Total hip arthroplasty after previous fracture surgery

Functional outcome of conversion total hip arthroplasty (CTHA) using uncemented distally loading femoral stem for failed fixation of proximal femoral nail - A case series

Introduction and aims

There is paucity of prospective studies on conversion total hip arthroplasty (CTHA) for failed proximal femoral nailing. The objective of this study is to evaluate the functional outcome of CTHA using extensively porous coated distal loading stem for failed proximal femoral nailing.

Patients and methods

Fifteen consecutively operated patients for failed proximal femoral nail treated with single stage procedure of nail extraction and CTHA were included in this prospective observational study. All patients received metal-on-polyethylene bearing with uncemented press-fit acetabular cup (Pinnacle cup; DePuy, Warsaw [IN], USA) and extensively porous coated distally loading revision stem (Solution stem; DePuy, Warsaw [IN], USA). All patients were assessed preoperatively and postoperatively at one, three, six and more than twelve months using the Harris Hip Score (HHS). The responsiveness of HHS was assessed using Effect Size (ES) and Standardised Response Mean (SRM). ES and SRM >0.8 indicates adequate responsiveness.

Results

The mean duration of follow-up was 16.9 months for the overall cohort (SD: 7.9; range: 6-28 months). The mean preoperative HHS was 32 ± 6.1, the mean HHS at six months follow-up was 89.7 ± 4.0 and the mean HHS at final follow-up of atleast one year was 93.7 ± 3.0. There was a statistically and clinically significant improvement in the HHS from preoperatively to final follow-up postoperatively (p < 0.0001). At the final follow-up, twelve patients (80%) had an excellent outcome and three patients (20%) had a good outcome as per HHS grading. The ES was 9.87 and the SRM was 8.86 thereby suggesting adequate responsiveness. One patient developed surgical site infection and another patient developed dislocation. Both were successfully treated and subsequently the patients made uneventful recovery. None of the patients required revision surgery.

Conclusion

HHS has adequate responsiveness for assessing the functional outcome of CTHA. We recommend the use of an uncemented cup and uncemented extensively porous coated, distal loading stem for failed PFN fixation in intertrochanteric hip fractures.

Functional outcomes and perceived quality of life following fixation of femoral neck fractures in adults from 18 to 69 years using dynamic hip screw (DHS) and an additional anti-rotation screw- a retrospective analysis of 53 patients after a mean follow-up time of 4 years

INTRODUCTION

The purpose of the study was to explore the functional outcome after osteosynthesis with dynamic hip screw (DHS) for adults up to 69 years, and identify potential predictive indicators of either positive impact on quality of life or increase the incidence of complications.

MATERIALS AND METHODS

Out of 85 patients 53 could be contacted, 36 were followed up clinically and radiologically, 17 patients could be interviewed by phone. All fractures have been treated by osteosynthesis with DHS and one additional anti-rotation screw. Functional outcome and quality of life were measured with use of Harris Hip Score (HHS) and Short Form 12 Health Survey (SF 12). The mean values were compared to two random sample t tests and ANOVA for independent random samples. The connection between an aim variable and selected variables of influence was examined by regression analysis.

RESULTS

The mean HHS showed good functional results with 88 points (median 95.6). Good or excellent results were achieved in 80.4% of cases. The current investigation also delivers promising results with regard to the complication rate: avascular femoral head necrosis (AVN) in 11.3% of cases (n = 6), 9.4% showed non-union (n = 5) and cut out (n = 3) occurred in 5.7%. A secondary conversion to hip arthroplasty (n = 7) had a strong negative impact on everyday life (HHS = 63.3 points, Physical Health Summary Score SF-12 = 34.9 points).

CONCLUSIONS

The results of this study are promising showing uncomplicated fracture healing in 84.9% of intracapsular femoral neck fractures and a low incidence of complications after osteosynthesis with DHS in patients aged up to 69 years. The quality of the fracture reduction achieved in the axial view and a small tip apex index after an osteosynthetically treated femoral neck fracture with DHS are significant predictive indicators for complications. Diabetes, age > 65 years, osteoporosis, ASA III may also be significant factors for worse results, but showed no statistical significance in our analysis.

