Mortality, cost, and downstream disease of total hip arthroplasty patients in the medicare population

The impact of surgical trainee involvement in total hip arthroplasty: a systematic review of surgical efficacy, patient safety, and outcomes

PURPOSE

Concerns persist that trainee participation in surgical procedures may compromise patient care and potentiate adverse events and costs. We aimed to analyse the potential impact and consequences of surgical trainee involvement in total hip arthroplasty (THA) procedures in terms of surgical efficacy, patient safety, and functional outcomes.

METHODS

We systematically reviewed Medline/PubMed, EMBASE, the Cochrane library, and Scopus databases in October 2021. Eligible studies reported a direct comparison between THA cases performed with and without trainee involvement.

RESULTS

Eighteen publications met our eligibility criteria and were included in our study. The included studies reported on 142,450 THAs completed on 142,417 patients. Specifically, 48,155 and 94,295 surgeries were completed with and without trainee involvement, respectively. The mean operative times for procedures with (n = 5,662) and without (n = 14,763) trainee involvement were 106.20 and 91.41 min, respectively. Mean overall complication rates were 6.43% and 5.93% for THAs performed with (n = 4842) and without (n = 12,731) trainees. Lastly, the mean Harris Hip Scores (HHS) for THAs performed with (n = 442) and without (n = 750) trainee participation were 89.61 and 86.97, respectively.

CONCLUSION

Our systematic review confirmed previous studies' reports of increased operative time for THA cases with trainee involvement. However, based on the overall similar complication rates and functional hip scores obtained, patients should be reassured concerning the relative safety of trainee involvement in THA. Future prospective studies with higher levels of evidence are still needed to reinforce the existing evidence.

Enhanced Tribocorrosion Resistance of Hard Ceramic Coated Ti-6Al-4V Alloy for Hip Implant Application: In-Vitro Simulation Study

Developing coatings for various applications is an area of research of uttermost importance, to protect surfaces from severe damage by improving the wear and corrosion resistance of the materials. Recently, there has been increasing interest in ceramic coatings for biomedical applications, as the surface may become more inert in nature for the biological reactions and potentially increase the lifespan of the implants and minimize the side effects on the patients. Hence this study is focused on the tribocorrosion behavior of the ceramic coatings for the hip implant application on commonly used implant titanium alloy. The three types of the ceramic coatings are conventional monolithic micron alumina (IDA), micron alumina-40 wt % yttria-stabilized zirconia (YSZ) composite coating (IDAZ), and by-layer nanostructured alumina-13 wt % titania/YSZ (IDZAT) on Ti-6Al-4V alloy. A series of tests, under free potential and potentiostatic mode, were conducted using a hip simulator tribocorrosion setup under simulated joint fluid (bovine calf serum with protein concentration 30g/L). The tribological conditions are pin-on-ball contact with a load of 16N (approximately contact pressure of 50 MPa), the frequency of 1 Hz (walking frequency), and with an amplitude of 30°. The tribocorrosion studies clearly revealed that the coatings have better wear and corrosion resistance and the predominant damage mechanism was mechanical wear rather than corrosion. Among the coatings, the IDZAT shows enhanced tribocorrosion performance by exhibiting more positive OCP, no induced current, and a lower coefficient of friction.

Occurrence of never events after total joint arthroplasty in the United States

BACKGROUND

Total joint arthroplasty (TJA) is a major orthopedic procedure associated with substantial morbidity and mortality. Never events (NEs) are harmful hospital-acquired conditions (HACs) that are preventable.

METHODS

Information on hospital admissions with TJA was collected from the National Inpatient Sample (NIS) from 2003 to 2012. NIS was queried to identify NE applicable to TJA patients based on the HAC definition listed by the Centers for Medicare and Medicaid Services (CMS). NEs were further compared before and after 2008 to evaluate the effect of the new CMS non-reimbursement policy on their incidence.

