Hospital volume and inpatient mortality outcomes of total hip arthroplasty in the United States

Regional versus general anesthesia for total hip and knee arthroplasty: a nationwide retrospective cohort study

INTRODUCTION

We aimed to determine whether regional anesthesia (RA) has any advantages over general anesthesia (GA) in total joint arthroplasty (TJA) in terms of mortality and postoperative complications.

METHODS

This population-based retrospective cohort study included data of adults who underwent total knee or hip arthroplasty under RA or GA between 2016 and 2021 from the National Health Insurance Service of South Korea. RA included spinal or epidural anesthesia or a combination of both. Endpoints were 30-day mortality, 90-day mortality, and postoperative complications. Propensity score (PS) matching was used for statistical analysis.

RESULTS

We included 517 960 patients (RA, n=380 698; GA, n=137 262) who underwent TJA. After PS matching, 186 590 patients (93 295 in each group) were included in the final analysis. In the logistic regression analyses using the PS-matched cohort, the RA group compared with the GA group showed 31% (OR: 0.69; 95% CI, 0.60 to 0.80; p<0.001) and 22% (OR: 0.78; 95% CI, 0.72 to 0.85; p<0.001) lower 30-day and 90-day mortality rates, respectively. However, the total postoperative complication rate did not differ significantly between the two groups (p=0.105).

CONCLUSION

RA compared with GA was associated with improved 30-day and 90-day survival outcomes in patients who underwent TJA. However, the postoperative complication rate did not differ significantly. Therefore, our results should be interpreted with caution, and more well-designed future studies are needed to clarify the most appropriate type of anesthesia for TJA.

Influence of Race on Utilization and Outcomes in Shoulder Arthroplasty: A Systematic Review

BACKGROUND

Studies have shown that utilization and outcomes after shoulder arthroplasty vary by sociodemographic factors, highlighting disparities in care. This systematic review synthesized all available literature regarding the relationship between utilization and outcomes of shoulder arthroplasty and race/ethnicity.

METHODS

Studies were identified using PubMed, MEDLINE (through Ovid), and CINAHL databases. All English language studies of Level I through IV evidence that specifically evaluated utilization and/or outcomes of hemiarthroplasty, total shoulder arthroplasty, or reverse shoulder arthroplasty by race and/or ethnicity were included. Outcomes of interest included rates of utilization, readmission, reoperation, revision, and complications.

RESULTS

Twenty-eight studies met inclusion criteria. Since the 1990s, Black and Hispanic patients have demonstrated a lower utilization rate of shoulder arthroplasty compared with White patients. Although utilization has increased among all racial groups throughout the present decade, the rate of increase is greater for White patients. These differences persist in both low-volume and high-volume centers and are independent of insurance status. Compared with White patients, Black patients have a longer postoperative length of stay after shoulder arthroplasty, worse preoperative and postoperative range of motion, a higher likelihood of 90-day emergency department visits, and a higher rate of postoperative complications including venous thromboembolism, pulmonary embolism, myocardial infarction, acute renal failure, and sepsis. Patient-reported outcomes, including the American Shoulder and Elbow Surgeon's score, did not differ between Black and White patients. Hispanics had a significantly lower revision risk compared with White patients. One-year mortality did not differ significantly between Asians, Black patients, White patients, and Hispanics.

CONCLUSION

Shoulder arthroplasty utilization and outcomes vary by race and ethnicity. These differences may be partly due to patient factors such as cultural beliefs, preoperative pathology, and access to care, as well as provider factors such as cultural competence and knowledge of health care disparities.

LEVEL OF EVIDENCE

Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Effect of Surgeon and Hospital Volume on Morbidity and Mortality After Femoral Shaft Fractures

OBJECTIVES

The aim of this study was to characterize the case volume dependence of both facilities and surgeons on morbidity and mortality after femoral shaft fracture (FSF) fixation.

METHODS

Adults who had an open or closed FSF between 2011 and 2015 were identified in the New York Statewide Planning and Research Cooperative System database. Claims were identified by International Classification of Disease-9, Clinical Modification diagnostic codes for a closed or open FSF and International Classification of Disease-9, Clinical Modification procedure codes for FSF fixation. Readmission, in-hospital mortality, and other adverse events were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression, controlling for patient demographic and clinical factors. Surgeon and facility volumes were compared between the lowest and highest 20% to represent low-volume and high-volume surgeons/facilities.

RESULTS

Of 4,613 FSF patients identified, 2,824 patients were treated at a high or low-volume facility or by a high or low-volume surgeon. Most of the examined complications including readmission and in-hospital mortality showed no statistically significant differences. Low-volume facilities had a higher 1-month rate of pneumonia. Low-volume surgeons had a lower 3-month rate of pulmonary embolism.

CONCLUSION

There is minimal difference in outcomes in relation to facility or surgeon case volume for FSF fixation. As a staple of orthopaedic trauma care, FSF fixation is a procedure that may not require specialized orthopaedic traumatologists at high-volume facilities.

Volume and Outcomes of Joint Arthroplasty

BACKGROUND

Joint arthroplasties are among the most commonly performed elective surgeries in the United States. Surgical outcomes are known to improve with volume but it is unclear whether this has led to consolidation among elective surgeries. We examined trends in volumes per surgeon and hospital to assess whether the known volume-outcome relationship has led to consolidation in elective joint arthroplasty and to determine if there exist volume thresholds above which outcomes do not change.

METHODS

Among Medicare beneficiaries who underwent either total knee or total hip arthroplasty from 2009 through 2015, we described volume trends and used mixed-effect models to relate annual surgeon and hospital volumes with 30-day complications or mortality. We tested for optimal volume cut points at both the hospital and surgeon level.

RESULTS

Adjusted annual complication rates were inversely associated with volume for both procedures at both the surgeon level and hospital level, but there was minimal consolidation between 2009 and 2015. Complications no longer declined after volumes of each case exceeded 260 per year. The vast majority of cases (around 93% of hip and 88% of knee arthroplasties) were performed by surgeons operating at suboptimal volumes.

CONCLUSION

More than 2 decades after the volume-outcome relationship was established for joint arthroplasty, many cases continue to be performed by low-volume surgeons, with far more cases performed by surgeons operating at suboptimal volumes. Further improvement could be expected through consolidation at both the hospital and surgeon level, with a target of at least 260 cases per surgeon annually for each operation. Payers seem best-equipped to drive consolidation.

Socioeconomic factors affecting outcomes in total knee and hip arthroplasty: a systematic review on healthcare disparities

Background

Recent studies showed that healthcare disparities exist in use of and outcomes after total joint arthroplasty (TJA). This systematic review was designed to evaluate the currently available evidence regarding the effect socioeconomic factors, like income, insurance type, hospital volume, and geographic location, have on utilization of and outcomes after lower extremity arthroplasty.

Methods

A comprehensive search of the literature was performed by querying the MEDLINE database using keywords such as, but not limited to, “disparities”, “arthroplasty”, “income”, “insurance”, “outcomes”, and “hospital volume” in all possible combinations. Any study written in English and consisting of level of evidence I-IV published over the last 20 years was considered for inclusion. Quantitative and qualitative analyses were performed on the data.

Results

A total of 44 studies that met inclusion and quality criteria were included for analysis. Hospital volume is inversely correlated with complication rate after TJA. Insurance type may not be a surrogate for socioeconomic status and, instead, represent an independent prognosticator for outcomes after TJA. Patients in the lower-income brackets may have poorer access to TJA and higher readmission risk but have equivalent outcomes after TJA compared to patients in higher income brackets. Rural patients have higher utilization of TJA compared to urban patients.

Conclusion

This systematic review shows that insurance type, socioeconomic status, hospital volume, and geographic location can have significant impact on patients’ access to, utilization of, and outcomes after TJA.

Level of evidence

IV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42836-022-00137-4.

[Planning revision hip arthroplasty : What are the structural requirements?]

The results of many studies and register reports show that the frequency of primary hip arthroplasty per hospital, but also per surgeon, influence the outcome. In the large spectrum of revision hip arthroplasty volume-outcome effects have also partially been proven. It is obvious that with the increasing complexity of revision surgery and comorbidities, higher demands exist concerning collaborating disciplines as well as training and intervention frequency of the surgical team. Further aspects regarding organisation and structure such as the availability of specific revision implants and instruments must be ensured. In order to provide sustainable resources for revision surgery in an arthroplasty centre, organization of education and training for staff members in different disciplines and working levels must be ensured without quality impairment.

Hospital Volume as a Source of Variation for Major Complications and Early In-Hospital Mortality After Total Joint Arthroplasty

Background

Material and methods

Results

Conclusion

Race, Utilization, and Outcomes in Total Hip and Knee Arthroplasty: A Systematic Review on Health-Care Disparities

BACKGROUND

Previous studies have shown that utilization and outcomes of total joint arthroplasty (TJA) are not equivalent across different patient cohorts. This systematic review was designed to evaluate the currently available evidence regarding the effect that patient race has, if any, on utilization and outcomes of lower-extremity arthroplasty in the United States.

METHODS

A literature search of the MEDLINE database was performed using keywords such as "disparities," "arthroplasty," "race," "joint replacement," "hip," "knee," "inequities," "inequalities," "health," and "outcomes" in all possible combinations. All English-language studies with a level of evidence of I through IV published over the last 20 years were considered for inclusion. Quantitative and qualitative analyses were performed on the collected data.