Single-stage total hip arthroplasty after failed fixation of proximal femoral fractures: an increased risk for periprosthetic joint infections?

BACKGROUND

Higher complication rates have been reported for total hip arthroplasty (THA) after osteosynthesis of proximal femur fractures (PFF). This study evaluated the infection risk for conversion of internal fixation of PFF to THA by a single-staged procedure in the absence of clear infection signs.

METHODS

Patients undergoing a one-staged conversion to THA (2013-2018) after prior internal fixation of the proximal femur were included. Preoperative diagnostics with laboratory results, hip aspirations as well as intraoperative microbiology and sonication were assessed. Postoperative complications were recorded as well as patient demographics, duration between initial and conversion to THA, explanted osteosynthesis and implanted THA.

RESULTS

Fifty-eight patients (24 male/34 female, 62.8 ± 14.5 years) were included with a mean time of 3.8 ± 7.5 years between internal fixation and conversion to THA (45 cementless, 3 cemented, 3 hybrid and 7 hybrid inverse THAs). Preoperative mean blood level CRP was 8.36 ± 14 mg/l (reference value < 5 mg/l) and leukocyte count was 7.11 ± 1.84^3/µl (4.5-10.000^3/µl). Fifty patients had intraoperative microbiological diagnostics, with either swabs in 86.2% and/or sonication in 29.3%. Positive microbiological results were recorded in 10% (5 of 50 patients), with pathogens identified being mainly Staphylococcus. Complications after conversion occurred in 9.6% including a postoperative low-grade infection rate of 5.8% after a mean of 2.5 years.

CONCLUSION

This study found a positive microbiological test result in 10% of a one-stage conversion of PFF fixation to THA. Moreover, we found a high infection rate (5.8%) for early postoperative periprosthetic joint infection. Interestingly, CRP has not been proven to be an adequate parameter for low-grade infections or occult colonized implants. Therefore, we recommend a comprehensive pre- and intraoperative diagnostic including hip aspiration, swabs and sonication when considering one-staged revision.

Outcome of total hip arthroplasty in patients with failed open reduction and internal fixation of acetabular fractures

BACKGROUND

The problem of failed acetabulum fracture fixation is increasing due to increased incidence of high-velocity injury and a large number of patients are being operated on in the past few years. Limited evidence is available regarding results of Total hip arthroplasty (THA) in patients with failed acetabulum fracture fixation surgery. We assessed the clinical, radiological and postoperative complications. Besides this, we also evaluated functional outcome and quality of life following THA in failed open reduction and internal fixation of acetabular fractures.

METHOD

The current retrospective study was performed at the tertiary center from 2015 to 2020. Eighteen patients of failed acetabulum fracture fixation surgery (14 males and 4 females) were included with a mean follow-up period of 2.4 years. Postero-lateral approach was done in all cases. Clinico-radiological outcome, functional outcomes were recorded according to Harris Hip score (HHS) and quality of life was assessed by using the 12-Item Short Form Health Survey (SF-12) score. Postoperative complications were also assessed.

RESULTS

The age of patients ranged from 20 years to 68 years with a mean age of 44.7 years. 16 of the patients (88.9%) had a united acetabular fracture while 2 of them (11.1%) presented with un-united acetabular fracture. The THA implant was found to be stable in all 18 cases. The Harris Hip score of the study ranged from 82 to 95 with a mean of 89.72 ± 4.24 while the SF-12 score ranged from 40.0 to 49.4 with a mean of 44.29 ± 2.95. Out of 18 cases, 11 (61.1%) returned with excellent outcomes while the rest 7 (38.9%) returned with good outcomes as per Harris Hips score criteria. The correlation and regression analysis shows between HHS and SF-12 was positive and statistically significant (r = 0.592, p = 0.010).

CONCLUSION

THA in patients with failed acetabulum fracture fixation surgery provides a reliable option with satisfactory outcomes along with a better quality of life.

