Geriatric Distal Femur Fractures Treated with Arthroplasty Are Associated with Lower Mortality but Greater Costs Compared with Open Reduction and Internal Fixation at 30 Days

Chukwuweike U. Gwam; Kristen Confroy Harmody; T. David Luo; Samuel Rosas; Johannes Plates

doi:10.1055/a-2232-7826

The Journal of Knee Surgery, Inhaltsverzeichnis

J Knee Surg 2024; 37(07): 538-544
DOI: 10.1055/a-2232-7826

Original Article

Geriatric Distal Femur Fractures Treated with Arthroplasty Are Associated with Lower Mortality but Greater Costs Compared with Open Reduction and Internal Fixation at 30 Days

Chukwuweike U. Gwam

¹Department of Orthopaedics, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina

,

Kristen Confroy Harmody

¹Department of Orthopaedics, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina

,

T. David Luo

¹Department of Orthopaedics, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina

²Orthopaedics Northeast, Fort Wayne, Indiana

,

Samuel Rosas

¹Department of Orthopaedics, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina

,

Johannes Plates

³Department of Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

› Institutsangaben

Abstract

Distal femur fractures (DFFs) are common injuries with significant morbidity. Surgical options include open reduction and internal fixation (ORIF) with plates and/or intramedullary devices or a distal femur endoprosthesis (distal femur replacement [DFR]). A paucity of studies exist that compare the two modalities. The present study utilized a 1:2 propensity score match to compare 30-day outcomes of geriatric patients with DFFs who underwent an ORIF or DFR. The National Surgical Quality Improvement Program data from 2008 to 2019 were utilized to identify all patients who sustained a DFF and underwent either ORIF or DFR. This yielded 3,197 patients who underwent an ORIF versus 121 patients who underwent a DFR. A final sample of 363 patients (242 patients with ORIF vs. 121 with DFR) was obtained after a 1:2 propensity score match. Costs were obtained from the National Inpatient Sample database using multiple regression analysis and validated with a 7:3 train-test algorithm. Independent samples t-tests and chi-square analysis were conducted to assess cost and outcome differences, respectively. Patients who received a DFR had higher transfusion rates than ORIF (p = 0.021) and higher mean inpatient hospital costs (p = 0.001). Subgroup analysis for patients 80 years of age or older revealed higher 30-day unplanned readmission (0 vs. 18.2%; p < 0.001) and 30-day mortality (0 vs. 18.2%; p < 0.001) rates for patients undergoing ORIF compared with DFR. The total number of DFR cases needed to prevent one ORIF-related 30-day mortality for DFR for patients 80 years of age was 6 (95% confidence interval: 3.02–19.9). The mean hospital costs associated with preventing one case of death within 30 days from operation by undergoing DFR compared with ORIF was $176,021.39. Our results demonstrate higher rates of transfusion and increased inpatient costs among the DFR cohort compared with ORIF. However, we demonstrate lower rates of mortality for patients 80 years and older who underwent DFR versus ORIF. Future studies randomized controlled trials are necessary to validate the results of this study.

