Peptic ulcer disease and heart disease are associated with periprosthetic fractures after total hip replacement

Figures & data

Table 1. Demographic and clinical features of study cohorts. Values are mean (SD) or n (%)

	Primary THR (n = 14,065)	Revision THR (n = 6,281)
Male/female	6,819/7,246	2,915/3,366
Percentage	(48.5%)/(51.5%)	(46.4%)/(53.6%)
Mean age at surgery in years	64.6 (13.7)	65.3 (13.7)
Age category
≤ 60 years	4,455 (31.7%)	1,985 (31.6%)
61–70 years	4,252 (30.2%)	1,678 (26.7%)
71–80 years	4,119 (29.3%)	1,932 (30.8%)
> 80 years	1,239 (8.8%)	686 (10.9%)
Mean body mass index (BMI)	29.0 (5.8)	28.4 (5.8)
BMI category, kg/m ^2
Missing	72 (0.5%)	66 (1%)
Normal, < 25.0	3,429 (24.5%)	1,833 (29.5%)
Overweight, 25.0–29.9	5,334 (38.1%)	2,292 (36.9%)
Obese, 30.0–39.9	4,589 (32.8%)	1,845 (29.7%)
Morbidly obese,≥ 40.0	641 (4.6%)	245 (3.9%)
Unilateral/bilateral	11,772/2,293	5,034/1,247
Percentage	(83.7%)/(16.3%)	(80.1%)/(19.9%)
ASA score ^b
Missing	60 (0.4%)	33 (0.5%)
1	653 (4.7%)	172 (2.8%)
2	7,947 (56.7%)	2,961 (47.4%)
3	5,254 (37.5%)	3,018 (48.3%)
4	151 (1.1%)	97 (1.6%)
Mean Deyo-Charlson index	1.3 (2.2)	1.1 (1.9)
Deyo-Charlson index group
Heart disease (MI, CHF)	1,211 (8.6%)	542 (8.6%)
Peripheral vascular disease	808 (5.7%)	298 (4.7%)
Cerebrovascular disease, hemiplegia or
paraplegia	1,125 (8.0%)	432 (6.9%)
Moderate-to-severe renal disease	889 (6.3%)	388 (6.2%)
Peptic ulcer disease	1,031 (7.3%)	435 (6.9%)
Chronic obstructive pulmonary disease	1,568 (11.1%)	564 (9.0%)
Diabetes (with or without organ damage)	1,235 (8.8%)	577 (9.2%)
Connective tissue disease	1,020 (7.3%)	603 (9.6%)
Cancer	2,166 (15.4%)	642 (10.2%)
Other (dementia, liver disease, AIDS)	829 (5.9%)	308 (4.9%)
Mean follow-up in years	6.3 (4.7)	5.6 (4.4)
Number of postoperative periprosthetic fractures during follow-up	305 (2.2%)	330 (5.3%)

^a ASA: American Society of Anesthesiologists.

Table 2. Crude (or unadjusted) and multivariable-adjusted risk of postoperative periprosthetic fracture following primary total hip replacement (THR)

A	B	C	D	E	F
Heart disease (MI, CHF)			p < 0.001	p = 0.006	p = 0.006
No	12,854	264 (2%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	1,211	41 (3%)	1.92 (1.38–2.67)	1.68 (1.16–2.42)	1.68 (1.16–2.42)
Peripheral vascular disease			p = 0.011	p = 0.1	p = 0.1
No	13,257	280 (2%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	808	25 (3%)	1.70 (1.13–2.56)	1.42 (0.91–2.19)	1.42 (0.91–2.20)
Cerebrovascular disease, hemiplegia or paraplegia			p = 0.7	p = 0.2	p = 0.2
No	12,940	282 (2%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	1,125	23 (2%)	1.08 (0.71–1.66)	0.75 (0.48–1.18)	0.74 (0.47–1.17)
Moderate-to-severe renal disease			p = 0.003	p = 0.4	p = 0.5
No	13,176	278 (2%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	889	27 (3%)	1.81 (1.22–2.69)	1.20 (0.78–1.85)	1.16 (0.75–1.79)
Peptic ulcer disease			p < 0.001	p = 0.02	p = 0.02
No	13,034	267 (2%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	1,031	38 (4%)	1.85 (1.32–2.60)	1.51 (1.06–2.15)	1.52 (1.07–2.17)
Chronic obstructive pulmonary disease (COPD)			p = 0.06	p = 0.5	p = 0.6
No	12,497	264 (2%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	1,568	41 (3%)	1.37 (0.98–1.90)	1.12 (0.79–1.57)	1.10 (0.78–1.56)
Diabetes (with or without organ damage)			p = 0.1	p = 0.7	p = 0.8
No	12,830	276 (2%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	1,235	29 (2%)	1.33 (0.91–1.95)	1.08 (0.72–1.61)	1.07 (0.71–1.60)
Other (dementia, liver disease, AIDS)			p < 0.001	p = 0.7	p = 0.07
No	13,236	275 (2%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	829	30 (4%)	1.95 (1.34–2.85)	1.48 (0.97–2.25)	1.47 (0.97–2.25)
Connective tissue disease			p = 0.007	p = 0.5	p = 0.5
No	13,045	270 (2%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	1,020	35 (3%)	1.62 (1.14–2.30)	1.15 (0.75–1.76)	1.15 (0.75–1.76)
Cancer			p = 0.003	p = 0.1	p = 0.1
No	11,899	243 (2%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	2,166	62 (3%)	1.52 (1.15–2.00)	1.29 (0.94–1.77)	1.28 (0.93–1.75)

AVariable

ASA: American Society of Anesthesiologists;

MI: myocardial infarction;

CHF: congestive heart failure.

