Primary Total Hip Arthroplasty Cases Research Articles

Functional Outcome after Direct Anterior Approach Total Hip Arthroplasty (DAA-THA) for Coxa Profunda and Protrusio Acetabuli—A Retrospective Study

Objective: The direct anterior approach (DAA) is a recognized technique for total hip arthroplasty (THA) that spares soft tissue. Functional and clinical outcomes following THA via the DAA in patients with complex acetabular deformities, specifically coxa profunda (CP) and protrusio acetabuli (PA), have yet to be determined. Methods: A retrospective analysis was conducted on 188 primary THA cases, including 100 CP hips and 88 PA hips, performed via the DAA. Functional and clinical outcomes were evaluated by means of the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Harris Hip Score (HHS) preoperatively and at a mean follow-up of 46 ± 14 months. Furthermore, potential complications were assessed. Results: From the preoperative to the latest postoperative visit, a significant improvement in the WOMAC total score was observed (CP: −34.89 ± 20.66; PA: −40.38 ± 21.11). The length of stay (LOS) was the only parameter predictive of the postoperative WOMAC total score, with each day of LOS increasing the postoperative WOMAC by a mean of 1.77 points (p < 0.01). The HHS improved by 38.37 ± 14.23 (PA-group) and 32.79 ± 14.89 points (CP-group). No significant difference in the patient-reported outcome measures (PROMs) between the CP- and PA-group was found. The survival rate for any revision was 97.70% (PA-group) and 92.80% (CP-group). Conclusion: The results of this study indicate that the minimally invasive DAA was not predictive of the functional and clinical outcome following DAA-THA in patients with CP and PA. Improvements in the mean WOMAC and HHS scores were above or within the reported MCID. Additionally, revision rates were well below those reported in the literature for short and intermediate follow-up periods.

Is American Joint Replacement Registry Data Consistent With International Survivorship in Hip and Knee Arthroplasty? A Comparative Analysis

BackgroundIn collaboration with the Orthopedic Data Evaluation Panel (ODEP), the American Joint Replacement Registry (AJRR) investigated the consistency of hip and knee arthroplasty survivorship results compared to the UK National Joint Registry (NJR). MethodsA total of three primary knee devices and three primary hip devices were selected by AJRR and ODEP with known variation in performance. Implant manufacturers independently produced Kaplan Meier survivorship based on NJR data and submitted to ODEP for comparison. The AJRR mirrored the methodology, and results from both sources were stratified into three cohorts (all-age, < 65, and ≥ 65 years). ResultsThere were 42,671 AJRR and 60,439 NJR primary knee cases and 70,169 AJRR and 422,657 NJR primary total hip arthroplasty cases. For TKA, performance between the AJRR and NJR were consistent, showing similar trends for comparatively high and low performing devices. Both PS and CR devices showed statistical agreement in survivorship for all 3 cohorts. Unicompartmental comparison also showed statistical agreement for the Medicare cohort. The all-age and < 65-year-old cohorts showed similar trends and reached statistical agreement through 7 and 6 years. For total hip arthroplasty, performance between the AJRR and NJR were consistent, showing similar trends for comparatively high and low performing devices; 0.18% average difference in survivorship at final follow-up (8 years). One femoral device did not reach statistical agreement but showed only 0.61% difference in survivorship. The remaining acetabular and femoral devices reached statistical agreement in all-ages and through 7 and 8 years in the ≥ 65-year-old cohort. ConclusionsAJRR and NJR performance trends and survivorship were similar across hip and knee arthroplasty with greatest consistency in the all-age and ≥ 65 cohorts. This focused comparison of survivorship showed encouraging results for reliability of patient outcomes in AJRR compared to the world’s largest joint arthroplasty registry which has strong implications for global improvement in patient safety.

Using Three-Dimensional Printing Technology to Solve Complex Primary Total Hip Arthroplasty Cases: Do We Really Need Custom-Made Guides and Templates? A Critical Systematic Review on the Available Evidence.

