Comparison of health care costs between aseptic and two stage septic hip revision

Estimation of two-year hospital costs of hip and knee periprosthetic joint infection treatments using activity-based costing

Aims

Our aim was to estimate the total costs of all hospitalizations for treating periprosthetic joint infection (PJI) by main management strategy within 24 months post-diagnosis using activity-based costing. Additionally, we investigated the influence of individual PJI treatment pathways on hospital costs within the first 24 months.

Methods

Using admission and procedure data from a prospective observational cohort in Australia and New Zealand, Australian Refined Diagnosis Related Groups were assigned to each admitted patient episode of care for activity-based costing estimates of 273 hip PJI patients and 377 knee PJI patients. Costs were aggregated at 24 months post-diagnosis, and are presented in Australian dollars.

Results

The mean cost per hip and knee PJI patient was $64,585 (SD $53,550). Single-stage revision mean costs were $67,029 (SD $47,116) and $80,063 (SD $42,438) for hip and knee, respectively. Two-stage revision costs were $113,226 (SD $66,724) and $122,425 (SD $60,874) for hip and knee, respectively. Debridement, antibiotics, and implant retention in hips and knees mean costs were $53,537 (SD$ 39,342) and $48,463 (SD $33,179), respectively. Suppressive antibiotic therapy without surgical management mean costs were $20,296 (SD $8,875) for hip patients and $16,481 (SD $6,712) for knee patients. Hip patients had 16 different treatment pathways and knee patients had 18 treatment pathways. Additional treatment, episodes of care, and length of stay contributed to substantially increased costs up to a maximum of $369,948.

Conclusion

Treating PJI incurs a substantial cost burden, which is substantially influenced by management strategy. With an annual PJI incidence of 3,900, the cost burden would be in excess of $250 million to the Australian healthcare system. Treatment pathways with additional surgery, more episodes of care, and a longer length of stay substantially increase the associated hospital costs. Prospectively monitoring individual patient treatment pathways beyond initial management is important when quantifying PJI treatment cost. Our study highlights the importance of optimizing initial surgical treatment, and informs treating hospitals of the resources required to provide care for PJI patients.

Direct Hospital Costs per Case of Periprosthetic Hip and Knee Joint Infections in Europe - A Systematic Review

BACKGROUND

The rise of periprosthetic joint infections (PJIs) due to aging populations is steadily increasing the number of arthroplasties and treatment costs. This study analyzed the direct health care costs of PJI for total hip arthroplasty and total knee arthroplasty (TKA) in Europe.

METHODS

The databases PubMed, Scopus, Embase, Cochrane, and Google Scholar were systematically screened for direct costs of PJI in Europe. Publications that defined the joint site and the procedure performed were further analyzed. Mean direct health care costs were calculated for debridement, antibiotics, and implant retention (DAIR), one-stage, and 2-stage revisions for hip and knee PJI, respectively. Costs were adjusted for inflation rates and reported in US-Dollar (USD).

RESULTS

Of 1,374 eligible publications, 12 manuscripts were included in the final analysis after an abstract and full-text review. Mean direct costs of $32,933 were identified for all types of revision procedures for knee PJI. The mean direct treatment cost including DAIR for TKA after PJI was $19,476. For 2-stage revisions of TKA, the mean total cost was $37,980. For all types of hip PJI procedures, mean direct hospital costs were $28,904. For hip DAIR, one-stage and 2-stage treatment average costs of $7,120, $44,594, and $42,166 were identified, respectively.

CONCLUSIONS

Periprosthetic joint infections are associated with substantial direct health care costs. As detailed reports on the cost of PJI are scarce and of limited quality, more detailed financial data on the cost of PJI treatment are urgently required.

Cost-effectiveness of implant movement analysis in aseptic loosening after hip replacement: a health-economic model

OBJECTIVE

To investigate the cost-effectiveness of using Implant Movement Analysis (IMA) to follow up suspected aseptic loosening when the diagnosis after an initial X-ray is not conclusive, compared with a diagnostic pathway with X-ray follow-up.

METHODS

A health-economic model in the form of a decision tree was developed using quality-adjusted life years (QALY) from the literature, cost-per-patient data from a university hospital and the probabilities of different events from expert physicians' opinions. The base case incremental cost-effectiveness ratio (ICER) was compared with established willingness-to-pay thresholds and sensitivity analyses were performed to account for assumptions and uncertainty.

