The Journal of Arthroplasty 30 (2015) 1183–1186
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The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Complication, Survival, and Reoperation Rates Following Girdlestone Resection Arthroplasty Tennison L. Malcolm, MD, Bishoy V. Gad, MD, Karim A. Elsharkawy, MD, Carlos A. Higuera, MD Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
a r t i c l e
i n f o
Article history: Received 4 November 2014 Accepted 6 February 2015 Keywords: Girdlestone resection arthroplasty comorbidity complications mortality
a b s t r a c t Failed hip arthroplasty patients unsuitable for reimplantation may be offered Girdlestone resection arthroplasty (GRA). The purpose of this study was to detail complication and failure rates following GRA. Our results show that 66% (25/38), 34% (13/38), and 76% (29/38) of GRA patients experienced minor, major, and overall complications, respectively. Within 90 days of surgery, three patients required additional surgery and four died. Reoperation or death occurred an average of 26.3 (SD = 3.5) and 55.6 (SD = 76) months after surgery, respectively. Male gender and increasing comorbidity significantly predicted higher reoperation and mortality rates, P = 0.01 and P = 0.04, respectively. Complication and mortality rates following GRA are among the highest reported succeeding elective hip surgery for non-traumatic etiology. © 2015 Elsevier Inc. All rights reserved.
Total hip arthroplasty (THA) is among the fastest growing procedures in the United States [1]. Despite advancements in bearing surface, fixation, and perioperative care, the number of failed implants continues to rise every year [2,3]. Loose or infected hardware serves as a nidus for persistent pain or infection and in most cases should be removed promptly. Some THA patients (both primary and revision) require prosthesis explant but are not suitable for hardware reimplantation due to poor bone stock, high likelihood of infection, or comorbid disease prohibiting such taxing surgery [4–6]. These patients may be offered Girdlestone resection arthroplasty (GRA) as a last resort for control of pain and infection and partial preservation of limb function. Girdlestone resection arthroplasty was popularized by Gathorne Robert Girdlestone in the early 1900’s as a salvage procedure for septic arthritis [7]. With this technique, the femoral head is resected leaving only a crude articulation between the femur and acetabulum. The use of GRA has been extended to total hip arthroplasty (THA) failure, in which all implanted hip components are removed leaving the same pseudoarthrosis. This very basic juxtaposition of the femur in what’s left of the acetabulum is, in most cases, poorly functional, thus only used when all other viable options are limited to non-operative intervention and hip disarticulation.
One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.02.011. Reprint requests: Carlos Higuera, MD, Cleveland Clinic, A41, 9500 Euclid Avenue, Cleveland, OH 44195. http://dx.doi.org/10.1016/j.arth.2015.02.011 0883-5403/© 2015 Elsevier Inc. All rights reserved.
With reports ranging from 7% to 62%, the mortality rates following GRA are very high [4,8]. Other prognostic data describing this procedure are much less clear. The aims of the current study were to assess comorbid disease burden in this patient population, complication rate, and time until death or reoperation after GRA.
Methods After approval from our Institutional Review Board, a query of the electronic medical records was performed to identify all revision hip arthroplasties conducted between 2000 and 2010. The medical records of all patients undergoing GRA (n = 38 hips) were selected and retrospectively reviewed. Patients undergoing hip disarticulation and GRA secondary to tumor metastasis were excluded as it was felt that these patients may represent a different surgical cohort with respect to expectations in hip function. All demographic (i.e., age and gender), clinical (i.e., side of surgery, preoperative diagnosis, antibiotic use N 6 weeks prior to surgery, anticoagulation use N 6 weeks prior to surgery, comorbidities, and complications) and survival (i.e., death, reoperation, death or reoperation [DOR]) data were obtained via retrospective medical record review. Preoperative diagnosis and DOR were defined as binary variables (preoperative diagnosis: 0 = chronic dislocation or aseptic loosening, 1 = periprosthetic joint infection; DOR: 0 = presently alive, no hip surgery since initial GRA, 1 = death or reoperation since GRA). Comorbidity data at and prior to GRA were used to calculate Charlson Comorbidity Indices (CCI) as previously described by Quan et al [9]. Minor systemic, major systemic, minor local, and major local complications were recorded as described by Higuera et al [10] up to three months postoperatively.
