Same-Day Discharge Following Total Joint Arthroplasty: Examining Trends, Discharge Dispositions, and Complications Over Time

Administrative database studies have reported on the safety of same-day discharge (SDD) following total joint arthroplasty (TJA); however, most patient cohorts have been defined by length of stay (LOS), and the proportion discharged directly home remains unknown. The purpose of this investigation was to (1) determine common dispositions for patients undergoing SDD TJA; (2) understand changes in discharge disposition over time; and (3) determine the safety of SDD TJA, stratified by discharge disposition. The PearlDiver Database was reviewed for patients who underwent SDD TJA (LOS of 0 days) from 2011 to 2016. Patients were stratified by discharge disposition, and rates and complications following SDD TJA were assessed accordingly. Chi-square analysis was performed to compare demographics and complications between patient groups stratified by disposition. From 2011 to 2016, there was an exponential increase in the annual rate of SDD TJA from 0.95% to 20.5%, respectively; however, the annual proportion of patients discharged directly home remained unchanged (approximately 68%), with the remaining discharged directly to an alternate care facility, most commonly inpatient rehabilitation. Patients discharged to an alternate facility were significantly older (P<.001), had significantly higher comorbidity scores (P<.001), and had significantly more complications (P<.001) than those patients discharged directly home. Although the annual rate of SDD TJA is increasing, up to one-third of patients are not discharged directly home-a proportion unchanged over time. Moving forward, administrative database studies examining SDD TJA must account for discharge disposition; moreover, there is a need to understand the practice of SDD TJA to an alternate care facility. [Orthopedics. 2020;43(4):204-208.].

Outpatient Total Joint Arthroplasty: A Review of the Current Stance and Future Direction

INTRODUCTION

The purpose of this review is to outline some of the major considerations when transitioning to performing total hip and knee arthroplasty in the out- patient setting. The review will discuss patient selections, peri-operative management pathways, and outcomes related to outpatient total joint arthroplasty (TJA).

PATIENT SELECTION

Appropriate patient selection is key to successful outpatient TJA. Multiple indices have been proposed to estimate patient risk before undergoing outpatient TJA. Perioperative Management: In order to provide a successful outpatient TJA experience, pre-operative education class and physical therapy session can set expectations and prepare the patient for the post-operative recovery at home. Specific anesthesia techniques focus on regional blocks, multi-modal pain control, and reduction of post-operative nausea and vomiting and rapid recovery protocols have been developed to provide early mobilization and physical therapy.

OUTCOMES

Nationwide analyses have found improved complication rates ranging from 1.3%-3% in outpatient TJA group compared to 3%-12% in the inpatient TJA group. Financial analyses have found significant cost savings for outpatient TJA mostly related to reduction in surgical floor care.

CONCLUSION

Outpatient TJA has the potential to improve patient experience with cost savings and no increased risk of complications in the appropriately selected patient population.

[Endoprostheses in the elderly : Biomaterials, implant selection and fixation technique]

The replacement of hip and knee joints is one of the greatest success stories in orthopedics. Due to continuous improvement of biomaterials and implant design, patient-associated problems are now mostly multifactorial and only rarely caused by the implant. Abrasion was significantly reduced by the introduction of highly cross-linked polyethylene (PE), antioxidant stabilized PE, new ceramics and the development of ceramic and protective surfaces. It is assumed that further reduction of frictional resistance will not lead to a significantly better clinical result: however, the problem of periprosthetic infections and implant-related incompatibility is still unsolved and remains challenging for biomaterial research. For the knee joint PE will be irreplaceable for joint articulation even in the future due to the contact situation. Mobile bearings and fixed bearings are two established successful philosophies, which have shown comparably good clinical results. For the hip joint, it is forecasted that ceramic-on-ceramic will be the system of the future if the correct positioning and mounting of the components can be solved so that the problems, such as development of noise and breakage can be reduced to a minimum. An in-depth understanding and detailed knowledge of the biomaterials by the surgeon can prevent implant-related problems. For elderly patients it is assumed that the economic burden on the public healthcare system will have the strongest impact on implant selection.

[What can we learn in future from the data of the German Arthroplasty Registry (EPRD) in comparison to other registries?]

