A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip

The Subjective Hip Value is a Valid, Reliable, and Responsive Instrument for Assessing Hip Function in Primary Total Hip Arthroplasty

BACKGROUND

Patient-reported outcome measures are essential tools in clinical decision-making and research. Multi-item scores like the modified Harris Hip Score (mHHS) are time-consuming to collect and evaluate. The subjective hip value (SHV), as a single-item value, assesses hip function with one question: "What is the overall percent value of your hip if a completely normal hip represents 100%?". The aims of our study were to assess the psychometric properties, and thus validity, reliability, and responsiveness; and to define the minimal clinically important difference (MCID) of the SHV in patients undergoing total hip arthroplasty.

METHODS

A total of 137 consecutive patients who underwent primary total hip arthroplasty between June 2020 and August 2021 were prospectively enrolled. A SHV and mHHS were collected preoperatively and at follow-ups (6 weeks, 3 months, 6 months, and 1 year). Validity, reliability, responsiveness, MCID, and floor/ceiling effects were evaluated.

RESULTS

There was a significant correlation between SHV and mHHS (P = .001) preoperatively (rs = 0.532), 6 weeks (rs = 0.649), 3 months (rs = 0.765), 6 months (rs = 0.854), and after 1 year (rs = 0.879). Test-retest reliability (rs = 0.74; P = .001) and responsiveness (rs = 0.24; P = .007) showed significant correlations. The MCID for SHV was 10.06%. Floor- and ceiling-effects were comparable to the mHHS.

CONCLUSIONS

The SHV is a valid, reliable, and responsive single-item score for the assessment of hip joint function in arthroplasty patients. It can detect clinically relevant changes in joint function and is easy to collect and interpret, which justifies its implementation in clinical practice.

The effect of 3 commonly used surgical approaches for total hip arthroplasty on mid- to long-term patient-reported outcome measures

INTRODUCTION

The most effective surgical approach for total hip arthroplasty (THA) remains controversial. Comparisons of surgical approach based on patient-reported outcome measures (PROMs) have been limited to short- to mid-term outcomes or the comparison of only 2 approaches. The aim of this study was to compare PROMs for the 3 main approaches for THA with up to 10 years follow-up.

METHODS

A total of 906 patients who underwent primary THA at a single hospital between 2009 and 2020 through an anterior (312), lateral (211) or posterior (383) approach were evaluated using the Oxford Hip Score (OHS), EuroQoL-5-Dimension (EQ-5D-5L) and visual analogue scale/verbal rating scale for pain (VAS/VRS). PROMs were prospectively collected before surgery and routinely at 6 weeks, 6 months and 1, 2, 5 and 10 years after surgery.

RESULTS

There was no significant difference in demographics or comorbidities between the 3 groups. All 3 approaches resulted in a significant improvement in overall PROMs after THA, and plateaued after 6 months postoperatively, with no difference between the approaches (OHS, p < 0.01;EQ-5D-5L Index, p < 0.01;VAS/VRS, p < 0.01). The EQ-5D-5L mobility dimension showed that the lateral approach resulted in 20% more patients reporting problems with mobility than the posterior and anterior approaches at the 6-week, 6-month, 2-year and 10-year follow-up.

CONCLUSIONS

This study shows that all 3 common THA approaches substantially and similarly improve the OHS, EQ-5D-5L Index and VRS between 6 months and 10 years postoperatively. However, patient-reported mobility was poorer after a lateral approach and continued to be so at long-term follow-up.

Medicaid Expansion Is Associated With Increases in Medicaid-Funded Total Joint Arthroplasty

BACKGROUND

Existing literature presents competing views concerning the impact of Medicaid expansion on total joint arthroplasty (TJA) utilizations. While some reports demonstrate that expansion does not increase Medicaid acceptance by surgeons, others show increases in Medicaid-funded TJA via limited analyses. We conducted a nationwide, multi-insurance, econometric study to determine if Medicaid-funded and all-funding-source total hip arthroplasty (THA) or total knee arthroplasty (TKA) utilizations increased following expansion.

METHODS

This study examined 999,015 THA and 2,099,975 TKA from 2010 to 2017 using a commercially available national payer database. Difference-in-differences analyses, econometric regression methods used to assess the impact of policy change, were used to examine the impact of Medicaid expansion on TJA utilizations, and event analyses were used to confirm the parallel trends assumption, which helps to ensure that the estimated effect is not a result of existing differences in trends between treatment and nontreatment groups.

RESULTS

Event analyses confirmed parallel trends in the pre-expansion period. Difference-in-differences analyses found a persistent increase in Medicaid-funded THA (40.4%, P = .001, confidence interval [CI]: 12.7, 62.1%), but not THA from all funding sources (4.6%, P = .128, CI: -1.3, 10.8%). Medicaid-funded TKA (35.8%, P < .001, CI: 17.4, 68.0%) increased, but not TKA from all funding sources (3.4%, P = .321, CI: -3.1, 10.1%).

CONCLUSION

While the number of Medicaid-funded TJAs increased, expansion had no significant effect when examining all funding sources. This suggests that Medicaid expansion primarily affected source of TJA funding, not overall volume. Further research is needed to examine state-specific predictors of response to Medicaid expansion.

A Retrospective Comparison of Clinical Efficacy between Multimodal Analgesia and Patient-Controlled Epidural Analgesia in Patients Undergoing Total Knee Arthroplasty

Background and Objectives: Adequate pain management during early rehabilitation is mandatory for improving the outcomes of patients undergoing total knee arthroplasty (TKA). Conventional pain management, mainly comprising opioids and epidural analgesia, may result in certain adverse effects such as dizziness, nausea, and motor blockade. We proposed a multimodal analgesic (MA) strategy involving the use of peripheral nerve block (NB), periarticular injection (PAI), and intravenous patient-controlled analgesia (IVPCA). This study compared the clinical efficacy and adverse effects of the proposed MA strategy and patient-controlled epidural analgesia (PCEA). Materials and Methods: We enrolled 118 patients who underwent TKA under spinal anesthesia. The patients followed either the MA protocol or received PCEA after surgery. The analgesic effect was examined using a numerical rating scale (NRS). The adverse effects experienced by the patients were recorded. Results: A lower proportion of patients in the MA group experienced motor blockade (6.45% vs. 22.98%) compared to those in the PCEA group on the first postoperative day. Furthermore, a lower proportion of patients in the MA group experienced numbness (18.52% vs. 43.33%) than those in the PCEA group on the first postoperative day. Conclusions: The MA strategy can be recommended for reducing the occurrence of motor blockade and numbness in patients following TKA. Therefore, the MA strategy ensures early rehabilitation while maintaining adequate pain relief.

Asymptomatic Gluteal Tendinosis Does Not Adversely Affect Outcomes of Primary Total Hip Arthroplasty

BACKGROUND

The aim of this study was to compare outcomes after total hip arthroplasty (THA) in patients who have preoperative asymptomatic gluteal tendinosis (aGT) to a control group with no gluteal tendinosis (GT).

METHODS

A retrospective analysis was performed using data from patients who underwent THA between March 2016 and October 2020. An aGT was diagnosed using hip magnetic resonance imaging (MRI) without clinical symptoms. Patients who had aGT were matched (1:1) to patients without GT on MRI. A total of 56 aGT hips and 56 hips without GT were found using propensity-score matching. Patient-reported outcomes, intraoperative macroscopic evaluation, outcome measurements, postoperative physical examinations, complications, and revisions were compared for both groups.

RESULTS

When compared to preoperative outcomes, both groups demonstrated significant improvements in patients-reported outcomes at the final follow-up. There were no significant differences between both groups for preoperative scores, 2-year postoperative outcome scores, or the magnitude of improvement. Patients in the aGT group were significantly less likely to obtain the MCID for the SF-36 MCS score (50.2 versus 69.3%, P = .034). However, there were no other differences in the rates of meeting the MCID between both groups. The aGT group demonstrated significantly higher rates of partial tendon degeneration of the gluteus medius muscle.

CONCLUSION

Asymptomatic gluteal tendinosis patients who have osteoarthritis and undergo THA may expect favorable patients-reported outcomes at minimum 2-year follow-up. These results were comparable with those of a control group of patients without gluteal tendinosis.

LEVEL OF EVIDENCE

III.

Contribution of the BioballTM head-neck adapter to the restoration of femoral offset in hip revision arthroplasty with retention of a well-fixed cup and stem

PURPOSE

Failure to restore the femoral offset of the native hip is a potential cause of dysfunctional hip arthroplasty. The aim of this study was to report our experience of using a modular head-neck adapter in revision THA, specifically analyzing its usefulness as a tool to correct a slightly diminished femoral offset.

MATERIALS AND METHODS

This was a retrospective single-center study including all hip revisions performed at our institution from January 2017 to March 2022 where the BioBallTM head-neck metal adapter was used. The preoperative and one year follow-up modified Merle d'Aubigné hip score was used to evaluate functional outcomes.

RESULTS

Of a total of 34 cases included for revision, the head-neck adapter system was used specifically in six patients (17.6%) to increase femoral offset, retaining both the acetabular and femoral components. In this subgroup of patients, mean offset decrease after primary THA was 6.6 mm (4.0-9.1), equivalent to a mean 16.3% femoral offset reduction. The median modified Merle d'Aubigné score went from 13.3 preoperatively to 16.2 at one year follow-up.

CONCLUSION

The use of a head-neck adapter is a safe and reliable procedure that may allow the surgeon to easily correct a slightly diminished femoral offset in a dysfunctional THA without the need to revise well-fixed prosthetic components.