RESULTS

A total of 8,176,774 patients were admitted with TJA from 2003 to 2012. 108,668 patients of these (1.33%) had ≥ 1 NE. The most prevalent NE was fall and trauma (0.7%). Significant multivariable predictors with higher odds of developing at least one NE included weekend admission [odds ratio (99.9% CI), 4.3 (3.1, 5.8), p < 0.001] and weight loss [odds ratio (99.9% CI), 2.8 (2.2, 3.5), p < 0.001]. A temporal comparison of NE before and after 2008 revealed a decrease in total NE occurrence after 2008 when the CMS announced discontinuing payment for NE (1.39% vs. 1.25%, p < 0.001). After adjustment for potential confounding risk factors, NE after TJA was significantly associated with an increased mortality (p < 0.001), a longer hospital stay (p < 0.001), and higher total hospitalization charges (p < 0.001).

CONCLUSIONS

These data demonstrated that NE in TJA patients was predictive of an increased mortality, length of hospital stay, and hospitalization costs. This study established baseline NE rates in the TJA patient population to use as benchmarks and identified target areas for quality improvement in US.

Changes in Discharge to Rehabilitation: Potential Unintended Consequences of Medicare Total Hip Arthroplasty/Total Knee Arthroplasty Bundled Payments, Should They Be Implemented on a Nationwide Scale?

BACKGROUND

As a part of the 2010 Affordable Care Act, Medicare was committed to changing 50% of its reimbursement to alternative payment models by 2018. One strategy included introduction of "bundled payments" or a fixed price for an episode of care. Early studies of the first operative bundles for elective total hip and knee arthroplasty (THA/TKA) suggest changes in discharge to rehabilitation. It remains unclear the extent to which such changes affect patient well-being. In order to address these concerns, the objective of this study is to estimate projected changes in discharge to various type of rehabilitation, 90-day outcomes, extent of therapy received, and patient health-related quality-of-life before and after introduction of bundled payments should they be implemented on a nationwide scale.

METHODS

A nationwide policy simulation was conducted using decision-tree methodology in order to estimate changes in overt and patient-centered outcomes. Model parameters were informed by published research on bundled payment effects and anticipated outcomes of patients discharged to various types of rehabilitation.

RESULTS

Following bundled payment introduction, discharge to inpatient rehabilitation facilities decreased by 16.9 percentage-points (95% confidence interval [CI] 16.5-17.3) among primary TKA patients (THA 16.8 percentage-points), a relative decline from baseline of 58.9%. Skilled nursing facility use fell by 24.0 percentage-points (95% CI 23.6-24.4). It was accompanied by a 36.7 percentage-point (95% CI 36.3-37.2) increase in home health agency use. Although simulation models predicted minimal changes in overt outcome measures such as unplanned readmission (TKA +0.8 percentage-points), changes in discharge disposition were accompanied by significant increases in the need for further assistive care (TKA +8.0 percentage-points) and decreases in patients' functional recovery and extent of therapy received. They collectively accounted for a 30% reduction in recovered motor gains.

CONCLUSION

The results demonstrate substantial changes in discharge to rehabilitation with accompanying declines in average functional outcomes, extent of therapy received, and health-related quality-of-life. Such findings challenge notions of reduced cost at no harm previously attributed to the bundled payment program and lend credence to concerns about reductions in access to facility-based rehabilitation.

Effectiveness of Perioperative Auricular Therapy on Postoperative Pain after Total Hip Arthroplasty: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Auricular therapy (AT) is a conventional therapy in traditional Chinese medicine. However, the effectiveness of perioperative AT in pain treatment after total hip arthroplasty (THA) is still controversial. Nine randomised controlled trials (RCTs) involving 605 patients who have undergone THA with or without AT from inception to March 2018 were collected and included in this study by searching more than 12 databases (e.g., PubMed, Excerpta Medica Database, and Cochrane Library). A random-effects model that pooled seven articles showed that the visual analogue scale (VAS) in the AT group was lower than that of the control group at each postoperative time point in patients after THA, except at the time points of 6 and 36 h. The intraoperative body mass-adjusted fentanyl amount in the AT group was also lower than that of the control group in two trials. The other outcomes (time to first analgesic request and incidence of postoperative nausea and vomiting, perioperative bradycardia, and transitory hypotension) showed insignificant difference. Then, subgroup analysis showed similar results to those of the total articles with the term “VAS”. Regression analysis found that the prolonged time after the operation decreased the difference in VAS between the two groups. Although all the outcomes were assessed as very low to low in the GRADE system, evidence on the effectiveness of perioperative AT in pain treatment after total hip replacement was positive.