The German Arthroplasty Registry (EPRD) was founded in 2010 and has been in full operation since 2014. Previous attempts at a systematic data collection of elective and non-elective knee and hip replacement in Germany failed mainly because of the long-term lack of funding. The EPRD is an interdisciplinary collaborative partnership between the German Association of Orthopedics and Orthopedic Surgery (DGOOC), all implant manufacturers of the German Medical Technology Association (BVMed), health insurers (AOK and the Association of Additional Healthcare Insurance) and hospitals (German Hospital Federation). As part of this cooperation a worldwide unique implant database has been set up, which includes all relevant components and a detailed description of implant specifications. This implant library enables a detailed evaluation of implant survival, revision rates and possible inferior implant performance of knee and hip replacements in Germany. At the end of 2015 the EPRD encompassed over 200,000 registered operations. Due to the high number of hip and knee arthroplasties in Germany with many different implants from different manufacturers there will be a rapid growth of data that are available for a national and also international comparison of the results.

[Recent advances in upper extremity surgery for rheumatoid arthritis]

The number of cases with rheumatoid arthritis who requires arthroscopic synovectomy is declining, but it is still a useful procedure in combination with effective pharmacologic disease control. For the destruction of glenohumeral joint, total shoulder arthroplasty is effective for pain relief and functional outcome for patients without rotator cuff impairment. The reverse shoulder arthroplasty has been shown favorable short-term results, but need a careful indication for rheumatoid shoulder with poor bone stock and bone quality. Linked or unlinked total elbow arthroplasty are now reliable methods for the reconstruction of rheumatoid elbows with acceptable long-term survival. Joint replacement surgery for proximal interphalangeal joint is a challenging procedure in terms of relatively high complication rate and disappointing improvement in range of motion, whereas achieves good patients' satisfaction for pain relief and improved finger appearances.

The contribution of reverse shoulder arthroplasty to utilization of primary shoulder arthroplasty

BACKGROUND

We assessed the contribution of reverse shoulder arthroplasty to overall utilization of primary shoulder arthroplasty and present age- and sex-stratified national rates of shoulder arthroplasty. We also assessed contemporary complication rates, mortality rates, and indications for shoulder arthroplasty, as well as estimates and indications for revision arthroplasty.

METHODS

We used the Nationwide Inpatient Samples for 2009 through 2011 to calculate estimates of shoulder arthroplasty and assessed trends using Joinpoint (National Cancer Institute, Bethesda, MD) regression.

RESULTS

The cumulative estimated utilization of primary shoulder arthroplasty (anatomic total shoulder arthroplasty, hemiarthroplasty, and reverse shoulder arthroplasty) increased significantly from 52,397 procedures (95% confidence interval [CI], 47,093-57,701) in 2009 to 67,184 cases (95% CI, 60,638-73,731) in 2011. Reverse shoulder arthroplasty accounted for 42% of all primary shoulder arthroplasty procedures in 2011. The concomitant diagnosis of osteoarthritis and rotator cuff impairment was found in only 29.8% of reverse shoulder arthroplasty cases. The highest rate of reverse shoulder arthroplasty was in the 75- to 84-year-old female subgroup (77 per 100,000 persons; 95% CI, 67-87). Revision cases comprised 8.8% and 8.2% of all shoulder arthroplasties in 2009 and 2011, respectively, and 35% of revision cases were because of mechanical complications/loosening whereas 18% were because of dislocation.

CONCLUSIONS

The utilization of primary shoulder arthroplasty significantly increased in just a 3-year time span, with a major contribution from reverse shoulder arthroplasty in 2011. Indications appear to have expanded because a large percentage of patients did not have rotator cuff pathology. The burden from revision arthroplasties was also substantial, and efforts to optimize outcomes and longevity of primary shoulder arthroplasty are needed.

Nationwide trends in total shoulder arthroplasty and hemiarthroplasty for osteoarthritis

Recent literature reports an increase in the rate of shoulder arthroplasties, particularly total shoulder arthroplasties (TSAs), being performed in the United States. However, the national epidemiology of use of hemiarthroplasty (HA) and TSA as treatments for glenohumeral osteoarthritis has not been elucidated. We conducted a study to analyze trends in using HA and TSA as treatments for glenohumeral osteoarthritis from 2000 to 2010, and to compare patient characteristics and inpatient complications. US Nationwide Inpatient Sample patients with a primary inpatient diagnosis of shoulder arthritis and a principal procedure of HA or TSA were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedural codes. From 2000 to 2010 the nationally adjusted population rate of shoulder arthroplasty performed for osteoarthritis increased 3.7-fold. Specifically, the population rate of TSA increased 5.0-fold, and that of HA increased 1.9-fold. In 2010, 80.3% of patients having shoulder arthroplasty for arthritis underwent TSA. TSA patients were older (P < .0001) and had a higher mean number of chronic illnesses (P = .034). TSA-associated discharges had a higher rate of surgical and medical care complications (P = .011) and blood transfusions (P = .041) after adjusting for comorbidities.

