Total Hip Arthroplasty Procedures Research Articles

Simultaneous Bilateral Total Hip Arthroplasty With Either the Direct Anterior or Posterior Approaches: A Propensity Score Match Study

BackgroundBilateral hip osteoarthritis is evident in approximately 20% of patients who present to the clinic for evaluation of hip pain, and for those undergoing total hip arthroplasty (THA), 22% will end up needing a contralateral THA. The risk and benefits of simultaneous bilateral total hip arthroplasty (SBTHA) versus staged bilateral THA procedures have been well studied, demonstrating equivalent safety profiles comparable to unilateral and SBTHA. However, the influence of the surgical approach on SBTHA on postoperative outcomes remains unclear. We sought to compare perioperative outcomes and complication rates between the direct anterior approach (DAA) and posterior approach (PA) in patients undergoing SBTHA. MethodsWe performed a 1:1 propensity score match based on age, sex, and body mass index. A total of 252 patients were available after matching, 126 patients in the DAA group and 126 in the PA group. Perioperative outcomes as well as surgical complications at the latest follow-up were retrospectively collected for each group. The mean follow-up was 36.7 months (range, 12.5 to 74.4). ResultsA SBTHA with DAA had significantly shorter surgical time (P < 0.001), anesthesia time (P < 0.001), and length of stay (P < 0.001), compared to the PA. A greater percentage of patients in the DAA group (91%) were discharged home compared to the PA group (57%) (P < 0.001). There were no differences in in-hospital complications (P = 0.617), 90-day complications (P = 0.605), or reoperation rates (P = 0.309) between surgical approaches. ConclusionsA SBTHA, either through the DAA or PA, can be safely performed with low complication rates. The DAA in the setting of SBTHA provides shorter surgical times, a shorter length of stay, and a greater percentage of patients discharged home.

Best timing of bilateral total hip arthroplasty – an analysis of revision and mortality rates from the German Arthroplasty Registry (EPRD)

BackgroundThe burden of osteoarthritis (OA) in multiple joints is high and for patients with bilateral OA of the hip there is no clear recommendation about the indication for simultaneous (one-stage) bilateral total hip arthroplasty (THA) versus two-staged procedures. The purpose of this study was therefore to compare revision and mortality rates after different strategies of surgical timing in bilateral hip OA from the German Arthroplasty Registry (EPRD).MethodsSince 2012 22,500 patients with bilateral THA (including 767 patients with one-staged bilateral surgery and 11,796 patients with another separate procedures within one year after first THA) are documented in the registry. The patients who underwent simultaneous bilateral THA were matched with a cohort of 767 patients who underwent the second THA between 1 and 90 days postoperatively (short interval) and another cohort of 4,602 patients with THA between 91 and 365 days postoperatively (intermediate interval). Revision for all reasons and mortality rates were recorded. Cox regression was performed to evaluate the influence of different patient characteristics.ResultsThe cumulative 5-year revision rate for patients with simultaneous bilateral THA was 1.8% (95% CI 0.9–2.6), for patients with two-staged THA 2.3% (95% CI 1.0-3.6) in the short interval and 2.5% (95% CI 2.1–2.9) in the intermediate interval, respectively. In all three groups, patients who underwent THA in a high-volume center (≥ 500 THA per year) had a significant lower risk for revision (HR 0.687; 95% CI 0.501–0.942) compared to surgeries in a low-volume center (< 250 THA per year). There was no significant difference regarding cumulative mortality rates in the three cohorts. Higher age (HR 1.060; 95% CI 1.042–1.078) and severe comorbidities as reflected in the Elixhauser Score (HR 1.046; 95% CI 1.014–1.079) were associated with higher mortality rates after simultaneous THA.ConclusionSimultaneous bilateral THA seems to be a safe procedure for younger patients with limited comorbidities who have bilateral end-stage hip OA, especially if performed in high-volume centers.Level of evidenceIII.

Comparison of femoral bone remodeling after total hip arthroplasty with cementless short-tapered wedge stem and fully hydroxyapatite-coated stem.