The majority of conversion total hip arthroplasties can be considered primary replacements - a matched cohort study

The success of conversion Total Hip Arthroplasty (THA) among primary THA and revision THA re- mains unclear. We hypothesized that most conversion THAss can be performed using primary implants and will have an uncomplicated post-operative course. Thirty-six patients (23 females, mean age 68,0y) who underwent conversion THA for failed interventions for proximal femur fractures in the period 2006-2018 were matched sequentially against patients of the same sex and age who underwent primary THA or revision THA. Data was collected on implants used, major complications, and mortality. PROMs used included the Western Ontario and McMaster Osteoarthritis Index, Harris Hip Score, Visual Analogue Scale and the EQ-5D Health Questionnaire. Seventy- two percent of patients who underwent conversion THA were treated with primary implants and never suffered from a major complication. PROMs were excellent for this group of patients. The distinction primary / conversion / revision THA could not explain differences in outcomes, however the necessity of using revision implants and the development of major complications could. The majority of conversion total hip arthroplasties can be considered a primary replacement. Predicting outcomes for THA should focus on patient frailty and technical difficulties dealing with infection, stability and loss of bone stock and should discard the conversion versus revision terminology.

Hip fractures in the young polytrauma patient: a review and the latest data from the UK

Managing a hip fracture in a young adult patient in the setting of polytrauma is a particularly challenging prospect. In the UK between 2018 and 2020, 11,969 patients were recorded in the Trauma Audit and Research Network as a patient with polytrauma. Of these patients, 611 (5.1%) had a hip fracture. In this article, we discuss the initial assessment and management of these patients and common problems that are encountered and how the evidence available can help guide management.

The majority of conversion total hip arthroplasties can be considered a primary replacement: a matched cohort study

Background and study aims

The success of conversion total hip arthroplasty (THA) among primary THA and revision THA remains unclear. We hypothesized that most conversion THA’s can be performed using primary implants and will have an uncomplicated post-operative course.

Materials and methods

Thirty-six patients (23 females, mean age 68,0y) who underwent conversion THA for failed interventions for proximal femur fractures in the period 2008–2018 were matched sequentially against patients of the same sex and age who underwent primary THA or revision THA. Data were collected on implants used, major complications, and mortality. PROMs used included the Western Ontario and McMaster Osteoarthritis Index, Harris Hip Score, Visual Analogue Scale and the EQ-5D Health Questionnaire.

Results

Seventy-two percent of patients who underwent conversion THA were treated with primary implants and never suffered from a major complication. PROMs were excellent for this group of patients. The distinction primary/conversion/revision THA could not explain differences in outcomes; however, the necessity of using revision implants and the development of major complications could.

Conclusions

The majority of conversion total hip arthroplasties can be considered a primary replacement. Predicting outcomes for THA should focus on patient frailty and technical difficulties dealing with infection, stability and loss of bone stock and should discard the conversion versus revision terminology.

Total Hip Arthroplasty After Prior Acetabular Fracture: Infection Is a Real Concern

BACKGROUND

Acetabular fractures often require surgical intervention for fracture fixation and can result in premature osteoarthritis of the hip joint. This study hypothesized that total hip arthroplasty (THA) in patients with a prior acetabular fracture who had undergone open reduction and internal fixation (ORIF) is associated with a higher rate of subsequent periprosthetic joint infection (PJI).

METHODS

About 72 patients with a history of acetabular fracture that required ORIF, undergoing conversion THA between 2000 and 2017 at our institution, were matched based on age, gender, body mass index, Charlson comorbidity index, and date of surgery in a 1:3 ratio with 215 patients receiving primary THA. The mean follow-up for the conversion THA cohort was 2.9 years (range, 1-12.15) and 3.06 years (range, 1-12.96) for the primary THA.

RESULTS

Patients with a previous acetabular fracture, compared with the primary THA patients, had longer operative times, greater operative blood loss, and an increased need for allogeneic blood transfusion (26.4% vs 4.7%). Most notably, PJI rate was significantly higher in acetabular fracture group at 6.9% compared with 0.5% in the control group. Complications, such as aseptic revision, venous thromboembolism, and mortality, were similar between both groups.