Trends in the use of total ankle replacement and ankle arthrodesis in the United States Medicare population

BACKGROUND

Total ankle replacement (TAR) has gained acceptance as an alternative to traditional ankle arthrodesis (AA) for end-stage ankle arthritis. Little is known about long-term trends in volume, utilization, and patient characteristics. The objective of this study was to use longitudinal data to examine temporal trends in TAR and AA.

METHODS

We identified all United States fee-for-service Medicare beneficiaries who underwent TAR and AA between 1991 and 2010 (n = 5871 and 29 532, respectively). We examined changes in patient demographics and comorbidity, nationwide and hospital volume, per capita utilization, and length of stay (LOS).

RESULTS

Between 1991 and 2010, both TAR and AA patients had modest shifts in characteristics, with higher rates of diabetes and obesity. Overall, TAR Medicare volume increased by more than 1000% from 72 procedures in 1991 to 888 in 2010, while per-capita standardized utilization increased 670.8% (P < .001). AA volume increased 35.8% from 1167 procedures in 1991 to 1585 in 2010, while per-capita standardized utilization declined 15.6% (P < .001). The percentage of all US hospitals performing TAR increased nearly 4-fold from 3.1% in 1991 to 12.6% in 2010, while the proportion performing AA remained relatively unchanged. LOS decreased dramatically from 8.7 days in 1991 to 2.3 days in 2010 in TAR and from 5.5 days to 3.2 days in AA (P < .001).

CONCLUSION

Between 1991 and 2010, Medicare beneficiaries undergoing either TAR or AA became more medically complex. Both volume and per-capita utilization of TAR increased dramatically but remained nearly constant for AA. At the same time, mean hospital volume for both procedures remained low. Further research should be directed toward determining design, surgeon, and hospital variables that relate to optimal outcomes following TAR, which has become increasingly used for the treatment of ankle arthritis.

LEVEL OF EVIDENCE

Level III, comparative series.

Assessing function in patients undergoing joint replacement: a study protocol for a cohort study

BACKGROUND

Joint replacement is an effective intervention for people with advanced arthritis, although there is an important minority of patients who do not improve post-operatively. There is a need for robust evidence on outcomes after surgery, but there are a number of measures that assess function after joint replacement, many of which lack any clear theoretical basis. The World Health Organisation has introduced the International Classification of Functioning, Disability and Health (ICF), which divides function into three separate domains: Impairment, activity limitations and participation restrictions. The aim of this study is to compare the properties and responsiveness of a selection of commonly used outcome tools that assess function, examine how well they relate to the ICF concepts, and to explore the changes in the measures over time.

METHODS/DESIGN

Two hundred and sixty three patients listed for lower limb joint replacement at an elective orthopaedic centre have been recruited into this study. Participants attend the hospital for a research appointment prior to surgery and then at 3-months and 1-year after surgery. At each assessment time, function is assessed using a range of measures. Self-report function is assessed using the WOMAC, Aberdeen Impairment, Activity Limitation and Participation Restriction Measure, SF-12 and Measure Yourself Medical Outcome Profile 2. Clinician-administered measures of function include the American Knee Society Score for knee patients and the Harris Hip Score for hip patients. Performance tests include the timed 20-metre walk, timed get up and go, sit-to-stand-to-sit, step tests and single stance balance test. During the performance tests, participants wear an inertial sensor and data from motion analysis are collected. Statistical analysis will include exploring the relationship between measures describing the same ICF concepts, assessing responsiveness, and studying changes in measures over time.

DISCUSSION

There are a range of tools that can be used to assess function before and after joint replacement, with little information about how these various measures compare in their properties and responsiveness. This study aims to provide this data on a selection of commonly used assessments of function, and explore how they relate to the ICF domains.

Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030

Previous projections of total joint replacement (TJR) volume have not quantified demand for TJR surgery in young patients (< 65 years old). We developed projections for demand of TJR for the young patient population in the United States. The Nationwide Inpatient Sample was used to identify primary and revision TJRs between 1993 and 2006, as a function of age, gender, race, and census region. Surgery prevalence was modeled using Poisson regression, allowing for different rates for each population subgroup over time. If the historical growth trajectory of joint replacement surgeries continues, demand for primary THA and TKA among patients less than 65 years old was projected to exceed 50% of THA and TKA patients of all ages by 2011 and 2016, respectively. Patients less than 65 years old were projected to exceed 50% of the revision TKA patient population by 2011. This study underscores the major contribution that young patients may play in the future demand for primary and revision TJR surgery.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Unicompartmental knee arthroplasty: past, present, and future

Unicompartmental knee arthroplasty (UKA) has a more than 30-year history in the treatment of arthritis of one compartment of the tibiofemoral joint. Despite early negative reports, the procedure has evolved into are liable and safe treatment. Successful outcomes withUKA require proper patient selection, meticulous surgical technique, and avoidance of deformity overcorrection.This procedure is indicated for patients with localized pain, preserved range of motion, and radiographically isolated tibiofemoral disease. UKA can provide more range of motion and improved patient satisfaction relative to total knee arthroplasty with comparable midterm longevity.

Contemporary total joint arthroplasty

Total joint arthroplasty is a highly successful procedure for end-stage lower extremity arthritis. Excellent pain relief and significantly improved function is usual after surgery when used for appropriate indications by highly skilled surgeons using contemporary designed components. Future improvement in design and materials to reduce wear will further enhance clinical outcomes and long-term implant survival.

Predicting joint replacement waiting times

Currently, the median waiting time for total hip and knee replacement in Ontario is greater than 6 months. Waiting longer than 6 months is not recommended and may result in lower post-operative benefits. We developed a simulation model to estimate the proportion of patients who would receive surgery within the recommended waiting time for surgery over a 10-year period considering a wide range of demand projections and varying the number of available surgeries. Using an estimate that demand will grow by approximately 8.7% each year for 10 years, we determined that increasing available supply by 10% each year was unable to maintain the status quo for 10 years. Reducing waiting times within 10 years required that the annual supply of surgeries increased by 12% or greater. Allocating surgeries across regions in proportion to each region's waiting time resulted in a more efficient distribution of surgeries and a greater reduction in waiting times in the long-term compared to allocation strategies based only on the region's population size.

Developments in shoulder arthroplasty

Indications for shoulder arthroplasty are numerous, mainly owing to glenohumeral osteoarthritis, rheumatoid arthritis, or fracture of the proximal humerus. However, the anatomy and the biomechanics of the shoulder are complex and shoulder arthroplasty has evolved significantly over the past 30 years. This paper presents the main recent evolutions in shoulder replacement, the questions not answered yet, and the main future areas of research. The review focuses firstly on the design, positioning, and fixation of the humeral component, secondly on the design, positioning, and fixation of the glenoid implant, and thirdly on other concepts of shoulder arthroplasty such as the reversed prosthesis, the cementless surface replacement arthroplasty, and the bipolar arthroplasty. This review demonstrates that more research is needed. Although, in the long term, large randomized trials are needed to settle the fundamental questions of what type of replacement and which kind of fixation should be used, biomechanical research in the laboratory should be focused primarily on the comprehension of glenoid loosening, which is a major cause of total shoulder arthroplasty failure, and the significance of radiolucent lines which are often seen but with no clear understanding about their relation with failure.

Trends in the epidemiology of total shoulder arthroplasty in the United States from 1990-2000

OBJECTIVE

Longitudinal trends in epidemiology and utilization of total shoulder arthroplasty (TSA) have not been previously reported. We evaluated trends in the distribution of age, race, hospital volume and teaching status, outcomes, and indications for TSA during the last decade.

METHODS

TSA cases (n = 12,758) were extracted from the 1990-2000 Nationwide Inpatient Sample databases. TSA trends were obtained for 3 time periods: 1990-1993 (period I), 1994-1997 (period II), and 1998-2000 (period III).

RESULTS

Between 1990 and 2000, there were minor increases in the rate of TSA in most age groups. Ninety-three percent of the patients undergoing TSA in all 3 time periods were white. An increased proportion of patients were operated on in high volume hospitals in period III as compared with period I. Patients discharged to inpatient rehabilitation facilities after surgery had longer lengths of in-hospital stays as compared with those discharged home. Osteoarthritis was diagnosed in an increasing proportion of patients undergoing TSA (56.6% in period I versus 70.9% in period III).