An extensive literature review was conducted to retrieve all articles centered on the use of 3D printing in the setting of primary THA. A total of seven studies were included in the present systematic review. Four studies investigated the use of 3D-printed surgical guides to be used during surgery. The remaining three studies investigated the benefit of the use of 3D-printed templates of the pelvis to simulate the surgery. The use of 3D printing could be a promising aid to solve difficult primary total hip arthroplasty cases. However, the general enthusiasm in the field is not supported by high-quality studies, hence preventing us from currently recommending its application in everyday practice.

INFLUENCE OF STEM FIXATION AND STEM TYPE ON REVISION AND MORTALITY RATES IN ELECTIVE TOTAL HIP ARTHROPLASTY PROCEDURES IN PATIENTS OVER 80 YEARS OF AGE

The early revision rate in elective Total Hip Arthroplasty (THA) three years after surgery in elderly patients over 80 years is significantly lower for cemented stems in the German Arthroplasty Register (EPRD): cemented 3,1% (3.0 – 3.2) vs. uncemented 4.2% (4.1 – 4.3; p &lt; 0.001). However, the mortality rate in elderly patients is elevated for cemented fixation. This study presents a detailed analysis of the influence of stem type and fixation on revision and mortality rate in this patient cohort.Elective primary THA cases for primary Coxarthrosis using uncemented cups from the EPRD data base were analysed (n0= 37,183). Four stem type groups were compared: cementless, cementless with collar, cementless short, and cemented. Stems with at least 300 cases at risk three years after surgery were analysed individually. The reference stem was determined as the stem with the lowest revision rate and at least 1000 cases under surveillance 3 years after surgery (n3 = 28,637).The revision rate for cemented stems (2.5% [2.2–1.81] was lower than for uncemented (4.5% [4.2–4.9]; p&lt;0.001) and uncemented short stems (4.2% [3.1–5.7]; p=0.002). The revision rate of uncemented collared stems (2.3% [1.5–3.6]) was similar to cemented stems (p=0.89) and lower than for uncemented stems (p=0.02). One year mortality showed no sig. differences between the groups (p&gt;0.17): cemented 3.2% [2.9–3.6], uncemented 3.4% [3.1–3.7], uncemented short 3.5% [2.5–4.9], uncemented collar 2.0% [1.2–3.2].“Cementless” and “cementless short” stems should not be used in patients over 80 years due to the higher revision risk. If cementing should be avoided, “cementless collared” stems seem to be a good alternative combined with a tendency for a lower one year mortality rate.

Cemented Femoral Fixation in Total Hip Arthroplasty Reduces the Risk of Periprosthetic Femur Fracture in Patients 65 Years and Older: An Analysis From the American Joint Replacement Registry

BackgroundPeriprosthetic femur fracture (PPFx) is a devastating complication after total hip arthroplasty (THA). Despite concerns for increased PPFx, cementless fixation predominates in the United States. This study used the American Joint Replacement Registry to compare PPFx risk between cemented and cementless femoral fixation for THA. MethodsAn analysis of primary THA cases in patients aged 65 years and more was performed with the American Joint Replacement Registry data linked to Centers for Medicare and Medicaid Services data from 2012 to 2020. Analyses compared cemented to cementless femoral fixation. We identified 279,052 primary THAs, 266,040 (95.3%) with cementless and 13,012 (4.7%) with cemented femoral fixation. Cox proportional hazard regression analyses evaluated the association of fixation and PPFx risk, while adjusting for sex, age, and competing risk of mortality. Cumulative incidence function survival curves evaluated time to PPFx. ResultsAge ≥ 80 years (P < .0001) and women (P < .0001) were associated with PPFx. Compared to cemented stems, cementless stems had an elevated risk of PPFx (Hazards Ratio 7.70, 95% Confidence interval 3.2-18.6, P < .0001). The cumulative incidence function curves demonstrated an increased risk for PPFx across all time points for cementless stems, with equal magnitude of risk to 8 years.` ConclusionCementless femoral fixation in THA continues to predominate in the United States, with cementless femoral fixation demonstrating increased risk of PPFx in patients aged 65 years or more. Surgeons should consider greater use of cemented femoral fixation in this population to decrease the risk of PPFx.

