An economic analysis of aseptic revision hip arthroplasty: calculation of partial hospital costs in relation to reimbursement

Proton Pump Inhibitors and the Risk of Early Aseptic Loosening in Hip and Knee Arthroplasty

Introduction

The use of proton pump inhibitors (PPIs) has been associated with a higher risk of osteoporotic fractures and non-unions rates. However, the relation between the use of PPIs and the development of aseptic loosening in arthroplasty procedures has not been studied. The objective of this study is to analyze the relation between the use of PPIs, and the risk of early aseptic loosening in total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Materials and methods

A nested case-control study was conducted on patients who were subjected THA or TKA in our center between 2010 and 2014. Cases were patients subjected to revision surgery due to early aseptic loosening during the study period. Cases were matched with controls who did not require any type of revision surgery by type of joint replacement (THA/TKA), gender, age (+/- 2 years), and follow-up time (±6 months). Odds Ratios were adjusted to potential confounders.

Results

The crude and adjusted ORs (95% CI) of undergoing revision surgery for aseptic loosening following primary total knee arthroplasty or total hip arthroplasty, were 6.25 (2.04-19.23) and 6.10 (1.71-21.73), respectively, for any use PPIs compared with non-users. Crude and adjusted ORs, were 11.6 (2.93-45.88) and 17.1 (2.41-121.66), respectively, for patients with a Proportion of Days Covered (PDC) for PPIs <.5 (Table 2). In addition, the crude and adjusted ORs of undergoing revision surgery, were 5.05 (1.59-16.02) and 5.01 (1.36-18.44), respectively, for patients with a PDC for PPIs ≥.5.

Discussion

These results suggest that PPIs should be used with caution in patients with TKA and THA, and that the use of these drugs should not be prolonged unless there was a justifiable indication.

Conclusions

The use of PPIs and was associated with a higher risk of early aseptic loosening in patients subjected to THA and TKA.

Radiographic assessment of radiolucent lines around a highly porous titanium cup (Tritanium) using digital tomosynthesis, after total hip arthroplasty

BACKGROUND

The objectives of this study were to assess radiolucent lines around a highly porous titanium cup (Tritanium) using digital tomosynthesis and to investigate the clinical and radiographic factors associated with radiolucent lines on tomosynthesis.

METHODS

Fifty-five patients underwent total hip arthroplasty using a Tritanium cup, and digital tomosynthesis and plain radiography were performed at 1 week, 6 months, 1 year, and 2 years after surgery. The radiolucent lines around the cup were measured on both DTS and plain radiography at each postoperative period. Clinical evaluations were performed by the Japanese Orthopaedic Association hip disease evaluation questionnaire (JHEQ), and revision surgeries were examined. Based on the presence of radiolucent lines on digital tomosynthesis at 2 years postoperatively, patients were divided into RL (+) and RL (-) groups and investigated for related factors.

RESULTS

There were 20 cases in the RL (+) group and 35 cases in the RL (-) group, and no revision surgeries were required. Statistically, there were more cases with radiolucent lines on digital tomosynthesis (45.4% at 1 week and 36.3% at 2 years) than on plain radiography (9.1% at 1 week and 9.1% at 2 years) at each postoperative point. Logistic analysis showed no significant associations between the presence of radiolucent lines at 2 years on digital tomosynthesis, and the JHEQ parameters of pain (p = 0.937), movement (p = 0.266), or mental status (p = 0.404).

CONCLUSION

In a short-term evaluation up to 2 years, digital tomosynthesis detected more radiolucent lines around the titanium cups than plain radiography. The occurrence of radiolucent lines was not related to the postoperative clinical evaluation.

Variability of Cutting and Thermal Dynamics Between New and Used Acetabular Reamers During Total Hip Arthroplasty

Background

Aseptic loosening of the acetabular component remains one of the leading causes of early failure of total hip arthroplasty. Poor apposition of bone onto the implant surface can be due to inaccurate reaming and osteonecrosis of the acetabular bone due to the heat generated while reaming.

Methods

New and used acetabular reamers were tested on an MTS system using a clinically relevant force of 87.6 N. A thermal profile and depth achieved by the reamers were analyzed and compared between the 2 cohorts. Heat generated and force required for the community used reamers to achieve the same depth as the new reamers were subsequently analyzed.

