of perioperative blood transfusion compared with the late cohort (P = 0.013).

In this study, we found a high rate of complications associated with early THA conversion. Patients should be counseled on the high risk for complications following early conversion to THA following failed fracture fixation.

Total hip arthroplasty (THA), including primary and conversion procedures, is commonly used for many types of joint disease in patients aged below 65 years, though few studies have evaluated THA outcomes in young patients (≤ 40 years old). This study examined a large cohort of patients who underwent THA at a young (≤ 40 years old) age to identify predictors of reoperation and compare survivorship between primary and conversion THAs.

A retrospective study was conducted on 497 patients who underwent 612 primary and conversion THAs at 40 years old or younger between 1990 and 2020. Medical records were reviewed to collect patient/surgical data. A multivariable logistic regression model identified independent predictors of reoperation, and Kaplan-Meier analysis with log-rank tests was used to compare survival curves by THA type.

The median age at surgery (interquartile range) was 31 years (25 to 36). The median follow-up time was 6.6 years (range, 3.8 to 10.5). Conversion THAs had an increased rate of both revisions (12.3 versus 5.6%, P = 0.02) and nonrevision reoperations (8.9 versus 3.2%, P = 0.03) compared to primary THAs. A ceramic-on-ceramic articulation (odds ratio: 5.17; P = 0.03) and a higher estimated blood loss (odds ratio: 1.0007; P = 0.03) were independent predictors of reoperation for primary and conversion THA, respectively. Conversion THAs had a lower 15-year survival (77.8 versus 90.8%, P = 0.009) compared to primary THAs.

Patients ≤ 40 years old who underwent primary and conversion THAs demonstrated an impressive 15-year survival comparable to that of older populations (74 to 93%), while conversion procedures had a higher reoperation rate. Although primary THA may be more ideal, there are promising outcomes for patients who need THA at a younger age than typically implemented, especially for those who are very young (≤ 30 years old).

In this editorial, I present my comments on the article by Solarino et al. Conversion hip arthroplasty, which is an optional salvage procedure performed following unsuccessful fixation of intertrochanteric femur fractures in elderly patients, entails more complex processes and higher rates of operative complications than primary arthroplasty. Hence, it is important to consider the appropriateness of the primary treatment choice, as well as the adequacy of nailing fixation for intertrochanteric fractures. This article briefly analyzes the possible factors contributing to the nailing failure of intertrochanteric fractures and attempts to find corresponding countermeasures to prevent fixation failures. It also analyzes the choice of treatment between nailing fixation and primary arthroplasty for intertrochanteric fractures.

The rate of proximal femur fractures (PFF) in the structure of musculoskeletal system injuries among all fractures of long bones ranges from 3.9 to 18%. According to Russian Ministry of Health 2020 data, the incidence of femoral fractures in Russia was up to 61 cases per 100,000 population (90,000 per year); and femoral neck fractures incidence was 4 times higher among people over 75 years of age. The choice of surgical technique and the fixator used depend on many factors, such as fracture location and its nature, the age of the patient, comorbidities, and the quality of bone tissue. Internal osteosynthesis, is the current treatment method of choice for extra-articular proximal femur fracture, but every treatment method has its limitations. a significant number of complications caused by technical errors, vicious union or nonunion with the subsequent development of false joints, the development of femoral head aseptic necrosis, which leads to coxarthrosis and persistent pain syndrome. To solve the above-described problems, it is necessary to use a conversion surgery - total hip replacement.

long-term analysis of the results of total hip replacement in patients with proximal femur pseudarthrosis.

The study was based on clinical and laboratory data analysis and on the results of total hip arthroplasty (THA) in 45 patients aged 56-84 years (mean age 68.3), including 32 (71.1%) women and 13 (26.1%) men. 12 patients initially received conservative treatment, and 33 patients received initial surgical treatment using various metal osteosynthesis procedures. The time from osteosynthesis or from the moment of injury to admission to the hospital for hip arthroplasty ranged from 12 to 30 months. All patients, before conversion arthroplasty and after discharge, were repeatedly invited to the clinical diagnostic department for a clinical examination and for assessment using rating scales. 3, 6 and 12 months after the surgery, pain syndrome and patient quality of life were assessed using the following questionnaire scales: Harris Hip Score, MOS SF-36, VAS. The maximum follow-up period ranged from 12 to 60 months.