We aimed to compare periprosthetic femoral bone remodeling after cementless total hip arthroplasty (THA) using a short-tapered wedge stem and a fully hydroxyapatite (HA)-coated stem. In this retrospective study, 24 primary cementless THA procedures with short-tapered wedge stem and 24 using a fully HA-coated stem were performed. The follow-up duration was 2 years for both groups. Clinical evaluation was performed using the Merle d'Aubigné and Postel scoring systems. Standardized anteroposterior radiographs of the pelvis and femur were obtained. Dual-energy X-ray absorptiometry was performed, and the bone mineral density (BMD) around the stem was assessed in each Gruen zone at the first postoperative week as a baseline value and at 6 weeks, 3 and 6 months, and 1 and 2 years postoperatively. The mean Merle d'Aubigné and Postel scores improved significantly postoperatively in both groups. None of the hips showed loosening in either group. Spot welds occurred in zones 1, 2, 6, and 7 in the short-tapered wedge group, and in all zones in the fully HA-coated group. Significant BMD loss occurred only in zone 4 in the short-tapered wedge group, and no significant bone loss occurred in any zone in the fully HA-coated stem group; a significant difference between the two groups was observed only in zone 4 at 2 years after THA. Clinical and radiographical outcomes in both groups were good, and both stems suppressed postoperative BMD loss at 2 years.

Are Routine Postoperative Hemoglobin Tests Justified in All Patients Who Undergo Total Hip Arthroplasty Due to a Displaced Femoral Neck Fracture?

Background: Total hip arthroplasty (THA) is a standard treatment for a displaced femoral neck fracture in the elderly. In contemporary healthcare, there is a global shift towards fast-track treatment modalities, prioritizing early hospital discharge for patients. Consequently, routine postoperative blood tests may become redundant, offering significant time and cost savings. We aim to evaluate postoperative hemoglobin levels in trauma-related THA cases and identify patient profiles for whom these tests hold significance. Methods: A retrospective review of 176 THA procedures performed between 2018 and 2022, focusing on individuals undergoing THA for displaced femoral neck fractures. Multivariable logistic regression analysis was employed to identify factors associated with postoperative hemoglobin levels below 8.5 g/dL. Results: Of the 176 patients included, 109 (61.9%) were women and the mean age was 69.09 ± 8.13 (range 27 to 90) years. The majority of the patients underwent surgery within 48 hours of admission. The mean preoperative hemoglobin (Hb) level was 13.1 ± 1.4 g/dL, while the mean postoperative Hb level was 10.5 ± 1.2 g/dL. Only six patients (3.41%) exhibited postoperative Hb levels of ≤8.5 g/dL. No significant associations were found between postoperative Hb levels ≤ 8.5 and any demographic, surgical, or medical characteristics. Conclusions: Our findings suggest that routine postoperative blood count testing may not be necessary for most patients undergoing THA for displaced femoral neck fractures, particularly those without complications or significant comorbidities.

Outcomes of salvage total hip arthroplasty after failed cannulated screw fixation of fractured neck of femur

IntroductionIn a UK setting, cannulated hip screws (CHS) are frequently used to fix femoral neck fractures. Although often a relatively quick procedure and one that is delegated to more junior surgeons, failure rates of up to 23 % have been reported. The salvage procedure is total hip arthroplasty (THA). In this paper we report the outcomes of a series of THA for failed cannulated screw fixation. MethodsRetrospective analysis of one of the largest reported single cohort of 600 CHS procedures spanning 14 years from 2007 to 2020 from a single centre was performed. This identified 55 patients who went on to have total hip arthroplasty, 36 women, 19 men, mean (SD) age: 71.5 (13.6) years. Patient characteristics, reason for fixation failure and complications were recorded. Oxford hip scores were available for 47 patients. Comparison was made with a series of patients who underwent primary THA for fracture. ResultsFailure rate of CHS was 9.2 % in our cohort. Mean (SD) time from fixation to arthroplasty was 15.5 (12.4) months. Two patients (3.6 %) patients had a postop complication, one requiring further surgery. Mean (SD) preoperative Oxford hip score was 11.4 (8.0). This improved to 38.8 (10.4) at 1 year and 32.1 (14.9) at 5 years postoperatively. This compares to a mean (SD) of 39.7 (8.6) at 1 year and 39.4 (8.1) at 5 years in a group of 185 patients undergoing primary THA for hip fracture. Displaced fractures that went on to failure had better postop scores than nondisplaced fractures. DiscussionThe failure rate of CHS is relatively low and the salvage procedure of THA has a minimal complication rate and outcomes as good as primary THA for hip fracture.

