Utilization Of Total Hip Arthroplasty Research Articles

Decreasing Length of Hospital Stay and Postoperative Complications After Primary Total Hip Arthroplasty: A Decade Analysis From 2006 to 2016

BackgroundIn an attempt to decrease costs without increasing complication burden, the development of rapid recovery protocols has led to an increased push for decreased length of hospital stay (LOS) following total hip arthroplasty (THA). The purpose of this study was to analyze trends in LOS and complications following THA over a 10-year period. MethodsUsing the National Surgical Quality Improvement Program registry from 2006 to 2016, we identified all patients who underwent primary THA. Patients were placed into 3 cohorts based on the year of surgery (2006-2009 [N = 3873], 2010-2013 [N = 45,992], 2014-2016 [N = 86,099]). Differences in LOS, operative time, readmission rates, and 30-day postoperative medical complications were compared using bivariate and multivariate analyses. ResultsMultivariate regression analysis identified a significant decrease in LOS in days for the 2010-2013 cohort (3.2 ± 4.8, P < .001) and 2014-2016 cohort (2.7 ± 2.5, P < .001) compared to the 2006-2009 cohort (3.8 ± 2.5). Despite decreasing LOS, there were significantly lower complications in the later cohorts, with significantly lower rates of all complications (5.27% [2006-2009], 3.77% [2009-2013], 3.14% [2013-2016]), sepsis (0.70%, 0.31%, 0.16%), and urinary tract infection (1.94%, 1.23%, 0.83%) using both bivariate and multivariate analyses (P < .001). In addition, there was no significant difference in unplanned 30-day readmissions (3.66% [2010-2013] vs 3.5% [2014-2016], P = .142). ConclusionOver the last decade, there has been a decrease in LOS and an improved short-term complication profile for THA. With continually increasing rates of utilization of THA along broader patient demographics, these changes are important to help mitigate the costs of higher volume.

Cost-Effectiveness of Total Hip Arthroplasty Versus Nonoperative Management in Normal, Overweight, Obese, Severely Obese, Morbidly Obese, and Super Obese Patients: A Markov Model

BackgroundWe estimated the cost-effectiveness of performing total hip arthroplasty (THA) vs nonoperative management (NM) among 6 body mass index (BMI) cohorts. MethodsWe constructed a state-transition Markov model to compare the cost utility of THA and NM in the 6 BMI groups over a 15-year period. Model parameters for transition probability (risk of revision, re-revision, and death), utility, and costs (inflation adjusted to 2017 US dollars) were estimated from the literature. Direct medical costs of managing hip arthritis were accounted in the model. Indirect societal costs were not included. A 3% annual discount rate was used for costs and utilities. The primary outcome was the incremental cost-effectiveness ratio (ICER) of THA vs NM. One-way and Monte Carlo probabilistic sensitivity analyses of the model parameters were performed to determine the robustness of the model. ResultsOver the 15-year time period, the ICERs for THA vs NM were the following: normal weight ($6043/QALYs [quality-adjusted life years]), overweight ($5770/QALYs), obese ($5425/QALYs), severely obese ($7382/QALYs), morbidly obese ($8338/QALYs), and super obese ($16,651/QALYs). The 2 highest BMI groups had higher incremental QALYs and incremental costs. The probabilistic sensitivity analysis suggests that THA would be cost-effective in 100% of the normal, overweight, obese, severely obese, and morbidly obese simulations, and 99.95% of super obese simulations at an ICER threshold of $50,000/QALYs. ConclusionEven at a willingness-to-pay threshold of $50,000/QALYs, which is considered low for the United States, our model showed that THA would be cost-effective for all obesity levels. BMI cut-offs for THA may lead to unnecessary loss of healthcare access.

Increased Total Hip Arthroplasty Utilization, Osteoarthritis Diagnoses, and Comorbidity Burden in Patients Younger Than the Age of 65 Years: National Inpatient Trends 1998 to 2013