Surgical Technique of Direct Anterior Approach for Primary Total Hip Arthroplasty Using a Leg Positioning Traction System.

Through the use of a natural intramuscular and internervous interval, the direct anterior approach (DAA) for total hip arthroplasty (THA) has been suggested to have several advantages over other popular arthroplasty approaches. The usage of DAA for THA has considerably grown in the West in recent years due to the emphasis on tissue preservation and minimally invasive joint replacements. However, due to the long learning curve, literature on this approach originating from India has been inadequate, suggesting a limited adoption of this surgical technique by the Indian diaspora of practicing surgeons. The DAA for THA is reliable and suitable to all conventional primary and revision THA cases. In the surgical procedure, the patient is positioned supine on the standard operating room (OR) table with the legs positioned in the Leg Positioning Traction System. The OR table may rotate, which enables the surgeon to perform the surgery more conveniently as it covers the majority of the patient's center of gravity. The incision is made over the tensor fascia lata. After femoral neck osteotomy, the head is removed, and traction is applied to the operative leg followed by acetabular cup insertion. The femoral stem is inserted after releasing soft tissues around the proximal femur using the leg positioning traction system. Using traction, flexion, and internal rotation, the femoral head is pushed into the acetabulum at the same time, and reduction is achieved. DAA for THA technique offers patients the advantage of minimally invasive surgery compared to other approaches. Many authors have published their experiences and technical keys to successfully completing this procedure, and several variations of the procedure have been described. The approach described is implemented utilizing specifically developed instruments, including a specialized table and intraoperative fluoroscopy while employing the standard surgical incision. This article attempts to outline the authors' technique for performing the DAA in the supine position for a primary THA using a Leg Positioning Traction System, with a focus on technical details in assisting an early DAA convert in making a safe transition.

Role of Operating Room Size on Air Quality in Primary Total Hip Arthroplasty

BackgroundAirborne biologic particles (ABPs) can be measured intraoperatively to evaluate operating room (OR) sterility. Our study examines the role of OR size on air quality and ABP count in primary total hip arthroplasty (THA). MethodsWe analyzed primary THA procedures done within 2 ORs measuring 278 ft2 and 501 ft2 at a single academic institution from April 2019 to June 2020. Temperature, humidity, and ABP count per minute were recorded with a particle counter intraoperatively and cross-referenced with surgical data from the electronic health records using procedure start and end times. Descriptive statistics were used to evaluate differences in variables. P-values were calculated using t-test and chi-squared test. ResultsA total of 116 primary THA cases were included: 18 (15.5%) in the “small” OR and 98 (84.5%) in the “large” OR. Between-group comparisons revealed significant differences in temperature (small OR: 20.3 ± 1.23 C versus large OR: 19.1 ± 0.85 C, P < .0001) and relative humidity (small OR: 41.1 ± 7.24 versus large OR: 46.9 ± 7.56, P < .001). Significant percent decreases in ABP rates for particles measuring 2.5 um (−125.0%, P = .0032), 5.0 um (−245.0%, P = .00078), and 10.0 um (−413.9%, P = .0021) were found in the large OR. Average time spent in the OR was significantly longer in the large OR (174 ± 33 minutes) compared to the small OR (151 ± 14 minutes) (P = .00083). ConclusionTemperature and humidity differences and significantly lower ABP counts were found in the large compared to the small OR despite longer average time spent in the large OR, suggesting the filtration system encounters less particle burden in larger rooms. Further research is needed to determine the impact this may have on infection rates.