RESULTS

The base case ICER indicated that the IMA pathway was cost effective (SEK 99,681, compared with the SEK 500,000 threshold). In the sensitivity analysis, the IMA pathway remained cost effective during most changes in parameters. ICERs above the threshold value occurred in cases where a larger or smaller proportion of people receive immediate surgery.

CONCLUSION

A diagnostic pathway using IMA after an inconclusive X-ray for suspected aseptic loosening was cost effective compared with a pathway with X-ray follow-up.

Impacts of residual 3D printing metal powders on immunological response and bone regeneration: an in vivo study

Residual powder is a defect in powder bed fusion-based additive manufacturing (3D printing), and it is difficult to completely remove it from as-printed materials. In addition, it is not necessary to apply 3D printed implants with residual powder in the clinic. The immunological response triggered by the residual powder is an important area of study in medical research. To further understand the possible immunological reactions and hidden dangers caused by residual powders in vivo, this study compared the immunological reactions and osteolysis caused by typical powders for four implant materials: 316 L stainless steel, CoCrMo, CP-Ti, and Ti-6Al-4V (particle size range of 15-45 μm), in a mouse skull model. Furthermore, the possible immunological responses and bone regeneration induced by the four 3D printed implants with residual powder in a rat femur model were compared. In the mouse skull model, it was found that the 316L-S, CoCrMo-S, and especially the 316L-M powders, upregulated the expression of pro-inflammatory factors, increased the ratio of RANKL/OPG, and activated more functional osteoclasts, resulting in more severe bone resorption compared with those in other groups. In the rat femur model, which is more suitable for clinical practice, there is no bone resorption in implants with residual powders, but they show good bone regeneration and integration ability because of their original roughness. The results indicate that the expressions of inflammatory cytokines in all experimental groups were the same as those in the control group, showing good biological safety. The results answered some critical questions related to additively manufactured medical materials in vivo and indicated that as-printed implants may have great potential in future clinical applications.

Short Course of Oral Antibiotic Treatment After Two-Stage Exchange Arthroplasty Appears to Decrease Early Reinfection

BACKGROUND

Recent evidence has suggested a benefit to extended postoperative prophylactic oral antibiotics after two-stage exchange arthroplasty for treatment of periprosthetic joint infections. We sought to determine reinfection rates with and without a short course of oral antibiotics after two-stage exchange procedures.

METHODS

A retrospective review identified patients undergoing two-stage exchange arthroplasty for periprosthetic joint infection of the hip or knee. Patients were excluded if they failed a prior two-stage exchange, had positive cultures at reimplantation, prolonged intravenous antibiotics postoperatively, and/or life-long suppression. This resulted in 444 reimplantations (210 hips and 234 knees). Patients were divided into three cohorts based on the duration of oral antibiotics after reimplantation: no antibiotics (102), ≤2 weeks (266), or >2 weeks (76). The primary endpoint was reinfection within 1 year of reimplantation.

RESULTS

Within 1 year of reimplantation, there were 34 reinfections. In the no-antibiotic, ≤ 2-week, and >2-week cohorts the reinfection rates were 14.1, 7.0, and 6.4%, respectively. Multivariate Cox regression showed a reduced reinfection rate in the ≤2-week cohort relative to no antibiotics (hazard ratio [HR]: 0.38, P = .01). While the smaller cohort with >2 weeks of antibiotics did not significantly reduce the reinfection rate (HR: 0.41, P = .12), when combined with the ≤2-week cohort, use of oral antibiotics had an overall reduction of the reinfection rate (HR: 0.39, P = .01).

CONCLUSIONS

These data support the hypothesis that a short course of oral antibiotics after reimplantation decreases the 1-year reinfection rate. Future randomized studies should seek to examine the efficacy of different durations of oral antibiotics to reduce reinfection.

LEVEL OF EVIDENCE

Prognostic Level IV.

The Prophylactic Effect of Single vs. Dual Antibiotic-Loaded Bone Cement against Periprosthetic Joint Infection Following Hip Arthroplasty for Femoral Neck Fracture: An Analysis of the German Arthroplasty Registry

BACKGROUND

Antibiotic-loaded bone cement in arthroplasties is currently experiencing increased usage. Therefore, single and double antibiotic-loaded bone cements are commercially available and used in orthopedic surgery. The aim of this investigation was to compare the clinical use of single compared to dual antibiotic-loaded bone cement for implant fixation after femoral neck fracture. Further infection rates were to be compared in (partial) arthroplasty for the treatment of femoral neck fracture for both treatment options.

