Elective Primary Total Hip Arthroplasty Research Articles

Osteopetrosis is Associated With an Increased Risk for Intraoperative Periprosthetic Fracture in Total Hip Arthroplasty but not in Total Knee Arthroplasty

BackgroundOsteopetrosis is a rare, inherited disorder in which bone remodels to become pathologically dense. There has been a paucity of data evaluating medical and surgical complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) in this patient population. The objective of this study was to evaluate osteopetrosis as a potential risk factor for medical and surgical complications following THA and TKA. MethodsPatients who had a diagnosis of osteopetrosis and underwent THA or TKA from 2010 to 2020 were identified in a national database. A total of 534 THA and 972 TKA patients who had osteopetrosis were identified and compared with matched cohorts of 2,670 and 4,860 patients, respectively. The rates of postoperative medical and surgical complications, hospital readmissions, and emergency room visits were calculated. In addition, reimbursements and lengths of stay were determined. Osteopetrosis patients were then compared to a 5:1 matched cohort without osteopetrosis using logistic regression analyses to control for additional confounding factors. ResultsThe osteopetrosis THA group had a substantially higher incidence of intraoperative periprosthetic fracture compared to the matched cohort (1.12% versus 0.19%, Odds Ratio 5.88, P = .005). Patients who had a history of osteopetrosis were not found to be at a significantly increased risk for other investigated medical or surgical complications compared to matched controls following THA or TKA. ConclusionPatients who had a history of osteopetrosis undergoing elective primary THA are associated with a significantly increased risk for intraoperative periprosthetic fracture. Patients with a history of osteopetrosis undergoing elective primary TKA were not found to be at an increased risk for any of the investigated complications.

Total Hip Arthroplasty in Patients Who Have Respiratory Disease Who use Supplemental Home Oxygen

BackgroundThe purpose of this study is to investigate the association between supplemental home oxygen prior to surgery and both medical and surgical complications after primary elective total hip arthroplasty (THA) in patients who have respiratory disease (RD). MethodsThe Mariner database was used to identify patients who have RD who received primary elective THA from 2010 to 2020. The THA patient cohorts consisted of 20,872 patients who had RD prescribed home oxygen and 69,520 patients who had RD without home oxygen. For patients who had a diagnosis of RD and were prescribed supplemental home oxygen (O2) and those who were not, the rates of postoperative medical and surgical complications, hospital readmissions, and emergency room visits were determined. Reimbursements and lengths of stay were also determined. Logistic regression analyses were utilized to compare both cohorts to matched cohorts without RD, as well as to each other directly. ResultsIn comparison to the matched control group, the RD with home oxygen group had a significantly higher rate of pneumonia (odds ratio [OR] 4.27, P < .0001), pulmonary embolism (OR 1.81, P < .0001), periprosthetic joint infection (OR 1.21, P < .0001), and periprosthetic fracture (OR 1.81, P = .001). The RD with home oxygen cohort also had a significantly higher incidence of pneumonia (OR 2.16, P < .0001), periprosthetic joint infection (OR 1.38, P < .0001), and periprosthetic fracture (OR 1.24, P = .009) compared to RD patients who did not have home oxygen. ConclusionSupplemental home oxygen use prior to surgery is associated with a significantly higher risk of postoperative medical and surgical complications after elective THA.

Selecting a Press-fit Stem for Total Hip Arthroplasty: The Rationale and Evolution of the Modern Femoral Prosthesis.

Noncemented press-fit femoral stems predominate in total hip arthroplasty for all age groups with generally excellent long-term survivorship. The 2021 American Joint Replacement Registry reports that 96% of all elective primary total hip arthroplasties used noncemented femoral implant fixation. 1 Today, there are many styles of press-fit stems, each with supposed benefits, based on a range of design philosophies. Design aspects to consider when selecting a stem are numerous, including stem geometry, stem length, collared or collarless, material properties, and surface structure. Although most stem designs demonstrate excellent results, the differences in stem designs are intimately linked to additional factors such as ease of use/implantation, percentage of surface osseointegration, overall bone removal versus bone stock preservation, subsequent femoral stress shielding, and consideration of complexity of later revision. A surgeon with a broad understanding and appreciation of femoral stem designs should be prepared to select between the multitude of options to best serve individual patients.