Based on the results obtained, patients of all 4 groups after conversion arthroplasty noted a significant quality of life improvement, a decrease in pain severity and functional results improvement. This was probably due to the presence of a severe limitation of range of movements in the joint, intense pain, absence of support ability of the extremity, as well as low operative efficacy expectations.In 1 (2%) patient, acute PJI was diagnosed in the early postoperative period, followed by sepsis and death.In 4 patients (9%) the result was considered unsatisfactory. At 1 year of follow-up after surgery, they complained of pain and claudication in the operated joint.3 (6%) patients underwent reduction of dislocation.

Strict adherence to the recommended treatment algorithm for patients with proximal femur pseudarthrosis made it possible to achieve good treatment results in 90% of surgically treated patients. An important step in the treatment of this patients is a careful preoperative planning with thorough assessment of bone tissue quality and muscles condition in the proximal femur area, allowing to choose the optimal endoprosthesis components.

Under Medicare's fee-for-service and bundled payment models, the basic unit of hospital payment for inpatient hospitalizations is determined by the Medicare Severity Diagnosis Related Group (MS-DRG) coding system. Primary total joint arthroplasties (hip and knee) are coded under MS-DRG code 469 for hospitalizations with a major complication or comorbidity and MS-DRG code 470 for those without a major complication or comorbidity. However, these codes do not account for the indication for surgery, which may influence the cost of care.Questions/purposes We sought to (1) quantify the differences in hospital costs associated with six of the most common diagnostic indications for THA (osteoarthritis, rheumatoid arthritis, avascular necrosis, hip dysplasia, posttraumatic arthritis, and conversion arthroplasty), (2) assess the primary drivers of cost variation using comparisons of hospital charge data for the diagnostic indications of interest, and (3) analyze the median length of stay, discharge destination, and intensive care unit use associated with these indications.

This study used the 2019 Medicare Provider Analysis and Review Limited Data Set. Patients undergoing primary elective THA were identified using MS-DRG codes and International Classification of Diseases, Tenth Revision, Procedure Coding System codes. Exclusion criteria included non-fee-for-service hospitalizations, nonelective procedures, patients with missing data, and THAs performed for indications other than the six indications of interest. A total of 713,535 primary THAs and TKAs were identified in the dataset. After exclusions were applied, a total of 135,194 elective THAs were available for analysis. Hospital costs were estimated using cost-to-charge ratios calculated by the Centers for Medicare and Medicaid Services. The primary benefit of using cost-to-charge ratios was that it allowed us to analyze a large national dataset and to mitigate the random cost variation resulting from unique hospitals' practices and patient populations. As an investigation into matters of health policy, we believe that assessing the surgical cost borne by the "average" hospital was most appropriate. To analyze estimated hospital costs, we performed a multivariable generalized linear model controlling for patient demographics (gender, age, and race), preoperative health status, and hospital characteristics (hospital setting [urban versus rural], geography, size, resident-to-bed ratio, and wage index). We assessed the principal drivers of cost variation by analyzing the median hospital charges arising from 30 different hospital revenue centers using descriptive statistics. Length of stay, intensive care use, and discharge to a nonhome location were analyzed using multivariable binomial logistic regression.