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Outcomes were compared between patients undergoing GRA due to mechanical failure and periprosthetic joint infection (PJI). Unadjusted differences between groups were evaluated using Student t-tests and likelihood ratio chi-square tests, as appropriate. The Kaplan–Meier survival method was used to estimate the mean time until death, reoperation, and DOR. Cox-proportional hazards models were used to estimate hazard ratios; univariate Cox regression was performed modeling DOR as functions of gender, preoperative diagnosis, chronic antibiotic use prior to surgery, chronic anticoagulation prior to surgery, and CCI. All analyses were completed using JMP v7.0 (SAS Institute Inc., Cary, NC). Results Between 2000 and 2010, 36 patients (n = 38 hips) underwent GRA due to mechanical failure (i.e., chronic dislocation [n = 8], aseptic loosening [n = 4]) and PJI (n = 26). Among PJI patients, methicillinresistant Staphylococcus aureus was the most common offending organism (n = 8) followed by methicillin-sensitive S. aureus (n = 6), Proteus mirabilis (n = 5), and Pseudomonas aeruginosa (n = 5). Mechanical failure and PJI patients were statistically similar (i.e., P N 0.10) in most characteristics (i.e., age, follow-up time, CCI, or operative side). Overall, GRA patients had a mean age of 70.5 years (SD = 12.3), were last seen postoperatively at a median of 10.8 months (range = 7 days–11 years), were mostly women (n = 19; 53%), and had an equal predilection for either hip (left, n = 19; right n = 19). Postoperatively, 53% (n = 20) and 37% (n = 14) experienced a minor systemic or minor local complication, respectively; 21% (n = 8) and 13% (n = 5) experienced a major systemic and major local complication, respectively (Table 1). PJI patients were 2.6 times more likely to experience a minor systemic complication (P = 0.02); the two groups were similarly predisposed toward minor local and major complications. Most GRA patients did not undergo additional hip surgery; however, those that did ranged between 1 and 5 additional procedures; 17% and 42% of mechanical failure and PJI patients, respectively, required reoperation (P = 0.11). Of the 36 study patients, 11(92%) mechanical failure and 12 (46%) PJI patients were deceased at the time of the study (P b 0.01). Frequencies of postoperative complications are listed in Table 2. Following GRA the incidences of minor, major, and overall complication Table 1 GRA Clinical and Survival Characteristics, 2000–2010. Preoperative diagnosis
N (hips) Median Follow Up Months (SD) Operative Hip, n (%) Left Right Complications, n (%) Minor Systemic Major Systemic Minor Local Major Local Any Complication Reoperation, n (%) n=0 n=1 n=2 n=3 n=4 n=5 Death, n (%) Living Deceased Death or Reoperation, n (%) Alive, No Reoperation Deceased or Reoperation
Mechanical Failurea
PJI
12 13.5 (28.8)
26 8.9 (37.6)
5 (42%) 7 (58%)
14 (54%) 12 (46%)
3 (25%) 2 (17%) 4 (33%) 2 (17%) 7 (58%)
17 (65%) 6 (23%) 10 (38%) 3 (12%) 22 (85%)
10 (83%) 1 (8%) 1 (8%) 0 (0%) 0 (0%) 0 (0%)
15 (58%) 4 (15%) 0 (0%) 4 (15%) 2 (8%) 1 (4%)
1 (8%) 11 (92%)
14 (54%) 12 (46%)
1 (8%) 11 (92%)
8 (31%) 18 (69%)
P Value 0.51 0.48
Table 2 Postoperative Complication Frequency. Complications Minor Systemic Anemia Deep Vein Thrombosis Altered Mental Status Pneumonia Postoperative Depression C. diff Enterocolitis Other Major Systemic Tachyarrthmia Congestive Heart Failure Hypotensive Crisis Acute Renal Failure Death Pulmonary Edema Gastrointestinal Bleed Ascending Cholangitis Minor Local Cellulitis/superficial infection Joint stiffness Hematoma Blisters Persistent Wound Drainage Uncontrollable Pain Major Local Joint Infection Peripheral Nerve Injury
Number
Rate
16 1 2 2 2 1 8
41% 3% 5% 5% 5% 3% 21%
2 1 3 2 4 4 1 1
5% 3% 8% 5% 10% 10% 3% 3%
2 1 2 2 8 6
5% 3% 5% 5% 21% 15%
6 1
15% 3%
were 66% (n = 25), 34% (n = 13), and 76% (n = 29), respectively. Postoperative anemia was found in 42% (n = 16) of GRA patients. Within the first 90 days of GRA, four patients had persistent evidence of joint infection; three of four underwent reoperation within 90 days. Four patients died within 90 days of GRA, two of whom underwent additional irrigation and debridement for infection. Fig. 1 shows the Kaplan–Meier survival curves of time until reoperation and death. On average, GRA patients experienced reoperation, death, or DOR 26.3 (SD = 3.5), 55.6 (SD = 76), and 34.2 (SD = 6.7) months after surgery, respectively. There was tendency to require additional surgery at a higher rate among PJI patients compared to mechanical failure GRA patients; however, this did not reach significance (P = 0.08). The likelihood of remaining event free (i.e., death or reoperation) was similar between PJI and mechanical failure patients. Univariate analyses of DOR hazard are shown in Table 3. Men experienced death or reoperation at a rate 2.84 times higher than women (P = 0.01). For every 1-point increase in CCI, short-term risk of death or reoperation increased by a factor of 1.26 (P = 0.04). Discussion
0.02 0.65 0.76 0.66 0.08 0.11
b 0.01
0.11
PJI, Periprosthetic joint infection. a Mechanical failure due to chronic dislocation (n = 8) and mechanical failure (n = 4).