Development of a Novel Prospective Model to Predict Unplanned 90-Day Readmissions After Total Hip Arthroplasty

BackgroundFor hospitals participating in bundled payment programs, unplanned readmissions after surgery are often termed “bundle busters.” The aim of this study was to develop the framework for a prospective model to predict 90-day unplanned readmissions after elective primary total hip arthroplasty (THA) at a macroscopic hospital-based level. MethodsA national, all-payer, inpatient claims and cost accounting database was used. A mixed-effect logistic regression model measuring the association of unplanned 90-day readmissions with a number of patient-level and hospital-level characteristics was constructed. ResultsUsing 427,809 unique inpatient THA encounters, 77 significant risk factors across 5 domains (ie, comorbidities, demographics, surgical history, active medications, and intraoperative factors) were identified. The highest frequency domain was comorbidities (64/100) with malignancies (odds ratio [OR] 2.26), disorders of the respiratory system (OR 1.75), epilepsy (OR 1.5), and psychotic disorders (OR 1.5), being the most predictive. Other notable risk factors identified by the model were the use of opioid analgesics (OR 7.3), Medicaid coverage (OR 1.8), antidepressants (OR 1.6), and blood-related medications (OR 1.6). The model produced an area under the curve of 0.715. ConclusionWe developed a novel model to predict unplanned 90-day readmissions after elective primary THA. Fifteen percent of the risk factors are potentially modifiable such as use of tranexamic acid, spinal anesthesia, and opioid medications. Given the complexity of the factors involved, hospital systems with vested interest should consider incorporating some of the findings from this study in the form of electronic medical records predictive analytics tools to offer clinicians with real-time actionable data.

Paper 78: Integrating PROM Collection for Shoulder Surgical Patients through the Electronic Medical Record: A Low Cost and Effective Strategy for High Fidelity PROM Collection

Objectives:Patient Reported Outcome Measures (PROMs) are critical measures of quality of care and treatment outcomes; however, they are challenging to collect without significant financial and administrative investment. The purpose of this study was to evaluate the efficacy and cost of an automated PROM collection through the electronic medical record for shoulder surgery patients in a large, integrated healthcare system.Methods:An existing, electronic medical record (EMR) based, automated, PROM scheduling system was integrated into the surgical check-in workflow for all elective primary total hip, total knee, and partial knee arthroplasty patients from November 2020 through August 2021 at 3 high volume surgical sites in a large, integrated health system. Rates of completion for Patient Reported Outcomes Measurement Information System Upper Extremity (PROMIS-UE), Patient Reported Outcomes Measurement Information System Pain Interference (PROMIS-PI) and American Shoulder and Elbow Surgeons Shoulder (ASES) surveys were determined. No additional staff were hired to assist in PROM collection. In our institution, if the patient had an ambulatory appointment within 25 days prior to surgery, their PROM scores were marked complete and were not reassigned on the day of surgery (DOS). For all other patients, PROMs were assigned by the automated system on DOS.Results:A total of 325 patients with a mean age of 42 + 28 years were included in this study. The vast majority, 94% (306), were assigned surveys on their day of surgery as a result of the automated system. The other 6% (19) had PROM scores completed in the ambulatory setting as they had a pre-operative visit less than 25 days prior to surgery. For patients completing PROMS on their day of surgery, 87% (266/306) completed at least 1 of PROMIS-UE or ASES, while 82% (251/306) completed both. In total 88% (285/325) of patients completed at least 1 PROM on or within 25 days prior to surgery and 85% (277/325) completed both. This entire system cost $5180 to deploy.Conclusions:A native PROM scheduling and collection system was successfully implemented with a survey completion rate of 82% to 95% of patients. This system serves as an efficient, low-cost model for other surgical departments to leverage existing systems to collect day of surgery PROMs.

