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Complications of periprosthetic fracture revision vs aseptic revision of total knee arthroplasty
∗Corresponding author: Ashish R. Chowdary. Ashish.Chowdary@UTSouthwestern.edu
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Periprosthetic fractures after total knee arthroplasty (TKA) are a challenging problem due to complex fracture patterns, poor bone quality, and a high-risk patient population. Treatment of both periprosthetic fractures and aseptic complications can include revision TKA. In this study, we compared systemic and orthopaedic complications following periprosthetic fracture associated revision TKA to aseptic revision TKA.
This is a retrospective cohort study using data from the years 2010–2020 from a national administrative claims database. Billing codes were used to identify revision TKAs with a diagnosis of periprosthetic fracture or aseptic complications (loosening, dislocation, arthrofibrosis, osteolysis, or prosthetic wear) within one year prior to revision. Pertinent systemic complications and rates of repeat revision TKA, periprosthetic infection, and repeat fractures were compared between the two groups.
We identified 9891 periprosthetic fracture associated revision TKAs and 47,071 aseptic revision TKAs. Our study found higher rate of systemic complications including AKI, DVT, wound disruption, hematoma, and surgical site infections in periprosthetic fracture associated revision TKA compared to aseptic revision TKA. Furthermore, we found higher rates of repeat revision TKA, periprosthetic infections, and repeat periprosthetic fractures in fracture associated revision TKA group compared to aseptic revision group.
Our work highlights the significant short- and long-term complications associated with periprosthetic fracture associated revision TKA. Future working comparing functional outcomes and optimal surgical techniques are needed.
Keywords
Revision arthroplasty
Knee
Periprosthetic fracture
Complications
Aseptic revision
1 Introduction
Periprosthetic fractures after total knee arthroplasty (TKA) are a challenging problem due to complex fracture patterns, poor bone quality, and a high-risk patient population1–.3 Fractures can involve distal femur, patella, or proximal tibia. Incidence of periprosthetic fractures following TKA range between 1.3% and 2.5%.2,4 Risk factors for periprosthetic fractures after TKA include older age, women gender, corticosteroid use, and neurological disorders.5,6 Currently, multiple nonoperative and operative interventions exist depending on fracture pattern and patient stability. Recently, revision total knee arthroplasty has been the selected method to restore alignment and stability following periprosthetic fracture.7,8 Mortality rates following periprosthetic fractures are similar to those of hip fractures and functional outcomes remain mixed.1,9 Furthermore, periprosthetic fractures are associated with high rates of readmissions and associated costs.10,11
Additional reasons for revision TKA include loosening, instability, polyethylene wear, and osteolysis. Aseptic complications of TKA remain one of the main causes of revision, secondary only to prosthetic joint infections.12 Previous work has extensively characterized the systemic and orthopaedic outcomes of aseptic vs septic revision TKA.13–15 Limited work on the outcomes of revision TKA following periprosthetic fractures exist. As the incidence of primary TKA increases, the rate of revision TKAs will continue increase as well. Identifying areas for potential complications in revision TKA improves patient outcomes and reduces cost.
While prior work has suggested that patients with a diagnosis of periprosthetic fractures have extensive comorbidities and require extensive follow up, few studies characterize systemic and orthopaedic outcomes following repair via revision TKA.2 Furthermore, rates of reimbursement are declining for all causes of revision TKA.16 Better characterization of the outcomes and associated complications between complex and simple revision TKA has the potential to advocate for improved reimbursement rates for high complexity revisions.
In this study, we use a national insurance claims database to directly compare systemic and orthopaedic outcomes of revision TKA associated with all cause periprosthetic fractures to revision TKA associated with aseptic complications. We hypothesize that periprosthetic fracture related revision TKAs will have higher rates of systemic complications and orthopaedic complications compared to aseptic revision TKAs.
2 Methods
This is a retrospective cohort study using national insurance claims database.