Incidence, Risk Factors, and Subsequent Complications of Postoperative Hematomas Requiring Reoperation After Primary Total Hip Arthroplasty

BackgroundStudies analyzing the incidence and clinical implications of postoperative hematomas after total hip arthroplasty (THA) remain limited. The purpose of the present study was to use the National Surgical Quality Improvement Program (NSQIP) dataset to determine rates, risk factors, and subsequent complications of postoperative hematomas requiring reoperation after primary THA. MethodsStudy population included patients who underwent primary THA (CPT code: 27130) from 2012-2016 recorded in NSQIP. Patients who developed a hematoma requiring reoperation in the 30-day postoperative period were identified. Multivariate regressions were created to identify patient characteristics, operative variables, and subsequent complications that were associated with a postoperative hematoma requiring reoperation. ResultsAmong the 149,026 patients who underwent primary THA, 180 (0.12%) developed a postoperative hematoma requiring reoperation. Risk factors included body mass index (BMI) ≥ 35 (relative risk [RR]: 1.83, P = .011), American Society of Anesthesiologists (ASA) class ≥3 (RR: 2.11, P < .001), and history of bleeding disorder (RR: 2.71, P < .001). Associated intraoperative characteristics were an operative time ≥100 minutes (RR: 2.03, P < .001) and use of general anesthesia (RR: 1.41, P = .028). Patients developing a hematoma requiring reoperation were at higher risk of subsequent deep wound infection (RR: 21.57, P < .001), sepsis (RR: 4.3, P = .012), and pneumonia (RR: 3.69, P = .023). ConclusionsSurgical evacuation for a postoperative hematoma was performed in about 1 in 833 cases of primary THA. Several nonmodifiable and modifiable risk factors were identified. Given the 21.6 times increased risk of subsequent deep wound infection, select, at-risk patients may benefit from closer monitoring for signs of infection.

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.

Pneumatic femoral broaching decreases post-operative subsidence of a cementless taper-wedge stem.

Stem subsidence is a known cause of early failure in cementless total hip arthroplasty (THA). The aim of this study was to determine the usefulness of pneumatic femoral broaching in preventing post-operative subsidence of a proximally porous-coated, taper-wedge stem. We reviewed 169 cases of primary THA with a single taper-wedge stem. Eighty THAs performed using pneumatic broaching were compared with 89 THAs performed using manual broaching in terms of postoperative canal fill ratio (CFR) at three levels, stem subsidence at oneyear post-operation, and stem fixation at latest follow-up (median, 24months). The median CFRs were higher in the pneumatic group than in the manual group at all levels (p < 0.05). The median stem subsidence at oneyear after THA was lower in the pneumatic group than in the manual group (0.2mm vs. 0.6mm, p = 0.007). A multivariate analysis determined a decreased CFR at 60mm below the lesser trochanter and the manual broaching as independent factors affecting post-operative stem subsidence. At the latest follow-up, all stems showed stable fixation by bone ingrowth in both groups. Our results showed that the pneumatic broaching device was useful in maximizing the mediolateral canal filling and initial stability and minimizing the subsidence of taper-wedge stems.

A High-Volume, Academic Orthopedic Specialty Hospital Provides the Shortest Operative Times in Total Hip Arthroplasty

AbstractOperative time is a potential modifiable target for reducing cost and optimizing efficiency in total hip arthroplasty (THA). Shorter operative times are associated with decreased costs and complications. One proposed solution for reducing operating room (OR) times is to preferentially perform THAs at a higher volume center. The purpose of this study is to investigate the impact of different hospital settings on mean operative time in THA. A retrospective analysis of 7,694 consecutive primary and revision THA cases across four different hospitals was conducted. The hospitals reviewed in this study include a high-volume academic (HVA) orthopedic hospital, a large tertiary, low-volume academic (LVA) center, a high-volume community (HVC) hospital, and a low-volume community (LVC) hospital. Operative times, patient baseline demographics, and procedure classification (inpatient vs. outpatient) were collected. For primary THA, the HVA hospital maintained the statistically lowest total OR times followed by the HVC hospital (155.96 vs. 167.27 minutes, p &lt; 0.0001). The LVC and HVC centers had similar total OR times (175.48 vs. 167.27 minutes, p = 0.578). For revision THA, the LVC center had the shortest total OR time followed by the HVA, LVA, and HVC sites (194.85 vs. 224.69 vs. 244.07 vs. 279.54 minutes). However, there were a larger amount of revision cases performed at our HVA sites than our community hospitals (523 vs. 123 cases). Our HVA hospital specialized in orthopedic care experiences shorter primary THA OR times than community hospitals. These findings suggest that in addition to hospital volume, factors such as specialized staffing, standardized OR protocols, and additional resources affect operative times, making HVA centers better equipped to handle primary THA.

