Primary Hip Surgery Research Articles

Medicaid Reimbursement for Total Hip and Knee Arthroplasty: A State-by-State Analysis Compared With Medicare

BackgroundMedicare (MCR) reimbursement for arthroplasty procedures has been declining, but little has been reported on Medicaid (MCD) reimbursement. We sought to determine MCD reimbursement rates using state MCD data for nine arthroplasty procedure codes and compare them to MCR rates. MethodsThe Centers for Medicare & Medicaid Services physician fee schedule was used to collect MCR reimbursement rates, and state MCD fee schedules were accessed to collect MCD rates for nine procedures encompassing primary and revision hip and knee arthroplasty surgery. State MCR and MCD rates were compared to determine the mean dollar difference and dollar difference per relative value unit. A cost of living adjustment was performed using the Medicare Wage Index for each state. Coefficients of variation were calculated for each state to determine overall variability between the two systems. ResultsThe mean reimbursement rates for MCD were lower for eight of the nine codes used in the study. Medicaid reimbursed physicians an average of 11.3% less overall and 23.1% less when adjusted for cost of living. The amount of variability in the MCR rates was low with a consistent coefficient of variation of 0.06, but was higher in the MCD rates with a range of 0.26 to 0.29 in the unadjusted rates and 0.34 to 0.37 in the adjusted rates. There was a mean $6.73 decreased reimbursement per relative value unit for MCD procedures. ConclusionsFor the most common arthroplasty procedures, MCD reimbursed physicians less than MCR on average. MCD also demonstrated increased variability when compared to MCR rates between states.

Hip reduction surgery versus scoliosis correction in non-ambulant neuromuscular patients: which surgery is the first step?

Children and young adults with neuromuscular disorders have a high incidence of both spine and hip deformities. The aim of this study was to evaluate the outcome of either primary scoliosis or hip surgery in children and young adults with neuromuscular disorders. A retrospective study was conducted on all children and young adults with neuromuscular-related synchronous hip subluxation/dislocation and scoliosis undergoing hip or scoliosis surgery in our institution between 2012 and 2021 with a minimum follow-up of 24months. Demographic and operative data were collected; radiological parameters were measured preoperatively and postoperatively at final follow-up. Forty neuromuscular patients with synchronous hip displacement and scoliosis were included. Twenty patients with an average age of10.2years had hip correction surgery performed primarily, with a mean follow-up of 54.9 (24-96)months. The other 20 patients with an average age of 12.4years had scoliosis correction first, with a mean follow-up of 40 (24-60)months. In the "Hip first" group, pelvic obliquity, hip MP and Cobb angle were 16.8°, 71%, and 49°, respectively. At final follow-up, the mean pelvic obliquity and Cobb angles significantly progressed to 27.2° (p = 0.003) and 82.2° (p = 0.001), respectively. Eighteen patients (90%) required scoliosis correction after the hip surgery. In the "Scoliosis first" group, the mean pelvic obliquity, hip MP and Cobb angle were 21.2°, 49% and 65.5°, respectively. At final follow-up, both pelvic obliquity and Cobb angle significantly improved to 8.44° (p = 0.002) and 23.4° (p = 0.001), respectively. In 11/20 (55%) patients, the hip MP had significantly increased following the spinal surgery to 62% (p = 0.001), but only 5/20 (25%) patients underwent hip surgery after scoliosis correction. In neuromuscular patients presenting with synchronous hip displacement and scoliosis deformity, corrective scoliosis surgery is associated with a significant correction of pelvic obliquity and lower rates of secondary hip surgery. On the other hand, primary hip surgery does not reduce the risk of pelvic obliquity and scoliosis deformity progression.

Technical note: acetabular augmentation with customisable cementless all-polyethylene insert.

Acetabular augmentation is a challenge for complex primary and revision hip surgery. Several methods exist to recreate a supportive, hemispherical acetabulum where a defect exists, however, these can be complex, expensive, time consuming, and limited by available size and shape. We present a simple, inexpensive, quick and customisable method of acetabular augmentation using cementless polyethylene with titanium coating. The first case is presented with follow-up up to 8 years.