Pneumatic Compression Combined with Standard Treatment after Total Hip Arthroplasty and Its Effects on Edema of the Operated Limb and on Physical Outcomes: A Pilot Clinical Randomized Controlled Study

Total hip arthroplasty (THA) is one of the most successful orthopedic procedures and is highly effective at improving function and quality of life. However, patients commonly experience edema immediately after hospitalization and also after discharge, which can lead to health consequences and a lower quality of life. For these reasons, the aim of this study (NCT05312060) was to evaluate the effectiveness of a specific intermittent leg pneumatic compression on lower limb edema and physical outcomes in patients after total hip arthroplasty, compared to standard conservative treatment. A total of 47 patients were enrolled and randomly allocated into two groups: the pneumatic compression group (PG = 24) and the control group (CG = 23). The CG performed the standard venous thromboembolism therapy, which included pharmacological prophylaxis, compressive stockings, and electrostimulation, while the PG combined pneumatic compression with standard VTE therapy. We evaluated thigh and calf circumferences, knee and ankle ranges of motion, pain, and walking autonomy. Our results showed a greater reduction in thigh and calf circumferences for PG (p < 0.001), while other outcomes were similar for the two groups (p > 0.05). The combination of standard therapy with pneumatic leg compression was more effective at reducing lower limb edema and thigh and calf circumferences than standard treatment. Our results suggest that pressotherapy treatment is a valuable and efficient option for managing lower limb edema after THA.

Effect of Total Hip Arthroplasty on Ipsilateral Lower Limb Alignment and Knee Joint Space Width: Minimum 5-Year Follow-up

BACKGROUND

This study aimed to 1) assess the effect of total hip arthroplasty (THA) on coronal limb alignment, namely, the hip-knee-ankle angle (HKA), 2) identify factors that determine changes in the HKA, and 3) determine whether alignment changes influence the knee joint space width.

METHODS

We retrospectively evaluated 266 limbs of patients who underwent THA. Three types of prostheses with neck shaft angles (NSAs) of 132°, 135°, and 138° were used. Several radiographic parameters were measured in the preoperative and final radiographs (at least 5 years after THA). A paired t-test was used to confirm the effect of THA on HKA change. Multiple regression analysis was performed to identify radiographic parameters related to HKA changes following THA and changes in knee joint space width. Subgroup analyses were performed to reveal the effect of NSA change on the HKA change, and the proportion of total knee arthroplasty usage and changes in radiographic parameters between maintained joint space and narrowed joint space groups were compared.

RESULTS

The preoperative mean HKA was 1.4° varus and increased to 2.7° varus after THA. This change was related to changes in the NSA, lateral distal femoral angle, and femoral bowing angle. In particular, in the group with a decrease in NSA of > 5°, the preoperative mean HKA was largely changed from 1.4° varus to 4.6° varus after THA. The prostheses with NSA of 132° and 135° also led to greater varus HKA changes than those with an NSA of 138°. Narrowing of the medial knee joint space was related to changes in the varus direction of the HKA, decrease in NSA, increase in femoral offset.

CONCLUSION

A large reduction in NSA can lead to considerable varus limb alignment after THA, which can have adverse effects on the medial compartment of the ipsilateral knee.

A New Dressing System for Wound in Enhanced-Recovery Total Hip Arthroplasty: A Randomized and Controlled Trial

BACKGROUND

Currently, there is a paucity of recommendations in regards to dressing selection within the enhanced recovery after surgery protocol. We devised a new dressing system to accelerate the recovery after total hip arthroplasty (THA). We aimed to present our experience with this new dressing system as an adjunct to wound management in THA and to evaluate its performance.

METHODS

From September 2020 to August 2021, we prospectively enrolled 124 patients who underwent a primary THA. The patients were randomly assigned to the intervention (the new dressing system group) or the control (the traditional gauze dressing) group. The primary outcome measures of this study were numbers of dressing changes, postoperative lengths of stay, wound scores including the Stony Brook Scar Evaluation Scale and ASEPSIS scores and wound-related complications. The secondary outcomes include satisfaction scores, dressing-related costs, and pain and functional recovery scores.

RESULTS

The intervention group numbers of dressing changes and postoperative lengths of stay were significantly less than the control group (P < .001, P < .001). During the one-month follow-up, the Stony Brook Scar Evaluation Scale in the intervention group was significantly better than that in the control group (P < .001). The intervention group satisfaction was significantly higher than that in the control group (P < .001). There were no statistically significant differences between the two groups in terms of dressing-related costs and pain and function scores.

CONCLUSION

The new dressing system could significantly reduce the number of dressing changes and postoperative lengths of stay and increase patient satisfaction scores, which can be an ideal adjunct to wound management in enhanced-recovery THA.

In meeting the increasing demands for total knee arthroplasty, can we achieve high levels of quality care in a small community hospital? A mixed-methods study

Purpose

Small community hospitals (SCHs) help meet the demand for total knee arthroplasty (TKA). This mixed-methods study compares outcomes and analyses of environmental differences following TKA at a SCH and a tertiary care hospital (TCH).

Methods

Quantitative: A retrospective review of 352 propensity-matched primary TKA procedures at both a SCH and a TCH, based on age, body mass index, and American Society of Anesthesiologists class, was completed. Groups were compared by length of stay (LOS), 90-day emergency department visits, 90-day readmissions, reoperations, and mortality. Qualitative: Based on the Theoretical Domains Framework, seven prospective semistructured interviews were performed. Interview transcripts were coded and belief statements were generated and summarized by two reviewers. Discrepancies were resolved by a third reviewer.

Results

Quantitative: The average LOS for the SCH was significantly shorter than that for the TCH (2.0 ± 0.2 vs. 3.6 ± 2.7 days; p < 0.001), a difference that persisted following a subgroup analysis of ASA I/II patients (2.0 ± 0.2 vs. 3.2 ± 2.2; p < 0.001). There were no significant differences in other outcomes. Qualitative: The main themes that revolved around a higher case load for physiotherapy at the TCH resulted in patients waiting longer to be mobilized after surgery. Patient disposition also affected their discharge rates.

Conclusion

Given the increasing demand for TKA, the SCH represents a viable option to increase capacity, while reducing LOS. Future directions to reduce LOS include addressing social barriers to discharge and patient prioritization for assessment by allied health services. When TKA is performed by the same set of surgeons, the SCH provides quality care with a shorter LOS and comparable with urban hospitals, and this can be attributed to the differences in resource utilization in the two hospital settings.

Large Femoral Heads and Select Dual-Mobility Bearings Are Associated With Reduced Instability in Contemporary Posterior Approach Total Hip Arthroplasty

BACKGROUND

Postoperative dislocation is considered the main drawback of posterior approach total hip arthroplasty (THA). Thinner highly cross-linked polyethylene and dual-mobility bearings allow maximizing femoral head diameter per a given cup size. This study evaluated dislocation rates as large femoral head bearings were introduced into a practice over an 11-year period.

METHODS

A total of 1,511 consecutive primary THAs were retrospectively reviewed. Demographics, implant sizes, femoral head-acetabular cup ratio, and dislocation status were collected from the electronic medical record. Data were evaluated using time series analysis techniques as larger femoral heads, thinner polyethylene liners, and dual-mobility bearings were introduced. The cohort was 57% women with mean age and body mass index of 62 years (range, 13 to 93) and 31 kg/m² (range, 13 to 54), respectively.

RESULTS

The overall dislocation rate was 0.98%. Use of femoral head sizes ≥ 40 millimeters increased from 4% in the years 2010 to 2016 to 51% in the years 2017 to 2021, correlating with a 50% reduction in dislocation rate from 1.4% to 0.7% (P = .279). Also, no dislocations occurred in patients who had dual-mobility bearings or ≥ 40-millimeter femoral heads (P = .007). Twelve of 14 dislocations occurred in cases with head-cup ratio < 0.7 (P = .013). Thirteen of 14 dislocations were in women (P = .005).

CONCLUSION

Maximizing the femoral head diameter per given cup size correlated with a decrease in dislocation rate in modern posterior approach THA. Furthermore, these results suggest that dual-mobility articulations should be reserved for high-risk patients or patients in whom a 40-millimeter femoral head is not possible.

LEVEL OF EVIDENCE

IV-consecutive case series; no control group.

Outcomes and complications reported from a multiuser canine hip replacement registry over a 10-year period

OBJECTIVE

To report outcomes and complications associated with total hip replacements (THR) using a multiuser canine hip registry (CHR) and owner-administered questionnaire.

STUDY DESIGN

Prospective longitudinal clinical study.

ANIMALS

Dogs (n = 1852).

METHODS

Total hip replacement cases submitted to a CHR were reviewed. An online questionnaire including an adapted "Liverpool Osteoarthritis in Dogs" (LOAD) score was e-mailed to owners. Data were analyzed to determine associations between clinical variables and the agreement by veterinary surgeons and owners for complications.

RESULTS

A group of 1329 (72%) dogs had unilateral THRs and another group of 523 (28%) dogs had bilateral THRs, resulting in 2375 THRs. Indications included hip dysplasia and osteoarthritis (n = 2028/2375, 85%). Implants were manufactured by Kyon (n = 1087, 46%), BioMedtrix CFX (n = 514, 22%), BioMedtrix hybrid (n = 264, 11%), BioMedtrix BFX (n = 221, 9%), and Helica (n = 107, 4.5%). Median veterinary surgeon and owner follow up were 1328 and 900 days respectively. Postoperative LOAD scores (21 ± 9) reported by 461 owners improved compared to preoperative scores (11 ± 9) (P < .001). Veterinary surgeons reported complications in 201/2375 (8.5%) THRs and owners in 107/461 (23%) THRs, with moderate agreement (weighted kappa = 0.44). No associations were identified between complications and weight, age, sex, or breed. BioMedtrix BFX and Helica implants were associated with increased complications (P = .031) when used for revisions of femoral head and neck excisions.

CONCLUSION

Excellent outcomes, including improved canine mobility, were reported after THRs. Complications were underreported by veterinary surgeons compared to owners in this first multiuser CHR.

CLINICAL SIGNIFICANCE

Canine THRs are safe, effective procedures but THR implants should be carefully selected when revising femoral head and neck excisions.

Achieving Target Cemented Femoral Stem Anteversion Using a 3-Dimensional Model

Background

Total hip arthroplasty aims to provide patients with a pain-free and stable hip joint through optimization of biomechanics such as femoral anteversion. There are studies evaluating the limits of cementless stem version, however, none assessing the range of version achieved by a cemented collarless stem. A computed tomography (CT)-based study was performed, utilizing a contemporary robotic planning platform to assess the amount of rotation afforded by a cemented collarless stem, whilst maintaining native biomechanics.