CONCLUSION

The present study demonstrates that conversion THA in patients with prior ORIF of acetabular fractures is associated with higher complication rate, in particular PJI, and less optimal outcome compared with patients undergoing primary THA. The latter findings compel us to seek and implement specific strategies that aim to reduce the risk of subsequent PJI in these patients.

Revision surgery due to failed internal fixation of intertrochanteric femoral fracture: current state-of-the-art

Failed treatment of intertrochanteric (IT) femoral fractures leads to remarkable disability and pain, and revision surgery is frequently accompanied by higher complication and reoperation rates than primary internal fixation or primary hip arthroplasty. There is an urgent need to establish a profound strategy for the effective surgical management of these fragile patients. Salvage options are determined according to patient physiological age, functional level, life expectancy, nonunion anatomical site, fracture pattern, remaining bone quality, bone stock, and hip joint competency. In physiologically young patients, care should be taken to preserve the vitality of the femoral head with salvage internal fixation; however, for the elderly population, conversion arthroplasty can result in early weight bearing and ambulation and eliminates the risks of delayed fracture healing. Technical challenges include a difficult surgical exposure, removal of broken implants, deformity correction, critical bone defects, poor bone quality, high perioperative fracture risk, and prolonged immobilization. Overall, the salvage of failed internal fixations of IT fractures with properly selected implants and profound techniques can lead to the formulation of valuable surgical strategies and provide patients with satisfactory clinical outcomes.

Efficacy of antimicrobial coated orthopaedic implants on the prevention of periprosthetic infections: a systematic review and meta-analysis

Introduction: Implant-associated infections are a major problem in orthopaedic surgery. Local delivery systems of antimicrobial agents on the implant surface have attracted great interest recently. The purpose of this study was to identify antimicrobial coatings currently used in clinical practice, examining their safety and effectiveness in reducing post-operative infection rates.

Materials and Methods: A systematic review was conducted in four databases (Medline, Embase, Cochrane, Cinahl) according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines up to December 2019, using the key words “orthopaedic implant coated”, “coated implant infection”, “silver coating ” and “antibiotic coating”.

Results: Seven articles involving 1307 patients (561 with coated implants and 746 controls who were not) comparing the incidence of periprosthetic infections after the application of internal fracture fixation, total arthroplasties and endoprostheses were evaluated. Three different coating technologies were identified: gentamicin coating for tibia nail and total arthroplasties; silver technology and povidone-iodine coating for tumour endoprostheses and titanium implants. Meta-analysis demonstrated that patients who were treated with antimicrobial coated implants presented lower infection rates compared to controls over the seven studies (Q = 6.1232, I2 = 0.00, 95% CI: 1.717 to 4.986, OR: 2.926, Z= 3.949, p<0.001). Subgroup statistical analysis revealed that each coating technique was effective in the prevention of periprosthetic infections (Q = 9.2606, I2 = 78.40%, 95% CI: 1.401 to 4.070, OR: 2.388, Z= 3.200, p<0.001).

Conclusion: All technologies were reported to have good biocompatibility and were effective in the reduction of post-operative peri-prosthetic infection rates.

Total Hip Arthroplasty for Bilateral Femoral Neck Stress Fracture: A Case Report and Review of the Literature

Femoral neck stress fractures (FNSFs) can be treated conservatively or surgically, depending on initial displacement and patient condition. Surgical treatment options include internal fixation, with or without valgus osteotomy or hip arthroplasty, either hemi or total. The latter is mainly considered when initial treatment fails. A review of the literature shows that total hip arthroplasty (THA) is only considered as primary treatment in displaced fractures (type 3) in low-demand patients. We present a case of successive bilateral FNSF in a young active patient, where a THA was performed on one side, after failed internal fixation, and where it was chosen as primary treatment on the other side after failed conservative treatment.