METHODS

On the basis of the German Arthroplasty Registry (EPRD), all cases of femoral neck fracture treated with hemiarthroplasty (HA), or total hip arthroplasty (THA) with single and dual antibiotic-loaded bone cement, were included into the data analysis. The infection risk was compared using Kaplan-Meier estimates.

RESULTS

In total, 26,845 cases (HA 76.3%-THA: 23.7%) with femoral neck fracture were included. Within recent years, an increasing usage of dual antibiotic-loaded cement in Germany, with a current proportion of 7.30% in arthroplasty procedures for femoral neck fracture treatment, has been observed. In patients treated with HA, the proportion of dual antibiotic-loaded cement was 7.86%, while in those treated with THA, 5.46% of all prostheses were fixated with a two antibiotic component cement. For all arthroplasty procedures using single antibiotic-loaded bone cement after six months 1.8%, after one year 1.9%, and after five years 2.3%, of the cases failed due to periprosthetic joint infection (PJI), while in the same time period, in cases with dual antibiotic-loaded bone cement 1.5%, 1.5% and 1.5% suffered from infection (p = 0.34). A infection rate of 1.1% after HA with dual antibiotic-loaded bone cement was reported, compared to a 2.1% infection rate whilst using single antibiotic-loaded bone cement after five years (p = 0.098). The number required for treatment when using HA was 91.

CONCLUSIONS

The use of dual antibiotic-loaded bone cement is increasingly used in arthroplasty procedures after femoral neck fractures. It demonstrates a reduction of PJI after HA and seems, therefore, to be a useful method for the prevention of infection, especially in patients with increased risk factors for PJI.

Economics of Total Hip Arthroplasty: Review

This review article focuses on issues of economic analysis in providing care to patients requiring total hip arthroplasty. A large number of factors affecting the final financial result force us to look at economic research in the field of arthroplasty with a certain degree of criticality. At the same time, the existing financing systems cannot fully take into account all the possible costs arising from total hip arthroplasty. For this reason, studies concerning revision total hip arthroplasty are of particular interest, where treatment costs can vary significantly depending on the etiology and complexity of the case. These differences are reflected in the works of authors from France, Germany and Great Britain, who compared the treatment costs of patients with septic and aseptic revisions. Very different data both between countries and within the same country well demonstrate the need for a critical approach to the results of cost-effectiveness studies, QALYs based on Markov and other models, as the quality of the original data can be highly variable and reproduce the error of the initially incorrect price structure. At the same time, the rapidly increasing number of operations of primary and revision hip arthroplasty and, accordingly, the increasing economic costs of these operations require clear and effective economic criteria for their evaluation. The formation and application of these criteria will be the purpose of further research.

Infection after total joint replacement of the hip and knee: research programme including the INFORM RCT

Background

People with severe osteoarthritis, other joint conditions or injury may have joint replacement to reduce pain and disability. In the UK in 2019, over 200,000 hip and knee replacements were performed. About 1 in 100 replacements becomes infected, and most people with infected replacements require further surgery.

Objectives

To investigate why some patients are predisposed to joint infections and how this affects patients and the NHS, and to evaluate treatments.

Design

Systematic reviews, joint registry analyses, qualitative interviews, a randomised controlled trial, health economic analyses and a discrete choice questionnaire.

Setting

Our studies are relevant to the NHS, to the Swedish health system and internationally.

Participants

People with prosthetic joint infection after hip or knee replacement and surgeons.

Interventions

Revision of hip prosthetic joint infection with a single- or two-stage procedure.

Main outcome measures

Long-term patient-reported outcomes and reinfection. Cost-effectiveness of revision strategies over 18 months from two perspectives: health-care provider and Personal Social Services, and societal.

Data sources

National Joint Registry; literature databases; published cohort studies; interviews with 67 patients and 35 surgeons; a patient discrete choice questionnaire; and the INFORM (INFection ORthopaedic Management) randomised trial.

Review methods

Systematic reviews of studies reporting risk factors, diagnosis, treatment outcomes and cost comparisons. Individual patient data meta-analysis.