RESULTS

A total of 82 articles were included. There was a significantly lower utilization rate of lower-extremity TJA among Black, Hispanic, and Asian patients compared with White patients (p < 0.05). Black and Hispanic patients had lower expectations regarding postoperative outcomes and their ability to participate in various activities after surgery, and they were less likely than White patients to be familiar with the arthroplasty procedure prior to presentation to the orthopaedic surgeon (p < 0.05). Black patients had increased risks of major complications, readmissions, revisions, and discharge to institutional care after TJA compared with White patients (p < 0.05). Hispanic patients had increased risks of complications (p < 0.05) and readmissions (p < 0.0001) after TJA compared with White patients. Black and Hispanic patients reached arthroplasty with poorer preoperative functional status, and all minority patients were more likely to undergo TJA at low-quality, low-volume hospitals compared with White patients (p < 0.05).

CONCLUSIONS

This systematic review shows that lower-extremity arthroplasty utilization differs by racial/ethnic group, and that some of these differences may be partly explained by patient expectations, preferences, and cultural differences. This study also shows that outcomes after lower-extremity arthroplasty differ vastly by racial/ethnic group, and that some of these differences may be driven by differences in preoperative functional status and unequal access to care.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Mortality, Length of Hospital Stay and Transfusion between Hemiarthroplasty and Total Hip Arthroplasty in Octo- and Nonagenarian Patients with Femoral Neck Fracture: a Nationwide Study in Korea

BACKGROUND

The purpose of this study was to compare the mortality rate between patients undergoing hemiarthroplasty (HA) and those undergoing total hip arthroplasty (THA) in two age groups: patients aged 65-79 years (non-octogenerian) and patients aged ≥ 80 years (octogenarian).

METHODS

We identified elderly (aged ≥ 65 years) femoral neck fracture patients who underwent primary THA or HA from January 1, 2005 to December 31, 2015 in South Korea using the Health Insurance and Review and Assessment database; the nationwide medical claim system of South Korea. We separately compared the mortality rate between the HA group and THA group in two age groups. A generalized estimating equation model with Poisson distribution and logarithmic link function was used to calculate the adjusted risk ratio (aRR) of death according to the type of surgery.

RESULTS

The 3,015 HA patients and 213 THA patients in younger elderly group, and 2,989 HA patients and 96 THA patients in older elderly group were included. In the younger elderly group, the mortality rates were similar between the two groups. In older elderly group, the aRR of death in the THA group compared to the HA group was 2.16 (95% confidence interval [CI], 1.20-3.87; P = 0.010) within the in-hospital period, 3.57 (95% CI, 2.00-6.40; P < 0.001) within 30-days, and 1.96 (95% CI, 1.21-3.18; P = 0.006) within 60-days.

CONCLUSIONS

In patients older than 80 years, THA was associated with higher postoperative mortality compared to HA. We recommend the use of HA rather than THA in these patients.

Effect of Oxidative Stress on Bone Remodeling in Periprosthetic Osteolysis

The success of implant performance and arthroplasty is based on several factors, including oxidative stress-induced osteolysis. Oxidative stress is a key factor of the inflammatory response. Implant biomaterials can release wear particles which may elicit adverse reactions in patients, such as local inflammatory response leading to tissue damage, which eventually results in loosening of the implant. Wear debris undergo phagocytosis by macrophages, inducing a low-grade chronic inflammation and reactive oxygen species (ROS) production. In addition, ROS can also be directly produced by prosthetic biomaterial oxidation. Overall, ROS amplify the inflammatory response and stimulate both RANKL-induced osteoclastogenesis and osteoblast apoptosis, resulting in bone resorption, leading to periprosthetic osteolysis. Therefore, a growing understanding of the mechanism of oxidative stress-induced periprosthetic osteolysis and anti-oxidant strategies of implant design as well as the addition of anti-oxidant agents will help to improve implants’ performances and therapeutic approaches.

Online Crowdsourcing to Explore Public Perceptions of Robotic-Assisted Orthopedic Surgery

BACKGROUND

The clinical benefits of robotic-assisted technology in total joint arthroplasty are unclear, but its use is increasing. This study employed online crowdsourcing to explore public perceptions and beliefs regarding robotic-assisted orthopedic surgery.

METHODS

A 30-question survey was completed by 588 members of the public using Amazon Mechanical Turk. Participants answered questions regarding robotic-assisted orthopedic surgery, sociodemographic factors, and validated assessments of health literacy and patient engagement. Multivariable logistic regression modeling was used to determine population characteristics associated with preference for robotic technology.

RESULTS

Most respondents believe robotic-assisted surgery leads to better results (69%), fewer complications (69%), less pain (59%), and faster recovery (62%) than conventional manual methods. About half (49%) would prefer a low-volume surgeon using robotic technology to a high-volume surgeon using conventional manual methods. The 3 main concerns regarding robotic technology included lack of surgeon experience with robotic surgery, robot malfunction causing harm, and increased cost. Only half of respondents accurately understand the actual role of the robot in the operating room. Overall, 34% of participants have a clear preference for robotic-assisted surgery over a conventional manual approach. After multivariable regression analysis, Asian race, working in healthcare, early technology adoption, and prior knowledge of robotic surgery were independent predictors of preferring robotic-assisted surgery.

CONCLUSION

The public's unawareness of the dubious outcome superiority associated with robotic-assisted orthopedic surgery may contribute to misinformed decisions in some patients. Robotic-assisted technology appears to be a powerful marketing tool for surgeons and hospitals.

Contemporary Mortality Rate and Outcomes in Nonagenarians Undergoing Primary Total Hip Arthroplasty

BACKGROUND

Nonagenarians (90-99 years) have experienced the fastest percent growth in primary THA utilization recently. However, there are limited data on this population. This study aimed to determine the mortality rate, implant survivorship, clinical outcomes, and complications of primary THAs in nonagenarians.

METHODS

Our institutional total joint registry was used to identify 144 nonagenarians who underwent 149 primary THAs for osteoarthritis only between 1997 and 2017. The mean age was 92 years, with 63% being female. Mortality, revision, and reoperation were assessed using cumulative incidence with death as a competing risk and Cox regression methods. Clinical outcomes were assessed using Harris hip scores (HHSs). Cemented femoral components were used in 68%. The mean follow-up was 4 years.

RESULTS

The mortality rates were 6%, 8%, 14%, and 49% at 90 days, 1 year, 2 years, and 5 years, respectively. The 5-year cumulative incidences of any revision and reoperation were 1% and 4%, respectively. The mean HHS improved significantly from 48 preoperatively to 76 at 5 years (P < .001). The 5-year cumulative incidence of any complication was 69%, with the most common being periprosthetic femur fracture (7) intraoperatively, delirium (25) early postoperatively, and periprosthetic femur fracture (10) later postoperatively. Uncemented stem fixation was associated with a higher risk for intraoperative femur fracture (Hazard ratio 5, P = .04) but not with a higher 5-year periprosthetic postoperative femur fracture risk (P = .19).

CONCLUSION

Nonagenarians undergoing primary THA had substantial mortality rates at 90 days (6%) and 1 year (8%). While the cumulative incidence of any revision and reoperations were low at 5 years, the high complication rate is mostly due to periprosthetic fractures.

LEVEL OF EVIDENCE

Level IV, retrospective cohort.

Factors predicting repeat revision and outcome after aseptic revision total knee arthroplasty: results from the New Zealand Joint Registry

PURPOSE

The number of Revision TKAs performed continues to increase; however there is limited data on risk factors for failure. Additionally, clinical decisions regarding when and how to revise a failed TKA may be as important as the technical aspects of the procedure. The purpose of this study was to analyze factors predicting repeat revision following aseptic revision TKA.

METHODS

Of 85,769 primary TKAs recorded on the New Zealand National Joint Registry, 1720 patients undergoing subsequent revision for aseptic indications between January 1999 and December 2015 were identified. Re-revision was recorded in 208 patients (12.1%). The analysis included demographic characteristics, surgeon revision case volume, surgical time, surgical ownership of index TKA as independent variables using logistic and linear regression. The primary outcome measure was incidence of subsequent re-revision and Oxford Knee Scores of revised TKAs (OKS). The secondary outcome measure was the influence of component exchange in major revisions on re-revision rate.

RESULTS

Younger patients undergoing a revision (HR 0.974) and male gender (HR 0.666) were predictors of re-revision. Elapsed time since index surgery (unstandardized coefficient 0.060) and lower ASA score (UC - 2.749) were significant predictors of OKS. Femoral component revision was a predictor of re-revision (HR 1.696) and had the lowest OKS, compared to tibial and all component revision (p = 0.003).

CONCLUSIONS

Repeat revision TKA is a rare and complex procedure influenced by a number of confounding factors. Using raw registry data, younger and male patients were found to be at a higher risk of re-revision after aseptic revision TKA. A longer time between primary TKA and revision was associated with better clinical outcomes. Isolated femoral component exchange led to worse outcomes both in terms of survivorship and functional scores.

LEVEL OF EVIDENCE

III.

