Date of Award

January 2021

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Jonathan Grauer

Abstract

Background: Geriatric femoral neck fracture is a common injury for which hemiarthroplasty (HA) or total hip arthroplasty (THA) may be considered in select patients. Part one of this project sought to systematically identify large database studies comparing THA to HA for geriatric hip fractures. The goal of this was to delineate strengths, limitations, and conclusions of such studies. Part two used multivariate analyses with and without propensity matching to compare perioperative outcomes between THA and HA performed for femoral neck fracture in geriatric populations identified in NSQIP. This was done to assess the impact of utilizing this statistical methodology and to best determine differences in perioperative outcomes for these groups.

Methods: A literature search was done iteratively with a systematic use of variations of key search terms in PubMed database. The main search terms for this review were (1) variations on hemiarthroplasty, including hemiarthroplasties, hemi arthroplasty, hemi arthroplasties, hemi-arthroplasty, hemi-arthroplasties; (2) variations on arthroplasty, including total arthroplasty, arthroplasties and hip replacement. From there, additional search terms including (3) complication or complications and adverse event or adverse events and (4) registry or database were included. The initial search identified 490 references. Of the 490, 15 full-text papers were reviewed. Ultimately, 9 papers were included in the review. Five of the included studies utilized the National Surgical Quality Improvement Program (NSQIP) database, one utilized Hospital Episode Statistics (HES), one utilized The National Hospital Discharge Survey (NHDS), one utilized Swedish Nation Hip Fracture/Arthroplasty Register, and the last utilized the ENCLAVE system of the Centers for Medicare & Medicaid Services (CMS). These all included data ranging from 2005 to 2013 and included at least 1,000 patients.

In part two, a database analysis comparing THA and HA was done based on close review of the 9 studies included in part one and identification of gaps in the literature. Patients ≥70 years of age who underwent HA or THA for hip fractures were identified from the 2012-2015 National Surgical Quality Improvement (NSQIP) database. Propensity score 1:1 matching was performed. Differences in rates of 30-day postoperative adverse outcomes were compared using multivariate logistic regression for unmatched and matched cohorts.

Results: In part one, clinical postoperative outcomes of THA and HA were grouped and compared among the 9 studies. All studies included used multivariable analysis to make comparisons, and it is of note that HA is much more common than THA in this patient population. Primary outcome variables evaluated included: major/minor complications, mortality, length of stay, postoperative transfusion, readmission, dislocation and revision. Overall, major and minor adverse events (or a combination of the two) were lower for THA than for HA patients, and postoperative transfusions were more common for THA patients. Mortality was significantly less for THA patients by 3-4%. Length of stay was lower for THA patients. Dislocation rates were higher for THA patients at 30-days, 18-months, 24-months and 4-years by odds ratios of 3-5 times. One study found THA patients more likely to undergo reoperation.

In part two, the analysis utilized propensity matching and included 15,558 patients (14,403 HA and 1,155 THA). Although multivariate outcomes for the unmatched populations were different for blood transfusion, mortality, minor adverse events, major adverse events, and reoperation, multivariate outcomes for matched populations only differed for blood transfusion (odds ratio 0.6 for HA vs THA, p<0.001). Of note, although readmissions were similar for the two groups, THA patients had a 5.4% greater rate of perioperative readmission due to dislocation.

Conclusions: In select geriatric patients with femoral neck fractures, THA and HA may be appropriately considered. Reviewed literature suggests that THA may be associated with fewer postoperative challenges than HA, however, postoperative transfusion and dislocation rates were noted to be higher for THA patients. Following the systematic review, an analysis of a robust clinical database to compare THA to HA was done. Geriatric patients undergoing THA and HA for hip fracture were compared with and without propensity matching. Once matching was done, the only differences in outcomes between the two groups were a lower transfusion rate among the HA group and a greater readmission rate due to dislocation among THA. This suggests that either procedure can be safely considered if found to be advantageous from a longer-term outcome perspective.

Comments

This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.

Download

Share

COinS