Failed total hip arthroplasty in medically precarious patients is infrequently discussed in the literature but will likely continue to appreciate. Despite limited viable options, candidates for GRA and their surgeons should understand the risks and outcomes associated with this procedure. The 90-day rates of major complication (34%), mortality (11%), and reoperation (8%) following GRA found in this study are exceedingly poor compared to the rates following primary and revision THA reported in the literature. In a review of 138,399 patients undergoing primary THA, SooHoo et al [11] reported 90-day complication, mortality, and reoperation rates of 3.8%, 0.68%, and 1%, respectively. Mahomed et al [12] reviewed records of 61,568 primary and 13,483 revision THA Medicare patients. Ninety-day mortality, pulmonary embolism (PE), and wound infection rates following primary THA were 1.0%, 0.9%, and 0.2%, respectively; ninety-day mortality, PE, and wound infection rates following revision THA were 2.6%, 0.8%, and 0.95%, respectively. A high prevalence of MRSA-infected hips was found within this cohort; however, most patients experienced similarly poor outcomes
Likelihood of No Reoperation
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Table 3 Effects of Gender, Preoperative Dx, Antibiotics, Anticoagulation, and CCI on Death or Reoperation.
p = 0.11
HR (95% CI)
All Mechanical failure PJI
A
-10
0
10
20
30
40
Months Since Girdlestone Resection Arthroplasty
Gender Male Female Age PreOperative Diagnosis Dislocation or Aseptic Loosening Periprosthetic joint infection Antibiotic No Chronic PreOp Use Chronic Use Anticoagulation No Chronic PreOp Use Chronic Use Charlson Comorbidity Index
P Value 0.01
1.00 (reference) 0.35 (0.16, 0.79) 0.98 (0.94, 1.02)
0.22 0.44
1.00 (reference) 1.36 (0.63, 3.05) 0.07 1.00 (reference) 2.12 (0.94, 4.75) 0.14 1.00 (reference) 0.52 (0.20, 1.23) 1.26 (1.01, 1.69)
0.04
Survival Rate
p = 0.40
All Mechanical failure PJI
B 0
50
100
Likelihood of Remaining Event Free
Months Since Girdlestone Resection Arthroplasty
p = 0.44
All Mechanical failure PJI
C 0
50
100
Months Since Girdlestone Resection Arthroplasty Fig. 1. Kaplan–Meier (KM) curves illustrating likelihood of remaining event-free over time following Girdlestone resection arthroplasty (GRA): (A) likelihood of no additional surgery, (B) survival rate, (C) likelihood living and no additional surgery. Kaplan–Meier curves shown plotting outcomes of all GRA patients, as well as GRA patients undergoing surgery due to mechanical failure and periprosthetic joint infection (PJI). P values reflect the probability that mechanical failure and PJI KM curves are equal.
following surgery despite preoperative diagnoses. Overall, we believe the high incidence of complications, reoperation, and death following GRA is largely a function of the advanced age and high burden of disease characteristic of this cohort. Although age was not found to be significantly associated with death or reoperation in these analyses, this effect may be confounded by other variables such as comorbid disease. Unfortunately, the limited size of this cohort precludes multivariable analysis examining the effect of many predictors at once. However, age and preexisting conditions are known predictors of morbidity and mortality following hip surgery [13–16]. The rate of overall complications following hip arthroplasty in elderly patients has been reported between 55% and 75% [10,14,17]. Parvizi et al [13] found that patients experiencing a major systemic complication after THA were on average eight years
older than patients with no complications (P = 0.0001). Koenig et al [18] found that after adjusting for age, every 1-point increase in CCI was associated with a 22% (95% CI, 3%–45%) increase in the odds of developing a major adverse event following revision THA. On average, GRA patients from this cohort were about 5–10 years older than typical primary THA patients [19–21]. Bozic et al [21], in a study of 112,095 THA patients nationwide, reported an average of 65 years of age. Additionally, on average, GRA patients had a much higher preoperative burden of disease (CCI = 6.6) than what is reported in the literature for typical THA patients [22–24]. For example, Johnsen et al [22] reported a CCI of 0 in 73% of Danish registry THA patients (n = 36, 984); 93% had a CCI below 3. Fortin et al [23] reported a median CCI of 0 in 222 total joint arthroplasty patients. The patients included in this study required surgery for control of life-threatening infection or intractable pain not attenuated by other treatment options. Due to advanced ages and high burden of disease found in these patients, surgical intervention was minimized; hence GRA was performed versus revision THA. All but one patient undergoing GRA due to mechanical failure is now deceased. The contributory factors lending to such poor postoperative outcomes remain unclear but are likely due to a combination of stress from surgery, comorbid disease, and physical debilitation. The gravity of these findings mandates a very thoughtful discussion preoperatively weighing the risks versus benefits of surgery. Univariate analyses also found gender to be an important predictor of postoperative outcomes and survival following hip surgery, as was comorbidity. Similarly, Endo et al [25] found the 1-year mortality rate following hip fracture 76% higher in men than women (P b 0.01). Penrod et al [26] found the 6 month mortality following hip fracture over twice as high in men than women (P b 0.0001). The associations between gender and comorbidity with postoperative outcomes and survival following GRA, however, have not previously been described or quantified. The new findings from this study may allow risk stratification based upon gender and preexisting conditions. Although not statistically significant, there was a tendency for patients receiving chronic preoperative antibiotics to experience death or reoperation at rates higher than those patients not receiving treatment. The absence of acute renal failure or hepatic decline postoperatively suggests this potential relationship is not due to antibiotic toxicity. It is possible chronic antibiotic use is a surrogate marker of very high infection burden preoperatively, thereby suggesting intuitive inference that patients with severe joint infections are at increased risk for death or reoperation following GRA. Limitations of this study stem from its small size, retrospective nature, and complete dependence upon medical records. Due to the small size, multivariate and additional univariate analyses were not conducted to minimize the likelihood of type I error. Preexisting disease and complication rates may be falsely reported due to inaccuracies in