Conversion to total hip arthroplasty in posttraumatic arthritis: short-term clinical outcomes

Background

Fractures of the acetabulum are challenging and very difficult to treat, and even after fixation, they can lead to posttraumatic arthritis. Total hip arthroplasty (THA) has been the most common surgery performed for the complications of posttraumatic arthritis in this group of patients.

Aim

In this article, it is aimed to assess the functional results and complications of the conversion to THA for posttraumatic arthritis after acetabular fracture.

Patients and methods

Forty-nine patients were followed up for a mean of 3.7 years (range 2-5 years). The complications included four cases of sciatic nerve palsy, all of which had injury during the first operation. Two cases underwent two-stage surgery because of infection which was demonstrated by a high level of erythrocyte sedimentation rate/C-reactive protein and according to frozen section samples, which were sent intraoperatively with >10 neutrophil/high-power field; one case was then managed by a one-stage protocol for infection after THA was infected with methicillin-resistant Staphylococcus aureus. In 1 case, we used the Girdlestone operation for severe infections and uncontrolled diabetes; in 2 cases, we used cages; and in 47 cases, we used uncemented cups.

Results

The mean of modified Hip Harris Score improved from 47 (31-66) before the conversion to 89 (79-95) at the final follow-up. The pain component of the Western Ontario and McMaster Universities also increased from an average of 15 (7-20) to 4 (0-11) at the final follow-up. No dislocation, deep vein thrombosis or pulmonary thromboembolism, new nerve injury, and heterotopic ossification occurred.

Conclusion

The conversion to THA after posttraumatic arthritis in acetabular fracture can lead to reasonable pain relief and functional improvement.

The Effect of Previous Hip Surgery on the Outcome of Hip Arthroplasty in Young Patients

BACKGROUND

The incidence of total hip arthroplasty (THA) is increasing in all age groups, especially in young patients. The outcome of THA is believed to be affected by morphological deformities created by previous pelvic or femoral procedures performed in childhood. The aim of the present study was to assess whether previous hip surgery impaired the functional outcome in young patients who underwent THA.

METHODS

Data were collected from the records of patients aged less than 30 years who had undergone THA between 2002 and 2011. Thirty-five patients (44 hips) were included. The Western Ontario and McMaster Universities Osteoarthritis Index and Harris Hip Scores were collected as primary functional outcome measures. The secondary outcome measures were the major and minor complications. Patients were divided into 2 groups: those who had not undergone hip surgery before THA (group I, 17 patients, 24 hips) and those with a history of prior hip surgery (group II, 18 patients, 20 hips).

RESULTS

The mean age at the time of surgery was 25 ± 4 years in group I and 23 ± 4 years in group II. The mean Harris Hip Score was slightly higher in group I (90 ± 7) than in group II (87 ± 7) (P = .2). The mean Western Ontario and McMaster Universities Osteoarthritis Index scores were similar in both groups (in group I 14 ± 7 and in group II 14 ± 6, P = .9). Complication rates were also similar in both groups (P = .7).

CONCLUSIONS

It is often difficult to decide whether to perform THA in young patients. One potential risk factor for complications is hip surgery before THA. Our study revealed that young patients with or without a history of previous hip surgery achieved satisfactory functional outcomes with similar complication rates after THA.

Threading the Needle: Intrapelvic Displacement of a Femoral Neck Fracture through the Obturator Foramen

Despite timely and appropriate management, displaced femoral neck fractures are often devastating injuries for the young patient. The risk of negative sequelae is further amplified with increasing displacement and vertical fracture patterns. Open anatomic reduction with rigid internal fixation is essential to maximize the healing potential in displaced fractures of the femoral neck. Successful primary osteosynthesis of significantly displaced femoral neck fractures in the young patient has been reported in the literature. We present a unique case of open reduction and internal fixation of a high-energy femoral neck fracture with extrusion of the head through the obturator foramen into the pelvis without associated acetabular or pelvic injury.

Total hip arthroplasty after failed treatment of proximal femur fracture

INTRODUCTION

Total hip arthroplasty (THA) is a good option as a salvage procedure after failed treatment of proximal femur fracture. The anatomy of the proximal femur, however, makes this surgery complicated and challenging. The purpose of this study was to evaluate the radiographic and clinical outcomes of THA after failed treatment of proximal femur fractures.