Femoral Anteversion Is Associated With a Thinner Anterior Capsule in Patients With Femoroacetabular Impingement Syndrome

To measure femoral torsion on computed tomography images in patients with femoroacetabular impingement syndrome and explore whether femoral torsion was significantly correlated with anterior capsular thickness. Prospectively collected data of surgical patients were retrospectively reviewed. Only patients aged 16 to 55 years who underwent primary hip surgery were included in this study. Patients with a history of revision hip surgery, previous knee surgery, hip dysplasia, hip synovitis, and/or incomplete radiographs and medical records were excluded from the study. Femoral torsion was measured via computed tomography imaging using transcondylar slices of the knee. Anterior capsular thickness was measured using oblique-sagittal sequences on a 3.0-T magnetic resonance imaging system. The association between anterior capsular thickness and related variables, including femoral torsion, was assessed via multiple linear regression. The patients were then divided into 2 groups to further confirm the effect of femoral torsion on capsular thickness: Patients in the study group had hips with moderate (20°-25°) or severe (>25°) antetorsion, whereas patients in the control group had hips with normal torsion (5°-20°) or retrotorsion (<5°). Anterior capsular thickness was also compared between the 2 groups. A total of 156 patients (89 female patients [57.1%] and 67 male patients [42.9%]) were finally included in the study. The mean age and body mass index of the included patients were 35.8 ± 11.2 years and 22.7 ± 3.5, respectively. The mean femoral torsion for the entire study population was 15.9° ± 8.9°. Multivariable regression analysis showed that femoral torsion (P < .001) and sex (P= .002) were significantly correlated with anterior capsular thickness. Propensity-score matching yielded 50 hips in the study group and 50 hips in the control group on femoral torsion subanalysis. The results showed that anterior capsular thickness was significantly smaller in the study group than in the control group (3.8 ± 0.5 mm vs 4.7 ± 0.7 mm, P < .001). Femoral torsion is significantly inversely correlated with anterior capsular thickness. Level III, retrospective comparative study.

Quel est l’impact des traitements hormonaux féminins sur le système cardiovasculaire ?

To systematically review and report the mid- to long-term patient reported outcomes (PROs) following hip labral reconstruction.A literature search of the Pubmed, Embase, and Cochrane Library databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for clinical studies reporting mid- to long-term PROs at minimum five year follow-up following arthroscopic hip labral reconstruction. A quality assessment was performed using the Methodological Index of Non-Randomized Studies (MINORS) grading system. Data collection included study characteristics, demographics, indications, radiographic metrics, perioperative findings, surgical technique, baseline and most recent PROs, and subsequent surgeries.Four studies met inclusion criteria, with 182 hips (age range, 27.9 to 38.7 years) undergoing labral reconstruction in primary and revision hip surgery with minimum five year follow-up. There were three level III studies and one level IV study, with an average MINORS score of 16.6. All studies cited labral tissue characteristics as a factor for surgical indications, including the quality and/or size of the labrum. Three studies performed segmental labral reconstructions, while another study utilized a circumferential technique. Varying grafts were selected, including hamstring autograft/allograft, ligamentum teres autograft, iliotibial band autograft, and tensor fascia lata autograft. All studies demonstrated improved PROs from baseline to most recent follow-up, with four studies reporting modified Harris Hip Score (mHHS) values that increased from baseline (range, 58.9 to 66.8) to most recent follow-up (range, 80.1 to 86.3). After labral reconstruction, rates of revision arthroscopy ranged from 4.8% to 13.3% and conversion to total hip arthroplasty ranged from 1.6% to 27%.Improved PROs were observed in all studies at minimum 5-year follow-up, suggesting that labral reconstruction can offer durable results beyond short-term follow-up. While surgical indications for all studies included labral tissue characteristics, differing graft selection and surgical techniques were utilized across studies, limiting the ability to determine an optimal treatment approach.

Femoral neck-shaft angle can predict the anterior capsular thickness in patients with femoracetabular impingement syndrome.

To measure the femoral neck-shaft angle (NSA) on computed tomography (CT) images in femoracetabular impingement syndrome (FAIS) patients and explore its relationship with the anterior capsular thickness (ACT). A retrospective review of prospectively collected data from 2022 was performed. Inclusion criteria included: primary hip surgery, 18 to 55years of age, and CT imaging of the hips. Exclusion criteria included: revision hip surgery, mild or borderline hip dysplasia, hip synovitis, and incomplete radiographs and medical records. NSA was measured on CT imaging. ACT was measured using magnetic resonance imaging (MRI). Multiple linear regression was performed to assess the association between ACT and related variables, including age, sex, body mass index (BMI), lateral center-edge angle (LCEA), alpha angle, Beighton test score (BTS), and NSA. A total of 150 patients were included. The mean age, BMI, and NSA were 35.8 ± 11.2years, 22.8 ± 3.5, and 129.4° ± 7.7°, respectively. Eighty-five (56.7%) patients were females. Multivariable regression analysis revealed that NSA (P = 0.002) and sex (P = 0.001) were significantly negatively correlated with ACT. Age, BMI, LCEA angle, alpha angle, and BTS were not correlated with ACT. This study confirmed that NSA significantly predicts ACT. A decrease in the NSA by 1° increases the ACT by 0.24mm. Level III.