The association between labour epidural case volume and the rate of accidental dural puncture

Accidental dural puncture is a recognised complication of labour epidural placement and can cause a debilitating headache. We examined the association between labour epidural case volume and accidental dural puncture rate in specialist anaesthetists and anaesthesia trainees. We performed a retrospective cohort study of labour epidural and combined spinal-epidural nerve blocks performed between 1 July 2013 and 31 December 2017 at Waitemata District Health Board, Auckland, New Zealand. The mean (SD) annual number of obstetric epidural and combined spinal-epidural procedures for high-case volume specialists was 44.2 (15.0), and for low-case volume specialists was 10.0 (6.8), after accounting for caesarean section combined spinal-epidural procedures. Analysis of 7976 labour epidural and combined spinal-epidural procedure records revealed a total of 92 accidental dural punctures (1.2%). The accidental dural puncture rate (95%CI) in high-case volume specialists was 0.6% (0.4-0.9%) and in low-case volume specialists 2.4% (1.4-3.9%), indicating probable skill decay. The odds of accidental dural puncture were 3.77 times higher for low- compared with high-case volume specialists (95%CI 1.72-8.28, p = 0.001). Amongst trainees, novices had a significantly higher accidental dural puncture complication rate (3.1%) compared with registrars (1.2%), OR (95%CI) 0.39 (0.18-0.84), p = 0.016, or fellows (1.1%), 0.35 (0.16-0.76), p = 0.008. Accidental dural puncture complication rates decreased once trainees progressed past the 'novice' training stage.

Nationwide Analysis of Lower Extremity Periprosthetic Fractures

BACKGROUND

Although the annual incidence of primary total joint arthroplasty is increasing, trends in the annual incidence of periprosthetic fractures have not been established. This study aimed to define the annual incidence of periprosthetic fractures in the United States.

METHODS

Inpatient admission data for 60,887 surgically treated lower extremity periprosthetic fractures between 2006 and 2015 were obtained from the National Inpatient Sample database. The annual incidence of periprosthetic fractures was defined as the number of new cases per year and presented as a population-adjusted rate per 100,000 US individuals. Univariable methods were used for trend analysis and comparisons between groups.

RESULTS

The national annual incidence of periprosthetic fractures presented as a population-adjusted rate of new cases per year peaked in 2008 (2.72; 95% confidence interval [95% CI], 2.39-3.05), remained stable from 2010 (1.65; 95% CI, 1.45-1.86) through 2013 (1.67; 95% CI, 1.55-1.8) and increased in 2014 (1.99; 95% CI, 1.85-2.13) and 2015 (2.47; 95% CI, 2.31-2.62). The proportion of femoral periprosthetic fractures managed with total knee arthroplasty revision remained stable (P_trend = .97) with an increase in total hip arthroplasty (THA) revision (P_trend < .001) and concurrent decrease in open reduction and internal fixation (ORIF) (P_trend < .001). Revision THA was significantly more costly than revision total knee arthroplasty (P = .004), and both were significantly more costly than ORIF (P < .001 for both).

CONCLUSION

The annual incidence of periprosthetic fractures remained relatively stable throughout our study period. The proportion of periprosthetic fractures managed with revision THA increased, whereas ORIF decreased. Our findings are encouraging considering the significant burden an increase in periprosthetic fracture incidence would present to the health care system in terms of both expense and patient morbidity.

Patient Complications after Total Joint Arthroplasty: Does Surgeon Gender Matter?

INTRODUCTION

Recent studies in general surgery and internal medicine have shown that female physicians may have improved morbidity and mortality compared with their male counterparts. In the field of orthopaedic surgery, little is known about the influence of surgeon gender on patient complications. This study investigates patient complications after hip and knee arthroplasty based on the gender of the treating surgeon.

METHODS

Using a risk-adjusted outcomes database of 100% Medicare data from a third party, an analysis of outcomes after primary hip and knee arthroplasty based on surgeon gender was performed. This data set, which provided risk-adjusted complication rates for each surgeon performing at least 20 primary knee or hip arthroplasties from 2009 to 2013, was matched with publically available Medicare data sets to determine surgeon gender, year of graduation, area of practice, and surgical volume. Confounding variables were controlled for in multivariate analysis.

RESULTS

Of the 8,965 surgeons with identified gender, 187 (2.0%; 187 of 8,965) were identified as women and performed 21,216 arthroplasties (1.4%; 21,216 of 1,518,419). Overall, female surgeons averaged fewer arthroplasties (total knee arthroplasty: 87.0 versus 124.9 [P < 0.001]; total hip arthroplasty [THA]: 62.8 versus 78.8 [P = 0.02]) and were earlier in their practice (20.6 versus 25.0 years; P < 0.001) compared with their male counterparts. Male and female surgeons had similar adjusted complication rates for THA (2.78% versus 2.84%) and total knee arthroplasty (2.24% versus 2.26%). Multivariate analysis found that the predictors of increased complications were decreased surgeon volume, THA, increased surgeons' years in practice, and geographic region.

DISCUSSION

Overall, female orthopaedic surgeons performed fewer arthroplasties and were earlier in their career. This, however, did not a have a negative impact on their surgical outcomes. Rather, complication rates were dependent on surgeon volume, surgeon experience, and region.

LEVEL OF EVIDENCE

Level III-prognostic retrospective case-control study.

Evidence-Based Hospital Procedural Volumes as Predictors of Outcomes After Revision Hip Arthroplasty

BACKGROUND

The aim of this study is to define the evidence-based institutional volume-outcome relationship in revision hip arthroplasty. We hypothesized that high-volume centers would be associated with superior outcomes, and that stratum-specific likelihood ratio (SSLR) analysis would delineate concrete volume thresholds for optimizing outcomes.

METHODS

The Nationwide Readmission Database was queried from 2011 to 2016 for patients undergoing revision hip arthroplasty. SSLR analysis was used to determine hospital volume cutoffs specific for outcomes of interest. Volume categories were confirmed with multivariate regression.

RESULTS

SSLR analysis produced distinct hospital volume cutoffs for all outcomes. Each subsequent volume threshold diminished patients' risk for adverse outcomes. Tertiles were identified for 90-day infection (≤6, 7-51, ≥52 cases per year). Quartiles were found for 90-day readmission (≤5, 6-15, 16-79, ≥80), 90-day prosthesis-related complication (≤5, 6-16, 17-65, ≥66), 90-day dislocation (≤5, 6-19, 20-79, ≥80), and non-home discharge (≤5, 6-15, 16-40, and ≥41). Quintiles were generated for extended length of stay >2 days (≤2, 3-10, 11-20, 21-30, ≥31). Heptiles were produced for medical complications within 90 days (≤2, 3-8, 9-16, 17-51, 52-89, ≥90).

CONCLUSION

This is the first known study to define evidence-based thresholds for the impact of hospital volume on revision joint arthroplasty. This supports the notion that institutional volume functions as a surrogate for protocolized interdisciplinary coordination of care and surgical experience, and that high-volume centers offer enhanced outcomes for complex cases. Additional studies should investigate the potential role for incentivization of such institutions, as they offer optimal outcomes for revision hip arthroplasty.

Does Very High Surgeon or Hospital Volume Improve Outcomes for Hemiarthroplasty Following Femoral Neck Fractures?

BACKGROUND

This study evaluates whether very high-volume hip arthroplasty providers have lower complication rates than other relatively high-volume providers.

METHODS

Hemiarthroplasty patients ≥60 years old were identified in the New York Statewide Planning and Research Cooperative System 2001-2015 dataset. Low-volume hospitals (<50 hip arthroplasty cases/y) and surgeons (<10 cases/y) were excluded. The upper and lower quintiles were compared for the remaining "high-volume" hospitals (50-70 vs >245) and surgeons (10-15 vs ≥60) using multivariable Cox proportional hazards regression. Multiple sensitivity analyses were performed treating volume as a continuous variable.

RESULTS

In total, 48,809 patients were included. Very high-volume hospitals demonstrated slightly less pneumonia (6% vs 7%, hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.68-0.88, P < .0001). Very high-volume surgeons experienced slightly higher rates of inpatient morality (3% vs 2%, HR 1.30, 95% CI 1.06-1.60, P = .01), revision surgery (3% vs 3%, HR 1.24, 95% CI 1.02-1.52, P = .03), and implant failure (1% vs <1%, HR 1.80, 95% CI 1.10-2.96, P = .02). Sensitivity analyses did not significantly alter these findings but suggested that inpatient mortality may decline as surgeon volume approaches 30 cases/y before gradually increasing at higher volumes.

CONCLUSION

A clinically meaningful volume-outcome relationship was not identified among very high-volume hemiarthroplasty surgeons or hospitals. Although prior evidence indicates that outcomes can be improved by avoiding very low-volume providers, these results suggest that complications would not be further reduced by directing all hemiarthroplasty patients to very high-volume surgeons or facilities. Future research investigating whether inpatient mortality changes with surgeon volume (particularly around 30 cases/y) in a different dataset would be valuable.

LEVEL OF EVIDENCE

Prognostic Level III.

No Difference in Outcomes Between Short and Longer-Stay Total Joint Arthroplasty with a Discharge Home: A Propensity Score-Matched Analysis Involving 46,660 Patients

BACKGROUND

Outcomes following total hip arthroplasty (THA) and total knee arthroplasty (TKA) with a short length of hospital stay have been reported; however, most studies have not accounted for an inherent patient selection bias and discharge disposition. The purpose of this study was to utilize a propensity score to match and compare the outcomes of patients undergoing THA or TKA with short and longer lengths of stay with a discharge directly home.