The projected burden of complex surgical site infections following hip and knee arthroplasties in adults in the United States, 2020 through 2030

BACKGROUND

As the US population ages, the number of hip and knee arthroplasties is expected to increase. Because surgical site infections (SSIs) following these procedures contribute substantial morbidity, mortality, and costs, we projected SSIs expected to occur from 2020 through 2030.

METHODS

We used a stochastic Poisson process to project the number of primary and revision arthroplasties and SSIs. Primary arthroplasty rates were calculated using annual estimates of hip and knee arthroplasty stratified by age and gender from the 2012-2014 Nationwide Inpatient Sample and standardized by census population data. Revision rates, dependent on time from primary procedure, were obtained from published literature and were uniformly applied for all ages and genders. Stratified complex SSI rates for arthroplasties were obtained from 2012-2015 National Healthcare Safety Network data. To evaluate the possible impact of prevention measures, we recalculated the projections with an SSI rate reduced by 30%, the national target established by the US Department of Health and Human Services (HHS).

RESULTS

Without a reduction in SSI rates, we projected an increase in complex SSIs following hip and knee arthroplasty of 14% between 2020 and 2030. We projected a total burden of 77,653 SSIs; however, meeting the 30% rate reduction could prevent 23,297 of these SSIs.

CONCLUSIONS

Given current SSI rates, we project that complex SSI burden for primary and revision arthroplasty may increase due to an aging population. Reducing the SSI rate to the national HHS target could prevent 23,000 SSIs and reduce subsequent morbidity, mortality, and Medicare costs.

Preoperative intravenous glucocorticoids can decrease acute pain and postoperative nausea and vomiting after total hip arthroplasty: A PRISMA-compliant meta-analysis

BACKGROUND

A systematic review and meta-analysis of published randomized controlled trials (RCTs) were performed to assess the efficacy and safety of preoperative intravenous glucocorticoids versus controls for the prevention of postoperative acute pain and postoperative nausea and vomiting (PONV) after primary total hip arthroplasty (THA).

METHODS

A computer literature search of electronic databases, including PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, China National Knowledge Infrastructure (CNKI), and China Wanfang database, was conducted to identify the relevant RCTs comparing preoperative intravenous glucocorticoids versus placebos for reducing acute pain and PONV in THA patients. The primary outcomes included the use of the visual analog scale (VAS) with rest or mobilization at 6, 24, 48, and 72 hours and the occurrence of PONV. The secondary outcome was total morphine consumption. We calculated the risk ratio (RR) with a 95% confidence interval (95% CI) for dichotomous outcomes, and the weighted mean difference (WMD) with a 95% CI for continuous outcomes.

RESULTS

Pooled data from 7 RCTs (411 THAs) favored preoperative intravenous glucocorticoids against acute pain intensity at 4, 24, and 48 hours (P < .05). There was no significant difference between the VAS with rest or mobilization at 72 hours (P > .05). Subsequently, preoperative intravenous glucocorticoids provided a total morphine-sparing effect of 9.36 mg (WMD = -9.36, 95% CI = -12.33 to -6.38, P = .000). In addition, preoperative intravenous glucocorticoids were associated with a significant reduction of the occurrence of PONV (RR = 0.41, 95% CI = 0.30-0.57, P = .000).

CONCLUSION

Intravenous glucocorticoids can decrease early pain intensity and PONV after THA. However, the low number of studies and variation in dosing regimens limits the evidence for its use. Thus, more high-quality RCTs are still needed to identify the optimal drug and the safety of intravenous glucocorticoids.