Methods

The study utilized 36 cadaveric hips. All had CT scans of the pelvis and hip joints. The CT scans were then loaded into a contemporary robotic planning platform. A stem that restored the patients native femoral offset was selected and positioned in the virtual femur. The stem was rotated while checking for cortical contact at the level of the neck cut. Cortical contact was regarded as the rotation limit, assessed in both anteversion and retroversion. Target range for stem anteversion was 10°-20°. Failure to achieve target version triggered a sequence of adjustments to simulate surgical decisions.

Results

Native femoral offset and target version range was obtained in 29 of 36 (80.5%) cases. Following an adjustment sequence, 4 further stems achieved target anteversion with a compromise in offset of 2.3 mm. Overall 33 of 36 (91.7%) stems achieved the target anteversion range of 10°-20°.

Conclusions

Target femoral stem anteversion can be achieved using a cemented, collarless stem in a CT-based 3-dimensional model in 80.5% of hips. With a small compromise in offset (mean 2.3 mm), this can be increased to 91.7%.

Early Total Hip Arthroplasty is a Cost-Effective Treatment for Severe Radiographic Slipped Capital Femoral Epiphysis Over an Individual's Lifetime

BACKGROUND

Slipped capital femoral epiphysis (SCFE) causes degenerative changes warranting total hip arthroplasty (THA) in approximately 50% of patients by age 60 years. For severe SCFE, a reorienting intertrochanteric osteotomy (ITO) following in situ pinning (ISP) can decrease impingement with hip flexion, but by altering proximal femoral geometry, complicates subsequent conversion THA. We hypothesized that increasing implant survivorship would affect the most cost-effective treatment strategy (ISP followed by ITO [ISP + ITO] with later THA versus ISP alone [ISPa] with earlier THA) over a patient's lifetime.

METHODS

A state-transition Markov model was constructed to analyze the cost-effectiveness of either ISPa or ISP + ITO over a 60-year time horizon for children who have severe, stable SCFE. Transition probabilities associated with implant and native hip survivorship, state utilities, and costs were derived from the literature. Sensitivity analyses assessed the model robustness. Incremental cost-effectiveness ratios (ICERs) were compared to a societal willingness to pay (WTP) of $100,000 per quality-adjusted life year (QALY).

RESULTS

Over a 60-year horizon, ISPa was costlier ($291,836) than ISP + ITO ($75,227) but achieved overall better outcomes (51.4 QALYs ISPa versus 48.7 QALYs ISP + ITO), rendering ISPa cost-effective with an ICER of $80,980/QALY. Implant survivorship and time horizon were sensitive variables.

CONCLUSION

Based upon current implant performance, ISPa with subsequent earlier THA is cost-effective when considering an individual's life expectancy and thereby deserves consideration in patients who have severe SCFE. Without clear level 1 clinical data, our economic model considers a difficult problem, while providing families and clinicians with a framework for understanding treatment options.

LEVEL OF EVIDENCE

Economic and decision analysis, Level III.

Can the intra-operative measurement of the diameter of the femoral head help surgeons to choose the best size of the acetabular cup?

PURPOSE

We hypothesized that the intra-operative measurement of the femoral head may increase the accuracy of the acetabular cup size optimal selection in total hip arthroplasty (THA). The purpose of this clinical research was to analyze the correlation between the estimated cup size from intra-operative measurement of the femoral head and the pre-operative templated cup size.

METHODS

A prospective observational single-center study was conducted from June 2019 to January 2020 including primary THA (n = 100). All cases were pre-operatively templated. The measurement of the anterior-posterior diameter of the femoral head was routinely intra-operatively performed. Any definitive implanted cup was considered as "oversized" when the size was > 4 mm than the diameter of the native head.

RESULTS

The median (interquartile range) size of the implanted cup, pre-operative planned cup size, and diameter of the femoral head were measured 52 (50-54) mm, 50 (48-54) mm and 49 (45-51) mm, respectively. Pre-operative planned size cup accurately predicted the implanted cup or differed in only one size (2 mm) in 77 (78%) cases. Otherwise, intra-operative femoral head measurement method accurately predicted the implanted or differed in only one size (2 mm) in 51 (87%) cases (p = 0.097).

CONCLUSION

The intra-operative femoral head measurement is a simple and reliable tool to help the surgeons choose the best size of the acetabular cup and is as reliable as the pre-operative templating in order to avoid cup oversizing in THA. Utmost caution is warranted whenever the cup reamer is > 4 mm than the anterior-posterior diameter of the native head.

Cost-Utility Analysis of Sacroiliac Joint Fusion in High-Risk Patients Undergoing Multi-Level Lumbar Fusion to the Sacrum

Purpose

Multi-level lumbar fusion to the sacrum (MLF) can lead to increased stress and angular motion across the sacroiliac joint (SIJ), with an incidence of post-operative SIJ pain estimated at 26–32%. SIJ fusion (SIJF) can help obviate the need for revisions by reducing range of motion and screw stresses. We aimed to evaluate the cost-utility of MLF + SIJF compared to MLF alone among high-risk patients from a payer perspective, where high risk is defined as high body mass index and high pelvic incidence.

Methods

A Markov process decision-analysis model was developed to evaluate cumulative 5-year costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) of MLF + SIJF compared to MLF alone using published data; costs from Medicare claims data analyses and health state utility values (derived from EQ-5D) informed by three prospective, multicenter, clinical trials. The base case assumed a reduction in post-operative SIJ pain from 30% to 10% (relative risk reduction [RRR] of 67%). Costs and utilities were discounted 3% annually. The ICER is reported in 2020 US dollars. One-way, multi-way, and probabilistic sensitivity analyses were performed.

Results

With an assumed 30% incidence of SIJ pain after MLF alone, stabilizing with SIJF was associated with an additional 5-year cost of $2421 and a gain of 0.14 QALYs, resulting in an ICER of $17,293 per QALY gained (similar to total knee arthroplasty and more favorable than open discectomy). ICERs were most sensitive to the RRR of post-operative SIJ pain conferred by SIJF, time horizon, and probability of successful treatment with MLF alone. At a willingness-to-pay threshold of $50,000/QALY gained, MLF + SIJF has a 97.7% probability of being cost-effective in the target patient population.

Conclusion

Fusing the SIJ in high-risk patients undergoing MLF was cost-effective when the incidence of post-operative SIJ pain after MLF alone exceeds approximately 25%, providing value-based healthcare from a payer perspective.

Is the Direct Anterior Approach to THA Cost-effective? A Markov Analysis

BACKGROUND

The use of the direct anterior approach, a muscle-sparing technique for THA, has increased over the years; however, this approach is associated with longer procedure times and a more expensive direct cost. Furthermore, studies have shown a higher revision rate in the early stages of the learning curve. Whether the clinical advantages of the direct anterior compared with the posterior approach-such as less soft tissue damage, decreased short-term postoperative pain, a lower dislocation rate, decreased length of stay in the hospital, and higher likelihood of being discharged home-outweigh the higher cost is still debatable. Determining the cost-effectiveness of the approach may inform its utility and justify its use at various stages of the learning curve.

QUESTIONS/PURPOSES

We used a Markov modeling approach to ask: (1) Is the direct anterior approach more likely to be a cost-effective approach than the posterior approach over the long-term for more experienced or higher volume hip surgeons? (2) How many procedures does a surgeon need to perform for the direct anterior approach to be a cost-effective choice?

METHODS

A Markov model was created with three health states (well-functioning THA, revision THA, and death) to compare the cost-effectiveness of the direct anterior approach with that of the posterior approach in five scenarios: surgeons who performed one to 15, 16 to 30, 31 to 50, 51 to 100, and more than 100 direct anterior THAs during a 6-year span. Procedure costs (not charges), dislocation costs, and fracture costs were derived from published reports, and model was run using two different cost differentials between the direct anterior and posterior approaches (USD 219 and USD 1800, respectively). The lower cost was calculated as the total cost differential minus pharmaceutical and implant costs to account for differences in implant use and physician preference regarding postoperative pain management. The USD 1800 cost differential incorporated pharmaceutical and implant costs. Probabilities were derived from systematic review of the evidence as well as from the Australian Orthopaedic Association National Joint Replacement Registry. Utilities were estimated from best available literature and disutilities associated with dislocation and fracture were incorporated into the model. Quality of life was expressed in quality-adjusted life years (QALYs), which are calculated by multiplying the utility of a health state (ranging from 0 to 1) by the duration of time in that health state. The primary outcome measure was the incremental cost-effectiveness ratio, or the change in costs divided by the change in QALYs when the direct anterior approach was used for THA. USD 100,000 per quality-adjusted life years was used as a threshold for willingness to pay. One-way and probabilistic sensitivity analyses were performed for the scenario in which the direct anterior approach is cost-effective to further account for uncertainty in model inputs.

RESULTS

At a cost differential of USD 219 (95% CI 175 to 263), the direct anterior approach was associated with lower cost and higher effectiveness compared with the posterior approach for surgeons with an experience level of more than 100 operations during a 6-year span. At a cost differential of USD 1800 (95% CI 1440 to 2160), the direct anterior approach remained a cost-effective strategy for surgeons who performed more than 100 operations. At both cost differentials, the direct anterior approach was not cost-effective for surgeons who performed fewer than 100 operations. One-way sensitivity analyses revealed the model to be the most sensitive to fluctuations in the utility of revision THA, probability of revision after the posterior approach THA, probability of dislocation after the posterior approach THA, fluctuations in the probability of dislocation after direct anterior THA, cost of direct anterior THA, and probability of intraoperative fracture with the direct anterior approach. At the cost differential of USD 219 and for surgeons with a surgical experience level of more than 100 direct anterior operations, the direct anterior approach was still the cost-effective strategy for the entire range of values.

CONCLUSION

For high-volume hip surgeons, defined here as surgeons who perform more than 100 procedures during a 6-year span, the direct anterior approach may be a cost-effective strategy within the limitations imposed by our analysis. For lower volume hip surgeons, performing a more familiar approach appears to be more cost-effective.