Results

In registry analyses, about 0.62% and 0.75% of patients with hip and knee replacement, respectively, had joint infection requiring surgery. Rates were four times greater after aseptic revision. The costs of inpatient and day-case admissions in people with hip prosthetic joint infection were about five times higher than those in people with no infection, an additional cost of > £30,000. People described devastating effects of hip and knee prosthetic joint infection and treatment. In the treatment of hip prosthetic joint infection, a two-stage procedure with or without a cement spacer had a greater negative impact on patient well-being than a single- or two-stage procedure with a custom-made articulating spacer. Surgeons described the significant emotional impact of hip and knee prosthetic joint infection and the importance of a supportive multidisciplinary team. In systematic reviews and registry analyses, the risk factors for hip and knee prosthetic joint infection included male sex, diagnoses other than osteoarthritis, high body mass index, poor physical status, diabetes, dementia and liver disease. Evidence linking health-care setting and surgeon experience with prosthetic joint infection was inconsistent. Uncemented fixation, posterior approach and ceramic bearings were associated with lower infection risk after hip replacement. In our systematic review, synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy for prosthetic joint infection. Systematic reviews and individual patient data meta-analysis showed similar reinfection outcomes in patients with hip or knee prosthetic joint infection treated with single- and two-stage revision. In registry analysis, there was a higher rate of early rerevision after single-stage revision for hip prosthetic joint infection, but, overall, 40% fewer operations are required as part of a single-stage procedure than as part of a two-stage procedure. The treatment of hip or knee prosthetic joint infection with early debridement and implant retention may be effective in > 60% of cases. In the INFORM randomised controlled trial, 140 patients with hip prosthetic joint infection were randomised to single- or two-stage revision. Eighteen months after randomisation, pain, function and stiffness were similar between the randomised groups (p = 0.98), and there were no differences in reinfection rates. Patient outcomes improved earlier in the single-stage than in the two-stage group. Participants randomised to a single-stage procedure had lower costs (mean difference –£10,055, 95% confidence interval –£19,568 to –£542) and higher quality-adjusted life-years (mean difference 0.06, 95% confidence interval –0.07 to 0.18) than those randomised to a two-stage procedure. Single-stage was the more cost-effective option, with an incremental net monetary benefit at a threshold of £20,000 per quality-adjusted life-year of £11,167 (95% confidence interval £638 to £21,696). In a discrete choice questionnaire completed by 57 patients 18 months after surgery to treat hip prosthetic joint infection, the most valued characteristics in decisions about revision were the ability to engage in valued activities and a quick return to normal activity.

Limitations

Some research was specific to people with hip prosthetic joint infection. Study populations in meta-analyses and registry analyses may have been selected for joint replacement and specific treatments. The INFORM trial was not powered to study reinfection and was limited to 18 months’ follow-up. The qualitative study subgroups were small.

Conclusions

We identified risk factors, diagnostic biomarkers, effective treatments and patient preferences for the treatment of hip and knee prosthetic joint infection. The risk factors include male sex, diagnoses other than osteoarthritis, specific comorbidities and surgical factors. Synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy. Infection is devastating for patients and surgeons, both of whom describe the need for support during treatment. Debridement and implant retention is effective, particularly if performed early. For infected hip replacements, single- and two-stage revision appear equally efficacious, but single-stage has better early results, is cost-effective at 18-month follow-up and is increasingly used. Patients prefer treatments that allow full functional return within 3–9 months.

Future work

For people with infection, develop information, counselling, peer support and care pathways. Develop supportive care and information for patients and health-care professionals to enable the early recognition of infections. Compare alternative and new treatment strategies in hip and knee prosthetic joint infection. Assess diagnostic methods and establish NHS diagnostic criteria.

Study registration

The INFORM randomised controlled trial is registered as ISRCTN10956306. All systematic reviews were registered in PROSPERO (as CRD42017069526, CRD42015023485, CRD42018106503, CRD42018114592, CRD42015023704, CRD42017057513, CRD42015016559, CRD42015017327 and CRD42015016664).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 10. See the NIHR Journals Library website for further project information.

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

Introduction

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

Materials and methods

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

Results

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

Discussion

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

Conclusions

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

Inflation-Adjusted Medicare Reimbursement for Revision Hip Arthroplasty: Study Showing Significant Decrease from 2002 to 2019

BACKGROUND

Investigations into reimbursement trends for primary and revision arthroplasty procedures have demonstrated a steady decline over the past several years. Revision total hip arthroplasty (rTHA) due to infection (rTHA-I) has been associated with higher resource utilization and complexity, but long-term inflation-adjusted data have yet to be compared between rTHA-I and rTHA due to aseptic complications (rTHA-A). The present study was performed to analyze temporal reimbursement trends regarding rTHA-I procedures compared with those for rTHA-A procedures.