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.

Do Bone Graft and Cracking of the Sclerotic Cavity Improve Fixation of Titanium and Hydroxyapatite-coated Revision Implants in an Animal Model?

BACKGROUND

We previously introduced a manual surgical technique that makes small perforations (cracks) through the sclerotic bone shell that typically forms during the process of aseptic loosening ("crack" revision technique). Perforating just the shell (without violating the proximal cortex) can maintain overall bone continuity while allowing marrow and vascular elements to access the implant surface. Because many revisions require bone graft to fill defects, we wanted to determine if bone graft could further increase implant fixation beyond what we have experimentally shown with the crack technique alone. Also, because both titanium (Ti6Al4V) and hydroxyapatite (HA) implant surfaces are used in revisions, we also wanted to determine their relative effectiveness in this model.

QUESTIONS/PURPOSES

We hypothesized that both (1) allografted plasma-sprayed Ti6Al4V; and (2) allografted plasma-sprayed HA-coated implants inserted with a crack revision technique have better fixation compared with a noncrack revision technique in each case.

METHODS

Under approval from our Institutional Animal Care and Use Committee, a female canine animal model was used to evaluate the uncemented revision technique (crack, noncrack) using paired contralateral implants while implant surface (Ti6Al4V, HA) was qualitatively compared between the two (unpaired) series. All groups received bone allograft tightly packed around the implant. This revision model includes a cylindrical implant pistoning 500 μm in a 0.75-mm gap, with polyethylene particles, for 8 weeks. This engenders a bone and tissue response representative of the metaphyseal cancellous region of an aseptically loosened component. At 8 weeks, the original implants were revised and followed for an additional 4 weeks. Mechanical fixation was assessed by load, stiffness, and energy to failure when loaded in axial pushout. Histomorphometry was used to determine the amount and location of bone and fibrous tissue in the grafted gap.

RESULTS

The grafted crack revision improved mechanical shear strength, stiffness, and energy to failure (for Ti6Al4V 27- to 69-fold increase and HA twofold increases). The histomorphometric analysis demonstrated primarily fibrous membrane ongrowth and in the gap for the allografted Ti6Al4V noncrack revisions. For allografted HA noncrack revisions, bone ongrowth at the implant surface was observed, but fibrous tissue also was present in the inner gap. Although both Ti6Al4V and HA surfaces showed improved fixation with grafted crack revision, and Ti6Al4V achieved the highest percent gain, HA demonstrated the strongest overall fixation.

CONCLUSIONS

The results of this study suggest that novel osteoconductive or osteoinductive coatings and bone graft substitutes or tissue-engineered constructs may further improve bone-implant fixation with the crack revision technique but require evaluation in a rigorous model such as presented here.

CLINICAL RELEVANCE

This experimental study provides data on which to base clinical trials aimed to improve fixation of revision implants. Given the multifactorial nature of complex human revisions, such a protocoled clinical study is required to determine the clinical applicability of this approach.

Intravenous versus topical tranexamic acid in primary total hip replacement: A meta-analysis

BACKGROUND

As the prevalence of total hip arthroplasty (THA) is increasing, it is usually associated with considerable blood loss. Tranexamic acid (TXA) has been reported to reduce perioperative blood loss in hip joint arthroplasty. But the best route of TXA administration continues to be controversial. So, we conducted a meta-analysis that integrated all data from the 7 included trials to compare the effectiveness and safety of topical and intravenous TXA administration in primary THA. The endpoints assessed in this meta-analysis include the comparisons of total blood loss, postoperative hemoglobin decline, transfusion rates, the incidence rate of deep vein thrombosis (DVT), pulmonary embolisms (PE), and wound infection.