Comparing Articulating Spacers for Periprosthetic Joint Infection After Primary Total Hip Arthroplasty: All-Cement Versus Real-Component Articulating Spacers

BACKGROUND

There are a variety of methods available to treat periprosthetic joint infection (PJI), including 2-stage revision with the use of an antibiotic spacer. This study compares the outcomes of real-component (RC) and all-cement (AC) articulating spacers for total hip arthroplasty (THA) PJI treatment.

METHODS

This multicenter retrospective study assessed all articulating spacers placed for THA PJI between April 2011 and August 2020. Patients were dichotomized based on spacer type (RC vs AC).

RESULTS

One hundred four patients received articulating spacer constructs (RC group = 75, AC group = 29). Leg-length discrepancy was significantly greater in the AC group after the second stage (3.58 vs 12.00 mm, P = .023). There were no significant differences in reoperation rates following first-stage spacer placement (P = .752) and time to reimplantation (P = .127) between the groups. There were no significant differences in reinfection rates (RC group = 10.0%, AC group = 7.1%, P = 1.000) and reoperation rates following second-stage revision THA (RC group = 11.7%, AC group = 10.7%, P = 1.000). Hospital length of stay (in days) had a trend toward being shorter following the first (7.35 vs 11.96, P = .166) and second stage (3.95 vs 5.43, P = .107) for patients in the RC group. Patients in the RC group were more likely to be discharged home following the first (P = .020) and second (P = .039) stages.

CONCLUSION

Given that there were no differences in reinfection and reoperation rates between the 2 spacer constructs, RC articulating spacers may provide a significant benefit for patient comfort during 2-stage exchange treatment of PJI while adding no increase in risk profile.

What Is the Impact of Body Mass Index Cutoffs on Total Hip Arthroplasty Complications?

BACKGROUND

Body mass index (BMI) cutoffs are commonly utilized to decide whether to offer obese patients elective total hip arthroplasty (THA). However, weight loss goals may be unachievable for many, and some patients are thereby denied complication-free surgery. The purpose of this study was to assess the impact of varying BMI cutoffs on the rates of complication-free surgery after THA.

METHODS

Patients undergoing THA between 2015 and 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Common Procedural Terminology code 27130. BMI and rates of 30-day complications were collected. BMI cutoffs of 30, 35, 40, 45, and 50 kg/m² were applied to model the incidence of complications if THA would have been allowed to proceed based on BMI.

RESULTS

A total of 192,394 patients underwent THA, and 13,970 (7%) of them had a BMI ≥40 kg/m². With a BMI cutoff of 40 kg/m², 178,424 (92.7%) patients would have proceeded with THA. From this set, 170,296 (95.4%) would experience complication-free surgery, and 11.8% of complications would be prevented. THA would proceed for 191,217 (99.3%) patients at a BMI cutoff of 50 kg/m², of which 182,123 (95.2%) would not experience a complication, and 1.3% of complications would be prevented. Using 35 kg/m² as the BMI cutoff would prevent 28.6% of complications and permit 75.9% of complication-free surgeries to proceed.

CONCLUSION

Lower BMI cutoffs for THA can result in fewer complications although they will consequentially limit access to complication-free THA. Consideration of risks of obesity in THA may be best considered as part of a holistic assessment and shared decision-making when deciding on goals for weight reduction.

Location of Initial Closed Reduction Attempt Significantly Increases Cost and Length of Stay in Total Hip Arthroplasty

Background

Prosthetic hip dislocation remains one of the most frequent complications following total hip replacement. Dislocations are predominantly managed by a closed reduction in the emergency department (ED) or the operating room (OR). This study aimed to evaluate how the location of an initial closed reduction attempt impacts a patient's course of care including length of stay (LOS) and cost of care.

Material and methods

A retrospective chart review was performed on all patients presenting to a single ED with a unilateral prosthetic hip dislocation from 2009 to 2019. A total of 108 patients were identified. Data collected included patient demographics, ED/hospital course, and hospital charges.

Results

Seventy-four patients (69%) had initial reduction attempted in the ED (65/74, 88% were successful), while 34 patients (31%) went directly to OR (100% successful with closed reduction). Failed closed reduction in ED or direct to OR resulted in a greater LOS and rate of placement to a skilled nursing facility following discharge. Median hospital charges for successful ED reduction were $6,837, while failed ED closed reduction or direct to OR resulted in median charges of $27,317 and $20,481, respectively.

Conclusion

Many patients successfully underwent closed reduction in the ED, and there was no difference in complications, independent of where the reduction was first performed. Patients undergoing reduction in the OR had greater LOS and cost of care, independent of whether a reduction attempt was performed and failed in the ED, than those successfully reduced in the ED.

A New Dressing System Reduces the Number of Dressing Changes in the Primary Total Knee Arthroplasty: A Randomized Controlled Trial

Purpose

We devised a novel dressing system to accelerate the recovery after total knee arthroplasty (TKA). The purpose of this study was to assess the clinical outcomes and economic expenses of the new dressing system.

Methods

In this randomized and controlled trial, we enrolled 98 patients who underwent the first unilateral TKA between September 2020 and June 2021. The patients were randomly assigned to one of two groups: the intervention (the new dressing system group) or the control (the traditional gauze dressing) group. We gathered and evaluated patient data including age, gender, body mass index, surgical side, number of dressing changes, post-operative hospital stay, dressing-related expense, satisfaction, pain and function scores, wound scores and wound-related complications.

Results

The number of dressing changes and post-operative hospital stay in the intervention group were significantly less than in the control group (p = 0.000, p = 0.002). Satisfaction in the intervention group was significantly higher than in the control group's (p = 0.000). There were no significant differences between the two groups in dressing-related expense, pain and function scores. During the one month follow-up, the intervention group's Stony Brook Scar Evaluation Scale (SBSES) was considerably higher than the control group's (p = 0.012).

Conclusion

The new dressing system can reduce the number of dressing changes and post-operative hospital stays while increasing patient satisfaction with no difference in medical costs in TKA. This wound dressing system has potential for application in TKA.

Clinical Trial Registration

https://clinicaltrials.gov, identifier ChiCTR2000033814.

Elective lower limb orthopedic arthroplasty surgery in patients with pulmonary hypertension

Patients with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension (PH) are at increased risk when undergoing anesthesia and major surgery. Data on outcomes for elective orthopedic surgery in patients with PH are limited. A patient pathway was established to provide access to elective lower limb arthroplasty. This included assessment of orthopedic needs, fitness for anesthesia, preoperative optimization, and intra- and postoperative management. Patient data were retrospectively retrieved using patient's hospital records. Between 2012 and 2020, 29 operations (21 total hip replacements [THRs], 7 total knee replacements [TKRs], 1 total hip revision) were performed in 25 patients (mean age: 67 years). Perioperatively, 72% were treated with low-dose intravenous prostanoid. All had arterial lines, and central access and perioperative lithium dilution cardiac output monitoring was used in 86% of cases. Four patients underwent GA, 21 spinal anesthesia, and 4 CSE anesthesia. Supplemental nerve blocks were performed in all patients undergoing general, and 12 of 21 undergoing spinal anesthesia. All were managed in high dependency postoperatively. Hospital length of stay and complication rates were higher than reported in non-PH patients. Perioperative complications included hypotension requiring vasopressors (n = 10), blood transfusion (n = 7), nonorthopedic infection (n = 4), and decompensated right heart failure (n = 1). There was no associated mortality. All implants were functioning well at 6 weeks and subsequent follow-up. EmPHasis-10 quality of score decreased by 5.5 (±2.1) (p = 0.04). A dedicated multiprofessional pathway can be used to safely select and manage patients with PH through elective lower limb arthroplasty.

Does Implant Selection Affect Patient-Reported Outcome Measures After Primary Total Hip Arthroplasty?

BACKGROUND

Total hip arthroplasty (THA) is a reliable operation, but it is critical that orthopaedic surgeons characterize which surgical factors influence patient-reported outcomes. The purpose of this study was to determine whether implant selection at the time of THA affects the odds of having (1) inadequate improvement according to patient-reported pain, function, and activity; (2) failure to achieve a substantial clinical benefit (SCB) with respect to pain; or (3) failure to achieve a patient-acceptable symptomatic state (PASS) according to pain and function.

METHODS

Prospective data were collected from 4,716 patients who underwent primary THA (from July 2015 to August 2018) in a single health-care system with standardized care pathways. Patients were categorized according to the type of femoral and acetabular components and bearing surface used. Outcomes included 1-year postoperative patient-reported outcome measures (PROMs) and improvement in the Hip disability and Osteoarthritis Outcome Score (HOOS) and the University of California at Los Angeles (UCLA) activity score. Inadequate improvement was defined as PROMs that changed by less than the minimal clinically important difference (MCID) for the HOOS pain and physical function short form (PS) and as failure to improve beyond a mostly homebound activity status for the UCLA activity score (a score of ≤3). The MCID and SCB thresholds were set at values reported in the literature.

RESULTS

One-year PROM data were available for 3,519 patients (74.6%). There were no differences in the proportion of patients who attained the MCID in terms of HOOS pain, HOOS PS, or UCLA activity scores at 1 year for all analyzed implant parameters. Multivariate regression demonstrated that implant selection was not a significant driver of inadequate improvement, according to HOOS pain and HOOS PS (p > 0.05). Larger (36-mm) femoral heads demonstrated lower odds of inadequate improvement versus 28-mm femoral heads according to UCLA activity scores (odds ratio [OR]: 0.64; 95% confidence interval, 0.47 to 0.86; p = 0.003). Implant-related criteria were not significant drivers of attaining a PASS or achieving an SCB with respect to HOOS pain.

CONCLUSIONS

For the most part, THA implant characteristics are not drivers of inadequate improvement with respect to pain and function. Surgeons should utilize implants with an acceptable track record that allow stable fixation and restoration of hip biomechanics.