METHODS

The Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule Look-Up Tool was used to extract Medicare reimbursements associated with 1-stage and 2-stage rTHA-I as well as 1-stage rTHA-A procedures from 2002 to 2019. Current Procedural Terminology (CPT) codes for rTHA were grouped according to the American Academy of Orthopaedic Surgeons coding reference guide. Monetary values were adjusted for inflation using the consumer price index (U.S. Bureau of Labor Statistics; reported as 2019 U.S. dollars) and used to calculate the cumulative and average annual percent changes in reimbursement.

RESULTS

Following inflation adjustment, the physician fee reimbursement for rTHA-A decreased by a mean [and standard deviation] of 27.26% ± 3.57% (from $2,209.11 in 2002 to $1,603.20 in 2019) for femoral component revision, 27.41% ± 3.57% (from $2,130.55 to $1,542.91) for acetabular component revision, and 27.50% ± 2.56% (from $2,775.53 to $2,007.61) for both-component revision. Similarly, for a 2-stage rTHA-I, the mean reimbursement declined by 18.74% ± 3.87% (from $2,063.36 in 2002 to $1,673.36 in 2019) and 24.45% ± 3.69% (from $2,328.79 to $1,755.45) for the explantation and reimplantation stages, respectively. The total decline in physician fee reimbursement for rTHA-I ($1,020.64 ± $233.72) was significantly greater than that for rTHA-A ($580.72 ± $107.22; p < 0.00001).

CONCLUSIONS

Our study demonstrated a consistent devaluation of both rTHA-I and rTHA-A procedures from 2002 to 2019, with a larger deficit seen for rTHA-I. A continuation of this trend could create substantial disincentives for physicians to perform such procedures and limit access to care at the population level.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Septic Revision Total Hip Arthroplasty Is Not Adequately Compensated by Work Relative Value Units

BACKGROUND

Performing revision total hip arthroplasty (rTHA) for periprosthetic joint infection is complex and may require greater time and resources than aseptic revision cases. Work relative value units (RVUs) assigned may not reflect the difference in actual work required for septic revision hip cases. The purpose of this study is to compare the work effort between aseptic and septic revision hip cohorts, and determine if physicians are appropriately compensated.

METHODS

Data were collected through the National Surgical Quality Improvement Program database for the years 2005 to 2018 to identify all aseptic rTHA cases and septic rTHA cases. Work RVU, operation time, RVU per minute, and dollars per minute were assessed between the aseptic and septic revision hip cohorts. Univariate and multivariate analyses were used for the study.

RESULTS

The mean operation times for aseptic and septic rTHAs were 146.12 and 173.24 minutes, respectively (P < .001). This resulted in an RVU per minute of 0.257 for the aseptic revision hip cohort compared to 0.212 for the septic cohort (P < .001). Aseptic rTHA cases were valued higher with a dollars per minute of 9.28, whereas septic rTHA cases were 7.65 (P < .001).

CONCLUSION

Although rTHA for infection is more complex and requires longer mean operative time than aseptic rTHA, physicians are not appropriately reimbursed for this challenging procedure. This inadequate RVU-based reimbursement for septic rTHA may deter physicians from performing these procedures, which could lead to decreased access to care for patients in need of rTHA for infection.

[Comparison of DRG revenues between fast and slow-track procedures for a two-stage replacement of prostheses for periprosthetic hip infections in the aG-DRG system 2020]

Hintergrund

Die Behandlung periprothetischer Hüftinfektionen ist meist kostenintensiv und gilt im Allgemeinen als nicht kostendeckend für die Kliniken. Bei chronischen Infektionen ist oft ein zweizeitiger Prothesenwechsel indiziert, der als Fast-Track mit kurzem prothesenfreiem Intervall (2–4 Wochen) oder als Slow-Track mit langem prothesenfreiem Intervall (über 4 Wochen) erfolgen kann.

Ziel

Ziel dieser Arbeit war die Erfassung der Erlössituation beider Behandlungsformen im aktuellen aG-DRG-System 2020 unter Berücksichtigung erlösrelevanter Einflussfaktoren.