METHODS

Literature searches of PubMed, EMBASE, the Cochrane Library, the Chinese Biomedical Literature database, the CNKI database, and Wan Fang Data were performed up to August 30, 2016. Randomized controlled trials (RCTs) were included in our meta-analysis if they compared the efficiency and safety of intravenous versus topical administration of TXA in patients who underwent primary THA. The endpoints included the comparisons of total blood loss, postoperative hemoglobin decline, transfusion rates, the incidence rate of DVT, PE, and wound infection. A meta-analysis was performed following the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement. The pooling of data was carried out by using RevMan 5.3, Denmark.

RESULTS

Seven RCTs involving 964 patients met the inclusion criteria. Our meta-analysis indicated that there were no significant differences in the 2 groups in terms of total blood loss ([mean difference (MD) = -14.74, 95% confidence interval (CI): -89.21 to 59.74, P = 0.7], transfusion rates [RD = -0.02, 95% CI: -0.05 to 0.02, P = 0.39]; no significant differences were found regarding the incidence of adverse effects such as deep venous thrombosis [DVT] [RD = 0.00, 95% CI: -0.01 to 0.01, P = 1.00], PE [RD = 0.00, 95% CI: -0.01 to 0.01, P = 0.71], or wound infection [RD = -0.01, 95% CI: -0.06 to 0.04, P = 0.66]). The pooled results showed that the intravenous groups had a lower postoperative hemoglobin decline (MD = -0.47, 95% CI: -0.74 to -0.20, P = 0.0006). It was probably due to insufficient data and the varied reporting of outcomes. There was some inherent heterogeneity due to the small sample size of each primary study.

CONCLUSION

The topical and intravenous administrations of TXA have a similar effect on the decrease of blood loss without an increased risk of complications (DVT, PE, and wound infection). Intravenous TXA administration may have a maximum efficacy. Topical TXA administration may be preferred in patients who with high risk of thromboembolic events. However, larger, high-quality RCTs are required to explore the optimal regimen, dosage, timing still in the future in order to recommend TXA widespread use in total joint arthroplasty.

Experimental and Numerical Models of Complex Clinical Scenarios; Strategies to Improve Relevance and Reproducibility of Joint Replacement Research

This research review aims to focus attention on the effect of specific surgical and host factors on implant fixation, and the importance of accounting for them in experimental and numerical models. These factors affect (a) eventual clinical applicability and (b) reproducibility of findings across research groups. Proper function and longevity for orthopedic joint replacement implants relies on secure fixation to the surrounding bone. Technology and surgical technique has improved over the last 50 years, and robust ingrowth and decades of implant survival is now routinely achieved for healthy patients and first-time (primary) implantation. Second-time (revision) implantation presents with bone loss with interfacial bone gaps in areas vital for secure mechanical fixation. Patients with medical comorbidities such as infection, smoking, congestive heart failure, kidney disease, and diabetes have a diminished healing response, poorer implant fixation, and greater revision risk. It is these more difficult clinical scenarios that require research to evaluate more advanced treatment approaches. Such treatments can include osteogenic or antimicrobial implant coatings, allo- or autogenous cellular or tissue-based approaches, local and systemic drug delivery, surgical approaches. Regarding implant-related approaches, most experimental and numerical models do not generally impose conditions that represent mechanical instability at the implant interface, or recalcitrant healing. Many treatments will work well in forgiving settings, but fail in complex human settings with disease, bone loss, or previous surgery. Ethical considerations mandate that we justify and limit the number of animals tested, which restricts experimental permutations of treatments. Numerical models provide flexibility to evaluate multiple parameters and combinations, but generally need to employ simplifying assumptions. The objectives of this paper are to (a) to highlight the importance of mechanical, material, and surgical features to influence implant-bone healing, using a selection of results from two decades of coordinated experimental and numerical work and (b) discuss limitations of such models and the implications for research reproducibility. Focusing model conditions toward the clinical scenario to be studied, and limiting conclusions to the conditions of a particular model can increase clinical relevance and research reproducibility.