LEVEL OF EVIDENCE

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

No Difference in Dislocation Rates Comparing Large Diameter Jumbo Femoral Heads and Dual-Mobility Bearings in Revision Total Hip Arthroplasty

BACKGROUND

Dual-mobility (DM) bearings reduce instability in revision total hip arthroplasty (THA); however, DM bearings are costly and reports of corrosion have recently emerged. Furthermore, no study has compared DM to standard bearings with large diameter femoral heads ≥40-mm. This study's purpose was to compare postoperative dislocation rates of standard and DM bearings with large femoral heads after revision THA.

METHODS

A retrospective review of 301 consecutive revision THAs was performed. The mean follow-up was 37.1 months. To isolate the effect of the double articulation, standard and DM bearings with femoral heads ≥40-mm were compared. Outcomes were postoperative dislocation and reoperation within 90 days.

RESULTS

The cohort consisted of 182 standard bearings and 75 DM bearings. There were no differences in revision indication comparing standard and DM bearings (P = .258). Overall dislocation rate was 8.6% (22 of 257). The dislocation rate was 5.7% for standard bearings with ≥40-mm femoral heads compared with 6.9% in DM bearings with ≥40-mm femoral heads (P = 1.000). In multivariate analysis, lower body mass index (odds ratio 1.72), female sex (odds ratio 2.01), and decreased outer femoral head diameter-to-cup component size ratio (odds ratio 1.64) were predictors of postoperative dislocation regardless of bearing type.

CONCLUSION

This study showed no difference in dislocation rates between standard and DM bearings when comparing similar femoral head diameters of ≥40-mm used in revision THAs. Considering the cost and potential deleterious issues associated with additional interfaces, DM bearings should be used judiciously considering similar results may be achieved with single-articulation bearings using large femoral heads.

LEVEL OF EVIDENCE

Level III.

Association Between Preoperative Depression and Readmission Rate Following Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

To date, no meta-analysis of the relationship between hospital readmission after total joint arthroplasty (TJA) and preoperative depression has been conducted. Hence, this systematic review and meta-analysis aimed to evaluate the association of preoperative depression with the readmission rate following TJA.

METHODS

We systematically searched MEDLINE, EMBASE, and Cochrane Library for studies published before March 28, 2021, which compared readmission rates in patients with or without preoperative depression who underwent TJA. The primary outcome was the relationship between preoperative depression and 30-day and 90-day readmission rates after TJA. We also performed surgery type subgroup analyses for total hip arthroplasty, total knee arthroplasty (TKA), total shoulder arthroplasty, and total ankle arthroplasty.

RESULTS

We included 9 studies with 395,815 TJA cases, of which 49,402 were diagnosed with preoperative depression and 346,413 were not. In pooled TJA analysis, the 30-day and 90-day readmission rates were significantly higher in the depression group than in the no-depression group (odds ratio [OR] 1.86, 95% confidence interval [CI] 1.26-2.73, P = .002 and OR 1.27, 95% CI 1.14-1.43,; P < .001, respectively). In the subgroup analyses, the 90-day readmission rate was higher in the depression group than in the no-depression group after TKA (OR 1.28, 95% CI 1.15-1.42, P < .001). There were no differences in other surgery types.

CONCLUSION

Based on available evidence, preoperative depression increases the readmission rate after TJA, particularly TKA. As depression is a modifiable risk factor, screening for depression and referring patients for proper psychiatric management are important.

LEVEL OF EVIDENCE

Level III, meta-analysis.

Preoperative and Perioperative Predictors of Length of Hospital Stay after Primary Total Hip Arthroplasty-Our Experience on 743 Cases

The aim of this retrospective investigation is to evaluate the correlation between several preoperative and perioperative factors and the length of hospital stay in patients that underwent elective total hip arthroplasty with overnight admission. Medical records of patients that underwent THA from the beginning of 2016 to the end of 2018 were retrospectively screened. Demographics, comorbidities, whole blood count, intraoperative details, and length of postoperative stay were retrieved. The association between clinical, laboratory and surgical factors and the length of hospital stay was explored by means of negative binomial and logistic regression models. The median length of postoperative hospital stay was four days (Inter Quartile Range, IQR 3, 5). After univariate regression a stepwise multivariate regression showed that operative time (p = 0.001), the preoperative serum creatinine (p < 0.001), the intraoperative blood loss (p = 0.04) and the use of an anterolateral approach (p < 0.001) were found to correlate significantly with the increase of the hospitalization length, while no significant correlation was found for all the other features. Multivariable model fitted through logistic regression (LOS below or over the median value of four days) had an Area Under the Curve (AUC) of 0.748. Our analysis suggests a significant role played by different preoperative and perioperative variables in influencing the length of hospital stay.

The cost-effectiveness of outpatient surgery for primary total hip arthroplasty in the United States: a computer-based cost-utility study

PURPOSE

The purpose of this study was to perform a cost-effectiveness analysis of outpatient versus inpatient total hip arthroplasty (THA) in the USA, considering complication probability and the potential cost of such complications.

METHODS

A cost-effectiveness analysis was conducted from the societal perspective to evaluate the incremental cost and effectiveness of inpatient THA compared to outpatient THA over a lifetime horizon. Effectiveness was expressed in quality-adjusted life years (QALYs). Costs, expressed in 2019 US dollars, transition probabilities, and health utilities were derived from the literature. The primary outcome was the incremental cost-effectiveness ratio (ICER), with a willingness to pay (WTP) threshold set at $50,000/QALY. 1-way and probabilistic sensitivity analyses was performed to evaluate the effect of the various variables on the model.

RESULTS

In the base case, inpatient THA was more effective in terms of total utility (10.36 vs. 10.30 QALY), but also more costly ($48,155 ± 1673 vs. $43,288 ± 1, 606 for Medicare) than outpatient THA. Even with a lifetime horizon, the ICER was $81,116 per QALY and $140,917 per QALY for Medicare and private payer insurance, respectively, which is higher than the willingness to pay threshold. 1-way sensitivity analyses indicated that the variables having the most influence on the model were the utility of inpatient and outpatient THA and cost of inpatient and outpatient THA.

CONCLUSIONS

This model determined that for a WTP threshold set at $50,000/QALY, outpatient THA is more cost-effective than inpatient THA from a societal perspective. Despite this, surgeons must weigh clinical factors first and foremost in determining if an individual patient can be safely operated on in the outpatient setting.

Comparison of Outcomes After Robotic-Assisted or Conventional Total Hip Arthroplasty at a Minimum 2-Year Follow-up: A Systematic Review

BACKGROUND

This systematic review aimed to present an updated analysis of the evidence comparing outcomes between robotic-assisted total hip arthroplasty (robotic THA) and conventional manual total hip arthroplasty (manual THA).

METHODS

A PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) systematic review was performed using the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, and Embase. Controlled studies comparing primary robotic THA and manual THA utilizing patient-reported outcome measures (PROMs) at a minimum follow-up of 2 years were included. We also compared radiographic outcomes, dislocation rates, and revision surgical procedures between groups. The ROBINS-I (Risk of Bias in Non-Randomized Studies - of Interventions) and Cochrane Risk of Bias 2.0 tools were used to assess study quality and risk of bias.

RESULTS

Of 765 studies identified, 7 articles comparing robotic THA with manual THA met inclusion criteria. A total of 658 patients were assessed, 335 of whom underwent robotic THA. The majority of studies found no significant differences (p > 0.05) in PROMs between the 2 techniques. Two low-quality studies (Level III) found significantly better postoperative PROMs favoring robotic THA at 2 years. When assessing radiographic outcomes, 6 studies showed that robotic THA resulted in more consistent and accurate component placement. No differences in postoperative dislocations, complications, or revision rates were found between groups except in 1 study, which found significantly more dislocations and revisions in the robotic THA cohort. Reported operative times were a mean of 12 to 25 minutes longer when using robotic THA.

CONCLUSIONS

The existing literature comparing robotic THA and manual THA is scarce and low-quality, with findings limited by methodological flaws in study design. Although evidence exists to support increased accuracy and reproducibility of THA component placement with robotic THA, this has not been shown to reduce postoperative dislocation and revision rates. Based on the available evidence, functional outcomes are comparable between techniques, and robotic THA appears to be associated with longer operative times. To fully evaluate the utility of robotic THA, additional well-designed, prospective controlled studies with continuous long-term monitoring are required.

LEVEL OF EVIDENCE

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

Robotic Arm-assisted Total Hip Arthroplasty is More Cost-Effective Than Manual Total Hip Arthroplasty: A Markov Model Analysis

BACKGROUND

Total hip arthroplasty (THA) is the benchmark surgical treatment of advanced and symptomatic hip osteoarthritis. Preliminary evidence suggests that the robotic arm-assisted (RAA) technology yields more accurate and reproducible acetabular cup placement, which may improve survival rate and clinical results, but economic considerations are less well-defined. The purpose of this study was to compare the cost effectiveness of the RAA THA with manual THA (mTHA) modalities, considering direct medical costs and utilities from a payer's perspective.

METHODS

A Markov model was constructed to analyze two potential interventions for hip osteoarthritis and degenerative joint disorder: RAA THA and mTHA. Potential outcomes of THA were categorized into the transition states: infection, dislocation, no major complications, or revision. Cumulative costs and utilities were assessed using a cycle length of 1 year over a time horizon of 5 years.

RESULTS

RAA THA cohort was cost effective relative to mTHA cohort for cumulative Medicare and cumulative private payer insurance costs over the 5-year period. RAA THA cost saving had an average differential of $945 for Medicare and $1,810 for private insurance relative to mTHA while generating slightly more utility (0.04 quality-adjusted life year). The preferred treatment was sensitive to the utilities generated by successful RAA THA and mTHA. Microsimulations indicated that RAA THA was cost effective in 99.4% of cases.

CONCLUSIONS

In the Medicare and private payer scenarios, RAA THA is more cost effective than conventional mTHA when considering direct medical costs from a payer's perspective.

LEVEL OF EVIDENCE

Economic Level III. Computer simulation model (Markov model).