2.1 Database description
Patient data was acquired using the PearlDiver patient records database (www.pearldiverinc.com, Colorado Springs, CO, USA), a commercially available administrative claims database with over 41 billion HIPAA-compliant patient records from over 91 million unique patients from all 50 states. The target patient cohorts were created from the MS151 dataset, which includes information from a wide range of payer types, including commercial insurance, Medicare, Medicaid, self-pay, and National Inpatient Sample database. Health Insurance Portability and Affordability Act (HIPAA) compliance is ensured for all patient information. The PearlDiver database does not report values less than 11 to protect patient identity. This study was exempt from institutional review board (IRB) approval since all patient data was publicly available and de-identified.
2.2 Data acquisition
For burden analysis, data from the year 2010–2020 was used. Adult patients (age greater than 18) and patients active in the database for one year or greater with periprosthetic fractures were identified. Patients without a primary TKA in the database were excluded. Primary TKA, revision TKA and periprosthetic fractures were identified using Current Procedural Terminology (CPT) and International Classification of Disease (ICD) codes previously published.17 Related closed and open procedures following periprosthetic fractures were identified using procedural codes (Table S1). Readmission rates over one year were determined using the PearlDiver function. Total cost for reach treatment group was calculated in PearlDiver one year after initial diagnosis of periprosthetic fracture using patients from each treatment group.
To compare periprosthetic fracture revision TKA to aseptic revision TKA, data from the years 2010–2020 was used. All revision TKAs with a diagnosis of periprosthetic fracture or aseptic complication within one year prior to revision date were identified using ICD and CPT codes. Patients less than age 18 and not active in the database for at least two years after were excluded. Aseptic complications included ICD codes for loosening, dislocation, arthrofibrosis, osteolysis, and prosthetic wear.17 Pertinent comorbidities (obesity, diabetes, smoking history) and systemic complications including acute kidney injury (AKI), cardiac arrest, deep vein thrombosis (DVT), wound disruption, hematoma, pneumonia, pulmonary embolism, and urinary tract infection (UTI) were identified using the ICD codes listed in Table S2. Codes for surgical site infections (SSI) were identified as previously published.18 Rates of systemic complications were characterized 90 days following revision TKA. Rates of repeat revision TKA, periprosthetic infection, and repeat fracture at two years, ten years, and five years following initial revision were also characterized (Table S2). Total average cost one year following date of revision TKA was calculated in PearlDiver. Complete lists of ICD and CPT codes used in this study can be found in Table S1 and Table S2.
2.3 Statistical analysis
Both an unmatched analysis and matched analysis were completed. All categorical variables were analyzed using Chi-squared tests and all continuous variables were analyzed using t-tests. Analysis for surgical outcomes and complications were done using odds ratios (incidence of group with periprosthetic fracture vs group with aseptic complications) with 95 percent confidence intervals. When comparing multiple groups simultaneously using the same dataset, the Bonferroni correction was performed to minimize false positive results. Therefore, the alpha for average cost comparison among three treatment groups was set to less than 0.0167. For all other analyses, p-values less than 0.05 were considered statistically significant. A regression analysis using the variables categorical age, gender, obesity, and tobacco use was done to create a 1:1 propensity matching algorithm within the PearlDiver software. Systemic complications rates were assessed at 90 days following surgery. Arthroplasty complications were assessed at two, five, and ten years following initial revision TKA. Cost analyses were performed at 1 year following fracture diagnosis or revision TKA. Visualizations were made using R version 4.2.
3 Results
3.1 Burden analysis of periprosthetic fractures following TKA
We identified a total of 12,646 patients with a diagnosis of periprosthetic fracture after primary TKA who had an identifiable treatment in database. We found that 1115 (8.82%) patients underwent closed repair, 4112 (32.52%) patients underwent open reduction internal fixation (ORIF), and 7419 (58.67%) patients underwent revision TKA as an initial treatment.