Results

The new reamers achieved a depth 3.4 mm deeper than the community reamers (P < .001). The new reamers generated 4.1°C less heat than the community reamers (P = .007) under the same force and time. When programmed to ream to the average depth of the new reamers, the community reamers generated 16.8°C more heat (P = .002) and required forces 95-318% greater than the 87.6 N force used by the new reamers.

Conclusions

Community use of reamers will cause variations in depth of penetration and increased temperatures at a clinically generated force vs new reamers. When community reamers were forced to the same depths the new reamers achieved, a significantly greater amount of heat was generated, and an increased amount of time was needed, both of which are known risk factors for osteonecrosis.

Acetabular reconstruction using porous metallic material in complex revision total hip arthroplasty: A systematic review

Bone defects during acetabular revision of total hip arthroplasty raise a problem of primary fixation and of durable reconstruction. Bone graft with direct cemented fixation or in a reinforcement cage was long considered to be the gold standard; however, failures were reported after 10 years' follow-up, especially in segmental defect of the roof or pelvic discontinuity. In such cases, metallic materials were proposed, to ensure primary fixation by a roughness effect with added screws, and especially to avoid failure due to bone resorption in the medium term. We report a systematic literature analysis, addressing the following questions: (1) What materials are available and can be used with dual mobility (DM) designs? Apart from Trabecular Metal™ (TM), in which a DM cup can be cemented for sizes≥56mm, 4 other porous metals are available (Tritanium™, Trabecular Titanium™, Conceloc™, Regenerex™ and Gription™) although only the first 3 can be associated to DM. (2) Can the cost of these materials be estimated and compared to allograft with reinforcement cage? Considering simply the cost of the implant itself, compared to reconstruction by graft+cage+cemented cup (€2100), TM incurs an extra cost of €534, but with €1434 not covered by the French healthcare insurance. The cost of custom implants (apart from hemi-pelvis) ranges between €4200 and €8500, with only €4749 cover. (3) Do metallic materials ensure better survival than allograft+cage, according to severity of bone loss? Metallic reconstruction is claimed (with a low level of evidence) to reduce the risk of iterative loosening, but with a higher rate of dislocation, probably due to the lack of DM in many series. (4) What are the advantages and drawbacks of modular and custom metallic reconstructions? Modular reconstructions do not require 3D preoperative planning, but incur the risks of complications inherent to modularity. Custom implants can deal with more extensive defects, but require 5 to 8 weeks' production and are difficult to implant for the larger ones and/or when revision is limited to the acetabulum. (5) In what indications are these materials irreplaceable? Prior failure of allograft+cage in Paprosky type III defect with or without pelvic discontinuity shows the greatest benefit from metallic reconstruction, conditional on certain technical tricks. Only reconstructions using TM have more than 10 years' follow-up; other materials will need close monitoring. Failures in allograft with reinforcement cages occurred after about 10 years, and TM will need longer follow-up to prove its effectiveness. The high risk of dislocation should enable DM to be used, especially for small-diameter metallic reconstructions.

Early aseptic loosening of the Tritanium primary acetabular component with screw fixation

Ultraporous acetabular components were developed to improve osseointegration and fit for increased longevity and better outcomes after total hip arthroplasty. There is a paucity of literature detailing this acetabular component's clinical performance, with even less detailing those with screw fixation. We identify 5 patients at our institution who underwent revision total hip arthroplasty for early aseptic acetabular cup loosening of an ultraporous acetabular component known as the Tritanium primary cup with secondary screw fixation. They all presented with groin and hip pain after index surgery and underwent follow-up radiographic examination consistent with component loosening requiring revision surgery. This case series reports on the risk of early acetabular cup loosening and its associated clinical presentation, workup, and surgical management in patients with the Tritanium primary cup augmented with screws.

Cost-effectiveness of timely versus delayed primary total hip replacement in Germany: A social health insurance perspective

Without clinical guideline on the optimal timing for primary total hip replacement (THR), patients often receive the operation with delay. Delaying THR may negatively affect long-term health-related quality of life, but its economic effects are unclear. We evaluated the costs and health benefits of timely primary THR for functionally independent adult patients with end-stage osteoarthritis (OA) compared to non-surgical therapy followed by THR after progression to functional dependence (delayed THR), and non-surgical therapy alone (Medical Therapy), from a German Social Health Insurance (SHI) perspective. Data from hip arthroplasty registers and a systematic review of the published literature were used to populate a tunnel-state modified Markov lifetime model of OA treatment in Germany. A 5% annual discount rate was applied to costs (2013 prices) and health outcomes (Quality Adjusted Life Years, QALY). The expected future average cost of timely THR, delayed THR and medical therapy in women at age 55 were €27,474, €27,083 and €28,263, and QALYs were 20.7, 16.7, and 10.3, respectively. QALY differences were entirely due to health-related quality of life differences. The discounted cost per QALY gained by timely over delayed (median delay of 11 years) THR was €1270 and €1338 in women treated at age 55 and age 65, respectively, and slightly higher than this for men. Timely THR is cost-effective, generating large quality of life benefits for patients at low additional cost to the SHI. With declining healthcare budgets, research is needed to identify the characteristics of those able to benefit the most from timely THR.