Validation of mediCAD® software for fully digital preoperative planning of total hip arthroplasty: a retrospective study

IntroductionThe planning step that precedes a total hip arthroplasty (THA) procedure is crucial. Digital planning software programs are being increasingly used, although few studies have reported on the reliability of such tools. Furthermore, no studies have been conducted on the mediCAD® software, despite it being widely used in France. This led us to conduct a retrospective study to: (1) assess the accuracy of this planning software, (2) determine the intra- and inter-rater reliability, (3) determine how obesity affects the accuracy of planning. HypothesisTHA planning is accurate and reliable when using the mediCAD® software. Patients and methodsThis was a single center, retrospective study. One hundred one consecutive cases performed by a single experienced surgeon were planned retrospectively by two blinded surgeons on two separate occasions. The acetabular cup was cemented in 90 hips (89%), cementless in 11 hips (11%). A dual mobility cup was used in 21 hips (21%). The femoral stem was cemented in 60 hips (59%). The endpoint was the number of exact plans, defined as the same size as the actual implants. An acceptable match was defined as a difference of one size. The match was unacceptable if the planned and implanted size differed by more than 2 for the acetabular cup or by more than 1 size for the femoral stem. The intra-rater and inter-rater reliability were calculated using the intraclass correlation coefficient (ICC) with 95% confidence intervals (CI). ResultsExact agreement was found by the first rater for 15 planned acetabular cups (15%) and for 45 planned femoral stems (45%) relative to the implants used. The second rater reached exact agreement for 20 planned acetabular cups (20%) and 50 planned femoral stems (50%). The intra-rater reliability for the acetabular cup was average (ICC = 0.57; 95%CI [0.43–0.69]) and poor (ICC = 0.38 95%CI [0.20–054]) for the 1st and 2nd rater, respectively. The intra-rater reliability for the femoral stem was poor for the 1st rater (ICC = 0.47 95%CI [0.30–0.61]) and the 2nd rater (ICC = 0.45 95%CI [0.29–0.60]). The interobserver reliability was low for the planned acetabular cup (ICC = 0.39 95%CI [0.21–0.54]) and the planned femoral stem (ICC = 0.42 95%CI [0.24–0.57]). Overall, when combining the two raters, exact prediction of the acetabular cup was achieved in 31 hips (19%) in non-obese patients and in 7 hips (21%) in obese patients (p = 0.62). DiscussionThis study found acceptable reliability of the mediCAD® software. Experience level, radiograph magnification affected the planning outcome in this study, but obesity did not. We currently do not have the ability to incorporate a reliable radiological scale for two-dimensional templating. Some surgeons prefer using a CT scan, but this costs more than conventional radiographs and exposes the patient to more radiation. This study shows that the mediCAD® software can provide satisfactory output for the preoperative planning of THA. Level of evidenceIII; retrospective, diagnostic, comparative study

Total Hip Replacement and Femoral Nail Lengthening for Hip Dysplasia and Limb Length Discrepancy: A Literature Review.

Developmental dysplasia of the hip (DDH) is a serious condition resulting in inadequate acetabular development, distorted bone configuration, and substantially alteredhip biomechanics. An extensive leg length discrepancy (LLD) is commonly encountered in such cases, making a total hip arthroplasty (THA) procedure extremely challenging. Although good results in terms of patients' satisfaction, implant survival rates and overall improved quality of life have been reported, complication rates are considerably higher than primary THA procedures performed for idiopathic osteoarthritis. Reconstructing a dysplastic hip arthrosis and equalizing a preexisting LLD is a technically demanding procedure that is associated with significant bone and soft tissue complications. Intramedullary lengthening through motorized nails has become increasingly popular to address difficult cases with extensive LLD following THA in recent years. However, limited data on femoral lengthening procedures implemented following THA are available considering complications, radiological results, and patient-reported outcomes following staged THA and subsequent femoral lengthening using a femoral magnetically-driven intramedullary lengthening nail. We performed a literature review of the past 10 years in PubMed using the terms neglected hip dislocation, DDH, THA, and intramedullary lengthening nail as keywords. A total amount of eight cases addressing LLD through a telescoping intramedullary nail following THA in DDH have been reported in recent literature. All eight patients underwent primary THA for DDH followed by the implantation of the intramedullary lengthening nail. The mean THA was lengthened by 28.9 mm (from 13.0 to 45.0). The mean time for nail implantation after THA was 11.1 months (from 3.5 to 21). The mean time for lengthening per day through the nail was 0.94 mm (from 0.65 to 1.0) from 26 days to 70 days, and the mean lengthening through the nail was 37.6 mm (from 24.0 to 70.0). Good union and consolidation rates were reported by the authors, while there were no complications. The intramedullary distraction osteogenesis method with a telescopic rod can be an effective method to manage leg length discrepancies while avoiding soft tissue complications in challenging cases of DDH.