Intraoperative Acoustics: Auditory Cues in Hip Reconstructive Surgery.

Orthopaedic surgeons rely on visual and tactile cues to guide performance in the operating room (OR). However, there is very little data on how sound changes during orthopaedic procedures and how surgeons incorporate audio feedback to guide performance. This study attempts to define meaningful changes in sound during vital aspects of total hip arthroplasty (THA) within the spectrum of human hearing. 84 audio recordings were obtained during primary elective THA procedures during sawing of the femoral neck, reaming of the acetabulum, acetabular cup impaction, polyethylene liner impaction, femoral broaching, planning of the femoral calcar and press-fit of a porous-coated stem in 14 patients. We graphed changes in frequency intensity across the human spectrum of hearing and sampled frequencies showing differences over time for statistically meaningful changes. Sawing of the femoral neck, polyethylene impaction, and stem insertion showed significant temporal increases in overall sound intensity. Calcar planing showed a significant decrease in sound intensity. Moreover, spectrographic analysis showed that, for each of the critical tasks in THA, there were characteristic frequencies that showed maximal changes in loudness. These changes were above the 1 dB change in intensity required for detection by the human ear. Our results clearly demonstrate reproducible sound changes during total hip arthroplasty that are detectable by the human ear. Surgeons can incorporate sound as a valuable source of feedback while performing total hip arthroplasty to guide optimal performance in the OR. These findings can be extrapolated to other orthopaedic procedures that produce characteristic changes in sound. Moreover, it emphasizes the importance of limiting ambient noise in the OR that might make sound changes hard to distinguish.

Assessment of Predictors of Infection in Primary Knee and Hip Arthroplasty: A Case-control Study.

Objective This study assesses risk factors for periprosthetic joint infection after elective primary total knee or hip arthroplasty. Methods The study included 706 medical records of patients undergoing elective primary total hip or knee arthroplasty from January to December 2018. We used a multivariate analysis of infection predictors through a logistic regression model. The R software performed all statistical analysis. Results The prevalence of infection in the sample was 2.0% (14 cases). Most patients were women (79.6%), with an afflicted right side (50.6%), and underwent a total knee arthroplasty (61.3%). Significant risk factors ( p < 0.05) for infection included surgical time greater than 120 minutes ( p = 0.009) and a history of diabetes ( p = 0.025). Conclusion The risk of infection after elective primary total knee or hip arthroplasty is higher when the surgical procedure is lengthy (over 120 minutes), or the patient has a history of diabetes mellitus. Level of Evidence IIIB, retrospective, case-control study.

Testing a Novel Inpatient Respiratory Depression Electronic Clinical Quality Measure (eCQM) for Orthopedic Practice in Two Large U.S. Health Systems.

The objective of this study was to assess the feasibility of using an electronic clinical quality measure (eCQM) to assess inpatient respiratory depression rates following elective primary total hip or total knee arthroplasty using data routinely collected in electronic health records. Measure testing was conducted at two large urban, academic health systems - Mass General Brigham and a geographically distant system in southern U.S. The risk-adjusted inpatient respiratory depression rates were 3.83 and 2.73% for the two health systems, respectively. Clinician group rates ranged from 1.40 to 4.35%, demonstrating opportunity for improvement. Both the data and measure specifications showed strong reliability and validity to allow for calculation of accurate and comparable rates of inpatient respiratory depression.

Are Patients With End-Stage Arthritis Willing to Delay Arthroplasty for Payer-Mandated Physical Therapy?