We determined all cause hospital readmission rates over one year for patients with diagnosis of periprosthetic fracture after primary TKA who had an identifiable treatment in database. Within 30 days of diagnosis of periprosthetic fracture, 29.03% (3671) were found to have a hospital readmission. Within 90 days, the percentage grew to 36.01% (4554). One year following diagnosis readmission rates were found to be 46.30% (5855). Our results show that periprosthetic fractures are associated with significant healthcare usage, regardless of treatment method.
Total healthcare cost one year following periprosthetic fracture diagnosis for each treatment group (closed, open, revision TKA) was also calculated. We found average cost for periprosthetic fractures treated with closed management was $25,546 (standard deviation [SD] = $34,118), ORIF was $27,929 (SD = $35,838), and revision TKA was $33,047 (SD = $43,182). Cost for closed and open reduction were not significantly different (p = 0.046) after Bonferroni correction (p less than 0.0167 to be considered significant). However, the cost for revision TKA was significantly greater than both closed management (p < 0.0001) and ORIF (p < 0.0001). The data shown here suggest that revision THA is most selected treatment option but is associated with significantly greater costs.
3.2 Systemic complications of periprosthetic fracture revision TKA vs aseptic revision TKA
We identified 9891 patients with a diagnosis of periprosthetic fracture one year prior to revision TKA and 47,071 patients with an aseptic complication (loosening, dislocation, arthrofibrosis, osteolysis, and prosthetic wear) one year prior to revision TKA. This population includes patients who may have received a primary TKA outside of the database or underwent other treatments prior to revision arthroplasty. We compared demographics and comorbidities of both cohorts. Fracture related revisions were significantly older and composed of predominantly women patients (Table 1). No differences in rates of diabetes, obesity, and tobacco use were found (Table 1). Length of stay for fracture related revisions was significantly longer than aseptic revisions (3.18 days vs 2.91 days; p < 0.0001).
| Characteristic | Periprosthetic fractures (n = 9891) | Aseptic (n = 47,071) | P value |
| Age, mean* | 65.2 | 64.1 | < 0.00001 |
| Sex* | < 0.00001 | ||
| Women (%) | 6481 (65.5) | 288827 (61.2) | |
| Men (%) | 3410 (34.5) | 18244 (38.8) | |
| Diabetes | 0.2272 | ||
| Yes (%) | 5375 (54.3) | 25266 (53.7) | |
| No (%) | 4516 (45.7) | 21805 (46.3) | |
| Obesity | 0.1136 | ||
| Yes (%) | 5983 (60.5) | 28069 (59.6) | |
| No (%) | 3908 (39.5) | 19002 (40.4) | |
| Tobacco use | 0.6537 | ||
| Yes (%) | 4091 (41.4) | 19354 (41.1) | |
| No (%) | 5800 (58.6) | 27717 (58.9) | |
| CCI* | < 0.00001 | ||
| 0–2 [mild] (%) | 5981 (60.5) | 31342 (66.6) | |
| 3–5 [moderate] (%) | 2763 (27.9) | 11342 (24.1) | |
| > 6 [severe] (%) | 1147 (11.6) | 4387 (9.3) | |
| Length of stay, mean days* | 3.18 | 2.91 | < 0.00001 |