Low Grip Strength Associated with Clinical Outcomes after Total Hip Arthroplasty - A Prospective Case-Control Study.

ObjectiveTo assess whether low grip strength (GS) is associated with clinical outcomes after total hip arthroplasty (THA).MethodsA prospective case–control study was designed to assess 231 cases of primary THA between January 1, 2015 to May 1, 2018, at an urban tertiary care hospital. Patients were placed into two cohorts based on preoperative GS levels. Low GS in the present study was defined as GS lower than 26 kg for men and 16 kg for women in the dominant hand. Baseline data were prospectively collected and included patient demographics (age, sex, body mass index [BMI]), the surgeon's diagnoses, medical history, length of stay, and American Society of Anaesthesiologists' (ASA) score. Clinical outcomes included surgery‐ and prosthesis‐related variables. The Harris hip score (HHS) and the Short Form Health Survey (SF‐12) were completed at the baseline visit and at 1 and 2 years postoperatively in the outpatient department to assess the hip's function and quality of life. Differences in baseline data, length of study (LOS), 90‐day postoperative complications, and hospital readmissions were compared. Besides, the correlations between GS and Harris hip score (HHS) and Short Form score (SF‐12) were tested.ResultsA total of 202 participants have completed records for analysis finally. The patients were followed up for an average of 24.8 months postoperatively (24–26 months). Eighty‐two patients (40.6%) had low GS before THA. Patients with low GS were more likely to be female, older, fracture of femoral head or neck as the primary cause, albumin <3.5 g/dL, and have a lower BMI, higher ASA score, increased rates of the pressure sore, blood transfusion, and LOS compared to normal GS (all P < 0.05). Also, patients in the low GS cohort showed a statistically significant increased unplanned hospital readmissions and decreased discharge home compared to normal GS (both P < 0.05). There was an increasing rate of complications between the two cohorts, for cardiac complications, pressure sore after THA, respiratory complications, urinary tract infection, stroke, and DVT (all P < 0.05). A partial correlation test by controlling medical comorbidities and demographic factors was used to determine the correlation between GS and HHS. There was a significant correlation between them (r = −0.673; P = 0.002). A similar condition was detected in the correlation between GS and SF‐12 (r = 0.645; P = 0.001).ConclusionsClinicians should be encouraged to include GS assessment in their evaluation of patients who planned to undergo THA in order to optimize the treatment of high‐risk individuals.

Functional and clinical anatomy of the obturator externus muscle: Cadaveric studies and clinical findings for total hip arthroplasty in the posterior approach

Repairing released posterior soft tissues is important in preventing dislocation after total hip arthroplasty (THA) via the posterior approach. We clarify the functional and the clinical anatomy of obturator externus. We performed cadaveric studies and investigated clinically in primary THA cases. The location, trajectory, and size of the muscular tendon was recorded. The trajectory of the obturator externus ran orthogonal to the femoral axis with the hip in 90° flexion whereas that of the obturator internus muscle ran parallel. Because the trajectory of obturator externus and the obturator internus differ, their functions also differ.

Combined treatment of intraoperative cell-salvage and tranexamic acid for primary unilateral total hip arthroplasty: Are there added benefits?