AbstractPrimary total hip arthroplasty (THA) in patients younger than the age of 65 years demands long-term success to minimize lifetime revision surgery risks. Age at implantation, etiology of arthrosis, and comorbidity burden all have associations with revision risk. This study uses Nationwide Inpatient Sample (NIS) data between 1998 and 2013 to (1) report the annual utilization of THA in patients age 18 to 99 years divided into age groups, (2) determine trends in primary diagnoses, and (3) explore Elixhauser comorbidity burden trends. The authors reviewed 5,174,020 THA cases from the NIS. Cases were divided into age groups: 18 to 24, 25 to 34, 35 to 44, 45 to 54, 55 to 64, and 65 to 99 years. The annual utilization rate, primary diagnoses, and average count of Elixhauser comorbidities were plotted. Mann–Kendall's nonparametric tests determined significance with p &lt; 0.05. The mean utilization of primary THA in patients aged 18 to 64 years was 57 cases per 105 persons (cpp). The incidence of utilization increased rapidly in patients age 55 to 64 years (123–240 cpp, p &lt; 0.001) and age 45 to 54 years (46–100 cpp, p &lt; 0.001). The predominant diagnoses were osteoarthritis increasing from 65 to 83% (p &lt; 0.001), avascular necrosis decreasing from 17 to 7% (p &lt; 0.001), and trauma decreasing from 11 to 6% (p &lt; 0.001). The average count of Elixhauser comorbidities increased in all age groups from a minimum of 58% (1.2–1.9, p &lt; 0.001) in patients age 55 to 64 years to a maximum of 200% (0.4–1.2, p = 0.003) in patients age 18 to 24 years. Increases in primary THA utilization are occurring disproportionately among patients age 45 to 64 years. The trends in etiologies and comorbidities show mixed anticipated effects on the risks for revision. Increased osteoarthritis diagnoses may be favorable as the etiology with the longest relative implant survival. However, increasing comorbidities may unfavorably heighten the risks of revision. Primary THA utilization is increasing for patients younger than the age of 65 years with osteoarthritis and rising comorbidity burdens. Current national administrative databases add valuable insights to large THA trends, but lack the granularity to fully characterize the causes behind revisions of primary THA.

Operative Trends in the Treatment of Hip Fractures and the Role of Arthroplasty.

Introduction:There is a projected exponential increase in the number of hip fractures in the United States. Trends in patient demographics and the role of total hip arthroplasty (THA) and its associated outcomes following hip fractures surgery have not been well studied.Methods:Patients with proximal femur fractures between 1990 and 2007 were identified in the National Hospital Discharge Survey database. Demographics, comorbidities, perioperative complications, and discharge status for patients undergoing THA, hemiarthroplasty, or internal fixation were examined. Multivariable regression was performed to determine independent risk factors for perioperative complications.Results:Between 1990 and 2007, there was a statistically significant increase in patient age, adverse events, medical comorbidities, surgical complications, medical complications, and nonroutine discharge across all surgical treatment modalities. In the same time period, the utilization of THA for all fracture types decreased significantly.Discussion:Total hip arthroplasty was found to be an independent risk factor for perioperative complications. Orthopedic surgeons should be aware that the hip fracture population continues to get older, with more medical comorbidities and are at higher risk for perioperative complications.Conclusion:Total hip arthroplasty is associated with a higher rate of perioperative complications in the hip fracture population.

Disparities in Total Hip Arthroplasty Versus Hemiarthroplasty in the Management of Geriatric Femoral Neck Fractures.

Introduction:Recent clinical evidence suggests that total hip arthroplasty (THA) provides improved clinical outcomes as compared to hemiarthroplasty (HA) for displaced femoral neck fractures in elderly individuals. However, THA is still utilized relatively infrequently. Few studies have evaluated the factors affecting utilization and the role socioeconomics plays in THA versus HA.Methods:In the United States, the National Inpatient Sample (NIS) database was used to identify patients treated surgically for femoral neck fracture, between 2009 and 2010. Patients were identified using International Classification of Diseases, Ninth Revision, codes for closed, transcervical femoral neck fractures and closed fractures at unspecified parts of the femoral neck. All candidate predictors of THA versus HA were entered into a multilevel mixed-effect regression model.Results:Older patient age, being Asian or Pacific Islander, and having Medicaid payer status were all associated with lower odds of receiving THA. Patients with private insurance including Health Maintenance organization (HMO) had higher odds of THA as did patients with other insurance. Odds of THA were significantly lower among patients in teaching hospitals and higher at hospitals with greater THA volume.Discussion:Ethnicity, payer status, hospital size, and institutional THA volume were all associated with the utilization of THA versus HA in the treatment of geriatric femoral neck fractures.Level of Evidence:Level III Retrospective Cohort study.