METHODS

An administrative database from Ontario, Canada, which has a single-payer health-care system, was retrospectively reviewed to identify patients who underwent THA or TKA from 2008 to 2016. Patients were subsequently stratified into 2 groups based on their length of stay: short length of stay (≤2 days; thereafter referred to as short stay) and longer length of stay (>2 days; thereafter referred to as longer stay). Using a propensity score, patients who underwent short-stay THA or TKA were matched to patients who underwent longer-stay THA or TKA. Matching was based on 15 demographic, medical, and surgical factors. Our primary outcomes included postoperative complications, health-care utilization (readmission and emergency department presentation), and health-care costs.

RESULTS

Overall, 89,656 TKAs (14,645 short stays and 75,011 longer stays) and 52,610 THAs (9,426 short stays and 43,184 longer stays) were included in this study. Patients who underwent short-stay THA or TKA were significantly more likely (p < 0.05) to be younger, male, healthier, and from a higher socioeconomic status and to have undergone the procedure with a higher-volume surgeon. Over 95% of short-stay cases were successfully matched to longer-stay cases, and we found no significant difference in complications, health-care utilization, and costs between patients on the basis of the length of stay.

CONCLUSIONS

Patients undergoing short-stay THA or TKA with a discharge home were more likely to be younger, healthy, male patients from a higher socioeconomic status. Higher-volume surgeons are also more likely to perform short-stay THA or TKA. These characteristics confirm the previously held belief that a selection bias exists when comparing cohorts based on time to discharge. When comparing matched cohorts of patients who underwent short-stay and longer-stay THA or TKA, we observed no difference in outcomes, suggesting that a short stay with a discharge home in the appropriately selected patient is safe following THA or TKA.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Simultaneous or Staged Bilateral Total Hip Arthroplasty? An Analysis of Complications in 14,460 Patients Using National Data

BACKGROUND

Simultaneous bilateral total hip arthroplasty (SimBTHA) is often performed in younger, fitter patients with bilateral hip disease. If patients are deemed not suitable for SimBTHA due to concurrent comorbidity, it may be more appropriate to perform staged bilateral total hip arthroplasties (StBTHAs) 3-6 months apart to minimize complications and morbidity. Complication rates following hip arthroplasty are low and large national datasets are helpful for assessing these rare events. We aimed at comparing SimBTHA vs StBTHA in order to determine any differences in morbidity and mortality.

METHODS

Hospital Episode Statistics data for all patients who underwent bilateral THAs in the English National Health Service between April 2005 and July 2014 were obtained. Patients were grouped into SimBTHAs (same day) or staged, with the second THA occurring between 3 and 6 months after the first. Medical and surgical complications were compared and total length of stay was assessed.

RESULTS

A total of 2507 underwent SimBTHAs and 9915 had StBTHAs. SimBTHA patients were significantly younger (60.6 vs 65.5 years, P < .001) and more likely to be male, but had similar Charlson comorbidity scores. Compared to StBTHAs, patients undergoing SimBTHAs had a greater risk of pulmonary embolism, myocardial infarction, renal failure, chest infection, and inhospital death. Patients undergoing SimBTHAs had a significantly shorter overall hospital stay (8.9 vs 10.4 days). Patients undergoing SimBTHA at high-volume units had a lower average Charlson score and subsequent complication rate than low-volume units.

CONCLUSION

These findings highlight the greater risks of SimBTHA in patients with Charlson score greater than 0 performed at lower-volume centers in England.

Effect of hospital volume on outcomes of total hip arthroplasty: a systematic review and meta-analysis

BACKGROUND

A shift in the healthcare system towards the centralization of common yet costly surgeries, such as total hip arthroplasty (THA), to high-volume centers of excellence, is an attempt to control the economic burden while simultaneously enhancing patient outcomes. The "volume-outcome" relationship suggests that hospitals performing more treatment of a given type exhibit better outcomes than hospitals performing fewer. This theory has surfaced as an important factor in determining patient outcomes following THA. We performed a systematic review with meta-analyses to review the available evidence on the impact of hospital volume on outcomes of THA.

MATERIALS AND METHODS

We conducted a review of PubMed (MEDLINE), OVID MEDLINE, Google Scholar, and Cochrane library of studies reporting the impact of hospital volume on THA. The studies were evaluated as per the inclusion and exclusion criteria. A total of 44 studies were included in the review. We accessed pooled data using random-effect meta-analysis.

RESULTS

Results of the meta-analyses show that low-volume hospitals were associated with a higher rate of surgical site infections (1.25 [1.01, 1.55]), longer length of stay (RR, 0.83[0.48-1.18]), increased cost of surgery (3.44, [2.57, 4.30]), 90-day complications (RR, 1.80[1.50-2.17]) and 30-day (RR, 2.33[1.27-4.28]), 90-day (RR, 1.26[1.05-1.51]), and 1-year mortality rates (RR, 2.26[1.32-3.88]) when compared to high-volume hospitals following THA. Except for two prospective studies, all were retrospective observational studies.

CONCLUSIONS

These findings demonstrate superior outcomes following THA in high-volume hospitals. Together with the reduced cost of the surgical procedure, fewer complications may contribute to saving considerable opportunity costs annually. However, a need to define objective volume-thresholds with stronger evidence would be required.

TRIAL REGISTRATION

PROSPERO CRD42019123776.

Variability in Exposure to Subspecialty Rotations During Orthopaedic Residency: A Website-based Review of Orthopaedic Residency Programs

Introduction:

The variability in exposure to various subspecialty rotations during orthopaedic residency across the United States has not been well studied.

Methods:

Data regarding program size, resident's sex, department leadership, university-based status of the program, outsourcing of subspecialty rotation, and geographic location were collected from websites of 151 US allopathic orthopaedic residency programs. The relationship of these factors with the time allotted for various clinical rotations was analyzed.

Results:

The number of residents in a program correlated positively with time allocated for elective rotations (r = 0.57, P = 0.0003). Residents in programs where the program director was a general orthopaedic surgeon spent more time on general orthopaedic rotations (22 versus 9.9 months, P = 0.001). Programs where the program director or chairman was an orthopaedic oncologist spent more time on oncology rotations ([3.8 versus 3 months, P = 0.01] and [3.5 versus 2.7 months, P = 0.01], respectively). Residents in community programs spent more time on adult reconstruction than university-based programs (6.6 versus 5.5 months, P = 0.014). Based on multiple linear regression analysis, time allotted for adult reconstruction (t = 2.29, P = 0.02) and elective rotations (t = 2.43, P = 0.017) was positively associated with the number of residents in the program.

Conclusions:

Substantial variability exists in the time allocated to various clinical rotations during orthopaedic residency. The effect of this variability on clinical competence, trainees' career choices, and quality of patient care needs further study.

Comparing Inpatient Complication Rates between Octogenarians and Nonagenarians Following Primary and Revision Total Hip Arthroplasty in a Nationally Representative Sample 2010-2014

We compared inpatient postoperative complication rates between octogenarians and nonagenarians undergoing primary and revision total hip arthroplasty (THA). We used inpatient admission data from 2010-2014 from the Nationwide Inpatient Sample (NIS). We compared the rates at which nonagenarians and octogenarians developed each complication in the inpatient setting following both primary THA (PTHA) and revision THA (RTHA). A total of 40,944 inpatient admissions were included in our study which extrapolates to a national estimate of 199,793 patients. A total of 185,799 (93%) were octogenarians and 13,994 (7%) were nonagenarians. PTHA was performed on 155,669 (78%) and RTHA was performed on 44,124 (22%) of the patients. Nonagenarians undergoing PTHA required transfusions significantly more frequently (33.13% v. 24.0%, p < 0.001) and developed urinary tract infection (5.14% v. 3.92%, p = 0.012) and acute kidney injury (5.50% v. 3.57%, p < 0.001) significantly more frequently than octogenarians. Nonagenarians undergoing RTHA required transfusions significantly more frequently (51.43% v. 41.46%, p < 0.001) and developed urinary tract infection (19.66% v. 11.73%, p < 0.001), acute kidney injury (13.8% v. 9.66%, p < 0.001), pulmonary embolism (1.24% v. 0.67%, p = 0.031), postoperative infection (1.89% v. 1.11%, p = 0.023), sepsis (3.59% v. 2.43%, p = 0.021) and other postoperative shock (1.76% v. 1.06%, p = 0.036) significantly more frequently than octogenarians. Nonagenarians undergoing RTHA also had a significantly higher inpatient mortality rate (3.28% v. 1.43%, p < 0.001) than octogenarians. Orthopedic surgeons and primary care providers can use these findings to help counsel both their octogenarian and nonagenarian patients preoperatively when considering THA. Our analysis can help these patients better understand expected inpatient complication rates and assist them in deciding whether to pursue surgical intervention when applicable.

Insurance Status Affects Complication Rates After Total Hip Arthroplasty

INTRODUCTION

Previous studies have examined the relationship between total hip arthroplasty (THA) and insurance status in small cohorts. This study evaluates the effect of patient insurance status on complications after primary elective THA using the Nationwide Inpatient Sample.

METHODS

All patients undergoing primary elective THA from 1998 to 2011 were included. Patient demographics, comorbidities, and complications were collected and compared based on insurance type. Multivariable logistic regression and a matched cohort analysis were performed.