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medical records. This effect is at least partially mitigated by overlapping data collection of multiple authors. Conversely, the attention to each medical record may result in elevated comorbidity and complication rates compared to those from studies using solely discharge data. Conclusion The complication, mortality, and reoperation rates following GRA in this study are among the highest reported to ensue after elective hip surgery. Additionally, the data show that these risks are especially high among men, patients with multiple pre-existing conditions, and potentially patients receiving antibiotics for six or more weeks before surgery. Girdlestone resection arthroplasty is an established option setting of failed THA. However, due to the frequency and gravity of subsequent complications, including death, GRA should not be pursued lightly. References 1. Healthcare Cost and Utilization Project (HCUP). HCUP facts and figures: statistics on hospital-based care in the United States. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011[Available at: http://www.ncbi.nlm.nih.gov/books/ NBK91984/. Accessed July 30, 2013]. 2. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89(4):780. 3. Bozic KJ, Ong K, Lau E, et al. Risk of complication and revision total hip arthroplasty among Medicare patients with different bearing surfaces. Clin Orthop 2010;468(9):2357. 4. Sharma H, Leeuw JD, Rowley DI. Girdlestone resection arthroplasty following failed surgical procedures. Int Orthop 2005;29(2):92. 5. Bittar ES, Petty W. Girdlestone arthroplasty for infected total hip arthroplasty. Clin Orthop 1982;170:83. 6. Grauer JD, Amstutz HC, O’Carroll PF, et al. Resection arthroplasty of the hip. J Bone Joint Surg Am 1989;71(5):669. 7. Brand RA. Acute pyogenic arthritis of the hip: an operation giving free access and effective drainage. Clin Orthop 2008;466(2):258. 8. Castellanos J, Flores X, Llusà M, et al. The Girdlestone pseudarthrosis in the treatment of infected hip replacements. Int Orthop 1998;22(3):178. 9. Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005;43(11):1130.
10. Higuera CA, Elsharkawy K, Klika AK, et al. 2010 Mid-America Orthopaedic Association Physician in Training Award: predictors of early adverse outcomes after knee and hip arthroplasty in geriatric patients. Clin Orthop 2011;469(5):1391. 11. Soohoo NF, Farng E, Lieberman JR, et al. Factors that predict short-term complication rates after total hip arthroplasty. Clin Orthop 2010;468(9):2363. 12. Mahomed NN, Barrett JA, Katz JN, et al. Rates and outcomes of primary and revision total hip replacement in the United States medicare population. J Bone Joint Surg Am 2003;85-A(1):27. 13. Parvizi J, Mui A, Purtill JJ, et al. Total joint arthroplasty: when do fatal or near-fatal complications occur? J Bone Joint Surg Am 2007;89(1):27. 14. Alfonso DT, Howell RD, Strauss EJ, et al. Total hip and knee arthroplasty in nonagenarians. J Arthroplasty 2007;22(6):807. 15. Kinkel S, Kaefer W, Reissig W, et al. Revision total hip arthroplasty: the influence of gender and age on the perioperative complication rate. Acta Chir Orthop Traumatol Cech 2002;70(5):269. 16. Whittle J, Steinberg EP, Anderson GF, et al. Mortality after elective total hip arthroplasty in elderly Americans. Age, gender, and indication for surgery predict survival. Clin Orthop 1993(295):119. 17. Boettcher WG. Total hip arthroplasties in the elderly. Morbidity, mortality, and cost effectiveness. Clin Orthop 1992(274):30. 18. Koenig K, Huddleston JI, Huddleston H, et al. Advanced age and comorbidity increase the risk for adverse events after revision total hip arthroplasty. J Arthroplasty 2012; 27(7):1402. 19. Bozic KJ, Katz P, Cisternas M, et al. Hospital resource utilization for primary and revision total hip arthroplasty. J Bone Joint Surg Am 2005;87(3):570. 20. Jassim SS, Vanhegan IS, Haddad FS. The epidemiology of total hip arthroplasty in England and Wales. Semin Arthroplasty 2012;23(4):197. 21. Bozic KJ, Kurtz S, Lau E, et al. The epidemiology of bearing surface usage in total hip arthroplasty in the United States. J Bone Joint Surg Am 2009;91(7):1614. 22. Johnsen SP, Sørensen HT, Lucht U, et al. Patient-related predictors of implant failure after primary total hip replacement in the initial, short- and long-terms. A nationwide Danish follow-up study including 36 984 patients. J Bone Joint Surg (Br) 2006;88B(10):1303. 23. Fortin PR, Clarke AE, Joseph L, et al. Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis Rheum 1999;42(8):1722. 24. Kreder HJ, Grosso P, Williams JI, et al. Provider volume and other predictors of outcome after total knee arthroplasty: a population study in Ontario. Can J Surg 2003;46(1):15. 25. Endo Y, Aharonoff GB, Zuckerman JD, et al. Gender differences in patients with hip fracture: a greater risk of morbidity and mortality in men. J Orthop Trauma 2005;19(1):29. 26. Penrod JD, Litke A, Hawkes WG, et al. The association of race, gender, and comorbidity with mortality and function after hip fracture. J Gerontol A Biol Sci Med Sci 2008; 63(8):867.
