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J Am Acad Orthop Surg Glob Res Rev
J Am Acad Orthop Surg Glob Res Rev
JAAOS Glob Res Rev
JAAOS Glob Res Rev
JAAOS Global Research & Reviews
2474-7661
Wolters Kluwer Philadelphia, PA

39269906
JAAOSGlobal-D-24-00005
10.5435/JAAOSGlobal-D-24-00005
00007
3
004
Research Article
Patient Factors Associated With Reimplantation After Girdlestone Resection Arthroplasty for Treatment of Periprosthetic Joint Infections of the Hip
Okewunmi Jeffrey MD *jeffrey.okewunmi@icahn.mssm.edu

https://orcid.org/0009-0005-3383-8138
Yendluri Avanish BS *
Cordero John K. MD john.cordero@mountsinai.org

Zubizarreta Nicole MPH nicole.zubizarreta@mountsinai.org

Chen Darwin MD darwin.chen@mountsinai.org

Moucha Calin S. MD calin.moucha@mountsinai.org

Poeran Jashvant MD, PhD jashvant.poeran@mountsinai.org

Hayden Brett L. MD Brett.Hayden@mountsinai.org

From the Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY.
Correspondence to Mr. Yendluri: avanish.yendluri@icahn.mssm.edu
9 2024
13 9 2024
8 9 e24.0000503 1 2024
18 6 2024
06 7 2024
Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.
2024
American Academy of Orthopaedic Surgeons
https://creativecommons.org/licenses/by-nd/4.0/ This is an open access article distributed under the Creative Commons Attribution-NoDerivatives License 4.0 (CC BY-ND) which allows for redistribution, commercial and non-commercial, as long as it is passed along unchanged and in whole, with credit to the author.

Introduction:

For patients unsuitable for prosthesis reimplantation or temporary spacer placement, Girdlestone resection arthroplasty (GRA) is a suitable option to eliminate infection. Using a large-scale database, this study aims to determine factors associated with reimplantation.

Methods:

This study included patients who underwent GRA and subsequent total hip arthroplasty (2012 to 2015 Medicare Limited Data Set with ≥5-year follow-up). A mixed-effects model measured associations between patient characteristics and reimplantation. Odds ratios (OR) with 95% confidence intervals (CI) were reported.

Results:

Among 2,772 GRA cases, 2,025 (73.1%) were reimplanted (median time to reimplantation 3.0 months). In multivariable analysis, patient factors associated with reduced odds of reimplantation were increased age (OR 0.96; CI, 0.94 to 0.97; P < 0.0001), Black race (OR, 0.58; CI, 0.37 to 0.90; P = 0.0149), obesity (OR, 0.74; CI, 0.58 to 0.94; P = 0.0150), and increased Deyo-Charlson comorbidities (1 comorbidity: OR, 0.78; CI, 0.61 to 0.99; P = 0.0453; two comorbidities: OR, 0.53; CI, 0.39 to 0.71; P < 0.0001; ≥3 comorbidities: OR, 0.69; CI, 0.49 to 0.95; P = 0.0244). Male (versus female) patients, however, had increased odds of reimplantation (OR, 1.64; CI, 1.32 to 2.02; P < 0.0001).

Discussion:

Age, race, and comorbidities influence the likelihood of reimplantation after GRA. Owing to variability in patients who undergo additional surgery, additional studies should be conducted to determine the rationale of patient selection.

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pmcThe treatment of periprosthetic joint infection (PJI) of the hip involves a complex approach and usually involves options of débridement, antibiotics, and implant retention, one-stage or two-stage exchange, or chronic antibiotic suppression. Most, but not all patients, are suitable for reimplantation of prostheses after removal.1 Often as a last resort to preserve limb function, relieve pain, and control infection, patients may be offered a resection arthroplasty. Introduced in 1943, Girdlestone resection arthroplasty (GRA) involves the resection of part of the femoral head without the insertion of prostheses and spacers, leaving a crude articulation between the femur and the acetabulum.2

Patients may later become suitable for a revision/reimplantation total hip arthroplasty (THA) to improve the function of the hip once the infection is eradicated or their modifiable risk factors improve.2 In a staged approach, GRA can serve as a bridge to an attempt at eventual reimplantation without the potential complications of an antibiotic spacer.2 Reimplantation after resection arthroplasty has been associated with many complications, including notable patient morbidity and mortality.2-4 Common clinical reasons for not undergoing reimplantation are poor bone stock, poor soft tissue coverage, uncontrolled infection, and unsuitable patient characteristics for surgery.5

Previous studies have investigated indications for resection arthroplasty versus other treatment options, but the literature provides little information about factors associated with reimplantation after GRA. Owing to the notable surgical risk in revision surgery after GRA, it is helpful to understand the current rates of reimplantation and the characteristics of patients undergoing revision THA after GRA. Therefore, the aim of this study was to determine patient factors associated with reimplantation within 5 years after treatment of PJI with GRA.

