[Current state of doing minimal invasive total hip replacement in Germany, the use of new implants and navigation--results of a nation-wide survey]

German surgeons' technical preferences for performing total hip arthroplasties: a survey from the National Endoprosthesis Society

PURPOSE

The goal of our study was to conduct an online survey that highlights patterns of practice during total hip arthroplasty (THA).

METHODS

The survey was conducted in June and August 2020. Three hundred thirteen members of the German Society for Endoprosthesis participated in the survey.

RESULTS

The anterolateral approach is by far the most popular approach used for primary total hip arthroplasty, followed by the anterior approach during minimally invasive (55% for the anterolateral and 29% for the anterior) and regular surgery (52% for the anterolateral and 20% for the anterior). Two-thirds of the orthopaedic surgeons do not use drainages during THA. Moreover, 80% of the survey participants routinely apply tranexamic acid during surgery. Surgeons who perform minimally invasive surgery for THA use more frequently fast-track-concepts for post-operative rehabilitation. According to the interviewees, the application of fast-track-concepts leads to reduced periods of hospital stay after THA.

CONCLUSION

Our data demonstrate that patterns of practice during THA in Germany are in line with the evidence provided by current literature. This study can be seen as a stimulus to conduct similar surveys in other countries in order to promote minimally invasive surgery for THA.

Periprosthetic bone density changes after MiniHipTM cementless femoral short stem: one-year results of dual-energy X-ray absorptiometry study

Introduction: The purpose of the current study was to investigate the reaction of the femur to the implantation of the MiniHip^TM in terms of: (1) bone density change during one year; (2) correlations between stem length, CCD (caput-collum-diaphyseal), femoral offset, T-value, and bone density; (3) other co-variables that influence the change of bone density.

Patients and methods: MiniHip^TM implant was performed for 62 patients. The age range of the patients who underwent treatment was 25–78 years. Periprothestic bone density was determined within two weeks postoperatively, after three, six, and twelve months utilizing the DEXA scan.

Results: The highest change was observed in the first three months post-implantation, while significant decrease in density was recorded at proximal Gruen zones 1, 2, and 7, and at distal Gruen zone 4. The decrease in density reached a plateau between the third and sixth months after operation. Afterwards, bone density recovered up to the 12th postoperative month. The correlation analysis showed significant difference between Gruen zone 1 and stem size and CCD. The same significant trend was not reached for Gruen zone 7. Femoral offset showed no correlation. Covariance analysis was unable to establish connection of the results with diagnosis, pairings, or gender.

Discussion: MiniHip^TM densitometric results are promising and comparable to good results of the other representatives of the femoral neck partially-sustaining short stem prostheses with a lower proximal bone density reduction. Periprosthetic bone resorption is a multifactorial process where stem size, CCD angle, and patient-specific variables such as T-value have an impact on the periprosthetic bone remodeling. In particular, this applies to Gruen zone 1.

[Hybrid and uncemented hip arthroplasty: Contribution margin in the German lump sum reimbursement system]

BACKGROUND

The economization of inpatient care began when lump sum reimbursement was introduced into the hospital sector. Since then, total hip arthroplasty (THA) has experienced a rapid development in terms of annual procedures and the optimization of the clinical pathway. Therefore, it is obvious to highlight THA as one of the most common procedures in the German health care system. In this work, the two most common techniques for the fixation of THA are investigated with regard to their cost structure and their influence on the clinical result.

OBJECTIVES

In Germany, uncemented and hybrid fixation are used for THA. In this study we investigated the differences in material costs, the duration of surgery, and the length of stay.

MATERIALS AND METHODS

For each fixation technique a retrospective cost analysis was carried out, based on the data from the treatment documentation of the University Hospital for Orthopedics, Rostock (OUK). The mean values of the parameters and expenses have been reviewed with descriptive statistics for differences.

RESULTS

With regard to total costs and the contribution margin there was no statistically significant difference.

CONCLUSIONS

Although there are differences in individual cost areas, in total costs, cost advantages and disadvantages cancel each other out. Thus, from an economic perspective no particular technique can be recommended.