Do custom 3D-printed revision acetabular implants provide enough value to justify the additional costs? The health-economic comparison of a new porous 3D-printed hip implant for revision arthroplasty of Paprosky type 3B acetabular defects and its closest alternative

PURPOSE

Total hip arthroplasty (THA) is a common operation for patients suffering from hip arthrosis. It has been proven effective in improving quality of life while being cost-effective. Meanwhile, the number of revision hip arthroplasty is growing and those may require bone reconstruction and are potential indications for 3D custom implants. In these specific indications, medical 3D-printing has grown over the years and the use of 3D-printed implants has become more frequent. To date, the cost-effectiveness of 3D-printed implants for acetabular revision THA has not been evaluated. Therefore we performed a health economic analysis to: (1) analyse the cost-effectiveness of the aMace implant compared to its closest alternative on the market, (2) have a better insight into Belgian costs of revision hip arthroplasties and (3) estimate the budget impact in Belgium.

HYPOTHESIS

3D-printed acetabular implants provide good value-for-health in Paprosky type 3B defects in a Belgian setting.

MATERIAL AND METHODS

Custom Three-flanged Acetabular Components (CTAC) were compared to a 3D-printed implant (aMace) by means of a Markov model with four states (successful, re-revision, resection and dead). The cycle length was set at 6 months with a 10-year time horizon. Data was obtained through systematic literature search and provided by a large social security agency. The analysis was performed from a societal perspective. All amounts are displayed in 2019 euros. Discount rates were applied for future cost (3%) and QALY (1.5%) estimates.

RESULTS

Revision hip arthroplasty has an average societal cost of €9950 without implant. Based on the outcomes of our model, aMace provides an excellent value for money compared to CTAC. The Incremental Cost-Effectiveness Ratio (ICER) was negative for all age groups. The base case of a 65 year old person, showed a QALY gain of 0.05 with a cost reduction of €1265 compared to CTAC. The advantage of using aMace was found to be greater if a patient is younger. The re-revision rates of both CTAC and aMace and the utility of successful revision have the highest impact on costs and effects. A Monte Carlo simulation showed aMace to be a cost-effective strategy in 90% of simulations for younger patients and in 88% of simulations for patients above 85 years old. In Belgium it would imply a cost reduction of €20500 on an annual basis.

CONCLUSIONS

Based on the findings of this model, the new 3D-printed aMace implant has the potential to bring an excellent value for money when used in revision arthroplasty of Paprosky type 3B acetabular defects. For all patients, aMace resulted in a dominant, cost-saving strategy in Belgium compared to CTAC.

LEVEL OF EVIDENCE

III, comparative medico economical diagnostic tool.

Kinematic and Kinetic Changes after Total Hip Arthroplasty during Sit-To-Stand Transfers: Systematic Review

Background

Total hip arthroplasty (THA) is a common and effective surgical procedure that allows patients with hip osteoarthritis to restore functional ability and relieve pain. Sit-to-stand transfers are common demanding tasks during activities of daily living and are performed more than 50 times per day. The purpose of this systematic review is to obtain a comprehensive understanding of biomechanical changes during sit-to-stand transfers after THA.

Methods

Relevant articles were selected through MEDLINE, Scopus, Embase, and Web of Science. Articles were included if they met the following inclusion criteria: 1) participants underwent total hip arthroplasty without restriction on the arthroplasty design, 2) involved either kinematic or kinetic variables as the primary outcome measure, 3) evaluated sit-to-stand, and 4) were written in English.

Results

A total of 11 articles were included in the current systematic review. The THA group exhibited altered movement patterns as compared to healthy controls. Improvement in loading asymmetry was found up to 1 year after THA, but other kinetic changes indicate intensified contralateral limb loading. Limb differences were apparent, but whether these differences persist over 10 months after THA is still unknown.

Conclusion

Despite the inevitable changes in kinematics and kinetics in sit-to-stand transfers after THA, it appears to be important to resolve asymmetrical loading between the operative and nonoperative limbs to minimize risk for subsequent joint problems.

What are the inpatient and day case costs following primary total hip replacement of patients treated for prosthetic joint infection: a matched cohort study using linked data from the National Joint Registry and Hospital Episode Statistics

BACKGROUND

Prosthetic joint infection (PJI) following total hip replacement (THR) surgery is a serious complication that negatively impacts patients' lives and is financially burdensome for healthcare providers. As the number of THRs increases, so does this financial burden. This research estimates the economic burden with respect to inpatient and day case hospital admissions for patients receiving revision surgery for PJI following primary THR.

METHODS

In this matched cohort study, the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) was used to identify patients. Patients revised for PJI with a one- or two-stage revision following THR and patients not revised for PJI were matched on several characteristics using exact and radius matching. Hospital inpatient and day case healthcare records from the English Hospital Episode Statistics database were obtained for 5 years following the identified patient's primary THR. UK national unit costs were applied to hospital admissions and the 5-year total cost was estimated. A two-part model (Probit and generalised linear model) was employed to estimate the incremental difference in costs between those revised and not revised for PJI.

RESULTS

Between 2006 and 2009, 1914 revisions for PJI were identified in the NJR. The matching resulted in 422 patients revised for PJI and 1923 matches not revised for PJI who were included in the analysis. The average cost of inpatient and day case admissions in the 5 years following primary THR was approximately £42,000 for patients revised for PJI and £8000 for patients not revised for PJI. The difference in costs over the 5 years was £33,452 (95% CI £30,828 to £36,077; p < 0.00).

CONCLUSIONS

In the 5 years following primary THR, patients who develop PJI and have revision surgery cost approximately £33,000 (over 5-fold) more than patients not revised for PJI based on their hospital inpatient and day case admissions alone. The total burden of PJI is likely to be much higher when also considering outpatient, primary and community care costs. This highlights the need to find both ways to reduce the incidence of PJI following THR and cost-effective treatment strategies if PJI occurs.

Systematic Review of the Evolution of Health-Economic Evaluation Models of Osteoarthritis

OBJECTIVE

To comprehensively synthesize the evolution of health-economic evaluation models (HEEMs) of all osteoarthritis (OA) interventions, including preventions, core treatments, adjunct nonpharmacologic interventions, pharmacologic interventions, and surgical treatments.

METHODS

The literature was searched within health-economic/biomedical databases. Data extracted included OA type, population characteristics, model setting/type/events, study perspective, and comparators; the reporting quality of the studies was also assessed. The review protocol was registered at the International Prospective Register of Systematic Reviews (CRD42018092937).

RESULTS

Eighty-eight studies were included. Pharmacologic and surgical interventions were the focus in 51% and 44% of studies, respectively. Twenty-four studies adopted a societal perspective (with increasing popularity after 2013), but most (63%) did not include indirect costs. Quality-adjusted life years was the most popular outcome measure since 2008. Markov models were used by 62% of studies, with increasing popularity since 2008. Until 2010, most studies used short-to-medium time horizons; subsequently, a lifetime horizon became popular. A total of 86% of studies reported discount rates (predominantly between 3% and 5%). Studies published after 2002 had a better coverage of OA-related adverse events (AEs). Reporting quality significantly improved after 2001.

CONCLUSION

OA HEEMs have evolved and improved substantially over time, with the focus shifting from short-to-medium-term pharmacologic decision-tree models to surgical-focused lifetime Markov models. Indirect costs of OA are frequently not considered, despite using a societal perspective. There was a lack of reporting sensitivity of model outcome to input parameters, including discount rate, OA definition, and population parameters. While the coverage of OA-related AEs has improved over time, it is still not comprehensive.

Nanopatterned Titanium Implants Accelerate Bone Formation In Vivo

Accelerated de novo formation of bone is a highly desirable aim of implants targeting musculoskeletal injuries. To date, this has primarily been addressed by biologic factors. However, there is an unmet need for robust, highly reproducible yet economic alternative strategies that strongly induce an osteogenic cell response. Here, we present a surface engineering method of translating bioactive nanopatterns from polymeric in vitro studies to clinically relevant material for orthopedics: three-dimensional, large area metal. We use a titanium-based sol-gel whereby metal implants can be engineered to induce osteoinduction both in vitro and in vivo. We show that controlled disordered nanotopographies presented as pillars with 15-25 nm height and 100 nm diameter on titanium dioxide effectively induce osteogenesis when seeded with STRO-1-enriched human skeletal stem cells in vivo subcutaneous implantation in mice. After 28 days, samples were retrieved, which showed a 20-fold increase in osteogenic gene induction of nanopatterned substrates, indicating that the sol-gel nanopatterning method offers a promising route for translation to future clinical orthopedic implants.

Seasonal influence on postoperative hip fracture complications: Retrospective cohort of more than 1000 patients from a tertiary-care university hospital

Background

Hip fractures account for one of the most debilitating conditions affecting the general population amongst the developed and developing nations. Investigators aimed to study the influence of the ongoing season i.e. whether patients operated upon in summer or winter, on post-operative complications occurring within 30 days of surgical procedure for hip fractures at a tertiary care hospital and level 1 trauma center.

Materials and methods

Investigators conducted a non-funded, non-commercialized retrospective cohort of 1045 patients with hip fractures managed surgically. Primary exposure was surgical procedures undertaken during the summer months (April–September). Our primary outcome was determining post-operative complication rates from January 2010 to December 2018 and evaluating impact of the season through univariate and multivariable regression analyses using Cox Proportional Hazard Algorithm with STATA V15. The work has been reported in line with the STROCSS criteria.

Results

Age, ASA status, type of procedure, mechanism of injury and Charlson Comorbidity Index (CCI) were identified as significant associated factors with postoperative complications after hip fracture surgery. Although overall results revealed a rising rate of complications during the summer season with a relative risk (RR; 95% CI) of 1.1(0.89–1.32), univariate and multivariable analysis did not show any significant correlations.

Conclusions

The results of this study did not demonstrate a significant seasonal variability in the rate of postoperative complications for hip fracture patients operated upon during the hot months of summer. More research is required to analyze postoperative complications in order to optimize patients’ outcomes.

•

The number of hip fractures has been observed to double as the population ages.

•

Surgical management is the gold standard and most effective management option.

•

Operating patients during summer is postulated to carry higher risk of postoperative complications.