Outcomes After Primary Hip Arthroscopy in Athletes Older Than 40 Years Compared With Nonathletes

Background: Master athletes (MAs), or athletes older than 40 years, make up a patient population whose outcomes after primary arthroscopic hip surgery are largely unknown. Purpose: To report minimum 2-year outcomes of MAs after primary hip arthroscopy and compare their results to a propensity-matched nonathlete (NA) control group. Study Design: Cohort study; Level of evidence, 3. Methods: Data were prospectively collected between February 2008 and April 2019 and retrospectively reviewed for all patients who underwent primary hip arthroscopy. Patients were included if they were older than 40 years and had preoperative data for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score–Sports Specific Subscale, and visual analog scale score for pain. MAs reported participating in organized sports competition within 1 year before surgery and were propensity matched to a control group of patients who did not report participating in organized sports competition (NAs). Patient characteristics, radiographic and intraoperative findings, surgical procedures performed, and patient-reported outcome measures (PROMs) were reported and compared between the groups. The rates of achieving the minimal clinically important difference and maximum outcome improvement satisfaction threshold were recorded. Results: A total of 366 hips were eligible; 328 (89.6%) had adequate follow-up data. 328 patients met inclusion criteria but 88 were not included due to the restrictions of the propensity score match ratio. Of these, 80 hips (76 patients) were classified as MAs (mean age, 48.9 ± 6.2 years) and were propensity matched 1:2 to an NA control group. Groups were comparable for baseline demographic and radiographic parameters, intraoperative findings, and procedures performed. MAs had significantly better baseline and minimum 2-year PROM scores (P < .05), higher satisfaction (P = .01), and higher rates of achieving clinically meaningful improvement across all the outcome tools used (P < .05). MAs, when compared with NAs, had lower rates of secondary arthroscopy (0% vs 7.5%, respectively; P = .001) and conversion to total hip arthroplasty (12.5% vs 26.9%, respectively; P = .011). Conclusion: MAs demonstrated favorable outcomes after primary hip arthroscopy. When compared with a propensity score–matched control group of NA patients, MAs demonstrated better preoperative and postoperative PROMs, higher rates of clinically meaningful improvement, and lower rates of secondary arthroscopy and conversion to total hip arthroplasty. Absolute improvements in PROM scores were similar between the groups.

The Effect of Femoral and Acetabular Version on Outcomes Following Hip Arthroscopy: A Systematic Review.

Torsional hip deformities are common among patients undergoing hip arthroscopy. However, recent studies have suggested conflicting outcomes following arthroscopy in the setting of abnormal hip version. The purpose of this study was to systematically evaluate the literature and determine the impact of femoral and acetabular version on patient-reported outcomes following primary arthroscopic hip surgery. This study was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Studies investigating femoral and acetabular version in primary hip arthroscopy with clinical outcomes were identified, and data were extracted in duplicate. Overall, 11 studies met inclusion criteria and comprised 1,297 hips (726 femora and 571 acetabulae), with a mean patient age of 29.2 years (range, 14 to 74.7 years). In patients with acetabular retroversion, there was no significant difference, when compared with the normal acetabular version group, in the modified Harris hip score (mHHS), the Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) pain scores postoperatively. Among patients with femoral retroversion, in 2 of 3 studies, the authors reported no difference in mHHS postoperatively compared with patients with normal femoral version. In patients with high femoral anteversion, in 2 of 3 studies, the authors reported a significant difference in postoperative mHHS favoring patients with normal femoral version. Studies examining high femoral anteversion included patients with borderline hip dysplasia and patients who underwent concurrent psoas-lengthening procedures. Although the definition of the normal version of the hip varied within the literature, hip arthroscopy in patients with acetabular retroversion resulted in no difference in functional outcomes compared with patients with normal version. Postoperative functional outcomes in patients with femoral retroversion and high femoral anteversion were mixed, although the procedure was possibly less effective in high femoral anteversion combined with specific clinical scenarios. Further prospective studies based on standardized definitions and version analysis techniques would be useful in identifying the precise surgical indications for safe arthroscopic surgical procedures in patients with version abnormalities of the femur and acetabulum, particularly those with high femoral anteversion and retroversion. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