RESULTS

About 515,037 patients (53.7% Medicare, 40.1% private insurance, 3.9% Medicaid/uninsured, and 2.2% other) were included, who underwent elective THA. Privately insured patients had fewer medical complications (odds ratio, 0.80; P < 0.001), whereas patients with Medicaid or no insurance demonstrated no notable difference (odds ratio, 1.03; P = 0.367) compared with Medicare patients. Similar trends were found for both surgical complications and mortality, favoring lower complication rates for privately insured patients. Furthermore, patients with private insurance tend to go to higher volume hospitals for total hip replacement surgery compared to those with Medicare insurance.

DISCUSSION

Patients with government-sponsored insurance (Medicare or Medicaid) or no insurance have higher risk of medical complications, surgical complications, and mortality after primary elective THA compared with privately insured patients. Insurance status should be considered an independent risk factor for stratifying patients before THA procedures.

Prosthetic Joint Infection Trends at a Dedicated Orthopaedics Specialty Hospital

Introduction

Historically, a majority of prosthetic joint infections (PJIs) grew Gram-positive bacteria. While previous studies stratified PJI risk with specific organisms by patient comorbidities, we compared infection rates and microbiologic characteristics of PJIs by hospital setting: a dedicated orthopaedic hospital versus a general hospital serving multiple surgical specialties.

Methods

A retrospective review of prospectively collected data on 11,842 consecutive primary hip and knee arthroplasty patients was performed. Arthroplasty cases performed between April 2006 and August 2008 at the general university hospital serving multiple surgical specialties were compared to cases at a single orthopaedic specialty hospital from September 2008 to August 2016.

Results

The general university hospital PJI incidence rate was 1.43%, with 5.3% of infections from Gram-negative species. In comparison, at the dedicated orthopaedic hospital, the overall PJI incidence rate was substantially reduced to 0.75% over the 8-year timeframe. Comparing the final two years of practice at the general university facility to the most recent two years at the dedicated orthopaedics hospital, the PJI incidence was significantly reduced (1.43% vs 0.61%). Though the overall number of infections was reduced, there was a significantly higher proportion of Gram-negative infections over the 8-year timeframe at 25.3%.

Conclusion

In transitioning from a multispecialty university hospital to a dedicated orthopaedic hospital, the PJI incidence has been significantly reduced despite a greater Gram-negative proportion (25.3% versus 5.3%). These results suggest a change in the microbiologic profile of PJI when transitioning to a dedicated orthopaedic facility and that greater Gram-negative antibiotic coverage could be considered.

Does surgeon volume influence the outcome after hip hemiarthroplasty for displaced femoral neck fractures; early outcome, complications, and survival of 752 cases

INTRODUCTION

Surgeon volume of hip arthroplasties is of importance with regard to complication and revision rates in total hip arthroplasty. For hip hemiarthroplasty, the effect of surgeon volume on outcome is far less studied. We analyzed the outcome of hip hemiarthroplasties performed by orthopedic surgeons in a retrospective cohort in different volume categories, focusing on early survival of the prosthesis and complications.

METHODS

Between March 2009 and January 2014, 752 hemiarthroplasties were performed for intracapsular femoral neck fracture by 27 orthopedic surgeons in a large Dutch teaching hospital. Surgeons were divided into four groups, a resident group and three groups based on the number of total hip arthroplasties and hemiarthroplasties performed per year: a low-volume (< 10 arthroplasties per year), moderate-volume (10-35 arthroplasties per year), and high-volume groups (> 35 arthroplasties per year). Outcome measures were stem survival using a competing risk analysis, complication rates, and mortality. Chi-square tests were used to compare complication rates and mortality between groups.

RESULTS

Patients were followed for a minimum of 2 years or until revision or death. Overall 60% of the patients included had died at time of follow-up. We found comparable stem survival rates in the low-volume group (n = 48), moderate-volume group (n = 201), high-volume group (n = 446), and resident group (n = 57). There were no significant differences between the groups with regard to dislocation rate, incidence of periprosthetic fracture, infection, and mortality.

CONCLUSION

Surgeon volume and experience did not influence early outcome and complication rates in hip hemiarthroplasty. Hemiarthroplasty can safely be performed by both experienced hip surgeons and low-volume surgeons.

The 2018 Otto Aufranc Award: How Does Genome-wide Variation Affect Osteolysis Risk After THA?

BACKGROUND

Periprosthetic osteolysis resulting in aseptic loosening is a leading cause of THA revision. Individuals vary in their susceptibility to osteolysis and heritable factors may contribute to this variation. However, the overall contribution that such variation makes to osteolysis risk is unknown.

QUESTIONS/PURPOSES

We conducted two genome-wide association studies to (1) identify genetic risk loci associated with susceptibility to osteolysis; and (2) identify genetic risk loci associated with time to prosthesis revision for osteolysis.

METHODS

The Norway cohort comprised 2624 patients after THA recruited from the Norwegian Arthroplasty Registry, of whom 779 had undergone revision surgery for osteolysis. The UK cohort included 890 patients previously recruited from hospitals in the north of England, 317 who either had radiographic evidence of and/or had undergone revision surgery for osteolysis. All participants had received a fully cemented or hybrid THA using a small-diameter metal or ceramic-on-conventional polyethylene bearing. Osteolysis susceptibility case-control analyses and quantitative trait analyses for time to prosthesis revision (a proxy measure of the speed of osteolysis onset) in those patients with osteolysis were undertaken in each cohort separately after genome-wide genotyping. Finally, a meta-analysis of the two independent cohort association analysis results was undertaken.

RESULTS

Genome-wide association analysis identified four independent suggestive genetic signals for osteolysis case-control status in the Norwegian cohort and 11 in the UK cohort (p ≤ 5 x 10). After meta-analysis, five independent genetic signals showed a suggestive association with osteolysis case-control status at p ≤ 5 x 10 with the strongest comprising 18 correlated variants on chromosome 7 (lead signal rs850092, p = 1.13 x 10). Genome-wide quantitative trait analysis in cases only showed a total of five and nine independent genetic signals for time to revision at p ≤ 5 x 10, respectively. After meta-analysis, 11 independent genetic signals showed suggestive evidence of an association with time to revision at p ≤ 5 x 10 with the largest association block comprising 174 correlated variants in chromosome 15 (lead signal rs10507055, p = 1.40 x 10).

CONCLUSIONS

We explored the heritable biology of osteolysis at the whole genome level and identify several genetic loci that associate with susceptibility to osteolysis or with premature revision surgery. However, further studies are required to determine a causal association between the identified signals and osteolysis and their functional role in the disease.

CLINICAL RELEVANCE

The identification of novel genetic risk loci for osteolysis enables new investigative avenues for clinical biomarker discovery and therapeutic intervention in this disease.

Relationship between hospital or surgeon volume and outcomes in joint arthroplasty: protocol for a suite of systematic reviews and dose-response meta-analyses

INTRODUCTION

Joint arthroplasty is a particularly complex orthopaedic surgical procedure performed on joints, including the hip, knee, shoulder, ankle, elbow, wrist and even digit joints. Increasing evidence from volume-outcomes research supports the finding that patients undergoing joint arthroplasty in high-volume hospitals or by high-volume surgeons achieve better outcomes, and minimum case load requirements have been established in some areas. However, the relationships between hospital/surgeon volume and outcomes in patients undergoing arthroplasty are not fully understood. Furthermore, whether elective arthroplasty should be restricted to high-volume hospitals or surgeons remains in dispute, and little is known regarding where the thresholds should be set for different types of joint arthroplasties.

METHODS AND ANALYSES

This is a protocol for a suite of systematic reviews and dose-response meta-analyses, which will be amended and updated in conjunction with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. Electronic databases, including PubMed and Embase, will be searched for observational studies examining the relationship between the hospital or surgeon volume and clinical outcomes in adult patients undergoing primary or revision of joint arthroplasty. We will use records management software for study selection and a predefined standardised file for data extraction and management. Quality will be assessed using the Newcastle-Ottawa Scale, and the meta-analysis, subgroup analysis and sensitivity analysis will be performed using Stata statistical software. Once the volume-outcome relationships are established, we will examine the potential non-linear relationships between hospital/surgeon volume and outcomes and detect whether thresholds or turning points exist.

ETHICS AND DISSEMINATION

Ethical approval is not required, because these studies are based on aggregated published data. The results of this suite of systematic reviews and meta-analyses will be submitted to peer-reviewed journals for publication.

PROSPERO REGISTRATION NUMBER

CRD42017056639.

Risk Factors Associated With Health Care Utilization and Costs of Patients Undergoing Lower Extremity Joint Replacement

BACKGROUND

The Comprehensive Care for Joint Replacement program implemented by the Centers for Medicare and Medicaid Services did not incorporate risk adjustment for lower extremity joint replacement (LEJR). Lack of adjustment places hospitals at financial risk and creates incentives for adverse patient selection.

OBJECTIVE

To identify patient-level risk factors associated with health care utilization and costs of patients undergoing LEJR.

METHODS

A comprehensive search of research databases from January 1, 1990, through January 31, 2016, was conducted. The databases included Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and SCOPUS and is reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search identified 2020 studies. Eligible studies focused on primary unilateral and bilateral LEJR. Independent reviewers determined study eligibility and extracted utilization and cost data.

RESULTS

Seventy-nine of 330 studies (24%) were included and were abstracted for analysis. Comorbidities, age, disease severity, and obesity were associated with increased costs. Increased number of comorbidities and age, presence of specific comorbidities, lower socioeconomic status, and female sex had evidence of increased length of stay. We found no significant association between indication for surgery and the likelihood of readmission.