We compared systemic complications of periprosthetic fracture associated revision TKA to aseptic revision TKA. In our unmatched cohorts, we found significantly higher rates of AKI (6.63% vs 4.45%; OR = 1.52; p < 0.0001), DVT (1.19% vs 0.78%; OR = 1.53; p = 0.0001), wound disruption (4.28% vs 3.35%; OR = 1.29; p < 0.0001), hematoma (2.24% vs 1.93%; OR = 1.17; p = 0.0410), pneumonia (2.35% vs 1.92%; OR = 1.23; p = 0.0063), UTI (6.51% vs 5.09%; OR = 1.30; p < 0.0001), and SSI (17.2% vs 14.4%; OR = 1.24; p < 0.0001) in periprosthetic fracture related revisions compared to aseptic revision TKA within 90 days of surgery (Table 2). Rates of cardiac arrest and pulmonary embolism were not significantly different between the two groups (Table 2)
| Periprosthetic fracture | Aseptic | OR | OR 95% CI | P value | |
| Unmatched, 90 days Systemic complications | n = 9891 | n = 47,071 | – | – | – |
| Acute kidney injury* (%) | 656 (6.63) | 2095 (4.45) | 1.52 | [1.39,1.67] | <0.0001 |
| Cardiac arrest (%) | 15 (0.15) | 48 (0.10) | 1.49 | [0.83,2.66] | 0.1795 |
| Deep vein thrombosis* (%) | 11 (1.19) | 369 (0.78) | 1.53 | [1.24,1.88] | 0.0001 |
| Wound disruption* (%) | 423 (4.28) | 1575 (3.35) | 1.29 | [1.16,1.44] | <0.0001 |
| Hematoma* (%) | 222 (2.24) | 908 (1.93) | 1.17 | [1.01,1.35] | 0.0410 |
| Pneumonia* (%) | 232 (2.35) | 905 (1.92) | 1.23 | [1.06,1.42] | 0.0063 |
| Pulmonary embolism (%) | 111 (1.12) | 496 (1.05) | 1.07 | [0.87,1.31] | 0.5465 |
| Urinary tract infection* (%) | 644 (6.51) | 2394 (5.09) | 1.30 | [1.19,1.42] | <0.0001 |
| Surgical site infection* | 1702 (17.2) | 6777 (14.4) | 1.24 | [1.17,1.34] | <0.0001 |
| Matched, 90 days Systemic complications | n = 9869 | n = 9869 | – | – | – |
| Acute kidney injury* (%) | 654 (6.63) | 449 (4.55) | 1.49 | [1.32,1.68] | <0.0001 |
| Cardiac arrest (%) | 15 (0.15) | 14 (0.14) | 1.07 | [0.52, 2.22] | 0.8526 |
| Deep vein thrombosis* (%) | 116 (1.18) | 75 (0.76) | 1.55 | [1.16,2.08] | 0.0031 |
| Wound disruption* (%) | 423 (4.29) | 307 (3.11) | 1.39 | [1.20,1.62] | <0.0001 |
| Hematoma* (%) | 222 (2.25) | 171 (1.73) | 1.31 | [1.07,1.6] | 0.0096 |
| Pneumonia (%) | 232 (2.35) | 206 (2.09) | 1.13 | [0.93,1.37] | 0.2093 |
| Pulmonary embolism (%) | 111 (1.12) | 91 (0.92) | 1.22 | [0.93,1.61] | 0.1579 |
| Urinary tract infection* (%) | 644 (6.53) | 545 (5.52) | 1.19 | [1.06,1.34] | 0.0031 |
| Surgical site infection* | 1698 (17.2) | 1350 (13.7) | 1.31 | [1.21, 1.42] | <0.0001 |
Following matching for the variables age, gender, diabetes, obesity, and smoking status, we identified 9869 patients in both periprosthetic fracture revision and aseptic revision cohorts. An analysis of systemic complications at 90 days was repeated. We found higher rates of AKI (6.63% vs 4.55%; OR = 1.49; p < 0.0001), DVT (1.18% vs 0.76%; OR = 1.55; p = 0.0031), wound disruption (4.29% vs 3.11%; OR = 1.39; p < 0.0001), hematoma (2.25% vs 1.73%; OR = 1.31; p = 0.0096), UTI (6.53% vs 5.52%; OR = 1.19; p = 0.0031), and SSI (17.2% vs 13.7%; OR = 1.31; p < 0.0001) in fracture related revision patients (Table 2).