Influence of broach surface design of a fully hydroxyapatite coated, double tapered stem on periprosthetic bone mineral density after total hip arthroplasty: a study based on the morphology of the proximal femur.

This study aimed to compare the impact of different broach surface designs on post-operative clinical outcomes, bone reactions and changes in bone mineral density (BMD) in patients who underwent total hip arthroplasty (THA) using a fully hydroxyapatite coated and double tapered stem with either compaction shape (COM) or hybrid shape (HYB) broaches. A retrospective analysis was conducted on 76 patients (100 hips) who underwent primary THA using the Avenir complete stem®. Patients were divided into two groups: the COM broach group (50 hips) and HYB broach group (50 hips). We evaluated clinical outcomes using the Japanese Orthopaedic Association hip scores one month before the surgery, and 12 and 24months after the surgery. Radiographic findings, including stem alignment angles, radiolucent lines, spot welds, and cortical hypertrophy, were assessed. BMD around the stem in Gruen zones 1-7 was evaluated using dual-energy X-ray absorptiometry (DEXA) at 7days, 12, and 24months post-operatively. The Dorr classification was used to assess femoral morphology. There were no significant differences in clinical outcomes, radiographic findings, or BMD changes between the COM and HYB broach groups in the overall patient cohort. However, in Dorr type A femurs, the COM broach group demonstrated superior BMD superior preservation in zones 1 and 7 after 12months and in zones 1, 6 and 7 after 24months. Additionally, in Dorr type B femurs, significant BMD preservation was observed in zone 3 at 24months in the COM broach group. This study suggests that the broach surface design of fully hydroxyapatite coated stems may influence periprosthetic BMD changes, especially in Dorr type A and B femurs. Surgeons should consider broach selection based on patient-specific femoral morphology to optimize BMD preservation in THA procedures using fully hydroxyapatite coated stems.

US-Guided Interventional Procedures for Total Hip Arthroplasty.

In patients with total hip arthroplasty (THA) with recurrent pain, symptoms may be caused by several conditions involving not just the joint, but also the surrounding soft tissues including tendons, muscles, bursae, and peripheral nerves. US and US-guided interventional procedures are important tools in the diagnostic work-up of patients with painful THA given that it is possible to reach a prompt diagnosis both directly identifying the pathological changes of periprosthetic structures and indirectly evaluating the response and pain relief to local injection of anesthetics under US monitoring. Then, US guidance can be used for the aspiration of fluid from the joint or periarticular collections, or alternatively to follow the biopsy needle to collect samples for culture analysis in the suspicion of prosthetic joint infection. Furthermore, US-guided percutaneous interventions may be used to treat several conditions with well-established minimally invasive procedures that involve injections of corticosteroid, local anesthetics, and platelet-rich plasma or other autologous products. In this review, we will discuss the clinical and technical applications of US-guided percutaneous interventional procedures in painful THA that can be used in routine daily practice for diagnostic and therapeutic purposes.

Hospital variation in quality indicators for patient blood management in total knee and hip arthroplasty: a retrospective cohort study

BackgroundAnaemia, blood loss, and blood transfusion are critical aspects of patient care in major orthopaedic surgery. We assessed hospital adherence to guideline-recommended Patient Blood Management (PBM) care, analysed variations between hospitals, and validated two composite indicators of hospital PBM performance in patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA). MethodsThis retrospective cohort study included all primary TKA and THA procedures performed during 2021 across 39 hospitals in Spain. We assessed hospital adherence to key guideline-recommended PBM interventions using nine individual quality indicators and two types of composite quality indicators (cQIs): opportunity-based (cQI1) and all-or-none (cQI2). We validated these cQIs by analysing their associations with the adjusted total transfusion index using linear regression. ResultsWe included 8561 patient episodes from 33 hospitals in the analysis. Delivery of PBM care was similar for TKA and THA. Patients received 62% of the analysed PBM interventions and only 12% of patients underwent the full PBM pathway. Higher hospital cQIs scores were associated with a lower adjusted total transfusion index, both in TKA and THA. The greatest association was found for cQI1 in THA patients (β=−1.18 [95% confidence interval −2.00 to −0.36]; P=0.007). ConclusionsHospital adherence to guideline-recommended patient blood management care in total hip and knee arthroplasty was suboptimal and varied across centres. Using data that are widely available in hospitals, quality indicators and composite scores could become valuable tools for patient blood management monitoring and comparisons between healthcare organisations.

The influence of body mass index on patient-reported outcome measures following total hip arthroplasty: a retrospective study of 3,903 Cases.