CONCLUSION

Developing a risk adjustment model for LEJR that incorporates clinical variables may serve to reduce the likelihood of adverse patient selection and enhance appropriate reimbursement aligned with procedural complexity.

Risk-Based Hospital and Surgeon-Volume Categories for Total Hip Arthroplasty

BACKGROUND

Studies of volume-outcome relationships typically subdivide volume via non-evidence-based methods, producing categories that vary widely among studies, preclude the comparison of results, and possibly obscure the true volume-outcome relationships. The goal of the current study was to use quantitative methods to derive meaningful, risk-based categories for hospital and surgeon total hip arthroplasty (THA) volume based on relationships with mortality, complications, and revision.

METHODS

Using New York statewide patient data (1997 to 2014; n = 187,557), we derived risk-based hospital and surgeon-volume categories for primary THA based on relationships with 90-day complications and mortality and 2-year revision.

RESULTS

The following categories, based on relationships with complications, mortality, and revision, were derived for surgeon volume: 0 to 12, 13 to 25, 26 to 72, 73 to 165, 166 to 279, and ≥280 THA/year. For hospital volume, the categories derived were 0 to 11, 12 to 54, 55 to 157, 158 to 526, and ≥527 THA/year. More than 35% of THA cases in New York State were conducted by surgeons performing ≤1 THA/month (0 to 12 THA/year), and these were associated with a 2 to 2.5-fold increase in the risk for complications, mortality, and revision relative to higher-volume surgeons. Similarly, 15% of THA cases in New York State were conducted in hospitals performing ≤1 THA/week (0 to 11 or 12 to 54 THA/year), and these were associated with a nearly 1.5-fold increase in complications and between a 4 and 6-fold increase in mortality. Traditional non-evidence-based quartile categories were concentrated at lower volumes, did not capture the full magnitude of the volume-related differences, and were a poorer representation of the outcome data, as assessed by several model metrics. Thus, quartiles showed only a <2-fold increase in complications, mortality, and revision for the lowest versus the highest surgeon-volume quartile and failed to show the increased risk for lower versus higher hospital volumes.

CONCLUSIONS

The volume-outcome relationships in THA are more pronounced than previously apparent through standard statistical techniques. Volume-based strategies for improving outcomes in THA should use benchmarks that are evidence-based to achieve optimal results.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Improved survival for extremity soft tissue sarcoma treated in high-volume facilities

BACKGROUND AND OBJECTIVES

The purpose of this investigation was to determine the effect of hospital volume on treatment decisions, treatment results, and overall patient survival in extremity soft tissue sarcoma.

METHODS

The National Cancer Database was used to identify patients ≥18 years of age with non-metastatic soft tissue sarcoma of the extremity treated with surgery. Patients in high- and low-volume centers were matched by propensity score and placed into two equal comparative groups of 2437 patients each.

RESULTS

Chemotherapy was used at a higher rate in high-volume centers (22% vs 17%, P < 0.001) and external beam radiation usage was similar (55% vs 52%, P = 0.108). There was a lower incidence of positive margins in high-volume centers (12% vs 17%, P < 0.001). There was no significant difference in the rates of limb salvage surgery or readmissions at high-volume hospitals compared to low-volume. In a multivariate Cox proportional hazards model, low-volume facilities demonstrated diminished overall survival at all time points (hazard ratio at 5 years = 1.24, 95%CI 1.10-1.39).

CONCLUSIONS

Treatment at high-volume hospitals was associated with fewer positive margins and increased overall survival at 2, 5, and 10 years. Continued efforts should focus on optimizing the balance between patient access to specialty care and experience of the treating center.

Associations between provider and hospital volumes and postoperative mortality following total hip arthroplasty in New Brunswick: results from a provincial-level cohort study

BACKGROUND

Several international studies have reported negative associations between hospital and/or provider volume and risk of postoperative death following total hip arthroplasty (THA). The only Canadian studies to report on this have been based in Ontario and have found no such association. We describe associations between postoperative deaths following THA and provider caseload volume, also adjusted for hospital volume, in a population-based cohort in New Brunswick.

METHODS

Our analyses are based on hospital discharge abstract data linked to vital statistics and to patient registry data. We considered all first known admissions for THA in New Brunswick between Jan. 1, 2007, and Dec. 31, 2013. Provider volume was defined as total THAs performed over the preceding 2 years. We fit logistic regression models to identify odds of dying within 30 and 90 days according to provider caseload volume adjusted for selected personal and contextual characteristics.

RESULTS

About 7095 patients were admitted for THA in New Brunswick over the 7-year study period and 170 died within 30 days. We found no associations with provider volume and postoperative mortality in any of our models. Adjustment for contextual characteristics or hospital volume had no effects on this association.

CONCLUSION

Our results suggest that patients admitted for hip replacements in New Brunswick can expect to have similar risk of death regardless of whether they are admitted to see a provider with high or low THA volumes and of whether they are admitted to the province's larger or smaller hospitals.

Improving Value in Total Hip and Knee Arthroplasty: The Role of High Volume Hospitals

BACKGROUND

Recent healthcare reform efforts have focused on improving the quality of total joint replacement care while reducing overall costs. The purpose of this study is to determine if higher volume centers have lower costs and better outcomes than lower volume hospitals.

METHODS

We queried the Centers for Medicare and Medicaid Services (CMS) Inpatient Charge Data and identified 2702 hospitals that performed a total of 458,259 primary arthroplasty procedures in 2014. Centers were defined as low (performing <100 total joint arthroplasty [TJA] per year) or high volume and mean total hospital-specific charges and inpatient payments were obtained. Patient satisfaction scores as well 30-day risk-adjusted complication and readmission scores were obtained from the multiyear CMS Hospital Compare database.

RESULTS

Of all the hospitals, 1263 (47%) hospitals were classified as low volume and performed 60,895 (12%) TJA cases. Higher volume hospitals had lower mean total hospital-specific charges ($56,323 vs $60,950, P < .001) and mean Medicare inpatient payments ($12,131 vs $13,289, P < .001). Higher volume facilities had a lower complication score (2.96 vs 3.16, P = .015), and a better CMS hospital star rating (3.14 vs 2.89, P < .001). When controlling for hospital geographic and demographic factors, lower volume hospitals are more likely to be in the upper quartile of inpatient Medicare costs (odds ratio 2.127, 95% confidence interval 1.726-2.621, P < .001).

CONCLUSION

Hospitals that perform <100 TJA cases per year may benefit from adopting the practices of higher volume centers in order to improve quality and reduce costs.

Do higher-volume hospitals provide better value in revision hip and knee arthroplasty?

AIMS

The purpose of this study is to determine if higher volume hospitals have lower costs in revision hip and knee arthroplasty.

MATERIALS AND METHODS

We questioned the Centres for Medicare and Medicaid Services (CMS) Inpatient Charge Data and identified 789 hospitals performing a total of 29 580 revision arthroplasties in 2014. Centres were dichotomised into high-volume (performing over 50 revision cases per year) and low-volume. Mean total hospital-specific charges and inpatient payments were obtained from the database and stratified based on Diagnosis Related Group (DRG) codes. Patient satisfaction scores were obtained from the multiyear CMS Hospital Compare database.

RESULTS

High-volume hospitals comprised 178 (30%) of the total but performed 15 068 (51%) of all revision cases, including 509 of 522 (98%) of the most complex DRG 466 cases. While high-volume hospitals had higher Medicare inpatient payments for DRG 467 ($21 458 versus $20 632, p = 0.038) and DRG 468 ($17 003 versus $16 120, p = 0.011), there was no difference in hospital specific charges between the groups. Higher-volume facilities had a better CMS hospital star rating (3.63 versus 3.35, p < 0.001). When controlling for hospital geographic and demographic factors, high-volume revision hospitals are less likely to be in the upper quartile of inpatient Medicare costs for DRG 467 (odds ratio (OR) 0.593, 95% confidence intervals (CI) 0.374 to 0.941, p = 0.026) and DRG 468 (OR 0.451, 95% CI 0.297 to 0.687, p < 0.001).

CONCLUSION

While a high-volume hospital is less likely to be a high cost outlier, the higher mean Medicare reimbursements at these facilities may be due to increased case complexity. Further study should focus on measures for cost savings in revision total joint arthroplasties. Cite this article: Bone Joint J 2017;99-B:1611-17.

Nationwide Analysis of Femoral Neck Fractures in Elderly Patients: A Receding Tide

BACKGROUND

Geriatric femoral neck fractures are associated with substantial morbidity and medical cost. We evaluated the incidence and management trends of femoral neck fractures in recent years in the U.S.

METHODS

Patient data from 2003 through 2013 were obtained from the Nationwide Inpatient Sample database. Femoral neck fractures in patients ≥65 years old were identified and grouped using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes for internal fixation, hemiarthroplasty, or total hip arthroplasty (THA). The nationwide incidence of femoral neck fractures was calculated and presented as an age-adjusted population rate. Univariable methods were used for trend analysis and comparisons between groups. Logistic regression modeling was used to analyze complications.

RESULTS

From 2003 to 2013, we identified 808,940 femoral neck fractures in patients ≥65 years old. The national age-adjusted incidence of femoral neck fractures decreased from 242 per 100,000 U.S. adults in 2003 to 146 in 2013. The proportion of fractures managed operatively with THA increased over time (5.9% in 2003 versus 7.4% in 2013; p < 0.001). Concurrently, the use of hemiarthroplasty declined (65.1% versus 63.6%; p < 0.001). In 2013, the median age of the patients treated with THA was significantly younger (77.3 years) compared with that in the hemiarthroplasty and internal fixation groups (83.2 and 82.0 years). The THA group had significantly higher median initial hospital costs ($17,097) compared with the hemiarthroplasty and internal fixation groups ($14,776 and $10,462).