Payer coverage policies have recently begun requiring physical therapy (PT) prior to total hip arthroplasty and total knee arthroplasty (TKA). It remains controversial if such a mandate is appropriate for patients with end-stage, symptomatic osteoarthritis. The purpose of this study is to assess if such patients are amenable to delaying surgery for a trial of PT. All patients scheduled for elective primary total hip arthroplasty and TKA in a 3-month period by 1 of 7 surgeons at a single institution were contacted and asked to participate in a survey. Participation in PT within the prior 6 months was noted. Patients were asked if they would be willing to delay surgery for a PT trial as a nonsurgical option to improve their symptoms. The primary reason for their answer was also recorded. In total, 200 patients were successfully contacted and agreed to participate. The mean age was 66 years, 47% were male, the mean body mass index was 31 kg/m2, and 66% were scheduled for TKA. In total, 157 patients (79%) stated they had not done PT in the preceding 6 months, and 185 patients (93%) stated they would not want to delay surgery for mandatory PT. The most common reasons for refusing PT were "surgery is inevitable" (44%) and "unlikely to improve pain" (29%). Patients with end-stage hip and knee osteoarthritis who are otherwise candidates for surgery appear overwhelmingly opposed to mandatory preoperative PT, mostly due to a lack of perceived efficacy in providing long-term symptom relief compared to total joint arhtroplasty.

An Analysis of a National Administrative Dataset Demonstrating No Evidence of Increase in Elective Primary Total Hip Arthroplasty Dislocation Rates When Postoperative Hip Precautions are Not Used

BackgroundThe purpose of this study is to determine whether there is a higher dislocation rate when postoperative hip precautions are not used for primary total hip arthroplasty (THA). MethodsA survey was conducted of the hip precautions used by orthopaedic departments in England performing elective primary THA. From the responses to the survey an interrupted time series analysis was performed using the hospital admissions data from the Hospital Episode Statistics (HES) database during the period April 1, 2011 to December 31, 2019 and subsequent dislocations of these prostheses up to June 30, 2020. These were used to determine dislocations within 180 days of primary surgery and emergency readmissions within 30 days of discharge. ResultsRecords were reviewed from 229,057 patients receiving primary, elective THA across 114 hospitals. In total, 1,807 (0.8%) dislocations were recorded within 180 days of surgery. There were 12,416 (5.4%) emergency readmissions within 30 days of surgery. Within hospitals where hip precautions were stopped, the proportion of patients having a dislocation was 0.8% both before and after stopping precautions, with a significant postintervention trend towards fewer dislocations (P < .001). There was also a significant immediate change in median length of stay from 4 to 3 days (P < .001) but no significant trend in the proportion of emergency readmissions within 30 days. ConclusionThere is no evidence of an increase in early dislocation or 30-day readmission rates after stopping traditional postoperative hip precautions in primary THA. Potential reductions in length of stay will reduce the risks associated with an extended hospital admission, improve service efficiency, and reduce costs.

Validation of CT-Based Three-Dimensional Preoperative Planning in Comparison with Acetate Templating for Primary Total Hip Arthroplasty.

ObjectiveThis study aims to compare the accuracy of CT‐based preoperative planning with that of acetate templating in predicting implant size, neck length, and neck cut length, and to evaluate the reproducibility of the two methods.MethodsThis prospective study was conducted between August 2020 and March 2021. Patients who underwent elective primary total hip arthroplasty by a single surgeon were assessed for eligibility. The included patients underwent both acetate templating and CT‐based planning by two observers after the operation. Each observer conducted both acetate templating and CT‐based planning twice for each case. The outcome measures included the following: (1) the accuracy of surgical planning in predicting implant size, calcar length, and neck length, which was defined as the difference between the planned size and length and the actual size and length; (2) reproducibility of the two planning techniques, which were assessed by inter‐observer and intra‐observer reliability analysis; (3) the influence of potential confounding factors on planning accuracy, which was evaluated using generalized estimating equations.ResultsA total of 57 cases were included in the study. CT‐based planning was more accurate than acetate templating for predicting cup size (93% vs 79%, p < 0.001) and stem size (93% vs 75%, p < 0.001). When assessed by mean absolute difference, the comparison between acetate templating and CT‐based planning was 4.28 mm vs 3.74 mm (p = 0.122) in predicting neck length and 3.05 mm vs 2.93 mm (p = 0.731) in predicting neck cut length. In the inter‐observer reliability analysis, an intraclass correlation coefficient (ICC) of 0.790 was achieved for predicting cup size, and an ICC of 0.966 was achieved for predicting stem size using CT‐based planning. In terms of intra‐observer reliability, Observer 1 achieved an ICC of 0.803 for predicting cup size and 0.965 for predicting stem size in CT‐based planning. Observer 2 achieved ICC values of 0.727 and 0.959 for predicting cup and stem sizes, respectively. The average planning time was 6.48 ± 1.55 min for CT‐based planning and 6.12 ± 1.40 min for acetate templating (p = 0.015).ConclusionThe CT‐based planning system is more accurate than acetate templating for predicting implant size and has good reproducibility in total hip arthroplasty.