3.3 Arthroplasty complications of periprosthetic fracture revision TKA vs aseptic revision TKA
We compared rates of all cause repeat revision TKA, periprosthetic infection, and repeat periprosthetic fractures at two years following initial revision. At two years following initial revision, we found significantly higher rates of repeat revision (17.6% vs 15.8%; OR = 1.14; p < 0.0001), periprosthetic infections (26.4% vs 21.8%; OR = 1.29; p < 0.0001), and repeat periprosthetic fractures (35.5% vs 8.9%; OR = 5.63; p < 0.0001) in the unmatched fracture related revision group compared to the aseptic revision group (Table 3). This difference in rates continued to be significant at 5 and 10 years following initial revision (Table 3, Fig. 1A).
| Periprosthetic fractures (n = 9891) | Aseptic (n = 47,071) | OR | OR 95% CI | P value | |
| Repeat revision TKA | – | – | – | ||
| 2 years* (%) | 1741 (17.6) | 7444 (15.8) | 1.14 | [1.07,1.20] | <0.0001 |
| 5 years* (%) | 2055 (20.8) | 8870 (18.8) | 1.13 | [1.07,1.19] | <0.0001 |
| 10 years* (%) | 2141 (21.7) | 9336 (19.8) | 1.12 | [1.06,1.18] | <0.0001 |
| Periprosthetic infection | – | – | – | ||
| 2 years* (%) | 2614 (26.4) | 10248 (21.8) | 1.29 | [1.23,1.36] | <0.0001 |
| 5 years* (%) | 2909 (29.4) | 11408 (24.2) | 1.30 | [1.24,1.37] | <0.0001 |
| 10 years* (%) | 3015 (30.5) | 11909 (25.3) | 1.29 | [1.23,1.36] | <0.0001 |
| Repeat fracture | – | – | –– | ||
| 2 years* (%) | 3511 (35.5) | 4191 (8.90) | 5.63 | [5.35,5.93] | <0.0001 |
| 5 years* (%) | 3681 (37.2) | 5095 (10.8) | 4.88 | [4.65,5.13] | <0.0001 |
| 10 years* (%) | 3748 (37.9) | 5513 (11.7) | 4.60 | [4.38,4.83] | <0.0001 |
In similar fashion, we compared outcomes using our matched cohorts. At two years, fracture related revisions were associated with significantly higher repeat revisions (17.6% vs 15.2%; OR = 1.19; p < 0.0001), periprosthetic infections (26.4% vs 20.8%; OR = 1.37; p < 0.0001) and repeat periprosthetic fractures (35.5% vs 8.80%; OR = 5.72; p < 0.0001) compared to aseptic revisions and remained significant at 5 and 10 years (Table 4, Fig. 1B).
| Periprosthetic fractures (n = 9869) | Aseptic (n = 9869) | OR | OR 95% CI | P value | |
| Repeat revision TKA | – | – | – | ||
| 2 years* (%) | 1733 (17.6) | 1498 (15.2) | 1.19 | [1.10,1.28] | <0.0001 |
| 5 years* (%) | 2046 (20.7) | 1792 (18.2) | 1.18 | [1.10,1.27] | <0.0001 |
| 10 years* (%) | 2133 (21.6) | 1883 (19.1) | 1.17 | [5.28,6.21] | <0.0001 |
| Periprosthetic infection | – | – | – | ||
| 2 years* (%) | 2608 (26.4) | 2051 (20.8) | 1.37 | [1.28,1.46] | <0.0001 |
| 5 years* (%) | 2902 (29.4) | 2286 (23.2) | 1.38 | [1.3,1.47] | <0.0001 |
| 10 years* (%) | 3008 (30.5) | 2392 (24.2) | 1.37 | [4.65,5.41] | <0.0001 |
| Repeat fracture | – | – | –– | ||
| 2 years* (%) | 3504 (35.5) | 866 (8.80) | 5.72 | [5.28,6.21] | <0.0001 |
| 5 years* (%) | 3674 (37.2) | 1044 (10.6) | 5.01 | [1.29,1.46] | <0.0001 |
| 10 years* (%) | 3741 (37.9) | 1130 (11.5) | 4.72 | [4.38,5.08] | <0.0001 |
3.4 Increased costs associated with periprosthetic fracture revision TKA
Finally, we compared total costs one year following revision TKA for fracture related revisions and aseptic revisions using the unmatched cohorts. Fracture related revisions (mean = $26,174, SD = $35,472) had a significantly higher cost compared to aseptic revisions (mean = $24,597, SD = $32,837; p < 0.0001).
