Elective Total Hip Arthroplasties in Nonagenarians-Age Does Matter: A National Surgical Quality Improvement Program Study

Is the increase in the number of total hip arthroplasties in Japan due to an aging society?

BACKGROUND

The number of total hip arthroplasty (THA) is increasing globally, including Japan. The Japanese Orthopaedic Association has been conducting a registry of joint replacement surgery, but there may be a gap between the reported numbers of THA in the registry and the actual number. This study aimed to investigate the exact number of THA and assess the trends in Japan using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB).

METHODS

We downloaded data from 2014 to 2019 from the NDB Open Data. Data on primary THA were extracted, and we calculated the annual number and number for each 10-year age group and sex. We also compared the number and trends between elderly and non-elderly groups.

RESULTS

During the study period, number of THAs increased by approximately 20,000, showing a continuous upward trend. The highest number of THAs were performed on patients in their 60s, except for the years 2014 and 2019. Comparison of the numbers in 2014 and 2019 by age group showed an increase in the number in patients in their 90s (by 2.05 times). There were significantly a greater number of elderly patients (P < 0.001). The number of THAs performed was higher in women than in men (P < 0.001).

CONCLUSION

The number of THAs in Japan increased substantially from 2014 to 2019, despite a decrease in population. Significantly higher number of THAs were performed on elderly patients in Japan, which might be due to an aging society. The NDB data is highly valuable for epidemiological research in Japan, as it might enable the early detection of issues occurring during THA, facilitating their prompt integration into daily clinical practice.

The impact of retaining the femoral stem in revision total hip arthroplasty: a systematic review, meta-analysis, and meta-regression

INTRODUCTION

The management of well-fixed femoral stems in revision total hip arthroplasty (rTHA) remains a subject of debate, with concerns over potential complications arising from stem retention. This study aimed to investigate the re-revision rates due to aseptic loosening of the stem, overall re-revision rates, dislocation rates, and factors influencing these outcomes in rTHA with a retained well-fixed femoral stem.

MATERIALS AND METHODS

A systematic search was conducted across several databases including PubMed, EMBASE, and CENTRAL to identify pertinent publications from their inception through 2023. We specifically focused on studies that reported outcomes of rTHA with retained well-fixed femoral stems. The study designs incorporated in our research encompassed both cohort studies and case series studies. Thirty-five studies involving isolated acetabular revision and retaining the stem were included, representing a total of 3497 patients. Data extraction was tailored to the study questions. Meta-analyses, meta-regression, and subgroup analyses were conducted to evaluate the outcomes and their relationship with various factors. Pooled results, meta-regression, and subgroup analyses were performed using random-effects models. To assess and reduce bias, we employed Egger's test and the trim and fill method.

RESULTS

The meta-analysis included 3497 patients with a mean follow-up of 9.28 years. The 10-year risk of re-revision after retaining femoral stem using highly cross-linked polyethylene was 1.7% (95% CI 1.1%-2.3%; I2: 60%) for stem aseptic loosening and 8.8% (95% CI 6.2%-11.4%; I2: 78%) overall re-revision. Dislocation risk was 5.7% (95% CI 4.1-7.0%; I2: 61%). Ceramic heads showed lower stem failure risk than metal heads in long-term follow-ups (P < 0.001). The posterolateral approach in revision surgery resulted in better long-term outcomes compared to the direct lateral approach (P < 0.001). Follow-up duration, timeline of study, Harris Hip Score, type of stem fixation, femoral head material, BMI, age, stem age, and surgical approach were evaluated as influential factors on these outcomes.

CONCLUSION

The re-revision rate due to aseptic loosening of the retained stem during rTHA was found to be significantly low, supporting the idea of retaining well-fixed stems during rTHA. The overall re-revision and dislocation rates also presented comparable or better outcomes to prior studies. A range of factors, including the use of highly cross-linked polyethylene and ceramic femoral heads, was found to influence these outcomes.

LEVEL OF EVIDENCE

IV.

PROSPERO REGISTRATION NUMBER

CRD42022351157.

Is Elective Total Hip Arthroplasty Safe in Nonagenarians?: An Arthroplasty Registry Analysis

BACKGROUND

An increasing number of elderly patients are becoming candidates for elective total hip arthroplasty (THA). Conflicting results exist with regard to the safety of THA in nonagenarians. The aims of this study were to evaluate postoperative mortality and morbidity after THA in nonagenarians and underlying risk factors. We hypothesized that nonagenarians undergoing elective THA would show higher morbidity than younger patients and higher mortality than nonagenarians in the general population.

METHODS

This was an observational cohort study using data from the German Arthroplasty Registry (Endoprothesenregister Deutschland [EPRD]). Of 323,129 THAs, 263,967 (including 1,859 performed on nonagenarians) were eligible. The mean follow-up (and standard deviation) was 1,070 ± 641 days (range, 0 to 3,060 days). The exclusion criteria were age of <60 years at admission and nonelective THAs or hemiarthroplasties. The cohort was divided into 4 age groups: (1) 60 to 69 years, (2) 70 to 79 years, (3) 80 to 89 years, and (4) ≥90 years. Comorbidities representing independent risk factors for postoperative complications and mortality were identified via a logistic regression model. Mortality rates were compared with those from the general population with data from the Federal Statistical Office. The end points of interest were postoperative major complications, minor complications, and mortality.