Computed tomography for preoperative planning in total hip arthroplasty: what radiologists need to know

The number of total hip arthroplasties is continuously rising. Although less invasive surgical techniques, sophisticated component design, and intraoperative navigation techniques have been introduced, the rate of peri- and postoperative complications, including dislocations, fractures, nerve palsies, and infections, is still a major clinical problem. Better patient outcome, faster recovery and rehabilitation, and shorter operation times therefore remain to be accomplished. A promising strategy is to use minimally invasive techniques in conjunction with modular implants, aimed at independently reconstructing femoral offset and leg length on the basis of highly accurate preoperative planning. Plain radiographs have clear limitations for the correct estimation of hip joint geometry and bone quality. Three-dimensional assessment based on computed tomography (CT) allows optimizing the choice and positions of implants and anticipating difficulties to be encountered during surgery. Postoperative CT is used to monitor operative translation and plays a role in arthroplastic quality management. Radiologists should be familiar with the needs of orthopedic surgeons in terms of CT acquisition, post-processing, and data transfer. The CT protocol should be optimized to enhance image quality and reduce radiation exposure. When dedicated orthopedic CT protocols and state-of-the-art scanner hardware are used, radiation exposure can be decreased to a level just marginally higher than that of conventional preoperative radiography. Surgeons and radiologists should use similar terminology to avoid misunderstanding and inaccuracies in the transfer of preoperative planning.

Patient-level hospital costs and length of stay after conventional versus minimally invasive total hip replacement: a propensity-matched analysis

OBJECTIVES

A current trend in total hip replacement (THR) is the use of minimally invasive surgery. Little is known, however, about the impact of minimally invasive THR on resource use and length of stay. This study analyzed the effect of minimally invasive surgery on hospital costs and length of stay in German hospitals compared with conventional treatment in THR.

METHODS

We used patient-level administrative hospital data from three German hospitals participating in the national cost data study. We conducted a propensity score matching to account for baseline differences between minimally invasively and conventionally treated patients. Subsequently, we estimated the treatment effect on costs and length of stay by conducting group comparisons, via paired t tests and Wilcoxon signed-rank tests, and regression analyses.

RESULTS

The three hospitals provided data from 2886 THR patients. The propensity score matching led to 812 matched pairs. Length of stay was significantly higher for conventionally treated patients (11.49 days vs. 10.90 days; P < 0.05), but total costs did not differ significantly (€6018 vs. €5986; P = 0.67). We found a difference in the allocation of costs, with significantly higher implant costs for minimally invasively treated patients (€1514 vs. €1375; P < 0.001) in contrast to significantly higher staff and overhead costs for conventionally treated patients.

CONCLUSIONS

Minimally invasive surgery was compared with conventional THR and was found to be associated with a reduced length of stay. Total hospital costs, however, did not differ between the two treatment groups, because of higher implant costs for minimally invasively treated patients.

[Muscle trauma in primary total hip arthroplasty depending on age, BMI, and surgical approach: minimally invasive anterolateral versus modified direct lateral approach]

BACKGROUND

Maximum preservation of periarticular musculature is essential for the success of total hip arthroplasty. A poorer functional outcome often occurs following total hip arthroplasty, especially in older and overweight patients and is presumed to have a muscular basis. Minimally invasive hip endoprosthetics for muscle-preserving implantation have now become established in orthopedic surgery.

METHODS

A primary hip endoprosthesis was implanted in a total of 39 patients using a transgluteal (modified direct-lateral, mDL, n=19) or anterolateral minimally invasive approach (ALMI, n=20). Magnetic resonance imaging was performed preoperatively as well as 3 and 12 months after the operation. Fatty atrophy (FA) of the gluteus medius muscle was evaluated as a function of body mass index (BMI), patient age and the influence of the access route.

RESULTS

In the overweight group a significantly higher FA of the gluteus medius muscle was found 3 and 12 months after the operation and a significantly higher grade FA using the standard access in contrast to the normal weight group. A significantly higher FA of the gluteus medius muscle was found in the older patient group 3 and 12 months postoperation as well as a significantly higher atrophy using the mDL access.