Agreement Between Proximal Femoral Geometry and Component Design in Total Hip Arthroplasty: Implications for Implant Choice

BACKGROUND

The present study aimed to analyze the agreement between proximal femoral geometry of adult hips and femoral component design in total hip arthroplasty.

METHODS

Anatomical femoral offset (FOAnat) and the anatomical neck-shaft angle (NSAAnat) of 800 adult hips were measured by computed tomography scans, and anatomical femoral neck height (FHAnat) was calculated. Corresponding best-fit implants of the most common hip system (standard, high offset and varus variant) were identified for each hip. Finally, the precision of the best possible anatomic reconstruction was assessed.

RESULTS

The mean FOAnat was 38.0 mm (range: 19.8-57.9 mm, standard deviation [SD]: 6.4 mm), the mean NSAAnat was 130.8° (range: 107.1°-151.9°; SD: 6.5°), and the mean FHAnat was 32.6 mm (range: 14.4-52.0 mm; SD: 5.5 mm). In 450 (56.3%) hips, the standard variant was identified to be the best-fit implant, followed by the varus (n = 282, 35.3%) and the high offset (n = 68, 8.5%) variants. The mean minimal distance from the best-fit implant was 4.5 mm (range: 0.1-20.2 mm, SD: 3.4 mm). Excellent agreement (distance: <2 mm) between hip anatomy and best-fit implant was found in 203 (25.4%) hips, combined excellent and acceptable agreement (distance: <6 mm) in 569 (71.1%) hips, whereas 213 (28.9%) hips were graded as poor (distance: ≥6 mm).

CONCLUSION

The present study revealed a mismatch between proximal femoral anatomy of a relevant proportion of adult hips and implant geometry of the most common femoral component in total hip arthroplasty.

The Economic Impact of Periprosthetic Infections After Total Hip Arthroplasty at a Specialized Tertiary-Care Center

BACKGROUND

Periprosthetic infections after total hip arthroplasty represent an increased risk for patient morbidity and mortality, and an increased economic burden. The purpose of this study was to compare a group of patients who had periprosthetic infections after total hip arthroplasty to a matched group of patients who underwent primary total hip arthroplasty in terms of the associated costs, length of hospitalization, and number of readmissions (within 1 year).

METHODS

Between 2007 and 2011, 16 consecutive infected patients were matched to 32 noninfected patients (1:2 ratio).

RESULTS

The mean episode cost, length of hospitalization, and median readmissions was significantly higher in the infected group when compared to the matched cohort: $88,623 vs $25,659, 7.6 vs 3.29 days, and 2 vs 0, respectively.

CONCLUSION

Periprosthetic infections after THA resulted in an increased episode cost by approximately 3-fold, mean hospitalization period 2-fold, and led to a higher median number of readmissions.

Changes in Payment Regulation and Acute Care Use for Total Hip Replacement: Trends in Length of Stay, Costs, and Discharge, 1997-2012

PURPOSE

To describe trends in the length of stay (LOS), costs, mortality, and discharge destination among a national sample of total hip replacement (THR) patients between 1997 and 2012.

DESIGN

Longitudinal retrospective design

METHODS

Descriptive analysis of the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample data.

FINDINGS

A total of 3,516,636 procedures were performed over the study period. Most THR patients were women, and the proportion aged 44-65 years increased. LOS decreased from 5 to 3 days. Charges more than doubled, from $22,184 to $53,901. Deaths decreased from 43 to 12 deaths per 10,000 patients. THR patients discharged to an institutional setting declined, while those discharged to the community increased.

CONCLUSION

We found an increase in THR patients, who were younger, women, had private insurance, and among those discharged to community-based settings.

CLINICAL RELEVANCE

Findings have implications for patient profiles, workplace environments, quality improvement, and educational preparation of nurses in acute and postacute settings.

The Effect of Advancing Age on Total Joint Replacement Outcomes

OBJECTIVE

To describe age-related differences in outcomes among older adults undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA).

DESIGN

Retrospective study.