The cost of THA for avascular necrosis was 1.050 times (95% confidence interval 1.042 to 1.069; p < 0.001), or 5% greater than, the cost of THA for osteoarthritis; the cost of hip dysplasia was 1.132 times (95% CI 1.113 to 1.152; p < 0.001), or 13% greater; the cost of posttraumatic arthritis was 1.220 times (95% CI 1.193 to 1.246; p < 0.001), or 22% greater; and the cost of conversion arthroplasty was 1.403 times (95% CI 1.386 to 1.419; p < 0.001), or 40% greater. Importantly, none of these CIs overlap, indicating a discernable hierarchy of cost associated with these diagnostic indications for surgery. Rheumatoid arthritis was not associated with an increase in cost. Medical or surgical supplies and operating room charges represented the greatest increase in charges for each of the surgical indications examined, suggesting that increased use of medical and surgical supplies and operating room resources were the primary drivers of increased cost. All of the orthopaedic conditions we investigated demonstrated increased odds that a patient would experience a prolonged length of stay and be discharged to a nonhome location compared with patients undergoing THA for osteoarthritis. Avascular necrosis, posttraumatic arthritis, and conversion arthroplasty were also associated with increased intensive care unit use. Posttraumatic arthritis and conversion arthroplasty demonstrated the largest increase in resource use among all the orthopaedic conditions analyzed.

Compared with THA for osteoarthritis, THA for avascular necrosis, hip dysplasia, posttraumatic arthritis, and conversion arthroplasty is independently associated with stepwise increases in resource use. These cost increases are predominantly driven by greater requirements for medical and surgical supplies and operating room resources. Posttraumatic arthritis and conversion arthroplasty demonstrated substantially increased costs, which can result in financial losses in the setting of fixed prospective payments. These findings underscore the inability of MS-DRG coding to adequately reflect the wide range of surgical complexity and resource use of primary THAs. Hospitals performing a high volume of THAs for indications other than osteoarthritis should budget for an anticipated increase in costs, and orthopaedic surgeons should advocate for improved MS-DRG coding to appropriately reimburse hospitals for the financial and clinical risk of these surgeries.

Level IV, economic and decision analysis.

Conversion THA, which we defined for this study as THA with concomitant removal of preexisting orthopaedic hardware, has been associated with increased hospital costs and perioperative complications compared with primary THA. Yet, conversion THA is classified as a primary procedure under the Medicare Severity Diagnosis-Related Group coding scheme, and hospitals are reimbursed based on the resource use expected for a routine primary surgery. Prior authors have argued for conversion THA to be reclassified as a revision procedure. Although prior research has focused on comparisons between conversion THAs and primary arthroplasties, little is known about the resource use of conversion THA compared with that of revision THA.

(1) Do inpatient hospital costs, estimated using cost-to-charge ratios, differ between conversion THA and revision THA? (2) Do the median length of stay, intensive care unit use, and likelihood of discharge to home differ between conversion and revision THA?

This was a retrospective study of the Medicare Provider Analysis and Review Limited Data Set for 2019. A total of 713,535 primary and 74,791 revision THAs and TKAs were identified initially. Exclusion criteria then were applied; these included non-fee-for-service hospitalizations, nonelective admissions, and patients with missing data. Approximately 37% (263,545 of 713,535) of primary and 34% (25,530 of 74,791) of revision arthroplasties were excluded as non-fee-for-service hospitalizations. Two percent (13,159 of 713,535) of primaries and 11% (8159 of 74,791) of revisions were excluded because they were nonelective procedures. Among the remaining 436,831 primary and 41,102 revision procedures, 31% (136,748 of 436,831) were primary THAs and 36% (14,774 of 41,102) were revision THAs. Two percent (2761 of 136,748) of primary THAs involved intraoperative removal of hardware and were classified as conversion THAs. After claims with missing data were excluded, there were 2759 conversion THAs and 14,764 revision THAs available for analysis. Propensity scores were generated using a multivariate logistic regression model using the following variables as covariates: gender, age, race, van Walraven index, hospital setting, geography, hospital size, resident-to-bed ratio, and wage index. After matching, 2734 conversion THAs and 5294 revision THAs were available for analysis. The van Walraven index, which is a weighted score of patient preoperative comorbidities, was used to measure patient health status. Hospital costs were estimated by multiplying cost-to-charge ratios obtained from the 2019 Impact File by total hospital charges. This methodology enabled the use of a large national database to mitigate the random effects of individual hospitals' unique practices and patient populations. Multivariable regression was performed after matching to determine the independent effects of surgery type (that is, conversion versus revision THA) on hospital cost, length of stay greater than 2 days, intensive care unit use, and discharge to home.