Comparative Analysis of Direct Hospital Care Costs between Aseptic and Two-Stage Septic Knee Revision

BACKGROUND

The most common intermediate and long-term complications of total knee arthroplasty (TKA) include aseptic and septic failure of prosthetic joints. These complications cause suffering, and their management is expensive. In the future the number of revision TKA will increase, which involves a greater financial burden. Little concrete data about direct costs for aseptic and two-stage septic knee revisions with an in depth-analysis of septic explantation and implantation is available.

QUESTIONS/PURPOSES

A retrospective consecutive analysis of the major partial costs involved in revision TKA for aseptic and septic failure was undertaken to compare 1) demographic and clinical characteristics, and 2) variable direct costs (from a hospital department's perspective) between patients who underwent single-stage aseptic and two-stage septic revision of TKA in a hospital providing maximum care. We separately analyze the explantation and implantation procedures in septic revision cases and identify the major cost drivers of knee revision operations.

METHODS

A total of 106 consecutive patients (71 aseptic and 35 septic) was included. All direct costs of diagnosis, surgery, and treatment from the hospital department's perspective were calculated as real purchase prices. Personnel involvement was calculated in units of minutes.

RESULTS

Aseptic versus septic revisions differed significantly in terms of length of hospital stay (15.2 vs. 39.9 days), number of reported secondary diagnoses (6.3 vs. 9.8) and incision-suture time (108.3 min vs. 193.2 min). The management of septic revision TKA was significantly more expensive than that of aseptic failure ($12,223.79 vs. $6,749.43) (p <.001). On the level of the separate hospitalizations the mean direct costs of explantation stage ($4,540.46) were lower than aseptic revision TKA ($6,749.43) which were again lower than those of the septic implantation stage ($7,683.33). All mean costs of stays were not comparable as they differ significantly (p <.001). Major cost drivers were the cost of the implant and general staff. The septic implantation part was on average $3,142.87 more expensive than septic explantations (p <.001).

CONCLUSIONS

Our study for the first time provides a detailed analysis of the major direct case costs of aseptic and septic revision TKA from the hospital-department's perspective which is the basis for long-term orientated decision making. In the future, our cost analysis has to be interpreted in relation to reimbursement estimates. This is important to check whether revision TKA lead to a financial loss for the operating department.

Economic analysis of two-stage septic revision after total hip arthroplasty: What are the relevant costs for the hospital's orthopedic department?

Background

The number of septic total hip arthroplasty (THA) revisions is increasing continuously, placing a growing financial burden on hospitals. Orthopedic departments performing septic THA revisions have no basis for decision making regarding resource allocation as the costs of this procedure for the departments are unknown. It is widely assumed that septic THA procedures can only be performed at a loss for the department. Therefore, the purpose of this study was to investigate whether this assumption is true by performing a detailed analysis of the costs and revenues for two-stage septic THA revision.

Methods

Patients who underwent revision THA for septic loosening in two sessions from January 2009 through March 2012 were included in this retrospective, consecutive cost study from the orthopedic department’s point of view. We analyzed variable and case-fixed costs for septic revision THA with special regard to implantation and explantation stay. By using marginal costing approach we neglected hospital-fixed costs. Outcome measures include reimbursement and daily contribution margins.

Results

The average direct costs (reimbursement) incurred for septic two-stage revision THA was €10,828 (€24,201). The difference in cost and contribution margins per day was significant (p < .001 and p = 0.019) for ex- and implantation (€4147 vs. €6680 and €429 vs. €306) while length of stay and reimbursement were comparable.

Conclusions

This is the first detailed analysis of the hospital department’s cost for septic revision THA performed in two sessions. Disregarding hospital-fixed costs the included variable and case fixed-costs were covered by revenues. This study provides cost data, which will be guidance for health care decision makers.