The influence of obesity on patient-reported outcome measures (PROMs) following total hip arthroplasty (THA) is currently controversial. This study aimed to compare PROM scores for pain, functional status, and global physical/mental health based on body mass index (BMI) classification. Primary, elective THA procedures at a single institution between 2018 and 2021 were retrospectively reviewed, and patients were stratified into four groups based on BMI: normal weight (18.5-24.99kg/m2), overweight (25-29.99kg/m2), obese (30-39.99kg/m2), and morbidly obese (> 40kg/m2). Patient-Reported Outcome Measurement Information System (PROMIS) and Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR) scores were collected. Preoperative, postoperative, and pre/post- changes (pre/post-Δ) in scores were compared between groups. Multiple linear regression was used to assess for confounders. We analyzed 3,404 patients undergoing 3,903 THAs, including 919 (23.5%) normal weight, 1,374 (35.2%) overweight, 1,356 (35.2%) obese, and 254 (6.5%) morbidly obese cases. HOOS, JR scores were worse preoperatively and postoperatively for higher BMI classes, however HOOS, JR pre/post-Δ was comparable between groups. All PROMIS measures were worse preoperatively and postoperatively in higher BMI classes, though pre/post-Δ were comparable for all groups. Clinically significant improvements for all BMI classes were observed in all PROM metrics except PROMIS mental health. Regression analysis demonstrated that obesity, but not morbid obesity, was independently associated with greater improvement in HOOS, JR. Obese patients undergoing THA achieve lower absolute scores for pain, function, and self-perceived health, despite achieving comparable relative improvements in pain and function with surgery. Denying THA based on BMI restricts patients from clinically beneficial improvements comparable to those of non-obese patients, though morbidly obese patients may benefit from additional weight loss to achieve maximal functional improvement.

Projected volume of primary total joint arthroplasty in the USA from 2019 to 2060.

The global incidence of total joint arthroplasty (TJA) has consistently risen over time, and while various forecasts differ in magnitude, future projections suggest a continued increase in these procedures. Differences in future United States projections may arise from the modeling method selected, the nature of the national arthroplasty registry employed, or the representativeness of the specific hospital discharge records utilized. In addition, many models have not accounted for ambulatory surgery as well as all payer types. Therefore, to attempt to make a more accurate model, we utilized a national representative sample that included outpatient arthroplasties and all insurance types to predict the volumes of primary TJA in the USA from 2019 to 2060. A national, all-payer database was queried. All patients who underwent primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) from January 1, 2010, to December 31, 2019, were identified using international classification of disease Ninth Revision (9) and Tenth Revision (10) codes and current procedure terminology codes. Absolute frequencies and incidence rates were calculated per 100,000 for both THA and TKA procedures, with 95% confidence intervals. Mean growth in absolute frequency and incidence rates were calculated for each procedure from 2010 to 2014, and 2010 to 2019, with 95% confidence intervals (CI). The overall increase in THA and TKA procedures are expected to grow + 10 and + 36%, respectively, using linear regressions and + 9 and + 37%, respectively. The most positive mean growth in procedure frequency occurred from 2010 to 2014 for THA (+ 24, 95% Confidence Interval (CI): + 21, + 27) and 2010-2019 for TKA (+ 11%, 95% CI: + 9, + 14). There positive trend patterns in incidence rate growth for both procedures, with similar 2010-2019 incidence rates + 6%) for THA (+ 3%, 95% CI: + 0, + 6%) and TKA (+ 3%, 95% CI: + 1%, + 6%). Utilizing a nationally representative database, we demonstrated that TJA procedures would continue with an increased growth pattern to 2060, though slightly decreased from the surge from 2014 to 2019. While this finding applies to the representativeness of the population at hand, the inclusion of outpatient arthroplasty and all payer types validates an approach that has not been undertaken in previous projection studies.

The cementless taper wedge vs. fit-and-fill stem in primary total hip arthroplasty: risk of stem-related complication differs across Dorr types.