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Complication, Survival, and Reoperation Rates Following Girdlestone Resection Arthroplasty Tennison L. Malcolm, MD, Bishoy V. Gad, MD, Karim A. Elsharkawy, MD, Carlos A. Higuera, MD Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
a r t i c l e
i n f o
Article history: Received 4 November 2014 Accepted 6 February 2015 Keywords: Girdlestone resection arthroplasty comorbidity complications mortality
a b s t r a c t Failed hip arthroplasty patients unsuitable for reimplantation may be offered Girdlestone resection arthroplasty (GRA). The purpose of this study was to detail complication and failure rates following GRA. Our results show that 66% (25/38), 34% (13/38), and 76% (29/38) of GRA patients experienced minor, major, and overall complications, respectively. Within 90 days of surgery, three patients required additional surgery and four died. Reoperation or death occurred an average of 26.3 (SD = 3.5) and 55.6 (SD = 76) months after surgery, respectively. Male gender and increasing comorbidity significantly predicted higher reoperation and mortality rates, P = 0.01 and P = 0.04, respectively. Complication and mortality rates following GRA are among the highest reported succeeding elective hip surgery for non-traumatic etiology. © 2015 Elsevier Inc. All rights reserved.
Total hip arthroplasty (THA) is among the fastest growing procedures in the United States [1]. Despite advancements in bearing surface, fixation, and perioperative care, the number of failed implants continues to rise every year [2,3]. Loose or infected hardware serves as a nidus for persistent pain or infection and in most cases should be removed promptly. Some THA patients (both primary and revision) require prosthesis explant but are not suitable for hardware reimplantation due to poor bone stock, high likelihood of infection, or comorbid disease prohibiting such taxing surgery [4–6]. These patients may be offered Girdlestone resection arthroplasty (GRA) as a last resort for control of pain and infection and partial preservation of limb function. Girdlestone resection arthroplasty was popularized by Gathorne Robert Girdlestone in the early 1900’s as a salvage procedure for septic arthritis [7]. With this technique, the femoral head is resected leaving only a crude articulation between the femur and acetabulum. The use of GRA has been extended to total hip arthroplasty (THA) failure, in which all implanted hip components are removed leaving the same pseudoarthrosis. This very basic juxtaposition of the femur in what’s left of the acetabulum is, in most cases, poorly functional, thus only used when all other viable options are limited to non-operative intervention and hip disarticulation.
One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.02.011. Reprint requests: Carlos Higuera, MD, Cleveland Clinic, A41, 9500 Euclid Avenue, Cleveland, OH 44195. http://dx.doi.org/10.1016/j.arth.2015.02.011 0883-5403/© 2015 Elsevier Inc. All rights reserved.
With reports ranging from 7% to 62%, the mortality rates following GRA are very high [4,8]. Other prognostic data describing this procedure are much less clear. The aims of the current study were to assess comorbid disease burden in this patient population, complication rate, and time until death or reoperation after GRA.
Methods After approval from our Institutional Review Board, a query of the electronic medical records was performed to identify all revision hip arthroplasties conducted between 2000 and 2010. The medical records of all patients undergoing GRA (n = 38 hips) were selected and retrospectively reviewed. Patients undergoing hip disarticulation and GRA secondary to tumor metastasis were excluded as it was felt that these patients may represent a different surgical cohort with respect to expectations in hip function. All demographic (i.e., age and gender), clinical (i.e., side of surgery, preoperative diagnosis, antibiotic use N 6 weeks prior to surgery, anticoagulation use N 6 weeks prior to surgery, comorbidities, and complications) and survival (i.e., death, reoperation, death or reoperation [DOR]) data were obtained via retrospective medical record review. Preoperative diagnosis and DOR were defined as binary variables (preoperative diagnosis: 0 = chronic dislocation or aseptic loosening, 1 = periprosthetic joint infection; DOR: 0 = presently alive, no hip surgery since initial GRA, 1 = death or reoperation since GRA). Comorbidity data at and prior to GRA were used to calculate Charlson Comorbidity Indices (CCI) as previously described by Quan et al [9]. Minor systemic, major systemic, minor local, and major local complications were recorded as described by Higuera et al [10] up to three months postoperatively.