BackgroundBlood management strategies in total hip arthroplasty (THA) are essential in reducing intraoperative blood loss, blood transfusion and associated complications. This study investigates whether using intraoperative cell-salvage (ICS) with tranexamic acid (TXA) has additional effects on blood loss and allogeneic transfusion in primary THA. Additionally, we evaluated the financial impact of using ICS on our institution. MethodsUsing an institutional database, 1171 cases of primary unilateral THA performed between May 2015 and January 2016 were identified. Subjects were separated into those who received only TXA (n = 323) and those who received TXA and ICS (n = 848). Calculated blood loss and post-operative blood transfusions were assessed using logistic regression. Drop in hematocrit was assessed using linear regression. Multivariable models adjusted for intraoperative blood transfusions, pre-operative autologous blood donation, anticoagulation medications, sex, and body mass index. Pricing data was used to calculate the costs associated with these interventions. ResultsThe likelihood of post-operative allogeneic blood transfusion was similar for the combined group relative to the TXA group (OR = 0.63; 95% CI: 0.26, 1.54), as was the likelihood of any post-operative blood transfusion (OR = 1.13; 95% CI: 0.63, 2.01). There was no correlative relationship between use of ICS and hematocrit drop when accounting for baseline hematocrit (R2 = 0.118). Factoring in rental, service fees, and disposable equipment, the utilization of ICS added $146 to each case, resulting in a gross expenditure of over $123,000 during the study period. ConclusionsThe combination of ICS with TXA for primary unilateral THA did not improve blood loss or transfusion outcomes compared to TXA alone. As there was no observed clinical benefit to combined treatment, additional costs associated with routine usage of ICS may not be justifiable. Our institution would have reduced expenditures for blood loss management products by 85% during the study period if all patients had only received TXA.

Impingement Between the Metal Stem and the Ceramic Liner in Total Hip Arthroplasty: The Neck Is Not the Only Place Where Impingement Occurs.

It is assumed that impingement between the ceramic liner and the stem increases the possibility of a liner fracture in total hip arthroplasty with a ceramic-on-ceramic bearing. The purpose of this study was to analyze the pattern of the impingement by evaluating the notches (U-shaped indented wear scars engraved on the stem) on radiographs to determine when and where impingement develops and to analyze the factors affecting its occurrence. Among the primary total hip arthroplasty cases using a ceramic-on-ceramic bearing performed from November 1997 to December 2003, 244 cases of 197 patients (123 male patients and 74 female patients) that had follow-up of ≥15 years were included. All of the radiographs were examined with special regard to the notches and the cup positions. Notches were detected at 77 sites of 57 cases (23.4%) for the first time between 8 months and 14.8 years after the surgical procedure. They were located on the neck or the shoulder of the stem. Shoulder notches were detected only in the cases with a short-neck head. Shoulder notches were found in 29 cases (20.0% of short-neck cases). Cup inclination was lower (p = 0.01) and anteversion was higher (p = 0.01) in the group with notches than the group without notches. There were 5 cases of ceramic head fracture. One of them experienced another ceramic liner fracture, assumed to be caused by prosthetic shoulder impingement, after the revision surgical procedure. The results of this study suggest that impingement between the stem and the ceramic liner occurs in a considerable proportion of patients who underwent total hip arthroplasty not only on the neck but also on the shoulder of the stem. Forceful and abrupt impingement on the stem shoulder can cause ceramic liner fracture. Impingement between the stem shoulder and the ceramic liner should be considered in designing a stem. It seems to be prudent to recommend that patients avoid squatting or sitting cross-legged on the floor as much as possible. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

In a Bundled Payment Model, the Costs Associated With Total Joint Replacement in Those Aged Older Than 80 Years Are Significantly Greater