MATERIALS AND METHODS

We retrospectively analysed 50 consecutive THAs (42 women, 8 men; mean age 77 years) after failed treatment of a proximal femur fracture. Mean postoperative follow-up was 58.1 months. Preoperative diagnoses were femoral neck fracture in 18 hips and trochanteric fracture in 32 hips, including three that were infected. Failure resulted from cutout in 22 cases, osteonecrosis in 12, non-union with failed fixation in nine, postoperative osteoarthritis in four, and infection in three. Factors compared included radiographic assessment, complication rate, visual analogue scale (VAS), and Harris Hip Scores (HHS). Radiographic variables included femoral neck anteversion and cup and stem alignment.

RESULTS

Absolute values of the differences in femoral neck anteversion between the affected and healthy sides were 6.0° in the femoral neck fracture group and 19.2° in the trochanteric fracture group (p = 0.01). There were no significant differences in cup anteversion (p = 0.20) or stem anteversion (p = 0.08). The complication rate was significantly higher in the trochanteric fracture group than in the femoral neck fracture group (25 vs 0%, p < 0.0001). Postoperative complications in the trochanteric fracture group included three periprosthetic fractures (9.4%), two dislocations (6.3%), two surgical-site infections (6.3%), and one stem penetration (3.1%). Although no significant differences between groups were seen in the VAS or HHS at final follow-up (p = 0.32, 0.09, respectively), these measures were significantly improved at final follow-up in both groups (p < 0.0001 for both).

CONCLUSIONS

Performing THA after failed treatment of trochanteric fractures requires consideration of complication risk and incorrect femoral neck anteversion.

Do Conversion Total Hip Arthroplasty Yield Comparable Results to Primary Total Hip Arthroplasty?

BACKGROUND

The incidence of hip fractures is growing with the increasing elderly population. Typically, hip fractures are treated with open reduction internal fixation, hemiarthroplasty, or total hip arthroplasty (THA). Failed hip fracture fixation is often salvaged by conversion THA. The total number of conversion THA procedures is also supplemented by its use in treating different failed surgical hip treatments such as acetabular fracture fixation, Perthes disease, slipped capital femoral epiphysis, and developmental dysplasia of the hip. As the incidence of conversion THA rises, it is important to understand the perioperative characteristics of conversion THA. Some studies have demonstrated higher complication rates in conversion THAs than primary THAs, but research distinguishing the 2 groups is still limited.

METHODS

Perioperative data for 119 conversion THAs and 251 primary THAs were collected at 2 centers. Multivariable linear regression was performed for continuous variables, multivariable logistic regression for dichotomous variables, and chi-square test for categorical variables.

RESULTS

Outcomes for conversion THAs were significantly different (P < .05) compared to primary THA and had longer hospital length of stay (average 3.8 days for conversion THA, average 2.8 days for primary THA), longer operative time (168 minutes conversion THA, 129 minutes primary THA), greater likelihood of requiring metaphysis/diaphysis fixation, and greater likelihood of requiring revision type implant components.

CONCLUSION

Our findings suggest that conversion THAs require more resources than primary THAs, as well as advanced revision type components. Based on these findings, conversion THAs should be reclassified to reflect the greater burden borne by treatment centers.

The Lawrence D. Dorr Surgical Techniques & Technologies Award: Conversion Total Hip Arthroplasty: Is it a Primary or Revision Hip Arthroplasty

BACKGROUND

Total hip arthroplasty (THA) is an increasingly common procedure among elderly individuals. Although conversion THA is currently bundled in a diagnosis related group (DRG) with primary THA, no study has identified whether patients undergoing conversion THA better resemble patients undergoing primary THA or revision THA. The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database collects data from hospitals nationwide about preoperative characteristics, intraoperative factors, and 30-day postoperative complications. The purpose of our study was to use these variables in the ACS-NSQIP dataset to compare patients undergoing conversion THA to those undergoing primary and revision THA in order to ensure proper DRG classification of these procedures.