The Utilization of Postoperative Inpatient Ultrasound for Lower Extremity Deep Venous Thrombosis Following Total Hip Arthroplasty has Decreased Dramatically Over the Past Decade With No Obvious Negative Impact on Patient Care

BackgroundSurgeons are increasingly performing total hip arthroplasty (THA) in the outpatient setting. Lower lengths of stay (LOS) could result in fewer lower extremity ultrasounds for deep vein thromboses (DVT). The objective of this study was to evaluate the incidence of lower extremity ultrasounds ordered and positive DVT results in the immediate postoperative period. MethodsAll patients undergoing elective primary THA at an academic tertiary care center from January 2010 to February 2020 were included. Primary outcome of interest was incidence of postoperative DVT ultrasounds while inpatient and within 2 weeks following THA. Statistical analysis, including descriptive statistics and significance testing, was performed. ResultsA total of 3,665 patients were included, of which, 2.0% (N = 72) of patients received a lower extremity ultrasound while inpatient, with only 2 being positive (2.8%), for an overall positivity rate of 0.05% of the entire cohort. The incidence of postoperative inpatient ultrasounds decreased from 7.0% in 2010 to 0.3% in 2020 (P < .001) whereas, the incidence of ultrasounds at 2 weeks and 2-week positivity rate remained stable. LOS was identified as a risk factor for postoperative inpatient ultrasound (P < .001). ConclusionsPostoperative ultrasounds to evaluate for DVT are associated with a low yield and appear to be a consequence of reduced LOS in the hospital. Given the stable diagnosis rate of DVT at 2 weeks, our data suggests that the increasing trend toward outpatient arthroplasty will not result in missed opportunities to diagnose postoperative DVTs or lead to adverse outcomes and may provide benefit to patients by eliminating unnecessary testing. Level III evidenceRetrospective cohort study.

Neighborhood Socioeconomic Disadvantage Associated With Increased Healthcare Utilization After Total Hip Arthroplasty

BackgroundThe multifaceted effects of socioeconomic status on healthcare outcomes can be difficult to quantify. The Area Deprivation Index (ADI) quantifies a socioeconomic disadvantage with higher scores indicating more disadvantaged groups. The present study aimed to describe the ADI distribution for primary total hip arthroplasty (THA) patients stratified by patient demographics and to characterize the association of ADI with healthcare utilization (discharge disposition and length of stay [LOS]), 90-day emergency department (ED) visits, and 90-day all cause readmissions. MethodsTwo thousand three hundred and ninety one patients who underwent primary elective THA over a 13-month period were included. A multivariable binary logistic regression analysis with outcomes of nonhome discharge, prolonged LOS (>3 days), 90-day ED visits, and 90-day readmission were performed using predictors of ADI, gender, race, smoking status, body mass index, insurance status, and Charlson comorbidity index. Plots of restricted cubic splines were used to graph associations between ADI as a continuous variable and the outcomes of interest using odds ratios. ResultsIn the multivariable regression model, there were statistically significant higher odds of nonhome discharge (OR, 1.82; 95% CI, 1.19-2.77, P = .005) for individuals in the 61-80 ADI quintile as compared to the reference group of 21-40. Individuals in the highest ADI quintile, 81-100, had the greatest odds of nonhome discharge (OR, 2.20; 95% CI, 1.39-3.49, P < .001) and prolonged LOS (OR, 1.91, 95% CI, 1.28-2.84, P = .001). ConclusionsHigher ADI is associated with an increased healthcare utilization within 90 days of THA.