Methods

Study Design and Variables

This retrospective cohort study used 2012 to 2020 data from the Medicare Limited Data Set. We included patients who underwent GRA between 2012 and 2015 with a diagnosis of PJI. The primary focus of this study is not on Girdlestone as a complication, but rather as an intended treatment strategy of PJI to determine patient factors that influence the likelihood of subsequent reimplantation. A 5-year follow-up was used to identify patients who were reimplanted using International Classification of Diseases, Ninth and Tenth Revision (ICD-9, ICD-10) codes, and Current Procedural Terminology (CPT) codes: ICD-9 81.51/ICD-10 0SR9019, 0SR901A, 0SR901Z, 0SR9029, 0SR902A, 0SR902Z, 0SR9039, 0SR903A, 0SR903Z, 0SR9049, 0SR904A, 0SR904Z, 0SR9069, 0SR906A, 0SR906Z, 0SR90J9, 0SR90JA, 0SR90JZ, 0SRB019, 0SRB01A, 0SRB01Z, 0SRB029, 0SRB02A, 0SRB02Z, 0SRB039, 0SRB03A, 0SRB03Z, 0SRB049, 0SRB04A, 0SRB04Z, 0SRB069, 0SRB06A, 0SRB06Z, 0SRB0J9, 0SRB0JA, 0SRB0JZ/CPT 27130 and 27132. This reimplantation window was chosen to ensure both adequate index operations and subsequent revisions based on previous studies.2 Additional inclusion criteria were continuous enrollment in Medicare for at least 5 years after GRA. In addition, as most GRA are done in the inpatient setting, outpatient GRA procedures were not included in this study. Exclusion criteria were patients who received a THA or conversion to a THA on the same date as resection, and patients who received a spacer (CPT: 11981). Demographic data collected included race (White, Black, Other), age, and sex. Other study variables were obesity (defined as body mass index >30), Deyo-Charlson Comorbidity Index,6 smoking status, and hospital region (North Central, Northeast, South, West). This study was exempt from full review by the authors' Institutional Review Board (project #STUDY-20-01677) due to the deidentified nature of the study data source.

Statistics

Study variables were divided into two groups: patients who received reimplantation and those who did not. To assess differences between groups, unadjusted analyses were assessed by P-values (chi-square [categorical variables] and Mann-Whitney tests [continuous variables]). The Kaplan-Meier method was used to estimate the median time to reimplantation, with a corresponding 95% confidence interval (CI).7 Patients were censored at 5 years if they did not have reimplantation. A mixed-effects (accounting for clustering of patients within individual hospitals) multivariable logistic regression model (including all of the above variables) measured the association between covariates and the outcome of reimplantation.8 Odds ratios (OR) and 95% CI were reported. P-value < 0.05 was considered significant. All analyses were done using SAS v9.4 (SAS Institute).

Results

From 2012 to 2015, there were 2,772 GRA cases, 2,025 (73.1%) of which were subsequently reimplanted in the following 5 years. The median time to reimplantation was 3.0 months (interquartile range, 2.1 to 4.6 months). In the unadjusted analyses, various patient characteristics were associated with reimplantation: sex, age, race, Deyo-Charlson comorbidity index, obesity, and smoking (all P < 0.05; Table 1). Interestingly, no hospital factors were significantly associated with reimplantation. Reimplantation rates summarily slightly decreased in 2013 but remained consistent in other years with the total number of GRA cases decreasing (Table 1).