BackgroundThe number of octogenarians requiring a total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) will rise disproportionally in the coming decade. Although outcomes are comparable with younger patients, management of these older patients involves higher medical complexity at a greater expense to the hospital system. The purpose of this study was to compare the cost of care for primary THA and TKA in our bundled care patients aged ≥80 years to those aged 65-80 years. MethodsA retrospective review of primary TKA (n = 641) and THA (n = 1225) cases from 2013 to 2017 was performed. Patient demographic and admission cost data were collected. Patients were grouped based on surgery type (ie, elective or nonelective THA/TKA) and age group (ie, older [≥80 years old] or younger [65-80 years old]). Multivariate regression analyses were used to account for demographic differences. ResultsElective primary THA in the older cohort (n = 157) cost 24.5% more than the younger cohort (n = 1025) (P < .0001). Elective primary TKA cases in the older cohort (n = 87) cost 17.0% more than the younger cohort’s (n = 554) (P < .0001). For nonelective THA cases, the older cohort’s (n = 29) episodes cost 39.1% more than the younger cohort (n = 14) (P < .0001). When comparing the <80 elective THA cohort (n = 1025) to the ≥90 cohort (n = 10), the cost difference swelled to 58.7% (P < .0001). ConclusionAlthough primary THA and TKA in ≥80-year-old patients yield similar outcomes, this study demonstrates that the additional measures required to care for older patients and ensure successful outcomes cost significantly more. Consideration should be given to age as a factor in determining reimbursement in a bundled payment system to reduce the incentive to restrict care to elderly patients.

Bleeding and thromboembolism risk of standard antithrombotic prophylaxis after hip or knee replacement within an enhanced recovery program

IntroductionPrevention of venous thromboembolism (VTE) generally consists of low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) after total hip arthroplasty (THA) or total knee arthroplasty (TKA). Enhanced recovery after surgery (ERAS) protocols may reduce the VTE risk after these procedures. The aim of this study was to compare the risk of VTE and the risk of bleeding complications in a non-selected population of primary THA and TKA cases done within an ERAS protocol. HypothesisThe risk of postoperative VTE after primary THA and TKA is lower than the risk of bleeding complications within an ERAS protocol. MethodsThis was a prospective observational study conducted on a national scale in France. All patients who underwent primary unilateral THA or TKA at one of 11 participating hospitals between October 2016 and October 2017 were enrolled and followed for 3 months. The occurrence of a VTE or major bleeding event was recorded. No patients were lost to follow-up at 3 months. ResultsOf the 1110 THA cases, there were 5 VTE (0.4%) and 19 bleeding events (1.7%). Of the 893 TKA cases, there were 9 VTE (1.0%) and 14 bleeding events (1.7%). There was no significant difference in the VTE incidence and bleeding event incidence after THA and TKA. The overall incidence of bleeding complications (1.7%) was significantly greater than the overall incidence of VTE complications (0.7%) (p=0.005). This was the case after THA (p=0.004) but not after TKA. DiscussionThe primary finding of this study is that bleeding complications are significantly more common than VTE complications after THA or TKA within an ERAS protocol. Based on these findings, the cost-benefit ratio of antithrombotic prophylaxis by LMWH or DOACs in this context should be reassessed.Level of evidence: IV; Prospective cohort study without control group.

Replacement of Fascia Iliaca Catheters with Continuous Erector Spinae Plane Blocks Within a Clinical Pathway Facilitates Early Ambulation After Total Hip Arthroplasty.