There was no difference in the estimated hospital cost between conversion THA and revision THA (β = 0.96 [95% confidence interval 0.90 to 1.01]; p = 0.13). Patients undergoing conversion THA had increased odds of staying in the hospital for more than 2 days (odds ratio 1.12 [95% CI 1.03 to 1.23]; p = 0.01), increased odds of using the intensive care unit (OR 1.24 [95% CI 1.03 to 1.48]; p = 0.02), and decreased odds of being discharged to home (OR 0.74 [95% CI 0.67 to 0.80]; p < 0.001).

The inpatient hospital cost of conversion THA is no different from that of revision THA, although patients undergoing conversion surgery have modestly increased odds of prolonged length of stay, intensive care unit use, and discharge to a nonhome location. These findings support the conclusion that reclassification of conversion THA is warranted. Orthopaedic surgeons must advocate for the reclassification of conversion THA using data-backed evidence or run the risk that orthopaedic procedures will be given decreased reimbursement.

Level III, economic and decision analysis.

Conversion total hip arthroplasty (THA) includes a variety of operations and prior implants. The implant present before conversion may influence the outcome and complexity of the procedure. The group hypothesized that conversion arthroplasty for patients with intramedullary nails (IMNs) is more complex from a surgical and resource utilization perspective than for those with screw fixation.

THA conversion cases were reviewed retrospectively from 2012 to 2020 from 6 surgeons across 3 institutions. The included cohort had 106 patients with fixation in the proximal femur for prior traumatic events. Demographics, operative data, outcomes, and implant information were collected from the medical record. The conversion THA group was categorized by preoperative fixation type: closed reduction and percutaneous pinning/screw fixation (CRPP) or IMN.

No age or body mass index differences were observed between the cohorts. Prior to conversion THA, IMN patients had undergone more surgeries than CRPP (P < .05). Perioperatively, the IMN cohort sustained increased blood loss (P < .001), had longer surgeries (P < .0001), had longer length of hospital stays (P < .01), necessitated trochanteric plates more often (P < .05), were readmitted more (P < .05), and required additional follow-up surgery (P < .01) than the CRPP cohort.

Conversion THA of a prior IMN implant is associated with worse perioperative outcomes than conversion of a CRPP construct. Surgeons, health systems, and payors should consider these differences when caring for these distinct groups of patients.

The combination of an aging population and increased utilization of total hip arthroplasty (THA) is leading to a higher incidence of conversion THA, defined as conversion from previous hip fracture surgery to THA. Conversion THA is a more technically challenging, time-consuming, and costly procedure compared to primary THA and frequently involve more medically complex patients. Thus, the aim of this review is to provide a rubric for surgeons to use when preparing for a conversion THA. We have assessed the compatibility of commonly available extraction devices with popular femoral nails. Furthermore, we review technical pearls for conversion THA including equipment planning, operative setup, intraoperative imaging, extraction sequencing, and troubleshooting commonly encountered obstacles.

Proximal femur fractures, including both intracapsular (femoral neck fractures) and extracapsular fractures (intertrochanteric femoral fractures, IFFs), affect around 1.5 million people per year worldwide. Mechanical failures of intertrochanteric nailing in IFFs could be managed with revision total hip arthroplasty (THA).

To describe the surgical complexity and the procedure-related complication rates in patients with trochanteric nailing failure and treated with THA.

Patients referred to our level I trauma center between April 2012 and July 2018 with failed cephalomedullary nailing following trochanteric fractures were retrospectively recruited. All patients underwent a salvage surgical procedure, i.e., cephalomedullary nail removal and conversion to THA. The same surgical and anesthesiology team performed the surgical procedures under spinal anesthesia. All patients underwent clinical and radiographic follow-ups for at least 24 mo. Complications and re-operations were recorded.