CONCLUSIONS

In the last decade, the total number and population rate of femoral neck fractures in the elderly declined significantly. There was a modest but significant increase in the utilization of THA.

CLINICAL RELEVANCE

This report identifies the changing trends in clinical practice in the treatment of geriatric femoral neck fractures in the U.S. Treating physicians should be aware of these trends, which include a decreasing national incidence of geriatric femoral neck fractures as well as an increase in the use of THA.

Modified Frailty Index Is an Effective Risk Assessment Tool in Primary Total Hip Arthroplasty

BACKGROUND

Frailty is described as decreased physiological reserve and typically increasing with age. Hospitals are being penalized for reoperations and readmissions, which can affect reimbursement. The purpose of this study was to determine if the modified frailty index (MFI) could be used as a risk assessment tool for preoperative counseling and to make an objective decision on whether to perform total hip arthroplasty (THA) on a frail patient.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried by Current Procedural Terminology code for primary THA (27130) from 2005 to 2014. MFI was calculated using 11 variables extracted from the medical record. Bivariate analysis was performed for outcomes and complications, and the multiple logistic regression model was used to compare MFI with other predictors of readmission, any complication, and reoperation.

RESULTS

A total of 51,582 patients underwent primary THA during the study period. MFI was a significant and stronger predictor than the American Society of Anesthesiologists class and age for readmission (odds ratio [OR], 14.72; 95% confidence interval [CI], 6.95-31.18; P < .001), any complication (OR, 3.63; 95% CI, 1.64-8.05; P = .002), and reoperation (OR, 8.78; 95% CI, 3.67-20.98; P < .001). As MFI increased, adverse discharge, any complication, readmission, reoperation, and mortality significantly increased (P < .001). Rates of systemic complications and length of stay significantly increased with increasing MFI.

CONCLUSION

MFI is a simple and effective risk assessment tool to preoperatively counsel and make an objective decision on whether to perform THA on a frail patient.

Effect of Surgeon and Hospital Volume on Morbidity and Mortality After Hip Fracture

BACKGROUND

Prior studies have examined the relationship between surgeon and hospital volumes and outcome following hip fracture surgical procedures, but the results have been inconclusive. The purpose of this study was to assess the hip fracture volume-outcome relationship by analyzing data from a large, managed care registry.

METHODS

The Kaiser Permanente Hip Fracture Registry prospectively records information on surgically treated hip fractures within the managed health-care system. Using this registry, all surgically treated hip fractures in patients 60 years of age or older were identified. Surgeon and hospital volume were defined as the number of hip fracture surgical procedures performed in the preceding 12 months and were divided into tertiles (low, medium, and high). The primary outcome was mortality at 1 year postoperatively. Secondary outcomes were mortality at 30 and 90 days postoperatively as well as reoperation (lifetime), medical complications (90-day), and unplanned readmission (30-day). To determine the relationship between volume and these outcome measures, multivariate logistic and Cox proportional hazards regression were performed, controlling for potentially confounding variables.

RESULTS

Of 14,294 patients in the study sample, the majority were female (71%) and white (79%), and the mean age was 81 years. The overall mortality rate was 6% at 30 days, 11% at 90 days, and 21% at 1 year. We did not find an association between surgeon or hospital volume and mortality at 30 days, 90 days, or 1 year (p > 0.05). There was also no association between surgeon or hospital volume and reoperation, medical complications, or unplanned readmission (p > 0.05).

CONCLUSIONS

In this analysis of hip fractures treated in a large integrated health-care system, the observed rates of mortality, reoperation, medical complications, and unplanned readmission did not differ by surgeon or hospital volume. In contrast to other orthopaedic procedures, such as total joint arthroplasty, our data do not suggest that hip fractures need to be preferentially directed toward high-volume surgeons or hospitals for treatment.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Relative Merits of Cemented and Uncemented Prostheses in Total Hip Arthroplasty

The results of modern cemented and uncemented total hip arthroplasties are outstanding and both systems have their advantages and disadvantages. This paper aims to examine the designs of different types of prostheses, some history behind their development and the reported results. Particular emphasis is placed on cemented stem design and the details of cementing technique.

Total Hip Arthroplasty for Femoral Neck Fractures: Improved Outcomes With Higher Hospital Volumes

OBJECTIVES

To determine if hospital arthroplasty volume affects patient outcomes after undergoing total hip arthroplasty (THA) for displaced femoral neck fractures.

METHODS

The Statewide Planning and Research Cooperative System database from the New York State Department of Health was used to group hospitals into quartiles based on overall THA volume from 2000 to 2010. The database was then queried to identify all patients undergoing THA specifically for femoral neck fracture during this time period. The data were analyzed to investigate outcomes between the 4 volume quartiles in 30-day and 1-year mortality, 1-year revision rate, and 90-day complication rate (readmission for dislocation, deep vein thrombosis, pulmonary embolism, prosthetic joint infection, or other complications related to arthroplasty in the treatment of femoral neck fractures with THA).

RESULTS

Patients undergoing THA for femoral neck fracture at hospitals in the top volume quartile had significantly lower 30-day (0.9%) and 1-year (7.51%) mortality than all other volume quartiles. There were no significant differences on pairwise comparisons between the second, third, and fourth quartiles with regard to postoperative mortality. There was no significant difference in revision arthroplasty at 1 year between any of the volume quartiles. On Cox regression analysis, THA for fracture at the lowest volume (fourth) quartile [hazard ratio (HR), 1.91; P = 0.016, 95% confidence interval (CI), (1.13-3.25)], second lowest volume (third) quartile (HR, 2.01; P = 0.013, 95% CI, 1.16-3.5) and third lowest volume (second) quartile (HR, 2.13; P = 0.005, 95% CI, 1.26-3.62) were associated with increased risk for a 1-year postoperative mortality event. Hospital volume quartile was also a significant risk factor for increased 90-day complication (pulmonary embolism/deep vein thrombosis, acute dislocation, prosthetic joint infection) following THA for femoral neck fracture. Having surgery in the fourth quartile (HR, 2.71; P < 0.001, 95% CI, 1.7-4.31), third quartile (HR, 2.61; P < 0.001, 95% CI, 1.61-4.23), and second quartile (HR, 2.41; P < 0.001, 95% CI, 1.51-3.84), all were significant risk factors for increased 90-day complication risk.

CONCLUSIONS

The results of this population-based study indicate that THA for femoral neck fractures at high-volume arthroplasty centers is associated with lower mortality and 90-day complication rates but does not influence 1-year revision rate. THA for femoral neck fractures at top arthroplasty volume quartile hospitals are performed on healthier patients more quickly. Patient health is a critical factor that influences mortality outcomes following THA for femoral neck fractures.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Inpatient mortality after elective primary total hip and knee joint arthroplasty in Botswana

PURPOSE

Total hip and knee joint arthroplasty (TJA) rank among the most successful orthopaedic operations. Several developing countries in Africa have started to perform these procedures that are routine in developed countries. The aims of this study were to measure the incidence and assess the determinants of in-hospital mortality after elective primary TJA in our unit and compare it with published data.

METHODS

This was a retrospective study of the first consecutive cohort of patients who underwent elective primary TJA in Princess Marina Hospital, Botswana between March 2009 and October 2015 (6.5 years).

RESULTS

346 elective joint replacements were performed comprising 153 total hip arthroplasties (THA) and 193 total knee arthroplasties (TKA); 36 % of the THA were in female patients and 82 % of TKA were in females. The mean age was 64.5 years (range 26-86). Three patients died giving an inpatient mortality rate of 0.86 %. These three mortalities represent 1.55 % (three out of 193) of all the TKA. There were no deaths after THA. The cause of mortality in two patients was an adverse cardiac event while the third mortality was due to pulmonary embolism.

CONCLUSION

The inpatient mortality rate of 0.86 % following TJA is higher than the reported rates in the developed countries but comparable with data from other developing countries. The inpatient mortality rate following TKA was higher than that following THA and cardiovascular events proved to be the main cause of death. We recommend formal cardiology assessment and close peri-operative monitoring of all patients with a history of cardiovascular disease undergoing TJA.

The Epidemiology of Primary and Revision Total Hip Arthroplasty in Teaching and Nonteaching Hospitals in the United States

INTRODUCTION

The purpose of this study was to examine the epidemiology of primary and revision total hip arthroplasty (THA) in teaching and nonteaching hospitals.

METHODS

The Healthcare Cost and Utilization Project Nationwide Inpatient Sample was queried from 2006 to 2010 to identify primary and revision THAs at teaching and nonteaching hospitals.

RESULTS

A total of 1,336,396 primary and 223,520 revision procedures were identified. Forty-six percent of all primary and 54% of all revision procedures were performed at teaching hospitals. Teaching hospitals performed 17% of their THAs as revisions; nonteaching hospitals performed 12% as revisions. For primary and revision THAs, teaching hospitals had fewer patients aged >65 years, fewer Medicare patients, similar gender rates, more nonwhite patients, and more patients in the highest income quartile compared with nonteaching hospitals. Costs, length of stay, and Charlson Comorbidity Index scores were similar; however, the mortality rate was lower at teaching hospitals.