METHODS

Between 2009-2014, the ACS-NSQIP database identified 2,009 conversion THA patients, 5,089 revision THA patients, and 67,854 primary THA patients. Univariate analysis was used to compare fifty-three preoperative, intraoperative, and postoperative variables among these groups. A conservative Bonferroni-adjusted P-value of .0003 was calculated, and a less conservative P-value of .01 was used for comparison.

RESULTS

Seventeen variables exhibited a significant difference (P ≤ .0003) only between conversion and primary THA, one variable exhibited a difference only between conversion and revision THA, and three variables exhibited a difference between both conversion and primary THA, and conversion and revision THA. With P ≤ .01, twenty-three, zero, and six differences were observed, respectively.

CONCLUSION

The disproportionate number of differences between conversion and primary THAs suggests that patients undergoing conversion THAs better resemble patients undergoing revision THAs. DRGs are traditionally comprised of procedures that have similar diagnoses and require comparable levels of resources from a hospital, so these results suggest that conversion THA should rather be bundled in the same DRG as revision THA. With hospitals emphasizing cost-containment strategies, this reclassification would be a step forward in improving the documentation of procedures in order to receive appropriate institutional reimbursement.

Primary vs Conversion Total Hip Arthroplasty: A Cost Analysis

INTRODUCTION

Increasing hip fracture incidence in the United States is leading to higher occurrences of conversion total hip arthroplasty (THA) for failed surgical treatment of the hip. In spite of studies showing higher complication rates in conversion THA, the Centers for Medicare and Medicaid services currently bundles conversion and primary THA under the same diagnosis-related group. We examined the cost of treatment of conversion THA compared with primary THA. Our hypothesis is that conversion THA will have higher cost and resource use than primary THA.

METHODS

Fifty-one consecutive conversion THA patients (Current Procedure Terminology code 27132) and 105 matched primary THA patients (Current Procedure Terminology code 27130) were included in this study. The natural log-transformed costs for conversion and primary THA were compared using regression analysis. Age, gender, body mass index, American Society of Anesthesiologist, Charlson comorbidity score, and smoker status were controlled in the analysis. Conversion THA subgroups formed based on etiology were compared using analysis of variance analysis.

RESULTS

Conversion and primary THAs were determined to be significantly different (P<.05) and greater in the following costs: hospital operating direct cost (29.2% greater), hospital operating total cost (28.8% greater), direct hospital cost (24.7% greater), and total hospital cost (26.4% greater).

CONCLUSIONS

Based on greater hospital operating direct cost, hospital operating total cost, direct hospital cost, and total hospital cost, conversion THA has significantly greater cost and resource use than primary THA. In order to prevent disincentives for treating these complex surgical patients, reclassification of conversion THA is needed, as they do not fit together with primary THA.

Conversion total hip arthroplasty: Primary or revision total hip arthroplasty

Total hip arthroplasty (THA) is an increasingly common procedure among elderly individuals. Although conversion THA is currently bundled in a diagnosis related group (DRG) with primary THA, there is a lack of literature supporting this classification and it has yet to be identified whether conversion THA better resembles primary or revision THA. This editorial analyzed the intraoperative and postoperative factors and functional outcomes following conversion THA, primary THA, and revision THA to understand whether the characteristics of conversion THA resemble one procedure or the other, or are possibly somewhere in between. The analysis revealed that conversion THA requires more resources both intraoperatively and postoperatively than primary THA. Furthermore, patients undergoing conversion THA present with poorer functional outcomes in the long run. Patients undergoing conversion THA better resemble revision THA patients than primary THA patients. As such, patients undergoing conversion THA should not be likened to patients undergoing primary THA when determining risk stratification and reimbursement rates. Conversion THA procedures should be planned accordingly with proper anticipation of the greater needs both in the operating room, and for in-patient and follow-up care. We suggest that conversion THA be reclassified in the same DRG with revision THA as opposed to primary THA as a step towards better allocation of healthcare resources for conversion hip arthroplasties.