Validation of Single-Outcome Questionnaire in Primary TKA and THA

BackgroundPatient-reported outcome measures can be used to evaluate post-operative health care quality and patient satisfaction. The Patient’s Joint Perception (PJP) question gathers a single patient-reported outcome to measure how patients appraise their joint. This study compares PJP to the Forgotten Joint Score (FJS) at 21 months post-operation to assess its value. MethodsA retrospective review was performed at an orthopedic specialty hospital for patients who completed both PJP and FJS questionnaires in 2020-2021 and underwent either a unilateral elective primary Total Knee Arthroplasty (TKA) or Total Hip Arthroplasty (THA). Spearman’s correlation coefficients and P-values were calculated to determine external validity of PJP. Floor and ceiling effects were analyzed and considered present if ≥ 15% of patients achieved the worst or best score (0-4 for PJP and 0-100 for FJS). ResultsIn total, 534 patients (327 THA and 207 TKA) were surveyed at 21 months post-operation. External validity against FJS was assessed for both TKA (r = 0.66, P < .01) and THA (r = 0.69, P < .01). For TKA, the floor and ceiling effects were 0.97% and 25.12% for PJP and 3.86% and 4.83% for FJS, respectively. For THA, the floor and ceiling effects were 0.92% and 50.46% for PJP and 2.47% and 20.50% for FJS, respectively. ConclusionThe PJP was correlated with FJS moderately for both TKA and THA and can be collected with lesser burden. However, ceiling effects were higher in both TKA and THA for PJP compared to FJS. Further studies are needed to investigate the questionnaires at additional time points and to evaluate the implications of high ceiling effects.

Identified gamification opportunities for digital patient journey solution during an arthroplasty journey: secondary analysis of patients' interviews.

AimThe use of gameful design for supporting health‐related behaviours has been one of the major trends in health technology. An opportunity to increase engagement and motivation in a given health behaviour and the possibility of reaching improved outcomes through continued or consistent behaviour could be provided by gamification. This study aimed to identify gamification opportunities for digital patient journey solutions to increase patients' engagement and motivation for health‐related behaviour during an arthroplasty journey.DesignA secondary analysis.MethodSemistructured interviews were performed among 20 elective primary total hip and knee arthroplasty patients in a single joint‐replacement centre in Finland during autumn 2018. NVivo software was used for deductive content analysis. The study was conducted among 20 patients in a single joint replacement centre during 2018.ResultsSeveral opportunities for gamification were identified for digital patient journey solutions, which could be used in advanced care to increase patients' engagement and motivation for health‐related behaviour during the arthroplasty journey. These opportunities were identified related to five dimensions: accomplishment, challenge, guided, playfulness and social experience. Clear, scheduled, progressive and personalized goals with an activity tracking, real‐time timespan visualization and social networking with peers, support networks and healthcare providers could be provided. Opportunities for competition and immersion were not identified.

A Systematic Review and Meta-Analysis of Non-database Comparative Studies on Cemented Versus Uncemented Femoral Stems in Primary Elective Total Hip Arthroplasty

BackgroundCemented and uncemented femoral stems have shown excellent survivorship and outcomes in primary total hip arthroplasty (THA). Cementless stems have become increasingly common in the United States; however, multiple large database studies have suggested that elderly patients may have fewer complications with a cemented stem. As conclusions from large databases may be limited due to variations in data collection, this study investigated femoral stem survivorship and complication rates based on cement status in non-database studies. MethodsPreferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized to identify articles for inclusion up until June 2021. Included articles directly compared outcomes and complications between patients undergoing primary THA without femoral stem cementing to those with cementing. Studies were excluded if they utilized large databases or consisted of patients with a preoperative diagnosis of trauma. ResultsOf the 1700 studies, 309 were selected for abstract review and nineteen for full-text review. A total of seven studies were selected. Meta-analyses indicated substantial heterogeneity between studies. There were no differences in revision rates (cementless: 5.53% vs. cemented 8.91%, P = .543), infection rates (cementless: 0.60% vs. cemented: 0.90%, P = .692), or periprosthetic fracture rates (cementless: 0.52% vs. cemented: 0.51%, P = .973) between groups. ConclusionThere is scarce literature comparing outcomes and complications between cemented and cementless femoral stems in primary elective THA without utilizing a database methodology. In our study, there were no differences in complications detected on meta-analyses. Given previous findings in database studies, additional high-quality cohort studies are required to determine if selected patients may benefit from a cemented femoral stem.