Evaluation of Contemporary Trends in Femoral Neck Fracture Management Reveals Discrepancies in Treatment

Background:Recent evidence supports total hip arthroplasty (THA) as compared to hemiarthroplasty (HA) for the management of displaced femoral neck fractures in a significant subset of elderly patients. The purpose of this study was to examine trends in femoral neck fracture management over the last 12 years.Methods:Using the National Inpatient Sample database, we identified patients treated for femoral neck fractures between 1998 and 2010 with THA, HA, or internal fixation (IF). We examined treatment trends and demographic variables including patient age, gender, socioeconomic status, and payer and hospital characteristics.Results:We identified 362 127 femoral neck fracture patients treated between 1998 and 2010. Overall, there were statistically significant increases in rates of THA and HA, whereas rates of IF decreased. Total hip arthroplasty varied based on patient age, with significant increases occurring in age-groups 0 to 49 years, 50 to 59 years, 60 to 69 years, and 70 to 79 years. Utilization of THA varied significantly based on socioeconomic status and race. Patient sex, urban versus rural hospital location, and teaching versus nonteaching hospital status were not related to rates of THA.Conclusion:Rates of THA for femoral neck fractures increased between 1998 and 2010 in patients younger than 80 years, suggesting that surgeons are responding to clinical evidence supporting THA for the treatment of elderly femoral neck fractures. This is the first study to demonstrate this change and expose disparities in practice patterns over time in response to this evidence in the United States. Further research is indicated to explore the effect of socioeconomic status and race on femoral neck fracture management.

Changing trends in the treatment of femoral neck fractures: a review of the american board of orthopaedic surgery database.

The purpose of this study was to investigate the trends in operative management of femoral neck fractures by orthopaedic surgeons applying for board certification. We queried the American Board of Orthopaedic Surgery database to identify all femoral neck fractures that had been treated and reported by candidates taking Part II of the licensing examination from 1999 to 2011 to determine the utilization of internal fixation, hemiarthroplasty, and total hip arthroplasty. The longitudinal trends were then stratified by patient age (younger than sixty-five, sixty-five to seventy-nine, eighty and older) and the declared subspecialty of the candidate. There were 19,541 femoral neck fractures that had been treated by 4450 board certification candidates. The use of total hip arthroplasty increased over time (0.7% of fractures in 1999, 7.7% in 2011, p < 0.001); use of hemiarthroplasty (67.1% in 1999, 63.1% in 2011, p = 0.020) and internal fixation (32.2% in 1999, 29.2% in 2011, p = 0.064) declined slightly. All geographic regions showed an increase in utilization of total hip arthroplasty, with substantial variation between locations. The proportion of patients younger than age sixty-five who were managed with total hip arthroplasty increased from 1.4% to 13.1% (p < 0.001). Candidates with a declared subspecialty of "adult reconstruction" showed a strong trend toward the use of total hip arthroplasty (4.3% from 1999 to 2002, 21.1% from 2009 to 2011, p < 0.001), while "trauma" subspecialty candidates demonstrated decreasing utilization of internal fixation (40.9% from 1999 to 2002, 32.9% from 2009 to 2011, p = 0.012). The percentage of candidates treating at least one femoral neck fracture decreased from 54.8% from 1999 to 2002 to 46.3% from 2009 to 2011 (p < 0.001). The most substantial changes in treatment of femoral neck fractures were seen in the younger group of patients. Currently, a smaller percentage of board certification candidates are treating femoral neck fractures than those in the past, possibly reflecting a trend toward specialty care.

Utilization rates of hip arthroplasty in OECD countries

Hip arthroplasty and revision surgery is growing exponentially in OECD countries, but rates vary between countries. We extracted economic data and utilization rates data about hip arthroplasty done in OECD countries between 1990 and 2011. Absolute number of implantations and compound annual growth rates were computed per 100,000 population and for patients aged 65 years old and over and for patients aged 64 years and younger. In the majority of OECD countries, there has been a significant increase in the utilization of total hip arthroplasty in the last 10 years, but rates vary to a great extent: In the United States, Switzerland, and Germany the utilization rate exceeds 200/100,000 population whereas in Spain and Mexico rates are 102 and 8, respectively. There is a strong correlation between gross domestic product (GDP) and health care expenditures per capita with utilization rate. Utilization rates in all age groups have continued to rise up to present day. A seven fold higher growth rate was seen in patients aged 64 years and younger as compared to older patients. We observed a 38-fold variation in the utilization of hip arthroplasty among OECD countries, correlating with GDP and health care expenditures. Over recent years, there has been an increase in the utilization rate in most countries. This was particularly evident in the younger patients. Due to increasing life expectancy and the disproportionally high use of arthroplasty in younger patients we expect an exponential increase of revision rate in the future.