535 Are Routine Post-Operative Blood Tests Necessary Following Hip or Knee Arthroplasty in Fit and Well Patients?

Abstract Introduction Enhanced recovery protocols in hip and knee arthroplasty have achieved same-day discharge in selected patients. However, abnormal serum sodium, haemoglobin and creatinine may affect postoperative management. In particular, Serum creatinine guides dosage of prophylactic direct oral anticoagulants (DOAC). In this study we aim to establish if post-operative blood tests following arthroplasty might affect management. Method Patients undergoing primary hip and knee arthroplasty surgery at our unit between April 2018 and March 2019 were included. National Joint Registry input forms were used to identify the patients and their American Society for Anaesthesiologists (ASA) grade. Patients with an ASA grade of 1 or 2 were included. The incidence of AKI, hyponatraemia, drop in haemoglobin below 80g/L (the threshold for consideration of transfusion) and altered DOAC dose were recorded. For statistical analysis, the z-test of single proportion was used to compare results to a hypothesised expected population proportion of 1% for group sizes greater than 10. The p-value was set to 0.05. Results Results leading to a change in management were seen in 19 of the 218 patients (8.7%) (p &amp;lt; 0.0001). Twelve patients (5.5%) developed stage 1 or 2 AKI (p &amp;lt; 0.0001). Three patients required a reduction in the DOAC dose in response to their post-operative creatinine result. Post-operative haemoglobin level was below 80 g/L in two patients. Hyponatraemia was observed in one fifth of the patients and required intervention in two patients. Conclusions Post-operative blood tests are essential prior to discharge for all patients following hip and knee arthroplasty, regardless of pre-operative status.

Patients Require Less Time to Complete Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Than Legacy Patient-Reported Outcome Measures

PurposeTo analyze time to completion of preoperative legacy patient-reported outcomes (PROs) and more recent computer adaptive Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires in patients with symptomatic femoroacetabular impingement syndrome undergoing primary hip arthroscopy.MethodsA retrospective analysis was conducted on patients undergoing hip arthroscopy by a single fellowship-trained hip arthroscopist. Inclusion criteria were patients undergoing primary arthroscopic hip surgery and completion of at least 1 legacy PRO or PROMIS questionnaire at the preoperative time point. Exclusion criteria were history of contralateral or ipsilateral hip surgery, non–English-speaking patients, patients who completed PROs by phone or by paper form, and patients who did not complete preoperative PROs. Legacy PROs included modified Harris Hip Score (mHHS), Hip Outcome Score (HOS), International Hip Outcome Tool (iHOT-12), and Hip Pain Visual Analog Scale (VAS-Pain). PROMIS PROs included Physical Function (PROMIS-PF), Pain Interference (PROMIS-PI), and Depression (PROMIS-D). Only preoperative PROs were included in the analysis. Completion time was calculated using the questionnaire start and stop time reported by the survey collecting software. The median and interquartile range of each PRO were reported for analysis of central tendency and statistical dispersion, respectively.ResultsA total of 1,901 patients and 269 patients were included in the legacy and PROMIS groups, respectively. The median time required for completion of each PRO in (minutes: seconds) format was as follows: mHHS (1:29), HOS (3:58), iHOT (2:11), VAS-Pain (0:32), PROMIS-PF (0:46), PROMIS-PI (0:37), and PROMIS-D (0:43). The interquartile range of the middle 50% of respondents was as follows; mHHS (0:58), HOS (2:46), iHOT (1:22), VAS-Pain (0:28), PROMIS-PI (0:19), PROMIS-D (0:29), and PROMIS-PF (0:20).ConclusionsThis study supports that preoperative PROMIS forms require less time to complete than preoperative legacy PROs and are not significantly influenced by age, race, or workers compensation status.Level of EvidenceLevel IV, case series.