PARTICIPANTS

A total of 1792 patients who underwent primary THA or TKA at the University of Iowa Hospitals and Clinics between 2010 and 2013 were identified in the University HealthSystem Consortium Database and University of Iowa Orthopedics Joint Replacement Registry.

MAIN OUTCOME MEASURES

Hospital length of stay (LOS), 30-day readmission rate, in-hospital mortality, number of days admitted to intensive care unit (ICU discharge disposition), in-hospital complications (pulmonary embolism, deep vein thrombosis, wound infection, hemorrhage, sepsis, or myocardial infarction), quality of life (measured using Short-Form 36 [SF-36]), discharge disposition (home, home with home health, nursing home, inpatient rehabilitation, transfer to another acute care hospital, and dead), and total patient level observed hospital cost (based on hospital charge information from each revenue code and estimated labor costs). Outcomes were compared in patients stratified by age and categorized by decade (ie, ≤50, 51-60, 61-70, 71-80, and ≥81).

RESULTS

A total of 871 THAs and 921 TKAs were performed. The mean age of our cohort was 60.5 years and 56.1% were women. In-hospital complication rates and ICU utilization progressively increased with increasing age. There was also a higher likelihood of skilled nursing facility placement and longer LOS. There was no increase in 30-day readmissions, mortality, or total cost. Improvements in patient reported outcomes (SF-36) scores were similar for all age-groups.

CONCLUSIONS

Compared to younger patients, older THA and TKA recipients were more likely to experience postoperative complications, admission to the ICU, discharge to a skilled care facility, and had longer hospital LOS. Improvements in patient-related outcomes were similar across all age-groups. These findings may be helpful when counseling older patients regarding elective total joint arthroplasty.

Medicare Reimbursement Attributable to Periprosthetic Joint Infection Following Primary Hip and Knee Arthroplasty

This study estimated Medicare reimbursement attributable to periprosthetic joint infection (PJI) across the continuum of covered services four years following hip or knee arthroplasty. Using 2001-2008 Medicare claims data, total and annual attributable reimbursements were assessed using generalized linear regression, adjusting for potential confounders. Within one year following arthroplasty, 109 (1.04%) of 10,418 beneficiaries were diagnosed with PJI. Cumulative Medicare reimbursement in the PJI arm was 2.2-fold (1.9-2.6, P<.0001) or $53,470 ($39,575-$68,221) higher than that of the non-PJI arm. The largest difference in reimbursement occurred the first year (3.2-fold); differences persisted the second (2.3-fold) and third (1.9-fold) follow up years. PJI following hip or knee arthroplasty appears costly to Medicare, with cost traversing several years and health care service areas.

Increased risk of peripheral arterial disease after hip replacement: an 11-year retrospective population-based cohort study

The correlation between hip replacement (Hip-Rep) and peripheral arterial disease (PAD) remains uncertain. Thus, we investigated the relationship between Hip-Rep and risk of developing PAD in a nationwide retrospective cohort study.National Health Insurance data were used to assemble a cohort of patients who were diagnosed from 2000 to 2011. Patients with a history of PAD were excluded. A total of 5284 patients who received a Hip-Rep and 21,124 matched controls were enrolled. We used Cox proportional hazards regression model to analyze the adjusted risk of developing PAD.The risk of developing PAD in the Hip-Rep group was 1.24-fold higher (95% CI = 1.05-1.48) than that in the control group. The adjusted risk of developing PAD increased with patient age; compared with patients aged 50 years or younger, the risk among those ages at least 80 years was 4.87-fold higher. Patients with diabetes exhibited the highest risk of developing PAD (HR = 1.58, 95% CI = 1.34-1.86). Compared with patients who had not received a Hip-Rep or reported any comorbidity, patients who received a Hip-Rep were 2.45-fold more likely to develop PAD (95% CI = 1.54-3.89); the risk increased with the number of comorbidities.Hip-Reps might be independently linked with an increased risk of developing PAD. The impact of Hip-Reps on this risk was greater in women and patients ages 65 years and younger and within the first year of follow-up.