BTotal (n = 14,065)

CPeriprosthetic fractures(n = 305)

DUnivariate hazard ratio (95% CI)

EMultivariable hazard ratio (95% CI)adjusted for age, gender, BMI, operative diagnosis, ASA class, implant fixation (cemented/hybrid, not

cemented) and each Charlson comorbidity

FMultivariable hazard ratio (95% CI) additionally adjusted for the year of surgery. Correlation coefficient between ASA and Charlson index

was 0.33.

Table 3. Crude (or unadjusted) and multivariable-adjusted hazard of postoperative periprosthetic fracture following revision total hip replacement (THR)

A	B	C	D	E	F
Heart disease (MI, CHF)			p = 0.04	p = 0.1	p = 0.1
No	5,441	298 (6%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	510	32 (6%)	1.47 (1.02–2.12)	1.39 (0.92–2.09)	1.38 (0.91–2.08)
Peripheral vascular disease			p = 0.2	p = 0.2	p = 0.3
No	5,670	313 (6%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	281	17 (6%)	1.35 (0.83–2.21)	1.37 (0.82–2.29)	1.32 (0.79–2.22)
Cerebrovascular disease, hemiplegia or paraplegia			p = 0.2	p = 0.2	p = 0.3
No	5,543	306 (6%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	408	24 (6%)	1.35 (0.89–2.05)	1.30 (0.84–2.02)	1.27 (0.82–1.98)
Moderate-to-severe renal disease			p = 0.2	p = 0.6	p = 0.8
No	5,585	308 (6%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	366	22 (6%)	1.38 (0.89–2.13)	1.12 (0.70–1.78)	1.08 (0.67–1.72)
Peptic ulcer disease			p = 0.003	p = 0.02	p = 0.01
No	5,551	295 (5%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	400	35 (9%)	1.69 (1.19–2.40)	1.58 (1.10–2.29)	1.61 (1.11–2.33)
Chronic obstructive pulmonary disease (COPD)			p = 0.6	p = 0.7	p = 0.7
No	5,416	301 (6%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	535	29 (5%)	1.10 (0.75–1.61)	1.08 (0.73–1.60),	1.08 (0.72–1.60)
Diabetes (with or without organ damage)			p = 0.1	p = 0.2	p = 0.2
No	5,407	297 (5%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	544	33 (6%)	1.38 (0.96–1.98)	1.32 (0.90–1.95)	1.31 (0.89–1.92)
Other (dementia, liver disease, AIDS)			p = 0.2	p = 0.7	p = 0.7
No	5,661	312 (6%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	290	18 (6%)	1.41 (0.88–2.27)	1.10 (0.66–1.84)	1.09 (0.66–1.82)
Connective tissue disease			p = 0.02	p = 0.6	p = 0.6
No	5,393	285 (5%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	558	45 (8%)	1.44 (1.05–1.97)	1.09 (0.78–1.53)	1.10 (0.79–1.54)
Cancer			p = 0.1	p = 0.09	p = 0.1
No	5,347	292 (5%)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Yes	604	38 (6%)	1.31 (0.93–1.83)	1.37 (0.95–1.99)	1.36 (0.94–1.97)

AVariable (See Table 2)

BTotal (n = 6,281)

CPeriprosthetic fractures (n = 330)

DUnivariate hazard ratio (95% CI)

EMultivariable hazard ^a ratio (95% CI) adjusted for age, gender, BMI, operative diagnosis, ASA class, and each Charlson comorbidity.

FMultivariable hazard ^b ratio (95% CI) additionally adjusted for the year of surgery.

Table 4. Fracture-free survival, by significant factors, in patients with primary or revision THR. Values are percentages

Fracture-free survival rate at
Variable	1 year	2 years	5 years	10 years
Primary THR
Overall	99.2 (99.1–99.4)	98.9 (98.4–99.4)	98.6 (98.4–98.8)	97.0 (96.6–97.4)
Heart disease (MI, CHF)
No	99.3 (99.1–99.4)	99.1 (98.9–99.2)	98.6 (98.4–98.8)	97.2 (96.8–97.6)
Yes	99.1 (98.5–99.6)	98.6 (97.9–99.3)	98.0 (97.2–98.9)	94.2 (92.0–96.3)
Peptic ulcer disease
No	99.3 (99.1–99.4)	99.1 (98.9–99.3)	98.7 (98.4–98.9)	97.2 (96.8–97.6)
Yes	98.6 (97.8–99.3)	98.0 (97.1–98.9)	97.4 (96.3–98.5)	94.1 (92.0–96.3)
Revision THR
Overall	98.1 (97.7–98.4)	97.4 (97.0–97.8)	95.6 (95.1–96.2)	92.0 (91.0–93.0)
Heart disease (MI, CHF)
No	98.1 (97.8–98.5)	97.5 (97.1–97.9)	95.8 (95.2–96.4)	92.3 (91.3–93.3)
Yes	97.3 (95.8–98.8)	96.8 (95.2–98.4)	93.8 (91.3–96.4)	87.2 (81.7–93.2)