Seventy-four patients met the inclusion criteria (male: 29; female: 45; mean age: 73.8-years-old; range: 65-89) and were included in the current study. The average operative time was 117 min (76-192 min). The average blood loss was 585 mL (430-1720 mL). Among the 74 patients, 43 (58.1%) required transfusion of three or more blood units. Two patients died within the 4th d after surgery because of pulmonary embolism, and 1 patient died 9 mo after surgery due to ischemic myocardial infarction. The complication rate in the 71 patients who completed the minimum 24-mo follow-up was 22.5%. In 3 cases out of 71 (4.2%) periprosthetic acetabular fracture was observed during the follow-up. One of these periacetabular fractures occurred intraoperatively. An intraoperative periprosthetic femur fracture was observed in 5 patients out of 71 (7.0%). Four of these patients needed a re-operation to fix the fracture with plates and cerclages; in one of these patients, femoral stem revision was also necessary. In 4 patients out of 71 (5.6%), an early THA dislocation was observed, whereas in 1 case (1.4%) a late THA dislocation was observed. Three patients out of 71 (4.2%) developed a periprosthetic joint infection during the study follow-up.

The present study demonstrated that salvage options for IFF fixation failure are complex procedures with a relevant intraoperative and postoperative complication rate.

Patient-reported outcome measures (PROMs) are often lower following conversion total hip arthroplasty (cTHA) compared to matched primary total hip arthroplasty (THA) controls. However, the minimal clinically important differences (MCIDs) for any PROMs are yet to be analyzed for cTHA. This study aimed to (1) determine if patients undergoing cTHA achieve primary THA-specific 1-year PROM MCIDs at comparable rates to matched controls undergoing primary THA and (2) establish 1-year MCID values for specific PROMs following cTHA.

A retrospective case-control study was conducted using 148 cases of cTHA which were matched 1:2 to 296 primary THA patients. Previously defined anchor values for 2 PROM measures in primary THA were used to compare cTHA to primary THA, while novel cTHA-specific MCID values for 2 PROMs were calculated through a distribution method. Predictors of achieving the MCID of PROMs were analyzed through multivariate logistic regressions.

Conversion THA was associated with decreased odds of achieving the primary THA-specific 1-year Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement PROM (Odds Ratio: 0.319, 95% Confidence Interval: 0.182-0.560, P < .001) and Patient Reported Outcomes Measurement Information System Physical Function Short-Form-10a PROM (Odds Ratio: 0.531, 95% Confidence Interval: 0.313-0.900, P = .019) MCIDs in reference to matched primary THA patients. Less than 60% of cTHA patients achieved an MCID. The 1-year MCID of the Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement and Patient Reported Outcomes Measurement Information System Physical Function Short-Form-10a specific to cTHA were +10.71 and +4.68, respectively.

While cTHA is within the same diagnosis-related group as primary THA, patients undergoing cTHA have decreased odds of achieving 1-year MCIDs of primary THA-specific PROMs.

Level III, retrospective comparative study.

Professional ballet dancers have high expectations after total hip arthroplasty (THA), particularly if they intend to resume dancing as performers or teachers.

To report clinical outcomes and return to dance after THA with a muscle-sparing direct anterior approach using a custom femoral stem in a cohort of current or former professional ballet dancers.

Case series; Level of evidence, 4.

Twenty-three patients (26 hips) were included, that identified as current or former professional ballet dancers, from a consecutive series of 1699 hips that underwent primary THA by 1 of 2 surgeons. Both surgeons routinely implanted custom femoral stems using a muscle-sparing direct anterior approach in active and/or high-demand patients. All patients completed a questionnaire postoperatively that assessed dance capabilities, the visual analog scale (VAS) for hip pain (0-10), the VAS for satisfaction with surgery (0-10), the Oxford Hip Score (OHS), and the Forgotten Joint Score (FJS).