•

However, this higher risk was statistically insignificant in the current study.

Preoperative Vitamin D Repletion in Total Knee Arthroplasty: A Cost-Effectiveness Model

BACKGROUND

Recent studies have identified vitamin D deficiency (serum 25-hydroxyvitamin D [25(OH)D] < 20 ng/L) as a potentially modifiable risk factor for prosthetic joint infection (PJI) in arthroplasty. The purpose of this study is to determine whether implementation of preoperative 25(OH)D repletion is cost-effective for reducing PJI following total knee arthroplasty (TKA).

METHODS

A cost estimation predictive model was generated to determine the utility of both selective and nonselective 25(OH)D repletion in primary TKA to prevent PJI. Input data on the incidence of 25(OH)D deficiency, relative complication rates, and costs of serum 25(OH)D repletion and 2-stage revision for PJI were derived from previously published literature identified using systematic review and publicly available data from Medicare reimbursement schedules. Mean, lower, and upper bounds of 1-year cost savings were computed for nonselective and selective repletion relative to no repletion.

RESULTS

Selective preoperative 25(OH)D screening and repletion were projected to result in $1,504,857 (range, $215,084-$4,256,388) in cost savings per 10,000 cases. Nonselective 25(OH)D repletion was projected to result in $1,906,077 (range, $616,304-$4,657,608) in cost savings per 10,000 cases. With univariate adjustment, nonselective repletion is projected to be cost-effective in scenarios where revision for PJI costs ≥$10,636, incidence of deficiency is ≥1.1%, and when repletion has a relative risk reduction ≥4.2%.

CONCLUSION

This predictive model supports the potential role of 25(OH)D repletion as a cost-effective mechanism of reducing PJI risk in TKA. Given the low cost of 25(OH)D repletion relative to serum laboratory testing, nonselective repletion appears to be more cost-effective than selective repletion. Further prospective investigation to assess this modifiable risk factor is warranted.

Patient-Reported Outcomes Following Total Hip Arthroplasty: A Multicenter Comparison Based on Surgical Approaches

BACKGROUND

Comparisons of patient-reported outcomes (PROs) based on surgical approach for total hip arthroplasty (THA) in the United States are limited to series from single surgeons or institutions. Using prospective data from a large, multicenter study, we compare preoperative to postoperative changes in PROs between posterior, transgluteal, and anterior surgical approaches to THA.

METHODS

Patient-reported function, global health, and pain were systematically collected preoperatively and at 1, 3, and 6 months postoperatively from patients undergoing primary THA at 26 sites participating in the Comparative Effectiveness of Pulmonary Embolism Prevention After Hip and Knee Replacement (ClinicalTrials.gov: NCT02810704). Outcomes consisted of the brief Hip disability and Osteoarthritis Outcome Score, the Patient-Reported Outcomes Measurement Information System Physical Health score, and the Numeric Pain Rating Scale. Operative approaches were grouped by surgical plane relative to the abductor musculature as being either anterior, transgluteal, or posterior.

RESULTS

Between 12/12/2016 and 08/31/2019, outcomes from 3018 eligible participants were examined. At 1 month, the transgluteal cohort had a 2.2-point lower improvement in Hip disability and Osteoarthritis Outcomes Score (95% confidence interval, 0.40-4.06; P = .017) and a 1.3-point lower improvement in Patient-Reported Outcomes Measurement Information System Physical Health score (95% confidence interval, 0.48-2.04; P = .002) compared to posterior approaches. There was no significant difference in improvement between anterior and posterior approaches. At 3 and 6 months, no clinically significant differences in PRO improvement were observed between groups.

CONCLUSION

PROs 6 months following THA dramatically improved regardless of the plane of surgical approach, suggesting that choice of surgical approach can be left to the discretion of surgeons and patients without fear of differential early outcomes.

Mixed Reality Combined with Three-Dimensional Printing Technology in Total Hip Arthroplasty: An Updated Review with a Preliminary Case Presentation

Three-dimensional (3D) printing technology, virtual reality, and augmented reality technology have been used to help surgeons to complete complex total hip arthroplasty, while their respective shortcomings limit their further application. With the development of technology, mixed reality (MR) technology has been applied to improve the success rate of complicated hip arthroplasty because of its unique advantages. We presented a case of a 59-year-old man with an intertrochanteric fracture in the left femur, who had received a prior left hip fusion. After admission to our hospital, a left total hip arthroplasty was performed on the patient using a combination of MR technology and 3D printing technology. Before surgery, 3D reconstruction of a certain bony landmark exposed in the surgical area was first performed. Then a veneer part was designed according to the bony landmark and connected to a reference registration landmark outside the body through a connecting rod. After that, the series of parts were made into a holistic reference registration instrument using 3D printing technology, and the patient's data for bone and surrounding tissue, along with digital 3D information of the reference registration instrument, were imported into the head-mounted display (HMD). During the operation, the disinfected reference registration instrument was installed on the selected bony landmark, and then the automatic real-time registration was realized by HMD through recognizing the registration landmark on the reference registration instrument, whereby the patient's virtual bone and other anatomical structures were quickly and accurately superimposed on the real body of the patient. To the best of our knowledge, this is the first report to use MR combined with 3D printing technology in total hip arthroplasty.

High-Volume Arthroplasty Centers Demonstrate Higher Composite Quality Scores and Enhanced Value: Perspective on Higher-Volume Hospitals Performing Arthroplasty from 2001 to 2011

BACKGROUND

In recent years, there has been a move toward value-based health care. Value is generally defined as outcome divided by cost; however, it is not clear exactly how to define and measure outcomes. In this study, we utilized the Nationwide Inpatient Sample (NIS) to determine how hospital volume and other factors affect quality for patients undergoing total hip and knee arthroplasty.

METHODS

Using the NIS of the Healthcare Cost and Utilization Project (HCUP) of the Agency for Healthcare Research and Quality (AHRQ), we conducted a retrospective study of all total hip and total knee arthroplasties performed from 2001 to 2011. We identified all procedure and outcome variables using the International Classification of Diseases, Ninth Revision (ICD-9) billing codes. Patients were grouped into quartiles based on the corresponding hospital's procedure volume. The quality measurement for each hospitalization was binary, with perfect inpatient care reflecting a favorable result for all of the following outcomes of interest: death, sepsis, postoperative infection, thromboembolic events, venous thrombosis, hematoma, blood transfusion, and length of stay below average. The Perfect Inpatient Care Index (PICI) was then calculated for each hospital. The PICI was defined as the number of hospitalizations with no unfavorable outcomes divided by total volume of arthroplasty. Value was measured as the PICI divided by the mean total charges. Multivariable nested regression was used to determine variables that predict perfect inpatient care.

RESULTS

From 2001 to 2011, the NIS database reported 1,651,354 total hip or total knee arthroplasties. Hospital arthroplasty volume ranged from 0 to 11,758 procedures. Overall, hospital PICI scores increased as arthroplasty volume increased. In multivariable nested regression analysis, procedure volume (odds ratio [OR] for the highest quartile compared with the lowest quartile, 2.116 [95% confidence interval (CI), 1.883 to 2.378]) and lower patient acuity (OR, 2.450 [95% CI, 2.429 to 2.472]) were independently associated with better PICI scores. Value increased as hospital procedure volume increased.

CONCLUSIONS

Hospital procedure volume varied widely. Although small differences were seen in individual outcome measures, composite scores (PICI) and value were substantially better at hospitals that had higher procedure volume and in lower-acuity patients.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Self-Management of Hip Osteoarthritis Five Years After a Cycling and Education Treatment Pathway

The Cycling against Hip Pain (CHAIN) programme is a six-week cycling and education treatment pathway for people with hip osteoarthritis. Preliminary results demonstrated significant improvements in clinical and patient-reported outcome measures following the course. Whilst the benefits of exercise for osteoarthritis are often reported in the short term, less is known about the long-term effects for this patient group. This study explores whether participants continued to self-manage their hip osteoarthritis five years after completing the course. A cross-sectional survey was conducted to collect data from participants who completed the CHAIN programme between October 2013 and February 2015 (n = 96). Questionnaires were sent by post in April 2019, and then non-responders were followed up again four weeks later. Eighty-three (87%) participants responded to the survey. Five years (range 4–6) after completion of a six-week cycling and education programme, 37 (45%) participants had not returned to their general practitioner for further treatment of their hip pain, and 47 (57%) had not pursued surgical intervention. All participants were still engaged in at least one physical activity per week and many reported that they had purchased a bike (29%), joined a gym (30%) or cycled regularly (indoor cycling 25%, outdoor cycling 24%). Eighty (96%) participants reported an increase in knowledge of self-managing their symptoms. The findings from this study suggest that many patients are motivated to self-manage their hip osteoarthritis, five years following a six-week cycling and education treatment pathway that encourages lifestyle change.

Patient-Reported Outcome Measures are not a Valid Proxy for Patient Satisfaction in Total Joint Arthroplasty

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly used as quality benchmarks in total joint arthroplasty. The objective of this study is to investigate whether PROMs correlate with patient satisfaction, which is arguably the most important and desired outcome.

METHODS

Our institutional joint database was queried for patients who underwent primary, elective, unilateral total joint arthroplasty. Eligible patients were asked to complete a satisfaction survey at final follow-up. Correlation coefficients (R) were calculated to quantify the relationship between patient satisfaction and prospectively collected PROMs. We explored a wide range of PROMs including Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form-12, Oxford Hip Score, Knee Society Clinical Rating Score (KSCRS), Single Assessment Numerical Evaluation, and University of California Los Angeles activity level rating.

RESULTS

In general, there was only weak to moderate correlation between patient satisfaction and PROMs. Querying the absolute postoperative scores had higher correlation with patient satisfaction compared to either preoperative scores or net changes in scores. The correlation was higher with disease-specific PROMs (WOMAC, Oxford Hip Score, KSCRS) compared to general health (Short Form-12), activity level (University of California Los Angeles activity level rating), or perception of normalcy (Single Assessment Numerical Evaluation). Within disease-specific PROMs, the pain domain consistently carried the highest correlation with patient satisfaction (WOMAC pain subscale, R = 0.45, P < .001; KSCRS pain subscale, R = 0.49, P < .001).