CONCLUSIONS

This study found small but significant differences in key epidemiologic and outcome variables in examining primary and revision THA at teaching and nonteaching hospitals.

LEVEL OF EVIDENCE

Level III.

Trend Toward High-Volume Hospitals and the Influence on Complications in Knee and Hip Arthroplasty

BACKGROUND

Hospitals in which a high volume of arthroplasty procedures are performed have been observed to have better outcomes. As the number of arthroplasties has increased, it is not known whether surgical cases have shifted to high-volume hospitals. In this study, we examined the change in the volume of arthroplasties to provide a contemporary definition of "high-volume" centers, quantified surgical volume that shifted to high-volume centers, and investigated the resulting effect on complications.

METHODS

Data from the National (Nationwide) Inpatient Sample (2000 to 2012) were used to quantify trends in total hip arthroplasty (THA) and total knee arthroplasty (TKA) volume. Elective primary THAs and TKAs were identified and grouped by hospital by utilizing the hospital identifier, which indicates the geographic location of the hospital. County geographic and population data were obtained from the U.S. Census, and the distances between hospitals and the centroids of counties were calculated. Risk-standardized surgical complication rates for hospitals (2009 to 2012) were obtained from Medicare Hospital Compare and grouped by hospital volume.

RESULTS

From 2000 to 2012, there was a marked increase in the number of hospitals that performed a combined volume of ≥400 elective primary THAs and TKAs. The number of elective primary TKAs and THAs performed annually increased from 343,000 to 851,000. In 2012, 65.5% of the arthroplasties were performed in high-volume hospitals (≥400 arthroplasties annually), and 26.6% of the arthroplasties were performed in very high-volume hospitals (≥1,000 procedures annually). The proportion of arthroplasties performed in low-volume hospitals (<100 arthroplasties annually) shrank from 17.9% to 5.4%. Very high-volume hospitals had the lowest complication rates (2.745 per 100; 95% confidence interval [CI], 2.56 to 2.93), and low-volume hospitals had the highest complication rates (3.610 per 100; 95% CI, 3.58 to 3.64; p < 0.0001) (odds ratio, 1.327; 95% CI, 1.26 to 1.40). Our analysis showed that 81.9% of the U.S. population lived within 50 miles of a high-volume hospital.

CONCLUSIONS

Arthroplasty patients are electing to have their procedures at higher-volume hospitals in the United States. Each successively higher hospital volume category manifested a lower complication rate.

Association between hospital procedure volume and risk of revision after total hip arthroplasty: a population-based study within the Nordic Arthroplasty Register Association database

OBJECTIVE

Outcome after total hip arthroplasty (THA) depends on several factors related to the patient, the surgeon and the implant. It has been suggested that the annual number of procedures per hospital affects the prognosis. We aimed to examine if hospital procedure volume was associated with the risk of revision after primary THA in the Nordic countries from 1995 to 2011.

DESIGN

The Nordic Arthroplasty Register Association database provided information about primary THA, revision and annual hospital volume. Hospitals were divided into five volume groups (1-50, 51-100, 101-200, 201-300, >300). The outcome of interest was risk of revision 1, 2, 5, 10 and 15 years after primary THA. Multivariable regression was used to assess the relative risk (RR) of revision.

RESULTS

417,687 THAs were included. For the 263,176 cemented THAs no differences were seen 1 year after primary procedure. At 2, 5, 10 and 15 years the four largest hospital volume groups had a reduced risk of revision compared to group 1-50. After 10 years RR was for volume group 51-100 0.79 (CI 0.65-0.95), group 101-200 0.76 (CI 0.61-0.95), group 201-300 0.74 (CI 0.57-0.96) and group >300 0.57 (CI 0.46-0.71). For the uncemented THAs an association between hospital volume and risk of revision were only present for hospitals producing 201-300 THAs per year, beginning at years 2 through 5 and in all subsequent time intervals to 15 years.

CONCLUSION

Hospital procedure volume was associated with a long term risk of revision after primary cemented THA. Hospitals operating 50 procedures or less per year had an increased risk of revision after 2, 5, 10 and 15 years follow up.

Operative Mortality After Arthroplasty for Femoral Neck Fracture and Hospital Volume

Background:

The purpose of the present study is to use a statewide, population-based data set to identify mortality rates at 30-day and 1-year postoperatively following total hip arthroplasty (THA) and hemiarthroplasty (HA) for displaced femoral neck fractures. The secondary aim of the study is to determine whether arthroplasty volume confers a protective effect on the mortality rate following femoral neck fracture treatment.

Methods:

New York’s Statewide Planning and Research Cooperative System was used to identify 45 749 patients older than 60 years of age with a discharge diagnosis of femoral neck fracture undergoing THA or HA from 2000 through 2010. Comorbidities were identified using the Charlson comorbidity index. Mortality risk was modeled using Cox proportional hazards models while controlling for demographic and comorbid characteristics. High-volume THA centers were defined as those in the top quartile of arthroplasty volume, while low-volume centers were defined as the bottom quartile.

Results:

Patients undergoing THA for femoral neck fracture rather than HA were younger (79 vs 83 years, P < .001), more likely to have rheumatoid disease, and less likely to have heart disease, dementia, cancer, or diabetes (all P < .05). Thirty-day mortality after HA was higher (8.4% vs 5.7%; P < .001) as was 1-year mortality (25.9% vs 17.8%; P < .001). After controlling for age, gender, ethnicity, and comorbidities, risk of mortality following THA was 21% lower (hazard ratio [HR] 0.79; P = .003) at 30 days and 22% lower (HR 0.78; P < .001) at 1 year than HA. Patients undergoing THA at high-volume arthroplasty centers had improved 1-year mortality when compared to those undergoing THA at low-volume hospitals (HR 0.55; P = .008).

Conclusions:

Based on this large, population-based study, there is no basis to assume THA carries a greater mortality risk after hip fracture than does standard HA, even when accounting for institutional volume of hip arthroplasty.

Dealing with the predicted increase in demand for revision total knee arthroplasty: challenges, risks and opportunities

Worldwide rates of primary and revision total knee arthroplasty (TKA) are rising due to increased longevity of the population and the burden of osteoarthritis. Revision TKA is a technically demanding procedure generating outcomes which are reported to be inferior to those of primary knee arthroplasty, and with a higher risk of complication. Overall, the rate of revision after primary arthroplasty is low, but the number of patients currently living with a TKA suggests a large potential revision healthcare burden. Many patients are now outliving their prosthesis, and consideration must be given to how we are to provide the necessary capacity to meet the rising demand for revision surgery and how to maximise patient outcomes. The purpose of this review was to examine the epidemiology of, and risk factors for, revision knee arthroplasty, and to discuss factors that may enhance patient outcomes.

The Effect of Disease Severity and Comorbidity on Length of Stay for Orthopedic Surgery in Rheumatoid Arthritis: Results from 2 UK Inception Cohorts, 1986-2012

OBJECTIVE

To examine factors predicting length of stay (LoS) for orthopedic intervention in rheumatoid arthritis (RA).

METHODS

LoS for orthopedic intervention was examined in 2 consecutive, multicenter inception cohorts: the Early RA Study (n = 1465, 9 centers) and the Early RA Network (n = 1236, 23 centers). Date, type of orthopedic procedure, and LoS were recorded and validated against national data, the UK National Joint Registry, and the UK Hospital Episode Statistics database. Clinical, laboratory, and radiographic measures and comorbidity recorded at baseline and annually were examined for their predictive power on LoS using regression analysis.

RESULTS

A total of 770 of 2701 patients (28.5%) had 1602 orthopedic interventions: 40% major (mainly total hip/knee replacements), 24% intermediate (mainly hand/wrist and ankle/foot surgery), and 16% minor (mainly soft tissue surgery). Median (interquartile range) LoS was 8 (5-13), 3 (1-5), and 1 (0-2) days for major, intermediate, and minor interventions, respectively. Older age predicted longer LoS (p < 0.001) whereas a more recent operation year predicted shorter LoS (p < 0.001). Markers of active disease, namely low hemoglobin, high Health Assessment Questionnaire, and high Disease Activity Scores in the first year all predicted longer LoS for all types of surgery (p = 0.001, p < 0.001, p = 0.05, respectively). Presence of 1 or more major comorbidities predicted longer LoS (p < 0.001).

CONCLUSION

Comorbidity and standard clinical and laboratory markers of disease activity affect the LoS for orthopedic surgery in RA, which has important clinical and economic implications, providing a target for improving patient outcomes.

Morbidity and mortality in the thirty-day period following total hip arthroplasty: risk factors and incidence

The study sought to ascertain the incidence rates and risk factors for 30-day post-operative complications after primary total hip arthroplasty (THA). Complications were categorized as systemic or local and subcategorized as major or minor. There were 17,640 individuals who received primary THA identified from the 2006-2011 ACS NSQIP. The mortality rate was 0.35% and complications occurred in 4.9%. Age groups ≥ 80 years (P <0.001) and 70-79 years old (P = 0.003), and renal insufficiency (P = 0.02) best predicted mortality. Age ≥80 years (P <0.001) and cardiac disease (P = 0.01) were the strongest predictors of developing any postoperative complication. Morbid obesity (P <0.001) and operative time > 141 minutes (P <0.001) were strongly associated with the development of major local complications.