A New Automated Way to Measure Polyethylene Wear in THA Using a High Resolution CT Scanner: Method and Analysis

As the most advantageous total hip arthroplasty (THA) operation is the first, timely replacement of only the liner is socially and economically important because the utilization of THA is increasing as younger and more active patients are receiving implants and they are living longer. Automatic algorithms were developed to infer liner wear by estimating the separation between the acetabular cup and femoral component head given a computed tomography (CT) volume. Two series of CT volumes of a hip phantom were acquired with the femoral component head placed at 14 different positions relative to the acetabular cup. The mean and standard deviation (SD) of the diameter of the acetabular cup and femoral component head, in addition to the range of error in the expected wear values and the repeatability of all the measurements, were calculated. The algorithms resulted in a mean (±SD) for the diameter of the acetabular cup of 54.21 (±0.011) mm and for the femoral component head of 22.09 (±0.02) mm. The wear error was ±0.1 mm and the repeatability was 0.077 mm. This approach is applicable clinically as it utilizes readily available computed tomography imaging systems and requires only five minutes of human interaction.

Bearing Surface Choice: A South American Experience

The overall utilization of total hip arthroplasty in South America is expected to increase substantially during the next decades due to the absolute increase in population, longer life expectancy, expansion of indications to younger patients, the increasing number of surgeons, and greater willingness of the patient to undergo a joint replacement. For the young and more active patient ceramic-on-ceramic and ceramic-on-polyethylene are the most widely used bearing surfaces in South America. The associated higher costs and revision rates should be taken into account by the health policy systems, so that disparities are decreased and access is not threatened.

Influence of ethnicity and socioeconomic factors on outcome after total hip replacement

Previous studies have documented ethnic differences in the utilization of total hip arthroplasty. Less is known if this operation is performed at the same stage of symptoms and has equal effects in patients with different ethnicity. We investigated whether patients born outside Sweden report equal effects of operation with the insertion of a total hip replacement in terms of EQ-5D, pain and overall satisfaction as those born in Sweden. Preoperative and 1-year postoperative data from Swedish Hip Arthroplasty Register, (1216 patients,1216 hips) with primary osteoarthritis of the hip operated between years 2002 and 2006, were analysed. All patients completed the EQ-5D form, filled in a VAS about pain preoperatively and at 1 year postoperatively, when a VAS about overall satisfaction was added. Before the operation and after adjustment for confounders, patients born abroad reported more problems (dichotomized into no or moderate/severe problems), with self-care (p = 0.01) and anxiety/depression (p = 0.02) in the EQ-5D form than those born in Sweden. They also had more pain (VAS, p = 0.04). One year after the operation and after statistical adjustments, patients born outside Sweden reported lower scores for self-care (p = 0.008) and usual activities (p = 0.001) in the EQ-5D form. They still reported more pain (VAS, p = 0.02), but no significant difference concerning degree of satisfaction (p = 0.3). Our finding of more preoperative disability and pain (VAS) before the operation in patients born abroad might depend on cultural differences, communication problems and differences in indications. Even if the effect of the total hip replacement was good, patients born abroad scored less for some of the items at 1 year. We think that this patient group could benefit from improved pre- and postoperative information and other measures to facilitate and improve their rehabilitation.

Association Between Provider Volume and Comorbidity on Hospital Utilization and Outcomes of Total Hip Arthroplasty Among National Health Insurance Enrollees

The impact of provider volume, comorbidity and adverse outcomes on hospital utilization of total hip arthroplasty (THA) has not yet been studied scientifically in Taiwan. This study aimed to examine the relationship between surgeon/hospital volume, perioperative complications, acute infections and hospital utilization for patients who underwent primary (THA). We analyzed National Health Insurance (NHI) annual reimbursement data for all hospital admissions due to primary THA between January 2005 and December 2006. A total of 9335 patients with rheumatoid arthritis, osteoarthritis, avascular necrosis and other joint disorders were identified. Multivari-ate regression analyses were used to assess the relationship between provider volume and hospital utilization and the risk of adverse outcomes. Statistical analyses were adjusted for patient age, gender, comorbidity, type of arthritis, as well as hospital attributes. Reversed linear associations were found among hospital utilization, surgeon volume, and comorbidity score. Patients with acute infection tended to stay 8 days more and cost NT$32,451 more than their counterparts. Patients with perioperative complication tended to stay 2.30 days more and cost NT$15,327 more than their counterparts. Longer hospital stay and higher total hospital charge were associated with patient's age and Charlson index. This study revealed that the volume of THAs performed by individual surgeons was a more important determinant of hospital utilization than hospital volume. Perioperative adverse events were associated with patients' age and comorbidity.