Table 1 Demographics of Patients Undergoing Girdlestone Resection Arthroplasty (GRA) From 2012 to 2015 by 5-Year Reimplantation Status

Variable	Reimplant (N = 2,025) (%)	No reimplant (N = 747) (%)	P	
Female sex	1,084 (53.5%)	481 (64.4%)	<0.001	
Median age (IQR)	72 (68–76)	73 (69–80)	<0.001	
Race			<0.001	
 White	1,878 (92.7%)	658 (88.1%)		
 Black	85 (4.2%)	54 (7.2%)		
 Other	62 (3.1%)	35 (4.7%)		
Deyo-Charlson comorbidity index			<0.001	
 0	916 (45.2%)	255 (34.1%)		
 1	588 (29.0%)	235 (31.5%)		
 2	277 (13.6%)	138 (18.5%)		
 3+	244 (12.0%)	119 (15.9%)		
Obesity	425 (21.0%)	185 (24.8%)	0.033	
Smoking	520 (25.7%)	156 (20.9%)	0.009	
Year			0.003	
 2012	585 (28.9%)	189 (25.3%)		
 2013	446 (22.0%)	214 (28.6%)		
 2014	581 (28.7%)	205 (27.4%)		
 2015	413 (20.4%)	139 (18.6%)		
Hospital location			0.891	
 Urban	1,881 (92.9%)	695 (93.0%)		
 Rural	144 (7.1%)	52 (7.0%)		
Hospital region			0.133	
 North Central	548 (27.1%)	183 (24.5%)		
 Northeast	377 (18.6%)	145 (19.4%)		
 South	731 (36.1%)	300 (40.2%)		
 West	369 (18.2%)	119 (15.9%)		
IQR = interquartile range

Bold entries indicate statistical significance (P < 0.05).

In the multivariable regression model, reduced odds of reimplantation were observed in patients who were older (OR, 0.95; 95% CI, 0.94 to 0.96; P < 0.001), presented with more comorbidities (in reference to Deyo-Charlson comorbidity index 0, Deyo-Charlson comorbidity index 1: OR, 0.70; 95% CI, 0.57 to 0.87; P = 0.001; Deyo-Charlson comorbidity index 2: OR, 0.57; 95% CI, 0.44 to 0.73; P < 0.001; Deyo-Charlson comorbidity index 3+: OR, 0.58; 95% CI, 0.44 to 0.77; P < 0.001), specifically obesity (OR, 0.77; 95% CI, 0.62 to 0.96; P = 0.020). Male (compared with female) sex was associated with higher odds of reimplantation (OR, 1.51; 95% CI, 1.25 to 1.81; P < 0.001); Table 2.

Table 2 Multivariable Analysis, Modeling for 5-Year Reimplantation Status

Variable	Odds Ratio	95% Confidence Interval	P	
Age	0.95	0.94-0.96	<0.001	
Male (reference = female)	1.51	1.25-1.81	<0.001	
Race (reference = White)				
 Black	0.60	0.41-0.88	0.008	
 Other	0.59	0.37-0.94	0.025	
Deyo comorbidity index (reference = 0)				
 1	0.70	0.57-0.87	0.001	
 2	0.57	0.44-0.73	<0.001	
 3+	0.58	0.44-0.77	<0.001	
Obesity	0.77	0.62-0.96	0.020	
Smoking	1.19	0.96-1.47	0.121	
Year (reference = 2012)				
 2013	0.64	0.50-0.82	<0.001	
 2014	0.87	0.69-1.11	0.272	
 2015	0.96	0.73-1.25	0.741	
Region (reference = South)				
 North Central	1.22	0.95-1.56	0.113	
 Northeast	1.04	0.79-1.36	0.779	
 West	1.23	0.93-1.63	0.153	
 Urban region (reference = rural)	1.01	0.71-1.45	0.947	
Bold entries indicate statistical significance (P < 0.05).

Discussion

GRA can be an effective salvage solution with PJI but may result in limb length discrepancy, muscle atrophy, and reduced range of motion.9 In suitable patients, however, reimplantation may offer the chance to improve function and increase patient satisfaction.10,11 With this potential effect on patient outcomes, it is important to understand the qualities of patients suitable for reimplantation. Using national claims data, the findings of this study suggest that patient age, sex, race, obesity, and Deyo-Charlson Comorbidity Index are factors that are associated with reimplantation rates.

The findings of this recent analysis show that patients are frequently reimplanted after GRA, with 73% of resection arthroplasties undergoing reimplantation. This rate is higher than previously found in a 2017 study, which reported a 60% reimplantation rate.12 This difference in rates of reimplantation is likely attributed to using more recent data because this study uses Medicare data from 2012 to 2020, while the previous study uses Medicare data from 2005 to 2012, and advances in surgical techniques and medical care.12,13 This trend in increasing reimplantation rates is also mirrored in the data of this study because the odds of reimplantation increased over the study period (0.64 in 2012 to 0.96 in 2015). In addition, in this study, we used a generous 5-year reimplantation window to capture most of the reimplantations. Noting the increasing rates of reimplantation, it becomes increasingly pertinent to further understand factors that contribute to the treatment of patients who undergo GRA. An understanding of such factors can contribute to evidence-based treatment algorithms that can guide both patient and surgeon expectations across the episode of care.