Methoden

Für Fast-Track und Slow-Track bei zweizeitigem septischem Hüftprothesenwechsel mit Nachweis eines Staphylococcus aureus (MSSA) wurden mittels einer Grouper-Software (3M KODIP Suite) anhand der Diagnosen (ICD-10-GM) und Prozeduren (OPS) Behandlungsfälle simuliert und in DRG eingruppiert. Erlösrelevante Parameter wie Verweildauer (VWD) und Nebendiagnosen (ND) wurden berücksichtigt. Zusätzlich wurden zwei reale Behandlungsfälle mit Fast-Track und Slow-Track miteinander verglichen.

Ergebnisse

Die Gesamterlöse betrugen beim Slow-Track bei einer VWD von 25 Tagen (ohne ND) 27.551 € und bei einer VWD von 42 Tagen (mit ND) 40.699 €. Beim Fast-Track hingegen lag der Gesamterlös bei 23.965 € bei einer VWD von 25 Tagen (ohne ND) und bei 27.283 € bei einer VWD von 42 Tagen (mit ND). Bei den realen Behandlungsfällen zeigte sich ebenfalls eine deutliche Differenz des Gesamterlöses von 12.244 € zugunsten des Slow-Tracks.

Diskussion

Auch im aG-DRG-System 2020 scheint der zweizeitige Hüftprothesenwechsel mit langem Interimsintervall insbesondere bei multimorbiden Patienten aus Krankenhaussicht ökonomisch vorteilhafter zu sein als das Fast-Track-Konzept, wodurch ein finanzielles Hemmnis zur Behandlung solcher Patienten mit kurzem Interimsintervall geschaffen wird.

An epidemiological analysis of revision aetiologies in total hip arthroplasty at a single high-volume centre

Aims

Advances in surgical technique and implant design may influence the incidence and mechanism of failure resulting in revision total hip arthroplasty (rTHA). The purpose of the current study was to characterize aetiologies requiring rTHA, and to determine whether temporal changes existed in these aetiologies over a ten-year period.

Methods

All rTHAs performed at a single institution from 2009 to 2019 were identified. Demographic information and mode of implant failure was obtained for all patients. Data for rTHA were stratified into two time periods to assess for temporal changes: 2009 to 2013, and 2014 to 2019. Operative reports, radiological imaging, and current procedural terminology (CPT) codes were cross-checked to ensure the accurate classification of revision aetiology for each patient.

Results

In all, 2,924 patients with a mean age of 64.6 years (17 to 96) were identified. There were 1,563 (53.5%) female patients, and the majority of patients were Caucasian (n = 2,362, 80.8%). The three most frequent rTHA aetiologies were infection (27.2%), aseptic loosening (25.2%), and wear (15.2%). The frequency of rTHA for adverse local tissue reaction (ALTR) was significantly greater from 2014 to 2019 (4.7% vs 10.0%; p < 0.001), while the frequency of aseptic loosening was significantly greater from 2009 to 2013 (28.6% vs 21.9%; p < 0.001).

Conclusion

Periprosthetic joint infection was the most common cause for rTHA in the current cohort of patients. Complications associated with ALTR necessitating rTHA was more frequent between 2014 to 2019, while aseptic loosening necessitating rTHA was significantly more frequent between 2009 to 2013. Optimizing protocols for prevention and management of infection and ALTR after THA may help to avoid additional financial burden to institutions and healthcare systems.Cite this article: Bone Joint Open 2020;2(1):16-21.

Comparison of efficacy and complications between two types of staging arthroplasty in treating chronic septic hip arthritis: A retrospective clinical study

Septic hip arthritis is a rare but serious disease, which is often persistent, able to transform into a chronic infection, and difficult to cure. The present study aimed to compare the midterm outcomes between the staging of a total hip arthroplasty via the Girdlestone surgery (a resection of the head and neck) and the Girdlestone combined with a cement spacer in treating chronic septic hip arthritis, as well as to compare the postsurgery efficacy and complications between the two groups. A total of 13 patients (14 total hip joints) were enrolled and retrospectively analyzed. For the stage I surgery, four patients (five hips) underwent the resection of the head and neck, and nine patients (nine hips) underwent the resection of the head and neck combined with the implantation of a bone cement spacer. After the infection was fully controlled, the patients in both groups underwent cementless total hip arthroplasties as stage II surgeries. The mean follow-up period was 24.2 months. The curative effects and complications of the patients were recorded and compared. It was found that the application of the staging arthroplasty for treating a chronic septic hip was conducive to the complete clearance of lesions. Notably, the implantation of a bone cement spacer containing antibiotics in the stage I surgery prevented joint contracture caused by a head and neck resection, reducing the risk of infection recurrence between the two stages of the operation. This effectively maintained the length of the lower limbs, simplified the stage II complete hip arthroplasty and reduced operative hemorrhage, thus achieving improved recovery of joint function after the stage II arthroplasty. The results suggested that the implantation of a cement spacer at the stage I surgery was more effective in treating chronic septic hip arthritis.