CONCLUSION

There was a minor increase in the rate of TSA, and almost no change in use of TSA by nonwhites from 1990 through 2000. Efforts to understand and narrow this apparent underutilization of TSA among nonwhites are required. Further research should determine whether the observed shift of TSA to high volume centers improves surgical outcomes.

The reverse shoulder prosthesis: A review of imaging features and complications

BACKGROUND

The reverse shoulder prosthesis is a prosthesis that has been in clinical use in Europe since 1985 and was approved for use in the United States in 2004. This unique prosthesis has a baseplate attached to the glenoid, which holds a spherical component, while the humeral component includes a polyethylene insert that is flat. This design is the "reverse" configuration of that seen with a conventional arthroplasty, in which the spherical component is part of the humeral component. The indications for the reverse prosthesis are: (1) painful arthritis associated with irreparable rotator cuff tears (cuff tear arthropathy), (2) failed hemiarthroplasty with irreparable rotator cuff tears, (3) pseudoparalysis due to massive, irreparable rotator cuff tears, (4) some reconstructions after tumor resection, and (5) some fractures of the shoulder not repairable or reconstructable with other techniques. This prosthesis can produce a significant reduction in pain and some improvement in function for most of the indications mentioned. However, the unique configuration and the challenge of its insertion can result in a high incidence of a wide variety of unusual complications. Some of these complications, such as dislocation of the components, are similar to conventional shoulder replacement. Other complications, such as notching of the scapula and acromial stress fractures, are unique to this prosthesis.

CONCLUSION

The configuration of the reverse prosthesis, its normal radiographic appearance and potential complications associated with its use are reviewed.

Changing demographics of patients with total joint replacement

There has been a substantial change in the population demographics of patients who potentially will require total joint replacements. We studied data regarding temporal trends in physical condition, life expectancy, education, and other population demographics of individuals most likely to receive total joint replacements. Changes in this population during the last several decades correlate with temporal changes in the prevalence of joint disease and the incidence of total hip and knee replacements. Compared with several decades ago, patients currently receiving total joint replacements are almost 20% heavier, more physically active, three times more likely to have a high school or college education, and live more than 25% longer. Patients needing total joint replacements are more likely to be female, and twice as likely to receive a total knee replacement than a total hip replacement. Treatment choices and outcome expectations are best determined with accurate knowledge of current surgical science and current patient demographics. Therefore, it is important to realize that today's population most likely to receive total joint replacements is demographically different than in the past.

Shoulder arthroplasty in Olmsted County, Minnesota, 1976-2000: a population-based study

Because little information is currently available on the epidemiology of shoulder arthroplasty, this study was designed to evaluate the characteristics of patients undergoing this procedure and changes in practice patterns. Residents of Olmsted County, Minnesota, who underwent shoulder arthroplasty between 1976 and 2000 were identified (98 residents, 112 procedures). A relatively lower initial rate of shoulder arthroplasty was followed by a statistically significant steady increase (P < .0001), with an age- and sex-adjusted annual operative incidence rate of 1.4 per 100,000 person-years (1976-1980) to 10.1 per 100,000 person-years (1996-2000). Increased utilization of shoulder arthroplasty during the last decade was mainly a result of its application in osteoarthritis. A significant need exists for examination of utilization patterns for shoulder arthroplasty. An aging population and an increased demand and awareness by the public regarding interventions to improve quality of life will shape the future of arthroplasty, reinforcing the need for future studies of this nature.

Artificial disc replacement: the new solution for discogenic low back pain?

As we develop an increased understanding of DDD (e.g., pain generators, natural history, associated facet disease), so too will our ability to provide patients with effective care increase. Cautious optimism should be the attitude of surgeons treating patients with ADR. Issues such as implant design, wear debris, the role of ADR in osteoporosis, revision strategies, the patient selection will play important roles in the clinical success of ADR. the various topics discussed in this text will require careful additional scientific scrutiny prior to unconstrained endorsement of this evolving technique.

New developments in nucleus pulposus replacement technology

Attempts to alleviate the pain attributed to degeneration of the nucleus pulposus using replacement or reinforcement techniques dating back to the 1950s are reviewed. The various materials and their insertion techniques are discussed as are results available from early clinical experiences. These techniques are in evolution and clinical outcomes will be necessary to establish the efficacy of these approaches.

History and evolution of disc replacement

Total joint replacement has revolutionized the treatment of limb arthritides. Spinal arthroplasty is emerging as a treatment for spinal disc degeneration. The purpose of this review is to highlight the evolution of artificial interventions for nucleus and total disc replacement. This review will provide the foundation for the understanding of present and future technologies in the field.