The initial cohort comprised 19 women and 4 men, with a mean age of 50.5 ± 14.9 years and a mean 38.0 ± 14.4 years of dance experience. One patient underwent revision THA for a leg-length discrepancy, leaving 22 patients (25 hips) with a mean follow-up of 3.4 ± 1.4 years. The mean VAS satisfaction score was 9.8 ± 0.6, and the mean VAS pain score was 0.5 ± 1.0. The postoperative OHS and FJS were 46 ± 2 and 92 ± 15, respectively. Overall, 16 patients resumed ballet at 5.1 ± 3.9 months, 3 resumed other types of dance, and 3 did not resume any type of dance. None of the 6 patients who did not resume ballet indicated pain in the operated hip as the reason for stopping.

In current or former professional ballet dancers, THA by a muscle-sparing direct anterior approach using a custom femoral stem yielded excellent clinical outcomes at a minimum of 2 years, with the highest satisfaction score of 10 points reported for 88% of hips and 72% of hips being totally pain free. Furthermore, 73% of patients resumed ballet, and 86% resumed dance in general.

Total hip arthroplasty (THA) in young patients has varying results, and some reports show inferior results when compared with those of older patients. This study evaluated the outcomes of contemporary uncemented THA in patients 45 years or younger. This was a retrospective review from 2003 to 2015 at an academic institution. Three hundred one uncemented THAs in 232 patients 45 years or younger were evaluated. All patients had a minimum follow-up of 5 years. Ninety-day complications, survivorship free of revision, and dislocations were evaluated. Mean age was 35.7 years, 43.1% of patients were women, and mean follow-up was 9.3 years. Ninety-day complications included 26 emergency department visits, 11 readmissions, 3 revisions, and 3 dislocations. The rate of 10-year survivorship free of revision was 85.5%, and the rate of 10-year survivorship free of aseptic revision was 87.7%. Excluding metal-on-metal (MOM) THAs, 10-year aseptic survivorship was 93.3%. The most common reasons for revision were adverse local tissue reaction after MOM THA (16 hips) and periprosthetic joint infection (6 hips). In a multivariable logistic regression model, sickle cell disease (SCD) and conversion THA were associated with 90-day readmissions. Both MOM THA and SCD were associated with revision (P<.05). Patients who are 45 years or younger undergoing THA (excluding MOM articulation) had a rate of 10-year survival free of aseptic revision of 93.3%. At 9.3 years' mean follow-up, THA in young patients was associated with low revision rates with acceptable risk of prosthetic joint infection and dislocation. Patients with SCD are at increased risk for early readmission and revision at latest follow-up. [Orthopedics. 2023;46(1):e45-e51.].

Hip fracture in older patients leads to high morbidity and mortality. Patients who are treated surgically but fail acutely face a more complex operation with conversion total hip arthroplasty (THA). This study investigated mortalities and complications in patients who experienced failure within one year following hip fracture surgery requiring conversion THA.

Patients aged 60 years or more undergoing conversion THA within one year following intertrochanteric or femoral neck fracture were identified and propensity-matched to patients sustaining hip fractures treated surgically but not requiring conversion within the first year. Patients who had two-year follow-up (91 conversions; 247 comparisons) were analyzed for 6-month, 12-month, and 24-month mortalities, 90-day readmissions, surgical complications, and medical complications.

Nonunion and screw cutout were the most common indications for conversion THA. Mortalities were similar between groups at 6 months (7.7% conversion versus 6.1% nonconversion, P = .774), 12 months (11% conversion versus 12% nonconversion, P = .999), and 24 months (14% conversion versus 22% nonconversion, P = .163). Survivorships were similar between groups for the entire cohort and by fracture type. Conversion THA had a higher rate of 90-day readmissions (14% versus 3.2%, P = .001), and medical complications (17% versus 6.1%, P = .006). Inpatient and 90-day orthopaedic complications were similar.