[Surgery of sepsis in orthopedics and trauma - A highlight : Current survey by the section for bone and soft tissue infections of the German Society for Orthopedics and Trauma]

Surgery of sepsis in trauma surgery and orthopedics is attracting increasingly more attention due to the rising presence of multidrug-resistant pathogens and the increasing number of operative interventions. Despite extensive experience over decades neither the symptoms nor the treatment strategies have been evaluated and it has become obvious that a scientific investigation of this complex topic is necessary for optimization of patient care under economically sound conditions. The aim of this article is to give a snapshot from German healthcare institutions for trauma surgery and orthopedics to answer some questions on this topic from the section for bone and soft tissue infections (SeKuWi) of the German Society for Orthopedics and Trauma (DGOU) in cooperation with the German Society for Hospital Hygiene (DGKH).

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Dual-Mobility Articulations for Patients at High Risk for Dislocation

BACKGROUND

The purpose of this study was to evaluate the performance of dual-mobility articulations in patients at high risk for dislocation after revision total hip arthroplasty.

METHODS

We reviewed the results of 36 consecutive revision total hip arthroplasties performed on patients considered high risk for instability. Indications for inclusion included abductor insufficiency, recurrent instability, failure of constrained liner, or inadequate intraoperative stability when trialing.

RESULTS

At a minimum of 2 years, there were 4 (11.1%) repeat revisions including both dual-mobility liners that were cemented into an acetabular shell and 2 for deep infection treated with a 2-stage exchange. There was one dislocation that was successfully closed reduced but no revisions for recurrent instability. The mean Harris hip score improved from 45 to 90 points (P < .001).

CONCLUSION

Dual-mobility articulations are associated with a low rate of failure with no revisions for instability in this challenging group of patients.

Morbidly Obese vs Nonobese Aseptic Revision Total Hip Arthroplasty: Surprisingly Similar Outcomes

BACKGROUND

We aimed to compare the outcomes between matched morbidly obese (BMI ≥ 40 kg/m(2)) and nonobese (BMI <30 kg/m(2)) patients undergoing first-time aseptic revision THA with at least 4 years of follow-up.

METHODS

Groups were matched 1:1 using sex, age, and date of revision surgery (123 patients in each group).

RESULTS

The overall incidence and risk of complication, reoperation, and re-revision were similar between groups. Morbidly obese patients were more likely to dislocate (odds ratio [OR], 3.3; P = .03), but were less likely to develop polyethylene wear (OR, 0.1; P = .04) and aseptic loosening (OR, 0.3; P = .03).

CONCLUSION

Quality outcome measures such as hospital readmission were not addressed by this study and could be the basis for future studies.

LEVEL OF EVIDENCE

level III, prognostic study.

A novel tribological study on DLC-coated micro-dimpled orthopedics implant interface

This study investigates a tribological performance of diamond like carbon (DLC) coated micro dimpled prosthesis heads against ceramic cups in a novel pendulum hip joint simulator. The simulator enables determining friction coefficient and viscous effects of a concave shaped specimen interface (conformal contact). Two types of DLC such as hydrogenated amorphous carbon (a-C:H) and tetrahedral amorphous carbon (Ta-C) and one set of micro dimple (diameter of 300µm, depth of 70µm, and pitch of 900µm) were fabricated on metallic prosthesis heads. The experiment results reveal a significant friction coefficient reduction to the 'dimpled a-C:H/ceramic' prosthesis compared to a 'Metal (CoCr)/ceramic' prosthesis because of their improved material and surface properties and viscous effect. The post-experiment surface analysis displays that the dimpled a-C:H yielded a minor change in the surface roughness, and generated a larger sizes of wear debris (40-200nm sized, equivalent diameter), a size which could be certainly stored in the dimple, thus likely to reducing their possible third body abrasive wear rate. Thus, dimpled a:C-H can be used as a 'metal on ceramic hip joint interface', whereas the simulator can be utilized as an advanced bio-tribometer.