[Hip arthroscopy--indications, surgical technique and implementation]

Hip arthroscopy was first described by Burman in 1931. During the 1980's this procedure was performed by a limited group of orthopedic surgeons. Implementation and development of the surgical procedure received most attention during those years, together with the formulation of specific indications to perform hip arthroscopy. In contrast to other large joints (knee, shoulder), where accurate diagnosis is feasible using standard imaging procedures such as plain radiographs, computed tomography and magnetic resonance imaging, the hip joint often presents as a diagnostic anomaly. In specific cases hip arthroscopy can add invaluable information, which, in correlation with the symptoms of the patient, can lead to an accurate diagnosis. Hip arthroscopy has various indications including the removal of foreign or loose bodies, irrigation of an infected hip joint and evaluation of the cartilage. The list of indications is still expanding as more surgeons become familiar with the technique. Hip arthroscopy is a safe and efficient procedure in experienced hands. This review of the literature describes the surgical procedure, various clinical situations, indications and the therapeutic potential of hip arthroscopy.

The future in the care of the cervical spine: interbody fusion and arthroplasty

✓ In the past 50 years tremendous advances have been made in the treatment of cervical disc disease with cervical fusion. Fusion rates have surpassed 95% after application of anterior cervical implants. Adjacent-segment degeneration, however, has plagued the long-term clinical success of cervical fusion.

Cervical arthroplasty has been introduced to maintain cervical motion and potentially avoid or minimize adjacent-segment degeneration. If cervical arthroplasty is successful, the long-term results of surgery for cervical disc disease may improve; however, there are associated drawbacks that must be overcome. Implant wear, fatigue, and failure have been reported in cases of large-joint arthroplasty, and research is underway to limit these problems in cervical arthroplasty.

In this article the authors trace the evolution of cervical fusion and the new technique of cervical arthroplasty. The nomenclature of cervical arthroplasty will also be introduced.

Trends in hip and knee joint replacement: socioeconomic inequalities and projections of need

OBJECTIVES

To examine trends in primary and revision joint (hip and knee) replacement in England between 1991 and 2000.

METHODS

Analysis of hospital episodes statistics between 1 April 1991 and 30 March 2001 for total hip replacement (THR) and total knee replacement (TKR). Descriptive statistics and regression modelling were used to summarise patients' demographic and clinical characteristics and to explore variations in joint surgery rates by age, sex, and deprivation.

RESULTS

Between 1991 and 2000, the incidence of primary THR increased by 18%, while the incidence of revision THR more than doubled. The incidence of primary TKR doubled, with revision TKR increasing by 300%. Over the 10 year period, the proportion of THR episodes that involved revision operations rose from 8% to 20%. Substantial variations in operation rates by socioeconomic status were seen, with the most deprived fifth of the population experiencing significantly lower rates. Projections estimate that primary THR numbers could rise by up to 22% by the year 2010, with primary TKR numbers rising by up to 63%.

CONCLUSIONS

Provision of joint replacement surgery in English NHS hospitals has increased substantially over the past decade. Revision operations in particular have increased markedly. The growth in primary operations has mostly occurred among those aged 60 years and over; rates among young people have changed very little. There is a significant deprivation based gradient in rates. If current trends continue there would be almost 47 000 primary hip and 54 000 primary knee operations annually by 2010.

Joint replacement surgery

Joint replacement is the most effective healthcare measure in improving patient quality-of-life outcomes. More than 46000 hip and knee replacements were performed in Australia between July 2000 and July 2001. The need for joint replacements will increase as the population ages. More than 90% of hip and/or knee replacements survive for 10-15 years. Prosthesis selection needs to be tailored to each patient, although rationalisation of types of prosthesis used is required.

[Endoprosthetic replacement of the ankle joint]

Endoprosthetic replacement of the ankle joint is considered to be a modern alternative of the well-tried fusions of the joint. We try to explain indications and limits of alloarthroplasty in comparison to arthrodesis. The recent technical evolution will be presented: starting with the two-component-("first generation") and leading to the three-component ("second generation") designs, Suitable for cemented and cementless implantation as well. Results of three-component endoprostheses in the literature and our own experiences with implants of both generations especially regarding the time of survival will be discussed. Basing on the actual knowledge, we try to deduce a prognosis of the future way of ankle replacement.