The optimal continuous peripheral nerve block (CPNB) technique for total hip arthroplasty (THA) that maximizes both analgesia and mobility is unknown. Continuous erector spinae plane (ESP) blocks were implemented at our institution as a replacement for fascia iliaca (FI) catheters to improve our THA clinical pathway. We designed this study to test the hypothesis that this change will increase early postoperative ambulation for elective primary THA patients. We identified all consecutive primary unilateral THA cases six months before and six months after the clinical pathway change to ESP catheters. All other aspects of the THA clinical pathway and multimodal analgesic regimen including perineural infusion protocol did not change. The primary outcome was total ambulation distance (meters) on postoperative day 1. Other outcomes included total ambulation on postoperative day 2, combined two-day ambulation distance, pain scores, opioid consumption, inpatient length of stay, and minor and major adverse events. Eighty-eight patients comprised the final sample (43 FI and 45 ESP). Postoperative day 1 total ambulation distance was greater for the ESP group compared with the FI group (median [10th-90th percentiles] = 24.4 [0.0-54.9] vs 9.1 [0.7-45.7] meters, respectively, P = 0.036), and two-day ambulation distance was greater for the ESP group compared with the FI group (median [10th-90th percentiles] = 68.6 [9.0-128.0] vs 46.6 [3.7-104.2] meters, respectively, P = 0.038). There were no differences in pain scores, opioid use, or other outcomes. Replacing FI catheters with continuous ESP blocks within a clinical pathway results in increased early ambulation by elective primary THA patients.

Effect of a Clean Surgical Airflow Layer on the Incidence of Infection in Total Hip Arthroplasty.

The Center for Health Design estimates that more than 30% of surgical site infections are caused by airborne pathogens. A device that creates a localized clean air field directly adjacent to and surrounding the incision site is meant to shield a surgical site from particulate in the operating room. The purpose of this study was to determine whether the routine use of this device would reduce the rate of infection following total hip arthroplasty (THA). The authors conducted a retrospective review of primary THA cases performed with and without the airflow device. Since July 2013, a total of 1093 primary THA cases were performed with the device at the authors' institution. The incidence of wound dehiscence and deep infection was compared with that of 1171 THA cases performed prior to July 2013 without the airflow device. There were no significant differences between the study groups regarding average patient age, sex, body mass index, or diagnosis. In the airflow group, there were 7 (0.64%) deep infections and 5 (0.46%) cases of wound dehiscence that required a return to the operating room for irrigation and wound revision. In the control group, there were 7 (0.60%) cases of deep infection and 4 (0.34%) wound revisions. The groups were not significantly different in the rates of infection (P=1.0) or wound revision (P=.75). Both groups had a very low incidence of infection and wound revision, with rates below 1%. Despite compelling bench data showing a dramatic reduction of particle load in the wound, the use of the airflow device did not reduce the clinical rate of infection over a large number of cases. [Orthopedics. 2020;43(5):e425-e430.].

Published Operative Times Do Not Reflect Surgeon Effort: A Novel Approach for Calculating Operative Times in Total Hip Arthroplasty to Better Quantify Surgeon Work

BackgroundCurrent estimates of operative time (OT) for total hip arthroplasty (THA) are reported as the mean OT across all procedures. This method does not reflect variability among surgeons and surgical settings and should not be used to infer individual surgeon work. We hypothesized that this method would underestimate the time it takes individual surgeons to perform THA. Therefore, we compared the mean OT for all THA cases (“overall OT”) with the mean OT for individual surgeons (“individual surgeon OT”) and examined which factors were associated with each. MethodsMean OT was calculated for 3972 primary THA cases (“overall OT”) by 41 surgeons from 2015 to 2018 in a single health system. The mean OT for each surgeon was determined (“individual surgeon OT”), averaged across surgeons, and compared with overall OT. Overall OT and individual surgeon OT were assessed for associations with surgeon-related (adult reconstruction fellowship training, THA volume, years’ experience), hospital-related (hospital type, trainee presence), and patient-related (age, body mass index category, American Society of Anesthesiologists physical status classification) factors (alpha = 0.05). ResultsMean individual surgeon OT was significantly longer (106 ± 21 minutes) than overall OT (96 ± 28 minutes) (P = .03), with 73% of individual surgeon OTs being greater than overall OT. Although all surgeon-, hospital-, and patient-related factors were associated with significant differences in overall OT, only hospital type was associated with differences in individual surgeon OT. ConclusionIndividual surgeon OT was longer than overall OT for most surgeons and provides a better estimate of surgeon work.