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Outcomes were compared between patients undergoing GRA due to mechanical failure and periprosthetic joint infection (PJI). Unadjusted differences between groups were evaluated using Student t-tests and likelihood ratio chi-square tests, as appropriate. The Kaplan–Meier survival method was used to estimate the mean time until death, reoperation, and DOR. Cox-proportional hazards models were used to estimate hazard ratios; univariate Cox regression was performed modeling DOR as functions of gender, preoperative diagnosis, chronic antibiotic use prior to surgery, chronic anticoagulation prior to surgery, and CCI. All analyses were completed using JMP v7.0 (SAS Institute Inc., Cary, NC). Results Between 2000 and 2010, 36 patients (n = 38 hips) underwent GRA due to mechanical failure (i.e., chronic dislocation [n = 8], aseptic loosening [n = 4]) and PJI (n = 26). Among PJI patients, methicillinresistant Staphylococcus aureus was the most common offending organism (n = 8) followed by methicillin-sensitive S. aureus (n = 6), Proteus mirabilis (n = 5), and Pseudomonas aeruginosa (n = 5). Mechanical failure and PJI patients were statistically similar (i.e., P N 0.10) in most characteristics (i.e., age, follow-up time, CCI, or operative side). Overall, GRA patients had a mean age of 70.5 years (SD = 12.3), were last seen postoperatively at a median of 10.8 months (range = 7 days–11 years), were mostly women (n = 19; 53%), and had an equal predilection for either hip (left, n = 19; right n = 19). Postoperatively, 53% (n = 20) and 37% (n = 14) experienced a minor systemic or minor local complication, respectively; 21% (n = 8) and 13% (n = 5) experienced a major systemic and major local complication, respectively (Table 1). PJI patients were 2.6 times more likely to experience a minor systemic complication (P = 0.02); the two groups were similarly predisposed toward minor local and major complications. Most GRA patients did not undergo additional hip surgery; however, those that did ranged between 1 and 5 additional procedures; 17% and 42% of mechanical failure and PJI patients, respectively, required reoperation (P = 0.11). Of the 36 study patients, 11(92%) mechanical failure and 12 (46%) PJI patients were deceased at the time of the study (P b 0.01). Frequencies of postoperative complications are listed in Table 2. Following GRA the incidences of minor, major, and overall complication Table 1 GRA Clinical and Survival Characteristics, 2000–2010. Preoperative diagnosis
N (hips) Median Follow Up Months (SD) Operative Hip, n (%) Left Right Complications, n (%) Minor Systemic Major Systemic Minor Local Major Local Any Complication Reoperation, n (%) n=0 n=1 n=2 n=3 n=4 n=5 Death, n (%) Living Deceased Death or Reoperation, n (%) Alive, No Reoperation Deceased or Reoperation
Mechanical Failurea
PJI
12 13.5 (28.8)
26 8.9 (37.6)
5 (42%) 7 (58%)
14 (54%) 12 (46%)
3 (25%) 2 (17%) 4 (33%) 2 (17%) 7 (58%)
17 (65%) 6 (23%) 10 (38%) 3 (12%) 22 (85%)
10 (83%) 1 (8%) 1 (8%) 0 (0%) 0 (0%) 0 (0%)
15 (58%) 4 (15%) 0 (0%) 4 (15%) 2 (8%) 1 (4%)
1 (8%) 11 (92%)
14 (54%) 12 (46%)
1 (8%) 11 (92%)
8 (31%) 18 (69%)
P Value 0.51 0.48
Table 2 Postoperative Complication Frequency. Complications Minor Systemic Anemia Deep Vein Thrombosis Altered Mental Status Pneumonia Postoperative Depression C. diff Enterocolitis Other Major Systemic Tachyarrthmia Congestive Heart Failure Hypotensive Crisis Acute Renal Failure Death Pulmonary Edema Gastrointestinal Bleed Ascending Cholangitis Minor Local Cellulitis/superficial infection Joint stiffness Hematoma Blisters Persistent Wound Drainage Uncontrollable Pain Major Local Joint Infection Peripheral Nerve Injury
Number
Rate
16 1 2 2 2 1 8
41% 3% 5% 5% 5% 3% 21%
2 1 3 2 4 4 1 1
5% 3% 8% 5% 10% 10% 3% 3%
2 1 2 2 8 6
5% 3% 5% 5% 21% 15%
6 1
15% 3%
were 66% (n = 25), 34% (n = 13), and 76% (n = 29), respectively. Postoperative anemia was found in 42% (n = 16) of GRA patients. Within the first 90 days of GRA, four patients had persistent evidence of joint infection; three of four underwent reoperation within 90 days. Four patients died within 90 days of GRA, two of whom underwent additional irrigation and debridement for infection. Fig. 1 shows the Kaplan–Meier survival curves of time until reoperation and death. On average, GRA patients experienced reoperation, death, or DOR 26.3 (SD = 3.5), 55.6 (SD = 76), and 34.2 (SD = 6.7) months after surgery, respectively. There was tendency to require additional surgery at a higher rate among PJI patients compared to mechanical failure GRA patients; however, this did not reach significance (P = 0.08). The likelihood of remaining event free (i.e., death or reoperation) was similar between PJI and mechanical failure patients. Univariate analyses of DOR hazard are shown in Table 3. Men experienced death or reoperation at a rate 2.84 times higher than women (P = 0.01). For every 1-point increase in CCI, short-term risk of death or reoperation increased by a factor of 1.26 (P = 0.04). Discussion
0.02 0.65 0.76 0.66 0.08 0.11
b 0.01
0.11
PJI, Periprosthetic joint infection. a Mechanical failure due to chronic dislocation (n = 8) and mechanical failure (n = 4).