The Forgotten Joint Score patient-acceptable symptom state following primary total hip arthroplasty.

AimsThe Forgotten Joint Score-12 (FJS-12) is a validated patient-reported outcome measure (PROM) tool designed to assess artificial prosthesis awareness during daily activities following total hip arthroplasty (THA). The patient-acceptable symptom state (PASS) is the minimum cut-off value that corresponds to a patient’s satisfactory state-of-health. Despite the validity and reliability of the FJS-12 having been previously demonstrated, the PASS has yet to be clearly defined. This study aims to define the PASS of the FJS-12 following primary THA.MethodsWe retrospectively reviewed all patients who underwent primary elective THA from 2019 to 2020, and answered both the FJS-12 and the Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS, JR) questionnaires one-year postoperatively. HOOS, JR score was used as the anchor to estimate the PASS of FJS-12. Two statistical methods were employed: the receiver operating characteristic (ROC) curve point, which maximized the Youden index; and 75th percentile of the cumulative percentage curve of patients who had the HOOS, JR score difference larger than the cut-off value.ResultsThis study included 780 patients. The mean one-year FJS-12 score was 65.42 (SD 28.59). The mean one-year HOOS, JR score was 82.70 (SD 16.57). A high positive correlation between FJS-12 and HOOS, JR was found (r = 0.74; p<0.001), making the HOOS, JR a valid external anchor. The threshold score of the FJS-12 that maximized the sensitivity and specificity for detecting a PASS was 66.68 (area under the curve = 0.8). The cut-off score value computed with the 75th percentile approach was 92.20.ConclusionThe PASS threshold for the FJS-12 at one year following primary THA was 66.68 and 92.20 using the ROC curve and 75th percentile approaches, respectively. These values can be used to achieve consensus about meaningful postoperative improvement to maximize the utility of the FJS-12 to evaluate and counsel patients undergoing THA.Cite this article: Bone Jt Open 2022;3(4):307–313.

Effect of Surgical Approach on Length of Stay, Cost, and Early Complication Rate in Total Hip Arthroplasty

Abstract Background Total hip arthroplasty (THA) is a historically popular and successful operation. While many steps of the operation are consistent between practitioners, discussion around which approach constitutes the “best” approach for routine, primary THA remains an open question. Objective The purpose of this study was to determine the effects of the surgical approach on hospital length of stay (LOS), hospital costs, and complication rates. A multisurgeon review of a single hospital was conducted to evaluate three surgical approaches: superior (SA), posterior (PA), and direct anterior (DAA). Methods All elective primary THAs performed between July 2013 and July 2016 were reviewed in an administrative database. Two surgeons performed SA, three surgeons performed PA, and two surgeons performed DAA. A total of 1,799 arthroplasties were analyzed: 980 (SA), 685 (PA), and 134 (DAA). Multivariate logistic, Poisson, and linear regression models were used to calculate the effects of each approach on LOS, cost, and per cent discharge home while adjusting for age, severity of illness scores, obesity, and smoking. Results After adjusting for patient characteristics, mean LOS for SA (1.8 days) was lower than both PA (2.4, p &lt; 0.001) and DAA (2.9, p &lt; 0.001), and PA (2.4) was lower than DAA (2.9, p &lt; 0.001). Mean hospital costs were lower for SA than PA ($738 difference, p &lt; 0.001) and DAA ($2,222 difference, p &lt; 0.001), and PA was lower than DAA ($1,420 difference, p &lt; 0.001). Both SA (88.7%) and PA (86.1%) were associated with a higher rate of discharge to home than DAA (78.4%, p = 0.002, p &lt; 0.001, respectively). SA and PA were associated with a lower 30-day readmission (1.3%) compared with DAA (5.2%, p &lt; 0.001) with no difference in 90-day readmissions seen. Conclusion When controlling for patient factors, the SA was associated with a decreased LOS, decreased costs, and increased likelihood of discharge home compared with both the PA and DAA with no increase in 90-day readmissions.