Patients Obtain Meaningful Clinical Benefit After Hip Arthroscopy Despite Preoperative Psychological Distress: A Propensity-Matched Analysis of Mid-Term Outcomes

To evaluate the influence of baseline psychological distress on patient-reported outcomes (PROs) after arthroscopic hip surgery for femoroacetabular impingement at a minimum of 5 years. Demographic and intraoperative data were prospectively collected from patients who underwent primary arthroscopic hip surgery for femoroacetabular impingement and labral tears after failure of conservative management between June 2012 and December 2014. Included patients had preoperative and minimum 5-year postoperative PROs and visual analog scale scores for pain and satisfaction. The 12-item Short Form Health Survey (SF-12) Mental Component Summary (MCS) score was used to stratify patients into 2 cohorts: Patients with an average or above-average score (SF-12 MCS score ≥ 50) were considered psychologically non-distressed, whereas those who scored below average (SF-12 MCS score < 50) were considered to have psychological distress. Distressed patients were propensity matched by age, sex, and body mass index to an equal number of non-distressed patients. Of the 153 hips that met the inclusion criteria, 117 (76.5%) had minimum 5-year follow-up. Eighty-two hips were included in the final analysis after propensity matching, with 41 in both the distressed and non-distressed cohorts. Preoperatively, patients in the distressed cohort reported inferior scores for all PROs. There was a significant difference in the SF-12 MCS score between groups at 2 years, but similar scores were observed for all other PROs. At minimum 5-year follow-up, there were no differences between groups for any PRO. There were no differences in the rates of achieving the minimal clinically important difference for all PROs or in achieving the patient acceptable symptomatic state for the modified Harris Hip Score. Patients with baseline psychological distress may have a lower functional status at the time of presentation but still gain meaningful clinical benefit and pain improvement from arthroscopic hip surgery, with mid-term outcomes comparable to those obtained by patients without preoperative psychological distress. Level III, retrospective comparative study.

Assessing responsiveness of the EQ-5D-3L, the Oxford Hip Score, and the Oxford Knee Score in the NHS patient-reported outcome measures

BackgroundThe degree to which a validated instrument is able to detect clinically significant change over time is an important issue for the better management of hip or knee replacement surgery. This study examines the internal responsiveness of the EQ-5D-3L, the Oxford Hip Score (OHS), and the Oxford Knee Score (OKS) by various methods. Data from NHS patient-reported outcome measures (PROMs) linked to the Hospital Episodes Statistics (HES) dataset (2009–2015) was analysed for patients who underwent primary hip surgery (N = 181,424) and primary knee surgery (N = 191,379).MethodsPaired data-specific univariate responsiveness was investigated using the standardized response mean (SRM), the standardized effect size (SES), and the responsiveness index (RI). Multivariate responsiveness was furthermore examined using the defined capacity of benefit score (i.e. paired data-specific MCID), adjusting baseline covariates such as age, gender, and comorbidities in the Box-Cox regression models. The observed and predicted percentages of patient improvement were examined both as a whole and by the patients' self-assessed transition level.ResultsThe results showed that both the OHS and the OKS demonstrated great univariate and multivariate responsiveness. The percentages of the observed (predicted) total improvement were high: 51 (54)% in the OHS and 73 (58)% in OKS. The OHS and the OKS showed distinctive differences in improvement by the 3-level transition, i.e. a little better vs. about the same vs. a little worse. The univariate responsiveness of the EQ-5D-3L showed moderate effects in total by Cohen’s thresholds. The percentages of improvement in the EQ-5D-3L were moderate: 44 (48)% in the hip and 42 (44)% for the knee replacement population.ConclusionsDistinctive percentage differences in patients’ perception of improvement were observed when the paired data-specific capacity of benefit score was applied to examine responsiveness. This is useful in clinical practice as rationale for access to surgery at the individual-patient level. This study shows the importance of analytic methods and instruments for investigation of the health status in hip and/or knee replacement surgery. The study finding also supports the idea of using a generic measure along with the disease-specific instruments in terms of cross-validation.

Pericapsular Nerve Group (PENG) Block in Combination With the Quadratus Lumborum Block Analgesia for Revision Total Hip Arthroplasty: A Retrospective Case Series.

Orthopedic procedures involving the hip have remained challenging for regional anesthesia given the complex innervation, painful nature contributing to difficulty positioning, and a desire to maintain mobility to hasten postoperative recovery. The revision total hip arthroplasty (THA) poses a greater challenge for an effective regional analgesia due to complex surgical approach, scarring from previous surgery and limited patient mobility. The quadratus lumborum (QL) block has demonstrated to provide effective analgesia for primary hip surgery in recent studies. The pericapsular nerve group (PENG) block has also shown to provide analgesia in patients with hip fractures. There is no standard of care regional anesthesia technique for hip surgeries, and the regional practice varies widely among anesthesia providers. This retrospective case series studied the effect of combining the QL with PENG block on the revision THA analgesia.