Failed total hip arthroplasty in medically precarious patients is infrequently discussed in the literature but will likely continue to appreciate. Despite limited viable options, candidates for GRA and their surgeons should understand the risks and outcomes associated with this procedure. The 90-day rates of major complication (34%), mortality (11%), and reoperation (8%) following GRA found in this study are exceedingly poor compared to the rates following primary and revision THA reported in the literature. In a review of 138,399 patients undergoing primary THA, SooHoo et al [11] reported 90-day complication, mortality, and reoperation rates of 3.8%, 0.68%, and 1%, respectively. Mahomed et al [12] reviewed records of 61,568 primary and 13,483 revision THA Medicare patients. Ninety-day mortality, pulmonary embolism (PE), and wound infection rates following primary THA were 1.0%, 0.9%, and 0.2%, respectively; ninety-day mortality, PE, and wound infection rates following revision THA were 2.6%, 0.8%, and 0.95%, respectively. A high prevalence of MRSA-infected hips was found within this cohort; however, most patients experienced similarly poor outcomes
Likelihood of No Reoperation
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Table 3 Effects of Gender, Preoperative Dx, Antibiotics, Anticoagulation, and CCI on Death or Reoperation.
p = 0.11
HR (95% CI)
All Mechanical failure PJI
A
-10
0
10
20
30
40
Months Since Girdlestone Resection Arthroplasty
Gender Male Female Age PreOperative Diagnosis Dislocation or Aseptic Loosening Periprosthetic joint infection Antibiotic No Chronic PreOp Use Chronic Use Anticoagulation No Chronic PreOp Use Chronic Use Charlson Comorbidity Index
P Value 0.01
1.00 (reference) 0.35 (0.16, 0.79) 0.98 (0.94, 1.02)
0.22 0.44
1.00 (reference) 1.36 (0.63, 3.05) 0.07 1.00 (reference) 2.12 (0.94, 4.75) 0.14 1.00 (reference) 0.52 (0.20, 1.23) 1.26 (1.01, 1.69)
0.04
Survival Rate
p = 0.40
All Mechanical failure PJI
B 0
50
100
Likelihood of Remaining Event Free
Months Since Girdlestone Resection Arthroplasty
p = 0.44
All Mechanical failure PJI
C 0
50
100
Months Since Girdlestone Resection Arthroplasty Fig. 1. Kaplan–Meier (KM) curves illustrating likelihood of remaining event-free over time following Girdlestone resection arthroplasty (GRA): (A) likelihood of no additional surgery, (B) survival rate, (C) likelihood living and no additional surgery. Kaplan–Meier curves shown plotting outcomes of all GRA patients, as well as GRA patients undergoing surgery due to mechanical failure and periprosthetic joint infection (PJI). P values reflect the probability that mechanical failure and PJI KM curves are equal.
following surgery despite preoperative diagnoses. Overall, we believe the high incidence of complications, reoperation, and death following GRA is largely a function of the advanced age and high burden of disease characteristic of this cohort. Although age was not found to be significantly associated with death or reoperation in these analyses, this effect may be confounded by other variables such as comorbid disease. Unfortunately, the limited size of this cohort precludes multivariable analysis examining the effect of many predictors at once. However, age and preexisting conditions are known predictors of morbidity and mortality following hip surgery [13–16]. The rate of overall complications following hip arthroplasty in elderly patients has been reported between 55% and 75% [10,14,17]. Parvizi et al [13] found that patients experiencing a major systemic complication after THA were on average eight years
older than patients with no complications (P = 0.0001). Koenig et al [18] found that after adjusting for age, every 1-point increase in CCI was associated with a 22% (95% CI, 3%–45%) increase in the odds of developing a major adverse event following revision THA. On average, GRA patients from this cohort were about 5–10 years older than typical primary THA patients [19–21]. Bozic et al [21], in a study of 112,095 THA patients nationwide, reported an average of 65 years of age. Additionally, on average, GRA patients had a much higher preoperative burden of disease (CCI = 6.6) than what is reported in the literature for typical THA patients [22–24]. For example, Johnsen et al [22] reported a CCI of 0 in 73% of Danish registry THA patients (n = 36, 984); 93% had a CCI below 3. Fortin et al [23] reported a median CCI of 0 in 222 total joint arthroplasty patients. The patients included in this study required surgery for control of life-threatening infection or intractable pain not attenuated by other treatment options. Due to advanced ages and high burden of disease found in these patients, surgical intervention was minimized; hence GRA was performed versus revision THA. All but one patient undergoing GRA due to mechanical failure is now deceased. The contributory factors lending to such poor postoperative outcomes remain unclear but are likely due to a combination of stress from surgery, comorbid disease, and physical debilitation. The gravity of these findings mandates a very thoughtful discussion preoperatively weighing the risks versus benefits of surgery. Univariate analyses also found gender to be an important predictor of postoperative outcomes and survival following hip surgery, as was comorbidity. Similarly, Endo et al [25] found the 1-year mortality rate following hip fracture 76% higher in men than women (P b 0.01). Penrod et al [26] found the 6 month mortality following hip fracture over twice as high in men than women (P b 0.0001). The associations between gender and comorbidity with postoperative outcomes and survival following GRA, however, have not previously been described or quantified. The new findings from this study may allow risk stratification based upon gender and preexisting conditions. Although not statistically significant, there was a tendency for patients receiving chronic preoperative antibiotics to experience death or reoperation at rates higher than those patients not receiving treatment. The absence of acute renal failure or hepatic decline postoperatively suggests this potential relationship is not due to antibiotic toxicity. It is possible chronic antibiotic use is a surrogate marker of very high infection burden preoperatively, thereby suggesting intuitive inference that patients with severe joint infections are at increased risk for death or reoperation following GRA. Limitations of this study stem from its small size, retrospective nature, and complete dependence upon medical records. Due to the small size, multivariate and additional univariate analyses were not conducted to minimize the likelihood of type I error. Preexisting disease and complication rates may be falsely reported due to inaccuracies in