The choice between a cementless taper wedge stem and a fit-and-fill stem in total Hip arthroplasty (THA) for various proximal femoral morphological types has not been thoroughly evaluated. This study aimed to compare the risk of stem-related complications between these two stem types in Dorr type A, B, and C femurs. From January 2015 through April 2021, we retrospectively reviewed 1995 cementless THA procedures. We stratified all procedures into three groups: Dorr type A (N = 360, 18.0%), B (N = 1489, 74.7%) and C (N = 146, 7.3%). The primary outcome domain was stem-related complications, including stem subsidence ≥ 3mm, intraoperative fracture, periprosthetic fracture and aseptic stem loosening. We performed multivariate regression analysis to compare the risk of stem-related complication between the two stem types. Other factors included age, sex, body mass index, diagnosis, age-adjusted Charlson comorbidity index, stem alignment and canal fill ratio. The incidence of stem-related complications in the taper wedge and fit-and-fill stem groups was 4.4% (N = 15) and 6.5% (N = 107), respectively. Fit-and-fill stems showed an increased risk of stem-related complications (aOR: 9.903, 95% CI: 1.567-62.597) only in Dorr type C femurs. No significant difference in risk was observed in Dorr type A and B femurs. Furthermore, the canal fill ratio at the lesser trochanter, 2cm and 7cm below the lesser trochanter, did not exhibit an association with stem-related complications in any Dorr type. Concerning the risk of stem-related complications, the taper wedge stem was a better choice in Dorr type C femurs. However, there was no difference in risk between the taper wedge stem and fit-and-fill stem in Dorr type A and B femurs.

Risk Versus Reward: Hospitals Incentivized More Than Surgeons to Care for Riskier Arthroplasty Patients

BackgroundThe purpose of this study was to assess the relationship between risk and reimbursement for both surgeons and hospitals among Medicare patients undergoing primary total joint arthroplasty (TJA). MethodsThe “2021 Medicare Physician and Other Provider” and “2021 Medicare Inpatient Hospitals” files were used. Patient comorbidity profiles were collected, including the mean patient hierarchal condition category (HCC) risk score. Surgeon data included all primary TJA procedures (inpatient and outpatient) billed to Medicare in 2021, while hospital data included all such inpatient episodes. Surgeon and hospital reimbursements were collected. All episodes were split into a “sicker cohort” with an HCC risk score of 1.5 or more and a “healthier cohort” with HCC risk scores less than 1.5. Variables were compared across cohorts. ResultsIn 2021, 386,355 primary total hip and knee arthroplasty procedures were billed to Medicare and were included. The mean surgeon reimbursement among the sicker cohort was $1,021.91, which was less than for the healthier cohort of $1,060.13 (P < .001). Meanwhile, for the hospital analysis, 112,012 Medicare TJA patients were admitted as inpatients and included. The mean reimbursement to hospitals was significantly greater for the sicker cohort at $13,950.66, compared to the healthier cohort of $8,430.46. For both analyses, the sicker patient cohorts had a significantly higher rate of all comorbidities assessed (P < .001). ConclusionsThis study demonstrates that mean surgeon reimbursement was lower for primary TJA among sicker patients in comparison to their healthier counterparts, while hospital reimbursement was higher for sicker patients. This represents a discrepancy in the incentivization of care for complex patients, as hospitals receive increased remuneration for taking on extra risk, while surgeons get paid less on average for performing TJA on sicker patients. Such data should inform future policy to assure continued access to arthroplasty care among complex patients.

Preoperative prediction model for risk of readmission after total joint replacement surgery: a random forest approach leveraging NLP and unfairness mitigation for improved patient care and cost-effectiveness

BackgroundThe Center for Medicare and Medicaid Services (CMS) imposes payment penalties for readmissions following total joint replacement surgeries. This study focuses on total hip, knee, and shoulder arthroplasty procedures as they account for most joint replacement surgeries. Apart from being a burden to healthcare systems, readmissions are also troublesome for patients. There are several studies which only utilized structured data from Electronic Health Records (EHR) without considering any gender and payor bias adjustments.MethodsFor this study, dataset of 38,581 total knee, hip, and shoulder replacement surgeries performed from 2015 to 2021 at Novant Health was gathered. This data was used to train a random forest machine learning model to predict the combined endpoint of emergency department (ED) visit or unplanned readmissions within 30 days of discharge or discharge to Skilled Nursing Facility (SNF) following the surgery. 98 features of laboratory results, diagnoses, vitals, medications, and utilization history were extracted. A natural language processing (NLP) model finetuned from Clinical BERT was used to generate an NLP risk score feature for each patient based on their clinical notes. To address societal biases, a feature bias analysis was performed in conjunction with propensity score matching. A threshold optimization algorithm from the Fairlearn toolkit was used to mitigate gender and payor biases to promote fairness in predictions.ResultsThe model achieved an Area Under the Receiver Operating characteristic Curve (AUROC) of 0.738 (95% confidence interval, 0.724 to 0.754) and an Area Under the Precision-Recall Curve (AUPRC) of 0.406 (95% confidence interval, 0.384 to 0.433). Considering an outcome prevalence of 16%, these metrics indicate the model’s ability to accurately discriminate between readmission and non-readmission cases within the context of total arthroplasty surgeries while adjusting patient scores in the model to mitigate bias based on patient gender and payor.ConclusionThis work culminated in a model that identifies the most predictive and protective features associated with the combined endpoint. This model serves as a tool to empower healthcare providers to proactively intervene based on these influential factors without introducing bias towards protected patient classes, effectively mitigating the risk of negative outcomes and ultimately improving quality of care regardless of socioeconomic factors.