Early periprosthetic hip joint infection managed by cementless one-stage revision - a case series.

Background: Early periprosthetic hip joint infection (PJI) is traditionally treated with debridement, antibiotics, and implant retention (DAIR). However, infection control rates after DAIR-treated periprosthetic hip joint infection do not exceed 77 %. Cementless one-stage revision of chronic PJI by the Cementless One-stage Revision of Infected Hip Arthroplasty (CORIHA) protocol has been evaluated positively with a 91 % success rate. We wanted to evaluate the effectiveness of cementless one-stage revision following the CORIHA protocol for early PJI in elective primary total hip arthroplasty, regarding risk of re-operation with exchange of implants. Methods: We identified 18 patients in our center with early (-week postoperative) PJI after primary total hip arthroplasty (THA) treated with one-stage cementless revision in the period January 2012–March 2018. Treatment followed the CORIHA protocol. Primary outcome was retention of implants at the most recent follow-up. Patients were followed for a minimum of 3 years. Results: Mean follow-up time was 60 months (39–105). All patients retained their implants, but two required superficial soft tissue debridement due to persistent wound seepage. Conclusion: Cementless one-stage revision appears to be an effective treatment of early PJI after primary THA and at least an equal choice of treatment compared with DAIR. Whether the potential benefit of a lower re-revision rate for postoperative PJI outweighs the increased surgical complexity of the CORIHA procedure needs further evaluation.

Effects of Hospital and Surgeon Volume on Patient Outcomes After Total Joint Arthroplasty: Reported From the American Joint Replacement Registry

The purpose of this study was to evaluate outcomes and complications because it relates to surgeon and hospital volume for patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) using the American Joint Replacement Registry from 2012 to 2017. A retrospective study was conducted on Medicare-eligible cases of primary elective THAs and TKAs reported to the American Joint Replacement Registry database and was linked with the available Centers of Medicaid and Medicare Services claims and the National Death Index data from 2012 to 2017. Surgeon and hospital volume were defined separately based on the median annual number of anatomic-specific total arthroplasty procedures performed on patients of any age per surgeon and per hospital. Values were aggregated into separate surgeon and hospital volume tertile groupings and combined to create pairwise comparison surgeon/hospital volume groupings for hip and knee. Adjusted multivariable logistic regression analysis found low surgeon/low hospital volume to have the greatest association with all-cause revisions after THA (odds ratio [OR], 1.63, 95% confidence interval [CI], 1.41-1.89, P < 0.0001) and TKA (OR, 1.72, 95% CI, 1.44-2.06, P < 0.0001), early revisions because of periprosthetic joint infection after THA (OR, 2.50, 95% CI, 1.53-3.15, P < 0.0001) and TKA (OR, 2.18, 95% CI, 1.64-2.89, P < 0.0001), risk of early THA instability and dislocation (OR, 2.47, 95% CI, 1.77-3.46, P < 0.0001), and 90-day mortality after THA (OR, 1.72, 95% CI, 1.27-2.35, P = 0.0005) and TKA (OR, 1.47, 95% CI, 1.15-1.86, P = 0.002). Our findings demonstrate considerably greater THA and TKA complications when performed at low-volume hospitals by low-volume surgeons. Given the data from previous literature including this study, a continued push through healthcare policies and healthcare systems is warranted to direct THA and TKA procedures to high-volume centers by high-volume surgeons because of the evident decrease in complications and considerable costs associated with all-cause revisions, periprosthetic joint infection, instability, and 90-day mortality. III.