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medical records. This effect is at least partially mitigated by overlapping data collection of multiple authors. Conversely, the attention to each medical record may result in elevated comorbidity and complication rates compared to those from studies using solely discharge data. Conclusion The complication, mortality, and reoperation rates following GRA in this study are among the highest reported to ensue after elective hip surgery. Additionally, the data show that these risks are especially high among men, patients with multiple pre-existing conditions, and potentially patients receiving antibiotics for six or more weeks before surgery. Girdlestone resection arthroplasty is an established option setting of failed THA. However, due to the frequency and gravity of subsequent complications, including death, GRA should not be pursued lightly. References 1. Healthcare Cost and Utilization Project (HCUP). HCUP facts and figures: statistics on hospital-based care in the United States. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011[Available at: http://www.ncbi.nlm.nih.gov/books/ NBK91984/. Accessed July 30, 2013]. 2. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89(4):780. 3. Bozic KJ, Ong K, Lau E, et al. Risk of complication and revision total hip arthroplasty among Medicare patients with different bearing surfaces. Clin Orthop 2010;468(9):2357. 4. Sharma H, Leeuw JD, Rowley DI. Girdlestone resection arthroplasty following failed surgical procedures. Int Orthop 2005;29(2):92. 5. Bittar ES, Petty W. Girdlestone arthroplasty for infected total hip arthroplasty. Clin Orthop 1982;170:83. 6. Grauer JD, Amstutz HC, O’Carroll PF, et al. Resection arthroplasty of the hip. J Bone Joint Surg Am 1989;71(5):669. 7. Brand RA. Acute pyogenic arthritis of the hip: an operation giving free access and effective drainage. Clin Orthop 2008;466(2):258. 8. Castellanos J, Flores X, Llusà M, et al. The Girdlestone pseudarthrosis in the treatment of infected hip replacements. Int Orthop 1998;22(3):178. 9. Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005;43(11):1130.
10. Higuera CA, Elsharkawy K, Klika AK, et al. 2010 Mid-America Orthopaedic Association Physician in Training Award: predictors of early adverse outcomes after knee and hip arthroplasty in geriatric patients. Clin Orthop 2011;469(5):1391. 11. Soohoo NF, Farng E, Lieberman JR, et al. Factors that predict short-term complication rates after total hip arthroplasty. Clin Orthop 2010;468(9):2363. 12. Mahomed NN, Barrett JA, Katz JN, et al. Rates and outcomes of primary and revision total hip replacement in the United States medicare population. J Bone Joint Surg Am 2003;85-A(1):27. 13. Parvizi J, Mui A, Purtill JJ, et al. Total joint arthroplasty: when do fatal or near-fatal complications occur? J Bone Joint Surg Am 2007;89(1):27. 14. Alfonso DT, Howell RD, Strauss EJ, et al. Total hip and knee arthroplasty in nonagenarians. J Arthroplasty 2007;22(6):807. 15. Kinkel S, Kaefer W, Reissig W, et al. Revision total hip arthroplasty: the influence of gender and age on the perioperative complication rate. Acta Chir Orthop Traumatol Cech 2002;70(5):269. 16. Whittle J, Steinberg EP, Anderson GF, et al. Mortality after elective total hip arthroplasty in elderly Americans. Age, gender, and indication for surgery predict survival. Clin Orthop 1993(295):119. 17. Boettcher WG. Total hip arthroplasties in the elderly. Morbidity, mortality, and cost effectiveness. Clin Orthop 1992(274):30. 18. Koenig K, Huddleston JI, Huddleston H, et al. Advanced age and comorbidity increase the risk for adverse events after revision total hip arthroplasty. J Arthroplasty 2012; 27(7):1402. 19. Bozic KJ, Katz P, Cisternas M, et al. Hospital resource utilization for primary and revision total hip arthroplasty. J Bone Joint Surg Am 2005;87(3):570. 20. Jassim SS, Vanhegan IS, Haddad FS. The epidemiology of total hip arthroplasty in England and Wales. Semin Arthroplasty 2012;23(4):197. 21. Bozic KJ, Kurtz S, Lau E, et al. The epidemiology of bearing surface usage in total hip arthroplasty in the United States. J Bone Joint Surg Am 2009;91(7):1614. 22. Johnsen SP, Sørensen HT, Lucht U, et al. Patient-related predictors of implant failure after primary total hip replacement in the initial, short- and long-terms. A nationwide Danish follow-up study including 36 984 patients. J Bone Joint Surg (Br) 2006;88B(10):1303. 23. Fortin PR, Clarke AE, Joseph L, et al. Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis Rheum 1999;42(8):1722. 24. Kreder HJ, Grosso P, Williams JI, et al. Provider volume and other predictors of outcome after total knee arthroplasty: a population study in Ontario. Can J Surg 2003;46(1):15. 25. Endo Y, Aharonoff GB, Zuckerman JD, et al. Gender differences in patients with hip fracture: a greater risk of morbidity and mortality in men. J Orthop Trauma 2005;19(1):29. 26. Penrod JD, Litke A, Hawkes WG, et al. The association of race, gender, and comorbidity with mortality and function after hip fracture. J Gerontol A Biol Sci Med Sci 2008; 63(8):867.