Trends in Gender Diversity Among Total Hip Arthroplasty Surgeons.

A pronounced gender imbalance is evident among orthopaedic surgeons. In the field of arthroplasty, there exists a dearth of comprehensive data regarding gender representation. This study aimed to analyze the gender diversity, or lack thereof, within the field of total hip arthroplasty (THA). In addition, this study used literature review to identify possible reasons for the gender disparity among THA surgeons and identify the best next steps to promote gender equity within orthopaedics. A retrospective analysis was conducted using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set to quantify orthopaedic surgeons who performed primary THA procedures from 2013 to 2020. To assess trends in the number of hip surgeons by sex and the evolving female-to-male ratio, two-sided correlated Mann-Kendall tests were conducted. Overall, 3,853 to 4,550 surgeons billed for primary THA annually. Of this number, an average of 1.7% was female. The mean number of services billed for by male surgeons was 31.62 ± 24.78 per year and by female surgeons was 26.43 ± 19.49 per year. Trend analysis of female-to-male ratio demonstrated an increasing trend of statistical significance (P = 0.009). The average number of procedures by female surgeons annually remained stable throughout the study, whereas there was a steady increase in that for male surgeons. Results showed a notable and sustained upward trajectory from 2013 to 2020 in the number of female surgeons billing for THA along with the female-to-male ratio. However, female surgeons constitute a mere 2% of surgeons engaging in primary THA billing. Furthermore, the annual average number of THAs conducted by female surgeons exhibited constancy, whereas there was a gradual increase in the median number of annual procedures performed by their male counterparts. Future studies should aim to identify and resolve specific barriers prohibiting female medical students from pursuing and obtaining a career as an orthopaedic THA surgeon. Retrospective analysis using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set.

Risk Factors of Failure to Discharge Before “Two Midnights” in Outpatient-Designated Total Hip Arthroplasty

Introduction: The Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the inpatient-only list but continued to classify admissions as inpatient if they include two midnights, complicating care if an outpatient THA requires extended hospitalization. This study evaluates risk factors of patients undergoing outpatient-designated THA with a length of stay (LOS) ≥ 2 days. Methods: A total of 17,063 THA procedures designated as outpatient in the National Surgical Quality Improvement Program database between 2015 and 2020 were stratified by LOS &lt; 2 days (n = 2,294, 13.4%) and LOS ≥ 2 days (n = 14,765, 86.6%). Demographics, comorbidities, and outcomes were compared by univariate analysis. Multivariable regression analysis identified predictors of LOS ≥ 2 days. Results: Outpatients with extended LOS were older (mean 65.3 vs. 63.5 years; P &lt; 0.01); were more likely to have body mass index (BMI) &gt; 35 (24.0 vs. 17.8%; P &lt; 0.01); and had higher incidences of smoking (15.1% vs. 10.3%; P &lt; 0.01), diabetes (15.4% vs. 9.9%; P &lt; 0.01), chronic obstructive pulmonary disease (4.4% vs. 2.3%; P &lt; 0.01), and hypertension (57.6% vs. 49.2%; P &lt; 0.01). Patients with LOS ≥ 2 days had a higher incidence of surgical site infection (P &lt; 0.01), hospital readmission (P &lt; 0.01), and revision surgery (P &lt; 0.01) over 30 days. Multivariable analysis demonstrated advanced age, female sex, African American race, Hispanic ethnicity, diabetes, smoking, and hypertension were independent risk factors for LOS ≥ 2 days. Conclusion: Despite removal from the inpatient-only list, a subset of outpatient THA remains at risk of an extended LOS. This study informs surgeons on the relevant risk factors of extended stay, enabling early inpatient preauthorization.