Future Clinical and Economic Impact of Revision Total Hip and Knee Arthroplasty

Kurtz, Steven M. PhD; Ong, Kevin L. PhD; Schmier, Jordana MA; Mowat, Fionna PhD; Saleh, Khaled MD, MSc, FRSCS; Dybvik, Eva MSc; Kärrholm, Johan MD, PhD; Garellick, Göran MD, PhD; Havelin, Leif I. MD, PhD; Furnes, Ove MD, PhD; Malchau, Henrik MD, PhD; Lau, Edmund MS Author Information

Total hip arthroplasty in ankylosing spondylitis: An analysis of 181 hips

The results of cemented total hip arthroplasty (THA) in patients with ankylosing spondylitis were studied to determine the utility of THA for these patients. A total of 103 patients with ankylosing spondylitis underwent 181 THAs; 72 patients (69.9%) had bilateral surgery. The mean follow-up was 10.3 years. The mean age of patients at surgery was 47 years. Before surgery, 42 hips (23.2%) were ankylosed. Revision surgery was carried out in 25 hips (13.8%). Heterotopic ossification was present in 21 hips (11.6%); however, no patients had functional impairment or reankylosis. At final follow-up examination, 173 hips (96%) had an excellent (low) pain score, and 53 hips had a normal or near-normal function score (29.2%). The probability of survival of the implant was 71% at 27 years. THA provides long-term improvement in hip function for patients with ankylosing spondylitis. Copyright 2002, Elsevier Science (USA). All rights reserved.

Lack of evidence for gender bias in the utilization of total hip arthroplasty among Olmsted County, Minnesota residents with osteoarthritis.

To evaluate whether women have more advanced osteoarthritis (OA) than men prior to total hip arthroplasty (THA). Preoperative clinical and radiographic severity of hip OA was determined among Olmsted County, Minnesota residents who underwent THA. The time from first radiographic changes and first symptoms to THA was compared between genders. Fifty men and 80 women underwent their first THA between 1985 and 1990. Men had higher disease activity levels preoperatively; however, 16 other clinical severity variables and 2 summary measures of OA severity were similar for both genders. Men had radiographically more advanced hip OA preoperatively. The time from first symptom of hip OA to THA was similar for both genders, while the time from first radiographic change to THA was significantly longer for men. These results fail to support the hypothesis that hip OA prior to THA is more severe among women compared with men.

Trends in the Utilization of Primary Total Hip Arthroplasty, 1969 Through 1990: A Population-Based Study in Olmsted County, Minnesota

Using the unique data resources of the Rochester Epidemiology Project, we identified the residents of Olmsted County, Minnesota, who underwent total hip arthroplasty (THA) between 1969, when this technique was introduced, and 1990. During this period, 735 residents underwent 859 primary THAs. An initial dramatic upsurge in utilization of THA soon after its introduction was followed by a lower rate of increase, to an age- and sex-adjusted rate of 59.9 per 100,000 person-years in 1987 through 1990. In Olmsted County, the procedure was used more often in women than in men, but men underwent THA at a younger age than did women. THAs were performed for various conditions of the hip, but the increased utilization during the last decade of the study was mainly attributable to its application in primary degenerative hip disease among patients (male more often than female) from a wider age range; utilization of THA for hip fractures decreased during the study period. Most THAs were of the cemented variety (86.1%); however, the rate of use of noncemented THAs, first performed in 1984, is increasing. The overall upward trend in Olmsted County was consistent with European data but less than the rate of increase observed for the United States as a whole between 1983 and 1987. Olmsted County utilization rates, if projected nationally, suggest a need for more than 139,000 primary THAs each year at an annual direct cost of more than $2.7 billion. An urgent need exists for detailed examination of national utilization patterns and clarification of the role of cementless implants and of THA for hip fractures.