Gamma-Glutamyl Transferase: A Useful Marker of Habitual Drinking in Cases of Alcohol-Associated Osteonecrosis of the Femoral Head.

Alcohol intake is one of the factors associated with the occurrence of osteonecrosis of the femoral head (ONFH), and its epidemiological information regarding alcohol intake depends on patients' self-reports. Therefore, we analysed the efficacy of laboratory tests as an objective diagnostic tool to indicate habitual drinking in patients with alcohol-associated ONFH. This study included 109 consecutive patients diagnosed with ONFH who underwent primary hip surgery in our institution between 2010 and 2018. The patients were classified into group AL (alcohol-associated ONFH; n=26) and group NO (alcohol-unassociated ONFH; n=83), based on their self-reported information. Serum levels of gamma-glutamyl transferase (GGT), mean corpuscular volume (MCV), aspartate aminotransferase (AST), alanine aminotransferase (ALT), total cholesterol and triglycerides were compared between both groups. The sensitivities and specificities with the optimal cut-off values for detecting alcohol-associated ONFH were compared among these markers. The median serum levels of GGT, AST and ALT were significantly higher in the AL group than in the NO group. The receiver operating characteristic curve analysis demonstrated an area under the curve of 0.795 for GGT, 0.731 for AST and 0.709 for ALT. The optimal cut-off level of GGT as a marker for alcohol-associated ONFH was 36.5units/L, with a sensitivity of 76% and specificity of 80%, and it was found to be the best marker among the other examined laboratory markers. Serum GGT level is a useful laboratory marker with moderate accuracy that indicates habitual drinking in patients with alcohol-associated ONFH.

Trans-osseous intraoperative limb length measurement in hip replacement surgery

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Discrepancy of the limb length following total hip replacement is one of common complication. To reduce the occurrence, various modalities are used like pre-operative templating, navigation assisted measurements and intraoperative methods. This study was done using trans-osseous method of measurement using hip gauge which provides a faster, simpler assessment of limb length.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;M&lt;/strong&gt;&lt;strong&gt;ethods: &lt;/strong&gt;A prospective study of 25 patients who underwent uncemented hip arthroplasty was taken in the study and the LLD was measured before and after the surgical procedure. Patient were re-assessed for limb length discrepancy after 6 months with functional Harris hip score and radiological analysis on weight bearing standard X-ray antero-posterior view of the pelvis with bilateral hip joint.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;R&lt;/strong&gt;&lt;strong&gt;esults: &lt;/strong&gt;The results showed significant improvement in limb length discrepancy, and analysis of postoperative radiographs found the mean length difference of 2.44 mm and average Harris hip score was 95.5. No device related complications were reported, and none of them complained of the discomfort related to limb-length discrepancy after surgery. &lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;C&lt;/strong&gt;&lt;strong&gt;onclusions: &lt;/strong&gt;Trans-osseous fixed method using hip gauge provides a faster, reproducible and simpler method for the assessment of Limb length and aids with offset placement, acetabular anteversion for precise cup placement. This is a reliable method as it can be used both in the primary and revision hip surgery and most importantly doesn’t require any additional intraoperative imaging.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;

Perioperative population management for primary hip arthroplasty reduces hospital and postacute care utilization while maintaining or improving care quality

Study objectivePhysician-led multidisciplinary care coordination decreases hospital-associated care needs. We aimed to determine whether such care coordination can show benefits through the posthospital discharge period for elective hip surgery. DesignTime Series of prospectively recorded and historical data. SettingAcademic tertiary care medical center and health system. Patients449 patients undergoing elective primary hip surgery. InterventionsFor the intervention group we redesigned care with a comprehensive 14–16 week multidisciplinary standardized clinical pathway, the Ochsner hip arthroplasty perioperative surgical home (PSH). Essential pathway components were preoperative medical risk assessment, frailty scoring, home assessment, education and expectation setting. Collaborative team-based care, rigorous application of perioperative milestones, and proactive postoperative care coordination were key elements. MeasurementsThe intervention group was compared to historical controls with regard to demographics, risk factors, quality metrics, resource utilization and discharge disposition, the primary outcomes were hospital length of stay and postacute facility utilization. Main resultsCompared to historical controls, the intervention group had similar risk factors and the same or better quality outcomes. It had less combined skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) utilization compared to controls (16.5% vs. 27.5%). More intervention patients were discharged with home self-care compared to historical controls (10.7% vs 5.3%). During the intervention period combined SNF/IRF utilization decreased substantially from 19.8% early on, to 13.2% during a later phase. Intervention patients had fewer hospital days compared to historical controls (1.86 vs 3.34 days, respectively; P < 0.0001). ConclusionsA perioperative population management oriented care model redesign was effective in decreasing hospital days and postacute facility-based care utilization, while quality metrics were maintained or improved.