The learning curve for robotic-assisted total hip arthroplasty in low, medium, and high-volume surgeons

BackgroundRobotic systems have been designed to increase the accuracy of implant alignment in total knee and hip arthroplasty. This technology is associated with a learning curve for the operative time to reach peak efficiency in its use. Prior studies done on high-volume orthopedic surgeons have suggested a learning curve of 14–35 cases for robotic-assisted total hip arthroplasty (THA). It is unclear if this learning curve is different for surgeons with lower volumes. MethodsData was collected retrospectively from 299 THA procedures done by three different surgeons, with low (1–15 cases/year), medium (16–50), and high (51+) volume caseload. The learning curve was assessed primarily by average operative time from cases 1–20, 21–50, and 51+. ResultsThe high-volume surgeon had a learning curve of 20 cases, while the low and medium volume surgeons had no significant decrease in their operative time through the cases included in the study (20 and 63, respectively). ConclusionsHigh volume surgeons have a learning curve of about 20 cases, while low and medium volume surgeons have a longer curve, which was not able to be measured in this study.

Estimation of acetabular cup prosthesis coverage rate in total hip arthroplasty based on X-ray films

To explore the method of accurately estimating the acetabular cup prosthesis coverage rate (hereinafter referred to as "cup coverage rate") in total hip arthroplasty (THA) based on X-ray films, and to determine the effective parameters that can be used to estimate the cup coverage rate. The three-dimensional printed pelvic models were established based on CT data of 16 healthy pelvis, and the acetabular prosthesis were implanted according to conventional THA procedure. The length and width of the uncovered area of the acetabular cup prosthesis were measured by a modified X-ray recording method with a rotating C-arm X-ray machine, and the cup coverage rate was calculated. Then the differences among the traditional anteroposterior X-ray recording method, the modified method, and actual measurement on pelvic model were statistically analyzed. The correlation between the area of the uncovered area of the prosthesis and its width and length was analyzed by using multiple linear regression analysis. The cup coverage rates of traditional method, modified method, and actual measurement were 78.22%±3.36%, 86.74%±3.61%, and 89.62%±2.62%, respectively, with significant differences ( P<0.05). The results of multiple linear regression analysis showed that the width and length were positively linear with the uncovered area of the prosthesis, and the regression equation was as follows: uncovered area of the prosthesis=-21.192+0.248×width+0.140×length, and the coefficient of determination R 2=0.857, P<0.001. Compared with the traditional method, the modified method can more accurately evaluate the cup coverage rate during THA, and the width of the uncovered area of the prosthesis can be used as an effective reference for the cup coverage rate.

Oral Postoperative Antibiotic Prophylaxis for Outpatient Total Hip and Knee Arthroplasty: Describing Current Practices

BackgroundDespite an increase in outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA), large-scale data are lacking on current practice for antibiotic prophylaxis prescribing. We aimed to describe current oral antibiotic prophylaxis practices nationally for outpatient THA and TKA. MethodsThis nationwide retrospective cohort study included primary outpatient THA or TKA procedures in patients aged 18 to 64 years from 2018 to 2021 using a national claims database. Oral antibiotic prescriptions filled perioperatively (defined as 5 days before to 3 days after surgery) were extracted; these were categorized and assumed to represent postoperative prophylaxis. Multivariable logistic regression measured associations between patient and surgery characteristics and perioperative oral antibiotic prophylaxis. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) are reported. ResultsOral antibiotic prescriptions were filled in 16.5% of 73,015 outpatient THA and TKA (18.4% of 24,857 THAs, 15.5% of 48,158 TKAs) procedures. Prescriptions were most often for cephalosporins (74.3%), with cephalexin (52.8%), and cefadroxil (19.1%) being the most common. Non-cephalosporin antibiotics prescribed were mainly clindamycin (6.8%), sulfamethoxazole-trimethoprim (6.7%), and doxycycline (6.2%). The odds of receiving oral antibiotic prophylaxis were higher for THA compared to TKA (OR 1.13, 95% CI 1.09 to 1.18, P < .001) and in the presence of obesity, diabetes, and autoimmune conditions (OR 1.08 to 1.13, P < .001 to .01). Ambulatory surgery center procedures also had significantly increased odds of prophylaxis compared to hospital-based outpatient surgeries (OR 2.62, 95% CI 2.51 to 2.73, P < .001). Additionally, regional and time-based variations were noted. ConclusionsPerioperative oral antibiotic prophylaxis prescriptions were filled in only 16.5% of outpatient THA and TKA cases, with variation in the type of antibiotic prescribed. The receipt of any prophylaxis and specific medications was associated with demographic, clinical, and procedure-related characteristics. Follow-up research will evaluate associations with infection risk reduction.