4 Discussion
We identified that revision TKAs associated with periprosthetic fractures are associated with significantly higher rates of systemic complications including AKI, DVT, and SSI among others compared to aseptic revision TKAs. Furthermore, we found that periprosthetic fracture related revision TKA were associated with higher rates of all cause repeat revision TKA, periprosthetic infections, and repeat periprosthetic fractures at two, five, and ten years following initial revision. Our data suggest periprosthetic fracture related revision TKAs are associated with significant systemic and orthopaedic complications over short and long term. Furthermore, we identified increases costs with fracture related revisions compared to aseptic revisions.
It is well documented that all cause revision TKA has worse systemic and functional outcomes compared to primary TKA.19 However, the relationship between reason for revision TKA and subsequent outcomes has been of recent interest. The high rate of systemic complications present in our fracture revision TKA group is similar to recent work that identified higher mortality, PE, and AKI rates in fracture revision TKA compared to aseptic TKA.20,21 Our work further expands on the previous literature by incorporating a larger cohort of patients and performing propensity matching for relevant comorbidities. While our study did not find significantly different rates of pneumonia, it has been suggested that hospital acquired pneumonia following revision TKA is a significant predictor of mortality.22 Although different, previous work has compared periprosthetic joint infection revision TKA to aseptic revision TKA and found higher rates of systemic complications including SSI, wound dehiscence, renal complications, and mortality.23 Our data, in combination with previous work, demonstrates that revision TKA secondary to periprosthetic fractures is associated with a higher rate of systemic complications that aseptic revision.
Risk factors for periprosthetic fractures have been extensively studied. Our demographic data for patients undergoing periprosthetic fracture related revision is comparable to previous work identifying women with a higher rate of periprosthetic fractures.4 Although data has suggested men undergo revision TKA at higher rates, our work demonstrates that women compose majority of the patients undergoing periprosthetic fracture related revision.24
Additionally, we hypothesize that considerable overlap between frail patients and patients with periprosthetic fractures may exist. Previous work has identified frailty associated with readmission, mortality, and medical complications in revision TKA.25 Fragility is a predictor of fractures in older people.26 Similarly, fragility fractures prior to TKA were associated with increased rate of periprosthetic fractures, aseptic revisions, periprosthetic infections, and increased readmission rates.27 Our data suggests that fractures following primary TKA are associated with a similar risk.
Our study identified a higher risk of periprosthetic infections following fracture associated revision TKA compared to aseptic revision TKA. We do not have a good explanation on why periprosthetic fracture revision TKA is associated with a higher risk of prosthetic joint infection risk. It is possible that underlying periprosthetic infection was present at the time of periprosthetic fracture, as septic loosening may have contributed to the fracture. Protocols used for prevention of repeat infection following periprosthetic joint related revision may be also used in periprosthetic fracture related revision as well. However, further work on the etiology of periprosthetic fracture related infection and treatments is needed.
An important finding of our work is that a previous periprosthetic fracture is associated with a greater than 30% chance of a repeat periprosthetic fracture within 2 years. Although this finding may be expected as similar relationship exists in osteoporosis related fractures, it highlights the importance of implant selection, surgical approach and bone quality during fracture related revision TKA.28 Further work is needed on the optimal implant and operative approach in preventing future fractures, especially in patients with decreased bone mineral density. It is well documented that primary TKA alters bone mineral density (BMD) in multiple areas. However, it is not known how revision TKA effects the rate of BMD decay. One study characterizing BMD in patients undergoing primary TKA and any cause revision TKA found lower T scores in revision group compared to primary group (−1.07 vs −0.21),29 suggesting the potential for elevated preoperative risk of fractures in the revision group. However, the study did not include patients undergoing fracture related revision TKA. We hypothesize that revision TKA itself may accelerate BMD loss in patients and even more so in patients with a prior history of periprosthetic fractures.