Venting the Central Compartment of the Hip Prior to Distraction Minimizes Overall Hip Distraction Forces

Objectives:Arthroscopic hip surgery requires application of ipsilateral lower extremity traction to achieve adequate joint distraction and hip central compartment access. Higher traction forces applied to the lower extremity allow greater hip joint distraction, improving the working space, in order minimize iatrogenic chondral and labral injury. However, greater traction forces have demonstrated a higher potential for iatrogenic traction related injuries. Controversy exists about the clinical relevance of procedural modifications, such as venting the hip, as a means of reducing the amount of traction force required to safely distract the hip joint. This study was designed to evaluate the difference between no venting versus venting the hip prior to application of traction on the overall amount of traction needed to distract the hip joint during hip arthroscopy.Methods:A total of 55 hips in 54 consecutive patients undergoing primary arthroscopic hip surgery were retrospectively reviewed. Prior to any instrumentation, interval fluoroscopic images of the operative hip joint were taken at 0, 25, 50, 75, and 100 pound-force (lb-f) (0, 11.3, 22.7, 34.0, and 45.4 kilogram-force (kg-f)) of applied traction. The hip was then taken off traction and the joint was vented using a standard hip access 14-gauge spinal needle and injected with 20 milliliters of air. Before any additional intervention, traction was again applied to the operative extremity and fluoroscopic images were obtained at the same traction force intervals. Joint displacement was measured at each traction force interval both before and after venting. Fluoroscopic images were scaled based on AP pelvis radiographs in order to obtain millimeteric joint space measurements.Results:The mean difference in hip joint displacement without venting and with venting was 0.29, 2.24, 4.06, 4.13, and 3.80mm at 25, 50, 75, and 100 lbs-f of traction, respectively. Paired samples t-testing demonstrated statistically significant increases in distraction distance (p<0.01) at all levels of traction (Table 1). Prior to venting, 0%, 7.3%, 27.8%, 44.0% of hips distracted at least 10 mm at 25, 50, 75, and 100 lbs-f of traction, respectively. After venting, 14.6%, 45.0%, 74.0%, 86% of hips distracted at least 10 mm at 25, 50, 75, and 100 lbs-f of traction, respectively (Figure 1).Conclusion:This study demonstrates that venting the hip prior to the application of traction significantly increases the amount of distraction distance achieved for a given traction force at multiple levels of traction. With venting of the hip, the percentage of hips achieving at least 10mm of distraction for 100lbsf almost doubled. These findings suggest venting the hip prior to application of traction could serve to reduce the maximal amount of traction required to safely instrument the hip arthroscopically.Table 1.Pre and post-venting distraction distances by amount of traction force Amount of Traction Pre-venting Mean Distraction Distance (mm)Post-venting Mean Distraction Distance (mm)Mean Pre- versus Post-venting Difference (mm)p-value0 lb-f (0 kg-f)4.614.900.290.00325 lb-f (11.3 kg-f)4.877.112.24<0.00150 lb-f (22.7 kg-f)5.829.884.06<0.00175 lb-f (34.0 kg-f)7.6611.784.13<0.001100 lb-f (45.4 kg-f)9.2213.023.80<0.001Figure 1.

Do patients with von Willebrand disease exhibit higher blood loss and revision rates in hip and knee arthroplasty? A case-control study.

