Impact of Anterior vs Posterior Approach for Total Hip Arthroplasty on Post-Acute Care Service Utilization

Early Practice All-Cause Complications for Fellowship-Trained Anterior Hip Surgeons Are Not Increased When Compared to "Gold Standard" Experienced Posterior Approach Surgeons

BACKGROUND

Increased complication rates have been reported during the learning curve for direct anterior approach (DAA) total hip arthroplasty (THA). However, emerging literature suggests that complications associated with the learning curve may be substantially reduced with fellowship training.

METHODS

Our institutional database was queried to identify 2 groups: (1) 600 THAs comprised of the first 300 consecutive cases performed by 2 DAA fellowship-trained surgeons; and (2) 600 posterolateral approach (PA) THAs, including the most recent 300 primary cases performed by 2 experienced PA surgeons. All-cause complications, revision rates, reoperations, operative times, and transfusion rates were evaluated.

RESULTS

Comparing DAA and PA cases, there were no significant differences in rates of all-cause complications (DAA = 18, 3.0% versus PA = 23, 3.8%; P = .43), periprosthetic fractures (DAA = 5, 0.8% versus PA = 10, 1.7%; P = .19), wound complications (DAA = 7, 1.2% versus PA = 2, 0.3%; P = .09), dislocations (DAA = 2, 0.3% versus PA = 8, 1.3%, P = .06), or revisions (DAA = 2, 0.3% versus PL = 5, 0.8%; P = .45) at 120 days postoperatively. There were 4 patients who required reoperation for wound complications, all within the DAA group (DAA = 4, 0.67% versus PA = 0; P = .045). Operative times were shorter in the DAA group (DAA <1.5 hours = 93% versus PA <1.5 hours = 86%; P < .01). No blood transfusions were given in either group.

CONCLUSION

In this retrospective study, DAA THAs performed by fellowship-trained surgeons early in practice were not associated with higher complication rates compared to THAs performed by experienced PA surgeons. These results suggest that fellowship training may allow DAA surgeons to complete their learning curve period with complication rates similar to experienced PA surgeons.

Role of arthroplasty in the Jehovah's Witness population

BACKGROUND

Total joint arthroplasties aim to improve quality of life from joint-related pain. Jehovah's Witnesses refuse blood products due to their religious beliefs. Surgeons may be reluctant to perform arthroplasty procedures on these patients for fear of uncontrolled bleeding. However, we hypothesize that through preoperative optimization, arthroplasty can be performed safely.

METHODS

We retrospectively reviewed 184 total joint arthroplasties in Jehovah's Witnesses between 2011 and 2019. Each patient was enrolled in the institutions' Bloodless Medicine program. Hemoglobin levels were recorded through standard laboratory testing while in the hospital. Primary outcomes were changes in preoperative and postoperative hemoglobin measures, short-term outcomes measures, and complications.

RESULTS

A total of 103 total knee arthroplasties (8 revisions) and 81 total hip arthroplasties (5 revisions) were performed. Hemoglobin drift was 2.5 ± 1.0 for primary TKA and 2.6 ± 1.3 for primary THA (p = 0.570). Hemoglobin drift was 1.9 ± 0.9 for revision TKA and 1.9 ± 0.2 for revision THA (p = 0.990). Only 2.7% of patients met the transfusion requirement of 7 g/dL. The major complication rate for the cohort was 1.6% systemic and 4.9% local, respectively, with no mortalities. The overall readmission rate was 2.7%.

CONCLUSION

To our knowledge, this is the largest reported sample of Jehovah's Witness patients undergoing total joint arthroplasty. Postoperative hemoglobin values did not prompt additional intervention in the overwhelming majority of patients, and complication rates were acceptable. Our data suggest that primary arthroplasty is safe in the Jehovah's Witness population. Additionally, we show preliminary evidence that revision arthroplasty is safe in Jehovah's Witness patients.

A Crossover Cohort of Direct Anterior vs Posterolateral Approach in Primary Total Hip Arthroplasty: What Does the Patient Prefer?