RESULTS

Among the greatest risk factors for major and minor complications and mortality were congestive heart failure, pulmonary circulation disorders, insulin-dependent diabetes, renal failure, coagulopathy, and fluid and electrolyte disorders. Compared with younger groups, the risks of major and minor complications and mortality were significantly higher in nonagenarians. Mortality increased when major complications occurred. After 1 year, the survival rate in patients without a major complication was 94.4% compared with 79.8% in patients with a major complication. The mortality rates of nonagenarians in the study population were lower than those in the corresponding age group of the general population. The 1-year mortality rates at 90 years of age were 10.5% for men and 6.4% for women within the study group compared with 18.5% for men and 14.7% for women among the general population.

CONCLUSIONS

Comorbidities favor the occurrence of complications after elective THA in nonagenarians and thus increase postoperative morbidity. In the case of complications, mortality is also increased. The fact that mortality is still lower than within the general population shows that this aspect can be controlled by careful patient selection and adequate preparation.

LEVEL OF EVIDENCE

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

Outcomes of the Anterior-Based Muscle-Sparing Approach in Elective Total Hip Arthroplasty in Nonagenarians

Background

As the population ages, total hip arthroplasty has become more common in elderly patients including patients over the age of 90 years. Efficacy in this age group has been established, though literature regarding safety of total hip arthroplasty in nonagenarians is mixed. The anterior-based muscle-sparing (ABMS) approach, which exploits the intermuscular plane between the tensor fasciae latae and the gluteus medius, has proposed benefits of fast recovery, excellent stability, and reduced bleeding and may be adventitious among elderly, more fragile patients.

Methods

A total of 38 consecutive nonagenarians undergoing elective, primary total hip arthroplasty via the ABMS approach for any indication from 2013 to 2020 were identified, and information regarding operative outcomes and patient-reported outcomes was gathered from review of medical records and our institutional joint replacement outcomes database.

Results

Included patients ranged from 90 to 97 years of age with the majority classified as American Society of Anesthesiologists score 2 (50%) or American Society of Anesthesiologists 3 (47.4%). The mean operative time was 74.6 minutes ± 13.6 minutes. Of all patients, 5 required a transfusion, 2 patients were readmitted within 90 days, and there were no major complications. The mean hospital length of stay was 2.8 days ± 0.8 days with 22 patients (57.9%) discharged to a skilled nursing facility. Limited patient-reported outcomes data showed statistically significant improvements in most outcomes scores at 6 months to 1 year postoperatively compared to preoperative scores.

Conclusions

The ABMS approach is safe and effective in nonagenarians who may benefit from decreased amounts of bleeding and recovery times associated with the ABMS approach, which is evident from the low complication rates, relatively short hospital lengths of stay, and acceptable transfusion rates compared to previous studies.

[Standard and special liner in primary hip arthroplasty : Current study and survey results from the German Arthroplasty Registry (EPRD)]

BACKGROUND

Instability constitutes the main reason for revision hip arthroplasties. Modified polyethylene liners are designed to improve the stability of a hip replacement. In July 2022 The Bone & Joint Journal published a study with data of the German Arthroplasty Registry (EPRD). The study investigated mechanical failure of standard and modified liner designs in primary, cementless total hip arthroplasty. Following the study, the EPRD conducted a survey of German clinics to research the utilization of lipped liners in primary total hip replacement.

METHODS

The liner study included 151,096 primary, elective, cementless total hip arthroplasties. Data from November 2012 to November 2020 were obtained from the EPRD. Standard polyethylene liners were compared with lipped, angulated, offset and angulated/offset inlays. Cumulative incidences for endpoint revision due to mechanical complication were calculated with a competing risk analysis. The influence of other variables was investigated with a multivariate Cox regression. In the following online survey, 237 out of 789 hospitals completed a form.

RESULTS AND CONCLUSION

In our analysis, only offset liners were, compared to standard liners, associated with a reduced risk of mechanical failure in a short to medium follow up. However, the resultant joint reaction force is increased with offset liners due to the lateralization of the hip center of rotation. Thus, the long-term performance of offset liners needs to be observed. Our survey indicated that lipped liners were implanted more often if the posterior approach was used. Moreover, lipped liners were mostly positioned with the elevated rim in the biomechanically less optimal posterior-superior quadrant. To improve stability it is suggested to position the elevated rim in the posterior-inferior quadrant.

Efficacy of pericapsular nerve group (PENG) block on perioperative pain management in elderly patients undergoing hip surgical procedures: a protocol for a systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

An increasing number of elderly patients suffer from hip diseases associated with moderate to severe perioperative pain during the accelerating global ageing process. Optimal analgesia can decrease perioperative complications and facilitate elderly patients' perioperative recovery. Pericapsular nerve group (PENG) block is a relatively new, analgesia adequate and motor-sparing block technique for perioperative pain management of hip diseases. However, the efficacy of PENG block remains unclear as the limited clinical evidence. Then, we will perform a protocol for a systematic review and meta-analysis to identify the efficacy of PENG block for perioperative pain management.

METHODS AND ANALYSIS

PubMed, Ovid Medline, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, Chinese BioMedical Literature, Wanfang and VIP databases will be searched from inception to August 2022 to identify randomised controlled trials of elderly patients accepting PENG block for hip diseases. The primary outcome will be the pain intensity after pain management. Secondary outcomes will be quadriceps strength, perioperative rescue analgesia information and perioperative complications. Assessment of heterogeneity will be primarily inspected by forest plots. If there is no indication of funnel plot asymmetry, a random-effects meta-analysis will be performed. The Cochrane risk-of-bias tool, Grading of Recommendations Assessment, Development and Evaluation and trial sequential analysis will be conducted to evaluate the evidence quality and control the random errors. Funnel plots and Egger's regression test will be performed to evaluate publication bias.

ETHICS AND DISSEMINATION

Ethical approval was not required for this systematic review protocol. The results will be disseminated through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42022313895.