Conversion THA for failed hip fracture surgery had comparable mortality rates to hip fracture surgery, with higher rates of perioperative medical complications and readmissions. Conversion THA following hip fracture represents a potential "second hit" that both surgeons and patients should be aware of with initial decision-making.

Slipped capital femoral epiphysis (SCFE) causes degenerative changes warranting total hip arthroplasty (THA) in approximately 50% of patients by age 60 years. For severe SCFE, a reorienting intertrochanteric osteotomy (ITO) following in situ pinning (ISP) can decrease impingement with hip flexion, but by altering proximal femoral geometry, complicates subsequent conversion THA. We hypothesized that increasing implant survivorship would affect the most cost-effective treatment strategy (ISP followed by ITO [ISP + ITO] with later THA versus ISP alone [ISPa] with earlier THA) over a patient's lifetime.

A state-transition Markov model was constructed to analyze the cost-effectiveness of either ISPa or ISP + ITO over a 60-year time horizon for children who have severe, stable SCFE. Transition probabilities associated with implant and native hip survivorship, state utilities, and costs were derived from the literature. Sensitivity analyses assessed the model robustness. Incremental cost-effectiveness ratios (ICERs) were compared to a societal willingness to pay (WTP) of $100,000 per quality-adjusted life year (QALY).

Over a 60-year horizon, ISPa was costlier ($291,836) than ISP + ITO ($75,227) but achieved overall better outcomes (51.4 QALYs ISPa versus 48.7 QALYs ISP + ITO), rendering ISPa cost-effective with an ICER of $80,980/QALY. Implant survivorship and time horizon were sensitive variables.

Based upon current implant performance, ISPa with subsequent earlier THA is cost-effective when considering an individual's life expectancy and thereby deserves consideration in patients who have severe SCFE. Without clear level 1 clinical data, our economic model considers a difficult problem, while providing families and clinicians with a framework for understanding treatment options.

Economic and decision analysis, Level III.

Failed internal fixation of intertrochanteric fractures (FIF-ITF) is often treated by conversion hip arthroplasty (CHA). This study aimed to evaluate the results and complications of using standard and long femoral stems in this operation.

This retrospective, multi-center study enrolled 31 total hip arthroplasty (THA) and 23 hemiarthroplasties (HA) cases (30 women, 24 men; mean age 76 years) after FIF-ITF between 2012 and 2019, divided into two groups: standard stem group (n = 20) and long stem group (n = 34). The initial internal fixation includes 38 cases of proximal femoral nail anti-rotation (PFNA), eight cases of the dynamic hip screw (DHS), and eight cases of locking proximal femoral plate (LPFP). The indications for CHA included 38 cases of failure of fixation, seven cases of nonunion, and nine cases of avascular necrosis or posttraumatic osteoarthritis. Perioperative data and complications related to fracture and operation were collected, and preoperative and postoperative clinical and radiological data were analyzed. Clinical outcomes were assessed using Harris hip score (HHS) and 36-item Short Form survey (SF-36: including physical function (PF) score and body pain (BP) score). Statistical analyses were performed using the chi-square or Fisher's exact test, and the 2-sample t-test or Wilcoxon rank sum test.

At an average of 5.6 years with a minimum of 2 years follow-up. A significant overall surgeon-related complication rate was detected (27.8% [15/54]), five cases had an intraoperative femur fracture, one case had a late periprosthetic femoral fracture, two cases had a stem penetration, one case had a cement leakage, and two patients had an early postoperative dislocation, one infection and three cases of stem loosening or subsidence. Long stems had an increased risk of complication (13/34) compared to standard stems (2/20) (P = 0.031). The operation time and blood loss in the long stem group were higher than those in the standard stem group (P = 0.002; 0.017). HHS and SF-36 significantly improved in both groups from preoperative to the final follow-up and did not present significant differences at the final follow-up (P > 0.05).

CHA following FIF-ITF showed a successful mid-term clinical result, long stem arthroplasty should be approached with caution for the risks of higher complication rate, especially intraoperative femoral fractures.