BACKGROUND

The utilization of the direct anterior approach (DAA) for total hip arthroplasty (THA) continues to markedly increase. Despite proposed advantages, there are limited data regarding outcomes of staged bilateral THA via 2 different approaches in the same patient. The purpose of this study was to elucidate patient perspective on the THA approach in a crossover cohort of patients who underwent consecutive THAs via the posterolateral approach (PLA) followed by a contralateral DAA.

METHODS

A retrospective chart review and telephone interview were performed on 37 patients who underwent both THA approaches by a single surgeon from 2009 to 2019. Perioperative outcomes, complications/reoperations, and the patient-preferred approach were collected. The mean clinical follow-up was 105 and 44 months after PLA and DAA, respectively.

RESULTS

After DAA THA, patients demonstrated lower postoperative day 1 visual analog scale pain scores (1.8 vs 2.9, P = .016) and ambulation (239 feet vs 31 feet, P < .001). The length of stay was significantly less (P < .001) for the DAA (1.9 days) compared with the PLA (3.1 days). There were no major complications or reoperations in either cohort. Most patients (26/37, 70%) preferred the DAA and stated that it was easier to recover from (30/37, 81%).

CONCLUSION

In the same patient direct comparison, the DAA for THA may lead to less pain and improved ambulation in the early postoperative period. Furthermore, most patients prefer the DAA and believe it is easier to recover from than the PLA.

Surgical Approaches in Total Hip Arthroplasty Cost Per Case Analysis: A Retrospective, Matched, Micro-costing Analysis in a Socialised Healthcare System

BACKGROUND

Total hip arthroplasty (THA) offers an effective method of pain relief and restoration of function for patients with end-stage arthritis. The anterior approach (AA) claims to benefit patients with decreased pain, increased mobilisation and decreasing length of hospital stay (LOS). In a socialised healthcare platform we questioned whether the AA, compared to posterior (PA) and lateral (LA) approaches, can decrease the cost burden.

METHODS

Using a retrospective matched cohort study, we matched 69 AA patients to 69 LA and 69 PA patients for age (p = 0.99), gender (p = 0.99) and number of pre-surgical risk factors (p = 0.99). First, we used the Resource Intensity Weights (RIW) using the Health Services agreed on method of calculating cost. Secondly, micro-costing analysis was performed using the financial services data for each patient's hospital stay.

RESULTS

Using the RIW based cost analysis and 2-day reduction (95% CI 1.8-2.4) in LOS, the AA offers an estimated savings per case of $4099 (p < 0.001) compared to the LA and PA. Using micro-costing analysis, we found a total saving of $1858.00 per case (95% CI 1391-2324) when comparing the AA to the PA and LA. There was a statistically significant cost savings using every category: Net Direct Salary ($901.00, p < 0.001), Net Drug ($8.00, p = 0.003), Patient Supply ($454.00, p = 0.001), Patient Drug ($15.00, p = 0.008), Indirect Cost ($385.00, p < 0.001), Patient Care Administration ($106.00, p < 0.001). Furthermore, the AA saved 142 minutes of in-hospital rehabilitation time.

CONCLUSION

The AA THA provides statistically significant reductions in cost compared to PA and LA while releasing rehabilitation resources.

Variation in Use of Postoperative Precautions and Equipment Following Total Hip Arthroplasty: A Survey of the AAHKS and CAS Membership

BACKGROUND

A traditional method to reduce dislocation risk following total hip arthroplasty involves prescribing postoperative precautions and ambulatory equipment to patients. The purpose of this study was to determine the prevalence of postoperative precaution and equipment use among North American arthroplasty surgeons for patients undergoing primary total hip arthroplasty.

METHODS

We conducted a survey of American Association of Hip and Knee Surgeons and Canadian Arthroplasty Society members using an electronic questionnaire format to determine how often precautions and equipment were prescribed, and whether their use was associated with surgical approach and other surgeon demographics.