Keywords

trauma - knee - DFR - ORIF

Volltext

Referenzen

References
1 Elsoe R, Ceccotti AA, Larsen P. Population-based epidemiology and incidence of distal femur fractures. Int Orthop 2018; 42 (01) 191-196
2 Hake ME, Davis ME, Perdue AM, Goulet JA. Modern implant options for the treatment of distal femur fractures. J Am Acad Orthop Surg 2019; 27 (19) e867-e875
3 Arneson TJ, Melton III LJ, Lewallen DG, O'Fallon WM. Epidemiology of diaphyseal and distal femoral fractures in Rochester, Minnesota, 1965-1984. Clin Orthop Relat Res 1988; (234) 188-194
4 Streubel PN, Ricci WM, Wong A, Gardner MJ. Mortality after distal femur fractures in elderly patients. Clin Orthop Relat Res 2011; 469 (04) 1188-1196
5 Jennison T, Divekar M. Geriatric distal femoral fractures: a retrospective study of 30 day mortality. Injury 2019; 50 (02) 444-447
6 Salazar BP, Babian AR, DeBaun MR. et al. Distal femur replacement versus surgical fixation for the treatment of geriatric distal femur fractures: a systematic review. J Orthop Trauma 2021; 35 (01) 2-9
7 Hart GP, Kneisl JS, Springer BD, Patt JC, Karunakar MA. Open reduction vs distal femoral replacement arthroplasty for comminuted distal femur fractures in the patients 70 years and older. J Arthroplasty 2017; 32 (01) 202-206
8 Cyr K, Greene H, Buckley R. C3 geriatric distal femoral fracture - ORIF or replace with a distal femoral replacement (DFR). Injury 2021; 52 (06) 1260-1262
9 Windhager R, Schreiner M, Staats K, Apprich S. Megaprostheses in the treatment of periprosthetic fractures of the knee joint: indication, technique, results and review of literature. Int Orthop 2016; 40 (05) 935-943
10 Saidi K, Ben-Lulu O, Tsuji M, Safir O, Gross AE, Backstein D. Supracondylar periprosthetic fractures of the knee in the elderly patients: a comparison of treatment using allograft-implant composites, standard revision components, distal femoral replacement prosthesis. J Arthroplasty 2014; 29 (01) 110-114
11 Chen AF, Choi LE, Colman MW. et al. Primary versus secondary distal femoral arthroplasty for treatment of total knee arthroplasty periprosthetic femur fractures. J Arthroplasty 2013; 28 (09) 1580-1584
12 Pour AE, Parvizi J, Slenker N, Purtill JJ, Sharkey PF. Rotating hinged total knee replacement: use with caution. J Bone Joint Surg Am 2007; 89 (08) 1735-1741
13 Appleton P, Moran M, Houshian S, Robinson CM. Distal femoral fractures treated by hinged total knee replacement in elderly patients. J Bone Joint Surg Br 2006; 88 (08) 1065-1070
14 Pearse EO, Klass B, Bendall SP, Railton GT. Stanmore total knee replacement versus internal fixation for supracondylar fractures of the distal femur in elderly patients. Injury 2005; 36 (01) 163-168
15 Bettin CC, Weinlein JC, Toy PC, Heck RK. Distal femoral replacement for acute distal femoral fractures in elderly patients. J Orthop Trauma 2016; 30 (09) 503-509
16 Molina CS, Thakore RV, Blumer A. et al Use of the national surgical quality improvement program in orthopaedic surgery. Clin Orthop Relat Res 2015; 473: 1574-1581
17 Osman F, Saleh F, Jackson TD, Corrigan MA, Cil T. Increased postoperative complications in bilateral mastectomy patients compared to unilateral mastectomy: an analysis of the NSQIP database. Ann Surg Oncol 2013; 20 (10) 3212-3217
18 Khuri SF. The NSQIP: a new frontier in surgery. Surgery 2005; 138 (05) 837-843
19 Gwam C, Rosas S, Sullivan R, Luo TD, Emory CL, Plate JF. The who, what, and where of primary TKAs: an analysis of HCUP data from 2009 to 2015. J Knee Surg 2020; 33 (04) 378-386
20 CPI Inflation Calculator. Accessed July 31, 2018, at: https://data.bls.gov/cgi-bin/cpicalc.pl?cost1=10.00&year1=201501&year2=201801
21 Ottesen TD, Zogg CK, Haynes MS, Malpani R, Bellamkonda KS, Grauer JN. Dialysis patients undergoing total knee arthroplasty have significantly increased odds of perioperative adverse events independent of demographic and comorbidity factors. J Arthroplasty 2018; 33 (09) 2827-2834
22 Li P, Stuart EA, Allison DB. Multiple imputation: a flexible tool for handling missing data. JAMA 2015; 314 (18) 1966-1967
23 Computing number needed to treat (NNT). Accessed March 28, 2021, at: https://www.graphpad.com/quickcalcs/NNT1.cfm
24 Weeks DL, Noteboom JT. Using the number needed to treat in clinical practice. Arch Phys Med Rehabil 2004; 85 (10) 1729-1731
25 Darrith B, Bohl DD, Karadsheh MS, Sporer SM, Berger RA, Levine BR. Periprosthetic fractures of the distal femur: is open reduction and internal fixation or distal femoral replacement superior?. J Arthroplasty 2020; 35 (05) 1402-1406
26 Smith JRA, Halliday R, Aquilina AL. et al; Collaborative - Orthopaedic Trauma Society (OTS). Distal femoral fractures: the need to review the standard of care. Injury 2015; 46 (06) 1084-1088
27 Myers P, Laboe P, Johnson KJ. et al. Patient mortality in geriatric distal femur fractures. J Orthop Trauma 2018; 32 (03) 111-115
28 Heiden JJ, Goodin SR, Mormino MA. et al. Early ambulation after hip fracture surgery is associated with decreased 30-day mortality. J Am Acad Orthop Surg 2021; 29 (05) e238-e242
29 Childers CP, Maggard-Gibbons M. Understanding costs of care in the operating room. JAMA Surg 2018; 153 (04) e176233
30 Nathan H, Dimick JB. Medicare's shift to mandatory alternative payment models: why surgeons should care. JAMA Surg 2017; 152 (02) 125-126
31 Kregor PJ, Stannard JA, Zlowodzki M, Cole PA. Treatment of distal femur fractures using the less invasive stabilization system: surgical experience and early clinical results in 103 fractures. J Orthop Trauma 2004; 18 (08) 509-520
32 Thomson AB, Driver R, Kregor PJ, Obremskey WT. Long-term functional outcomes after intra-articular distal femur fractures: ORIF versus retrograde intramedullary nailing. Orthopedics 2008; 31 (08) 748-750
33 Rodriguez EK, Boulton C, Weaver MJ. et al. Predictive factors of distal femoral fracture nonunion after lateral locked plating: a retrospective multicenter case-control study of 283 fractures. Injury 2014; 45 (03) 554-559
34 Caines A, Adamczyk A, Mahaffey R, Pickell M. Open reduction internal fixation versus distal femoral replacement (DFR) for treatment of OTA/AO 33C fractures in the elderly: A review of functional outcomes and cost analysis. J Orthop Trauma 2023; 37 (01) 14-18
35 Brodke DJ, Devana SK, Upfill-Brown A, Lee C. Cost-effectiveness of fixation versus arthroplasty for geriatric distal femur fractures. Injury 2022; 53 (02) 661-668
36 Tandon T, Tadros BJ, Avasthi A, Hill R, Rao M. Management of periprosthetic distal femur fractures using distal femoral arthroplasty and fixation - comparative study of outcomes and costs. J Clin Orthop Trauma 2020; 11 (01) 160-164
37 Ko CY, Hall BL, Hart AJ, Cohen ME, Hoyt DB. The American College of Surgeons National Surgical Quality Improvement Program: achieving better and safer surgery. Jt Comm J Qual Patient Saf 2015; 41 (05) 199-204

Zusatzmaterial

Supplementary Material