The aim of the study was to compare the perioperative blood loss, need for transfusion and one-year revision rates in patients undergoing hip and knee arthroplasty who also have a diagnosis of von Willebrand disease (VWD) with a matched control group. A retrospective single-centre case-control study was conducted. Fifty-eight patients with VWD and 116 controls (1:2 match) who were operated for primary or revision hip and knee arthroplasty at our hospital were included. Blood loss, haemoglobin (Hb)-drop, need for blood transfusion, intraoperative complications and revision rates within one year were noted in all cases. Outcome measures for subgroups of the primary hip, primary knee, revision hip and revision knee procedures, were also analysed. The mean perioperative Hb-drop was 3.47 (±1.27) g/dL and blood loss was 293 (±97) ml for the VWD group while Hb-drop was 2.85 (±1.21) g/dL and blood loss was 232 (±105) mL for the control group (P<.001). There were no significant increased transfusion rates (P=.264) and revision rates in the VWD group (P=.634). Patients having primary hip surgery had significantly higher Hb-drop (3.68±1.25g/dL vs 2.62±1.19g/dL; P=.003), higher blood loss (293 vs 203mL; P=.002) and increased need for a transfusion (21% vs 2.6%; P=.038) compared to the controls. No outcome measure was found to be significantly different for primary and revision knee surgery. The results of this study suggest that patients with VWD undergoing primary or revision total hip and knee arthroplasty have higher levels of blood loss than the control cohort. Perioperative protective measures including meticulous surgical techniques should be considered.

Preoperative Risk Factor Optimization Lowers Hospital Length of Stay and Postoperative Emergency Department Visits in Primary Total Hip and Knee Arthroplasty Patients

BackgroundThe evaluation and management of outcomes risk has become an essential element of a modern total joint replacement program. Our multidisciplinary team designed an evidence-based tool to address modifiable risk factors for adverse outcomes after primary hip and knee arthroplasty surgery. MethodsOur protocols were designed to identify, intervene, and mitigate risk through evidence-based patient optimization. Nurse navigators screened patients preoperatively, identified and treated risk factors, and followed patients for 90 days postoperatively. We compared patients participating in our optimization program (N = 104) to both a historical cohort (N = 193) and a contemporary cohort (N = 166). ResultsRisk factor identification and optimization resulted in lower hospital length of stay (LOS) and postoperative emergency department (ED) visits. Patients in the optimization cohort had a statistically significant decrease in mean LOS as compared to both the historical cohort (2.55 vs 1.81 days, P < .001) and contemporary cohort (2.56 vs 1.81 days, P < .001). Patients in the optimization cohort had a statistically significant decrease in 30- and 90-day ED visits compared to the historical cohort (P30-day = .042, P90-day = .003). When compared with the contemporary cohort, the optimization cohort had a statistically significant decrease in 90-day ED visits (21.08% vs 10.58%, P = .025). The optimization cohort had a statistically significant increase in the percentage of patients discharged home. We noted nonsignificant reductions in readmission rate, transfusion rate, and surgical site infections. ConclusionOptimization of patients before elective primary total hip arthroplasty and total knee arthroplasty reduced average LOS, ED visits, and drove telerehabilitation use. Our results add to the limited body of literature supporting this patient-centered approach.

Extended Routine Follow-up of Primary Uncomplicated Hip and Knee Arthroplasty is not Necessary

Aims: To create a more effective system to identify patients in need of revision surgery. Background: There are over 160,000 total hip and knee replacements performed per year in England and Wales. Currently, most trusts review patients for up to 10 years or more. When we consider the cost of prolonged reviews, we cannot justify the expenditure within a limited budget. Study Design &amp; Methods: We reviewed all patients' notes that underwent primary hip and knee revision surgery at our institution, noting age, gender, symptoms at presentation, referral source, details of the surgery, reason for revision and follow up history from primary surgery. Results: There were 145 revision arthroplasties (60 THR and 85 TKR) that met our inclusion criteria. Within the hip arthroplasty group, indications for revision included aseptic loosening (37), dislocation (10), and infection (3), periprosthetic fracture, acetabular liner wear and implant failure. All thirty-seven patients with aseptic loosening presented with pain. Twenty-five were referred from general practice with new symptoms. The remaining were clinic follow-ups. The most common reason for knee revision was aseptic loosening (37), followed by infection (21) and then progressive osteoarthritis (8). Most were referred from GP as a new referral or were clinic follow-ups. All patients were symptomatic. Conclusion: All the patients that underwent revision arthroplasty were symptomatic. Rather than yearly follow up, we recommend a cost-effective system. We are implementing a 'non face-to-face' system. Patients would be directly sent a questionnaire and x-ray form. The radiographs and forms will be reviewed by an experienced arthroplasty surgeon. The concerning cases will be seen urgently in a face-to-face clinic.