RESULTS

Of the respondents, 44% universally prescribed precautions while 33% never prescribed precautions. Use of the posterolateral approach, surgeon experience, and larger head size use were significantly associated (P < .01) with precaution and equipment use. Direct anterior approach surgeons were significantly less likely to prescribe precautions (P < .0001) and significantly less likely to prescribe equipment (P < .0001).

CONCLUSION

Although postoperative precautions continue to be used to some degree by the majority of members, their consumption of healthcare resources through utilization of additional care providers and purchasing of equipment, known association with reduced patient satisfaction, and lack of supporting evidence make them a target for future scrutiny.

Medical resource utilization and costs for total hip arthroplasty: benchmarking an anterior approach technique in the Medicare population

AIMS

The anterior approach (AA) for total hip arthroplasty (THA) is associated with more rapid recovery when compared to traditional approaches. The purpose of this study was to benchmark healthcare resource utilization and costs for patients with THA via AA relative to matched patients.

MATERIALS AND METHODS

This study queried Medicare claims data (2012-2014) to identify patients who received THA via an AA from experienced surgeons, and matched these patients to a control cohort (all THA approaches). Direct and propensity-score matching were employed to maximize similarity between patients and hospitals in the two cohorts. Hospital length of stay (LOS), the proportion of patients discharged to home or home health, and post-acute claim payments during the 90-day episode were assessed. Generalized estimating equations were applied to control for imbalances between the cohorts and clustering of outcomes within hospitals.

RESULTS

A total of 1,794 patients were included after patient matching. Patients who received AA had significantly lower mean hospital LOS vs patients in the control group (2.06 ± 1.36 vs 2.98 ± 1.58 days, p < .0001). The adjusted proportion of patients discharged to home was nearly 20 percentage points higher in the AA cohort vs the control cohort (87.3% vs 68.7%, p < .0001). Post-acute claim payments for AA patients were nearly 50% lower than those for control patients ($4,139 vs $7,465, p < .0001).

CONCLUSION

AA patients had significantly lower post-acute care resource use when compared to control patients. Further research is warranted to evaluate the cost effectiveness of AA among surgeons of varying experience levels.

The Impact of Discharge Disposition on Episode-of-Care Reimbursement After Primary Total Hip Arthroplasty

BACKGROUND

Total joint arthroplasty (TJA) accounts for more Medicare expenditure than any other inpatient procedure. The Comprehensive Care for Joint Replacement model was introduced to decrease cost and improve quality in TJA. The largest portion of episode-of-care costs occurs after discharge. This study sought to quantify the cost variation of primary total hip arthroplasty (THA) according to discharge disposition.

METHODS

The Medicare and Humana claims databases were used to extract charges and reimbursements to compare day-of-surgery and 91-day postoperative costs simulating episode-of-care reimbursements. Of the patients who underwent primary THA, 257,120 were identified (204,912 from Medicare and 52,208 from Humana). Patients were stratified by discharge disposition: home with home health, skilled nursing facility, or inpatient rehabilitation facility.

RESULTS

There is a significant difference in the episode-of-care costs according to discharge disposition, with discharge to an inpatient rehabilitation facility the most costly and discharge to home the least costly.

CONCLUSION

Postdischarge costs represent a sizeable portion of the overall expense in THA, and optimizing patients to allow safe discharge to home may help reduce the cost of THA.

Current Trends in Discharge Disposition and Post-discharge Care After Total Joint Arthroplasty

PURPOSE OF REVIEW

The purpose of this manuscript is to review published literature over the last 5 years to assess recent trends and influencing factors regarding discharge disposition and post-discharge care following total joint arthroplasty. We evaluated instruments proposed to predict a patient's discharge disposition and summarize reports investigating the safety in sending more patients home by reviewing complications and readmission rates.

RECENT FINDINGS

Current literature supports decreased length of hospital stay and increased discharge to home with cost savings and stable readmission rates. Surgeons with defined clinical pathways and those who shape patient expectations may more effectively control costs than those without defined pathways. Further research is needed analyzing best practices in care coordination, managing patient expectations, and cost-effective analysis of home discharge while at the same time ensuring patient outcomes are optimized following total joint arthroplasty.