Extended oral antibiotic prophylaxis may decrease rates of prosthetic joint infection (PJI) after total joint arthroplasty (TJA) in patients at high risk for infection. However, the cost-effectiveness of this practice is not clear. In this study, we used a break-even economic model to determine the cost-effectiveness of routine extended oral antibiotic prophylaxis for PJI prevention in high-risk TJA patients.

Baseline PJI rates in high-risk patients, the cost of revision arthroplasty for PJI, and the costs of extended oral antibiotic prophylaxis regimens were obtained from the literature and institutional purchasing records. These variables were incorporated in a break-even economic model to calculate the absolute risk reduction (ARR) in infection rate necessary for extended oral antibiotic prophylaxis to be cost-effective. ARR was used to determine the number needed to treat (NNT).

Extended oral antibiotic prophylaxis with Cefadroxil in patients at high risk for PJI was cost-effective at an ARR in baseline infection rate of 0.187% (NNT = 535) and 0.151% (NNT = 662) for TKA and THA, respectively. Cost-effectiveness was preserved with varying costs of antibiotic regimens, PJI treatment costs, and infection rates.

The use of extended oral antibiotic prophylaxis may reduce PJI rates in patients at high risk for infection following TJA and appears to be cost-effective. However, the current evidence supporting this practice is limited in quality. The use of extended oral antibiotic prophylaxis should be weighed against the possible development of future antimicrobial resistance, which may change the value proposition.

With the annual incidence of hip fractures and hip fracture fixation rising, the need for conversion total hip arthroplasty has also risen. About half of the 280,000 hip fractures that occur annually in the United States are extracapsular. Commonly extracapsular hip fractures are treated with either cephalomedullary nails (CMNs) or sliding hip screws (SHS). More recently, there has been a shift toward increased CMN use due to increased training with this fixation method as well as perioperative and biomechanical benefits. Given this shift, orthopedic surgeons need to understand the factors that lead to CMN failure. Failed CMN treatment leaves both patients and surgeons with few management options including revision fixation with or without osteotomy, conversion total hip arthroplasty, and conversion hemiarthroplasty. Surgeons must consider the patient and injury characteristics before deciding the best treatment plan. Conversion total hip arthroplasty is indicated in younger patients without femoral head and/or acetabular articular injury, degenerative joint disease, or avascular necrosis. Conversion total arthroplasty is a technically demanding and resource-intensive surgery associated with lower success rates and outcomes than primary total hip arthroplasty. Orthopedic surgeons should have thorough understanding of preoperative workup needed prior to surgery, implant selection associated with best outcomes, most common surgical approaches used, intraoperative considerations, and complications associated with conversion total hip arthroplasty. A comprehensive understanding of these concepts gives patients the best chance of having a successful outcome.

Conversion total knee arthroplasty (TKA) is suggested to incur similar complication rates to revision arthroplasties. However, current billing codes do not allow for the differentiation between this operation and primary TKAs. Therefore, the purpose of this study was to compare outcomes of these two surgeries, as well as revision TKAs. Specifically, we analyzed (1) medical complications, (2) surgical complications, and (3) revision rates at 90 days and 1 year. We queried a national, all-payer database to identify patients who underwent TKA without prior implants (n = 1,358,767), required conversion TKA (n = 15,378), and who underwent revision TKA (n = 33,966) between January 1, 2010, and April 30, 2020. Conversion TKA patients (prior implant removal) were identified using the Current Procedural Terminology (CPT) codes. Outcomes studied included 30-day readmission rates and 90-day, as well as 1-year, medical and surgical complications. Conversion TKAs had greater 30-day readmission rates and incidences of most of the complications studied when compared with primary TKAs. The majority of outcomes when comparing between primary, conversion, and revision TKAs were significantly different (p < 0.01). In contrast, conversion TKA complications were similar to revision TKA. Conversion TKAs have higher postoperative complications than primary TKAs and share more similarities with revision TKAs. Thus, the lack of billing codes differentiating conversion and primary TKAs creates a challenge for orthopaedic surgeons.