In an attempt to improve care for all patients, identifying racial disparities in orthopaedics is a subject of great interest.14 In assessments considering the effect of race, differences are regarded as disparities when findings may not be attributable to clinical factors and may be directly associated with poorer outcomes.15 The study finding of reduced rates of reimplantation in Black patients needs to be contextualized. Although there are no studies that identify racial differences in the incidence of GRA, one study showed that a lower socioeconomic status is associated with an increased risk of GRA, which historically can be linked to minority patients, influencing the incidence of GRA.16 Furthermore, it is important to consider that a variety of socioeconomic and cultural factors contribute to patient utilization, access to care, and the decision to undergo subsequent surgery.17 Because of the nuance involved in the decision to reimplant after GRA, additional investigation is required to better understand this difference.

Comorbidities are a proven risk factor for treatment failure of various joint reconstruction surgeries.11 The findings of this study support this claim because the analysis shows that increased obesity and comorbidities were also associated with a reduced likelihood of reimplantation. Previous studies have shown that obese patients are less successful after reimplantation, with worse pain relief, overall function, and reduced 5-year survival after septic revision surgery.18,19 This outcome is likely multifactorial. Obesity leads to a chronic low-level inflammatory state, altered metabolism, and weakened immunity, independent of other comorbidities such as diabetes.18 Furthermore, increased adipose tissue increases the surgical complexity of revision surgery, increasing the likelihood of soft-tissue injury and a higher tendency for wound complications.18 Although perioperative weight loss has been postulated as a method to improve outcomes, lessons from the primary hip arthroplasty literature have shown this practice to be linked to poorer outcomes.19 Another interesting finding in this analysis was the finding that smoking, a comorbidity understood to serve as an independent predictor of surgical site infection, was not associated with reimplantation odds.20 The data in this study, however, only reflect a history of smoking and changed behaviors, including abstinence in the perioperative setting, which has been shown to contribute to infection-free survival in septic revision arthroplasty.19 In addition, this study found that older patients were less likely to be reimplanted after GRA. Of note, studies have shown an increasing trend in the age of patients who receive GRA.21 Clinically, older patients may be more frail and less able to tolerate repeated procedures. In considering the various factors that contribute to the decision to reimplant, clinical risk stratification is a factor that should not be overlooked.

This study is not without limitations. First, this study does not distinguish between GRA for a primary septic hip joint versus infected THA. Although the former is rare, there is great variability in how infections manifest, with differences in bone loss and femoral canal involvement.2 Furthermore, this study is hampered by limitations commonly associated with observational data like the absence of context and detailed clinical characteristics. Because of this, the authors are only able to make confident statements regarding associations, not causation. Finally, given the use of claims data, our results should be interpreted in the context of coding accuracy. However, we do not expect any potential coding inaccuracies to influence our findings because the associations make clinical sense and are mirrored by findings in similar research. This study also has limitations related to the surgical factors analyzed. We were unable to account for microbiology of the infecting organisms or classification of femoral and acetabular defects, which are known to influence reimplantation outcomes. Tracking the microbiology underlying explant and bacterial organisms responsible for PJI may provide important insights into patient outcomes in future research.

Despite the aforementioned limitations, this study contributes an additional element to the literature surrounding the natural history of GRA. Within the observation of the increasing trend of reimplantation after resection arthroplasty, this study highlights patient age, sex, race, obesity, and patient comorbidities as factors that may contribute to the likelihood of reimplantation. A better understanding of factors that affect the treatment course in the setting of PJI can contribute to enhanced evidence-based clinical decisions and patient-centered care. For example, if a patient's profile makes them unlikely to undergo reimplantation at any point, different surgical techniques may be more appropriate when compared with a patient with a higher likelihood of successful reimplantation.12 As GRA literature continues to grow, additional research is needed to better understand how the roles of patient demographics, comorbidities, and the infecting organism contribute to clinical outcomes and affect the overall treatment course.

Dr. Hayden or an immediate family member serves as a paid consultant to Depuy Johnson & Johnson and Heraeus. Dr. Chen or an immediate family member serves as a paid consultant to Stryker, Depuy-Synthes, and Mongram Orthopedics. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Okewunmi, Mr. Yendluri, Dr. Cordero, Dr. Zubizarreta, Dr. Moucha, and Dr. Poeran.

* Shared first authorship.
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