CONCLUSIONS

Muscle trauma is demonstrably reduced using a minimally invasive access, especially in older and overweight patients. In these patients there is also a substantially higher postoperative muscular atrophy after implantation of a prosthesis than in corresponding normal weight and younger patients. The higher vulnerability and poorer capacity for regeneration of periarticular musculature means that this patient group particularly profits from a minimally invasive access route.

Tackling the learning curve: comparison between the anterior, minimally invasive (Micro-hip®) and the lateral, transgluteal (Bauer) approach for primary total hip replacement

BACKGROUND AND PURPOSE

There is still conflicting evidence about the true benefit of minimally invasive (MI) techniques in total hip replacement (THR). The aim of this prospective study was to evaluate the safeness of a MI approach during the learning curve of a single surgeon. Second, clinical and radiographic results among the MI THR group were compared with the results using a standard transgluteal (Bauer) approach.

METHODS

86 primary unilateral total hip arthroplasties (THAs) through a MI, anterior (Micro-hip(®)) approach were performed by a single senior surgeon (ES), representing a consecutive series of patients after beginning with the MI technique. Cases were compared to a matched cohort of patients who were treated with a standard transgluteal (Bauer) approach. Operation time, incision length, perioperative blood loss, haemoglobin level and blood transfusions were monitored. Complications were documented and followed up 1 year postoperatively. The Harris Hip Score (HHS), range of motion, use of analgetics, the Trendelenburg sign, sensibility of the lateral femoral cutaneous nerve and the acetabular/femoral component placement as well as potential heterotopic ossifications were analysed in both the groups after 12 months postoperatively.

RESULTS

74 MI THR patients and 60 standard THR patients were available for the one year follow-up. Operative time was significantly longer in the MI group, reduction in the haemoglobin level during the first 24 h was significant and the length of skin incision was significantly shorter. No significant differences were found for HHS, range of motion, use of analgetics, the Trendelenburg sign, and the acetabular/femoral component placement, heterotopic ossifications and intra- and postoperative complications. Sensibility of the lateral femoral cutaneous nerve was affected in three patients in the MI group. Radiographic evaluation revealed no component migration, implant subsidence or radiolucency signs in both the groups.

DISCUSSION

Consistent with recent meta-analysis we found reduced blood loss, similar clinical/radiographic outcome and similar complication rates compared to standard THA. Our study shows, that MI THR is a safe procedure during the learning curve of an experienced surgeon.

Fractured neck of femur--internal fixation versus arthroplasty

BACKGROUND

Surgery is the treatment of choice for fractured neck of femur. For middle-aged patients (aged ca. 40 to 65), there is considerable debate over the indications for arthroplasty or internal fixation. The choice of surgical technique varies widely from one region to another. In this article, we discuss the main criteria that should be used in making this decision.

METHODS

We selectively reviewed the literature on the diagnosis and treatment of fractured neck of femur, including the current guideline of the German Society for Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie, DGU) and recent findings from the field of health services research.

RESULTS

The treatment of middle-aged patients with dislocated fractures should be based on rational decision-making. The patient's level of activity before the accident should be judged in terms of his or her previous mobility, independence in daily activities, and mental status. Internal fixation is recommended if the fracture can be adequately repositioned, the bone is of good quality, and there is no evidence of osteoarthritis. Fractures that are more than 24 hours old should be treated with total hip arthroplasty. Hemiprostheses are appropriate for very old patients. Physically frail, bedridden, and/or demented patients should undergo internal fixation of the fracture. For non-displaced or impacted fractures, functional treatment (i.e., prophylactic securing of the fracture with screws or nails) is indicated. Rapid diagnosis and a short time in bed before surgery lower the rate of complications. Internal fixation with preservation of the femoral head should ideally be performed within the first 6 hours of trauma, and within the first 24 hours at most.

CONCLUSION

Despite the increasing scarcity of resources, treatment should still be based on well-founded clinical guidelines. Minimally invasive surgery enables better function in the early postoperative phase and can thereby lower complication rates. An interdisciplinary concept for the postoperative care of elderly patients also has a major effect on the outcome.