Managing cost of TKA is rising in importance as value-based care becomes implemented across the industry and reimbursements of arthroplasty continue to decline. Previous work on outcomes of revision TKA has seldom analyzed cost data.30 One study identified revisions for infections or fractures had a 25% increased cost compared to instability and loosening revisions.31 Related literature analyzing revision joint arthroplasty periprosthetic joint infections identified higher costs for periprosthetic fracture related revisions compared to all the causes.32,33 In our study, we characterized the full spectrum of medical care one year following revision TKA. Our work expands on previous literature by demonstrating that cost one year following revision remains significantly elevated compared to aseptic related revisions. We highlight the need to stratify the different etiologies of revision TKA to better support reimbursement rates and maintain accessibility to care.34
The strengths of our study include a large longitudinal patient sample, use of a propensity matched cohort for multiple comorbidities, and detailed characterization of systemic outcomes. However, there are limitations to our work. Patients in the aseptic group may have undergone revisions for relatively simple complications such as polyethylene wear. Although aseptic revisions and periprosthetic fracture revisions are inherently different procedures, revision arthroplasty cases are frequently grouped and analyzed together. Identifying the differences in outcomes between the two groups advocates for separation of the two in future clinical and research work. We were unable to determine the treatments for all patients in the database with a diagnosis of periprosthetic fractures due to database limitations. The CPT codes use to capture related treatments may not be all encompassing. Furthermore, we recognize portion of fracture related revision TKAs may have occurred following attempted closed or open reduction. These were not excluded to understand the total complication experienced in clinical practice. While data with patients records present in the database for a minimum of two years was used, rates of outcomes at 5 and 10 years may be underestimated due to loss of follow up. Therefore, conclusions about the rate of revision over time cannot be drawn. Furthermore, we queried patients with revision TKAs associated with periprosthetic fractures or aseptic revisions up to a year before. While patients may undergo definite fixation sooner, we wanted to ensure we captured a wide spectrum of patients. As prior work has demonstrated that time to fixation does not correlate improved outcomes,35 surgeons and anesthesiologists may ensure optimal anesthesia stability prior to surgery. Intraoperative variations in surgical methods or implant selection during revision arthroplasty may have contributed to the poor outcomes. We were unable to perform subset analyses on these variables as the database does not provide detailed patient records. Finally, it should be noted that our work is a retrospective cohort study using a large database and is subject to selection bias, data coding errors, and residual confounding variables among other limitations. While propensity matching was used to limit the effect of confounding variables, it cannot be guaranteed that the full effect was controlled for.
5 Conclusions
Our study found higher rate of systemic and prosthetic related complications in periprosthetic fracture associated revision TKA compared to aseptic revision TKA. Our work highlights the significant complications associated with periprosthetic fracture revision TKA. Future working comparing functional outcomes and optimal surgical techniques are needed.
Funding
The authors of no sources of funding to disclose.
Ethical approval
As the use of this publicly available database does not involve any direct interaction with human subjects, this study was exempt from ethical approval.
Informed consent
Informed consent was not required for the study, as the research utilized publicly available data.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Guardian/patient's consent
Informed consent was not required for the study, as the research utilized publicly available data.
CRediT authorship contribution statement
Ashish R. Chowdary: Data collection, Data analysis and interpretation, Writing – original draft. Dane K. Wukich: Conceptualization, design of the work, Data analysis and interpretation, Writing – original draft, Critical revision of the article. Senthil Sambandam: Conceptualization, design of the work, Data collection, Critical revision of the article, All authors approved the final version of the manuscript.
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