CONCLUSION

There is only weak to moderate correlation between PROMs and patient satisfaction. PROMs alone are not the optimal way to evaluate patient satisfaction. We recommend directly querying patients about satisfaction and using shorter PROMs, particularly disease-specific PROMs that assess pain perception to better gauge patient satisfaction.

What Are the Contemporary Etiologies for Revision Surgery and Revision After Primary, Noncemented Total Hip Arthroplasty?

INTRODUCTION

Contemporary failure etiologies of primary total hip arthroplasties (THAs) have not been precisely defined because of heterogeneity of referral practices.

METHODS

A single-institution registry of 4,555 primary, noncemented THAs performed by subspecialty trained arthroplasty surgeons between 2000 and 2012 was analyzed. Only revision surgeries and revisions that occurred after THAs initially performed at the institution were included.

RESULTS

The estimated 10-year survivorships free from THA revision surgery, modular implant revision, and nonmodular implant revision were 98.2%, 98.1%, and 96.3%, respectively. The most common reasons for revision surgeries were wound-related complications (49%), periprosthetic fracture (25%), and pain (18%). Hip instability (53%) and acute periprosthetic joint infection (26%) were the most common etiologies of revision procedures with isolated exchange of at least one modular implant. The most common reasons for replacement or removal of nonmodular implant were periprosthetic fracture (32%), aseptic loosening (22%), and adverse tissue reaction (17%).

DISCUSSION

Focusing on primary THAs initially performed by a contemporary, subspecialty practice allowed an accurate determination of etiologies and rates of failure (defined by revision surgery or revision) after THA.

LEVEL OF EVIDENCE

Level IV.

Complications and Costs Are Not Increased After Total Hip Arthroplasty in Patients With a History of Prostate Cancer

BACKGROUND

Prostate cancer (PCa) is a largely prevalent disease in the United States. Moreover, it is unclear whether the thromboembolic burden of disease remains present after the cancer has been treated and whether such state impacts the short-term outcomes of orthopedic procedures. Therefore, the purpose of this study is to assess 90-day postoperative complications and costs after total hip arthroplasty (THA) for osteoarthritis in patients with a history of PCa.

METHODS

Two groups of patients who underwent THA for osteoarthritis in the Medicare Standard Analytical Files were identified through the PearlDiver server. Both groups were matched based on age, diabetes, smoking status, chronic kidney disease, alcohol abuse, chronic liver disease, and obesity in order to create a case-control study comparison. The 90-day complication rates after THA were compared using univariate regressions (odds ratio). We hypothesized that patients with a history of PCa would develop increased rates of thromboembolic complications based on a prolonged procoagulative state.

RESULTS

After matching, each group was comprised of 62,571 patients. Our findings identified greater 90-day pneumonia rates for those without a history of PCa (3.26% vs 2.68%; odds ratio, 0.82). All other complications including thromboembolic diseases were clinically comparable in both groups during the 90-day postoperative period. The charges and reimbursements for the 90-day period were also comparable.

CONCLUSION

In our large case-control study of 125,142 patients, we found that patients with a history of PCa do not have increased risk of short-term complications after THA and that the mean 90-day reimbursements were similar for both groups at $14,153 for PCa patients and $14,033 for those without (P = .114).

Cost-Effectiveness Analysis of Multifocal Intraocular Lenses Compared to Monofocal Intraocular Lenses in Cataract Surgery

PURPOSE

To determine the cost-effectiveness of multifocal intraocular lenses (IOLs) compared to that of monofocal IOLs from a societal and health care sector perspective.

DESIGN

Cost-effectiveness analysis.

METHODS

A Markov model was constructed that simulated patients who received either multifocal or monofocal IOLs during cataract surgery. Postoperatively, patients could experience spectacle dependence, glare, and haloes. Cost-effectiveness was determined by measuring the incremental cost-effectiveness ratio (ICER) as the incremental cost in dollars per quality-adjusted life year (QALY) gained. Treatments with an ICER below the standard willingness-to-pay (WTP) threshold of $50,000/QALY were considered cost effective. One-way sensitivity analyses and probabilistic sensitivity analyses were used to evaluate model sensitivity to cost, utilities, and other model inputs.

RESULTS

Multifocal IOLs were associated with a 0.71 QALY increase at an increased cost of $3,415 compared with monofocal IOLs, leading to an ICER of $4,805/QALY from the societal and health care sector perspectives. The cost-effectiveness model was most sensitive to patient age, probability of spectacle dependence with multifocal IOLs and monofocal IOLs, and the disutility of glasses. Probabilistic sensitivity analysis found multifocal IOLs to be the cost-effective option compared with monofocal IOLs 99.9% of the time at a WTP threshold of $50,000/QALY.

CONCLUSIONS

From a societal and health care perspective, multifocal IOLs would be considered a cost-effective strategy compared to monofocal IOLs for patients who desire a higher chance to be spectacle-free. However, more studies need to be conducted to further evaluate the efficacy of multifocal IOLs.

Injury-related variation in patient-reported outcome after musculoskeletal trauma: a systematic review

PURPOSE

The purpose of this study was to explore injury-related characteristics that differentiate between patient-reported outcomes (PROs) following traumatic musculoskeletal injury.

METHODS

We reviewed English-language articles in PubMed/MEDLINE, Google Scholar, and the Cochrane Database of Systematic Reviews (January 1995 to September 2018). We included studies that compared patient-reported outcomes of musculoskeletal trauma based on injury characteristics, and excluded studies related to development or validation of outcome tools without implementation, measurement, or comparison. Studies on patients with isolated neurotrauma or spine trauma were not included. Study level of evidence was assessed by 2 reviewers using the modified Oxford Centre for Evidence-based Medicine rating system.

RESULTS

A total of 20 studies (21 articles) that reported on a total of 10,186 patients were included (4 were prospective cohort-studies, 8 were matched-control retrospective cohort-studies, and 8 were retrospective cohort-studies). Median minimum follow-up was 3 years (range 0.5-10 years). Injury-related factors associated with worse PROs were polytrauma or multiple injuries (10 studies), neurotrauma (11 studies), and high-energy injury mechanism (7 studies). Among all studies, 32 different outcome metrics were used (17 general health status metrics and 15 limb-specific metrics) making meta-analysis infeasible.

CONCLUSIONS

Based on the included studies, we propose a framework where musculoskeletal injuries occur in one of 4 scenarios that is associated with a different context-dependent outcome: (1) polytrauma with neurotrauma, (2) polytrauma without neurotrauma, (3) high-energy monotrauma, and (4) low-energy monotrauma. Our results suggest that standardization of outcome instruments is needed to facilitate future meta-analyses that assess PROs in this population.

Machine Learning Algorithms Can Use Wearable Sensor Data to Accurately Predict Six-Week Patient-Reported Outcome Scores Following Joint Replacement in a Prospective Trial

BACKGROUND

Tracking patient-generated health data (PGHD) following total joint arthroplasty (TJA) may enable data-driven early intervention to improve clinical results. We aim to demonstrate the feasibility of combining machine learning (ML) with PGHD in TJA to predict patient-reported outcome measures (PROMs).

METHODS

Twenty-two TJA patients were recruited for this pilot study. Three activity trackers collected 35 features from 4 weeks before to 6 weeks following surgery. PROMs were collected at both endpoints (Hip and Knee Disability and Osteoarthritis Outcome Score, Knee Osteoarthritis Outcome Score, and Veterans RAND 12-Item Health Survey Physical Component Score). We used ML to identify features with the highest correlation with PROMs. The algorithm trained on a subset of patients and used 3 feature sets (A, B, and C) to group the rest into one of the 3 PROM clusters.

RESULTS

Fifteen patients completed the study and collected 3 million data points. Three sets of features with the highest R² values relative to PROMs were selected (A, B and C). Data collected through the 11th day had the highest predictive value. The ML algorithm grouped patients into 3 clusters predictive of 6-week PROM results, yielding total sum of squares values ranging from 3.86 (A) to 1.86 (C).

CONCLUSION

This small but critical proof-of-concept study demonstrates that ML can be used in combination with PGHD to predict 6-week PROM data as early as 11 days following TJA surgery. Further study is needed to confirm these findings and their clinical value.

The Personal Financial Burden Associated with Musculoskeletal Trauma

BACKGROUND

Little is known about the effect of orthopaedic trauma on the financial health of patients. We hypothesized that some patients who sustain musculoskeletal trauma experience considerable financial hardship during treatment, and we also assessed for factors associated with increased personal financial burden.

METHODS

We surveyed 236 of 393 consecutive patients who were approached at 1 of 2 American College of Surgeons level-I trauma centers between 2016 and 2017 following the completion of treatment for a musculoskeletal injury (60% response rate). Two validated measures (financial burden composite score and dichotomized worry score) were used to assess the financial hardship that patients experienced with the injury.

RESULTS

There were 236 participants in the study, the mean age was 56.3 years (range, 19 to 94 years), and 48.7% of patients were male. Of the 236 patients, 97.9% had medical insurance, yet the mean financial burden composite score (and standard deviation) was 2.4 ± 2.2 (0 indicated low and 6 indicated high). In this study, 25.0% of patients had high levels of worry about financial problems that resulted from the injury. Fifty-four percent of patients used their savings to pay for their care, and 23% of patients borrowed money or took out a loan. Twenty-three percent of patients missed payment on other bills. Fifty-seven percent of patients were required to cut expenses in general. Patients with higher composite financial burden scores had a significantly increased likelihood of high financial worry (odds ratio [OR], 1.8 [95% confidence interval (CI), 1.5 to 2.2]; p < 0.001). Factors associated with increased financial hardship were high-deductible health plan insurance (coefficient, 0.3 [95% CI, 0.002 to 0.528]; p = 0.048), Medicaid insurance (coefficient, 0.6 [95% CI, 0.342 to 0.863]; p < 0.001), failure to complete high school (coefficient, 0.475 [95% CI, 0.033 to 0.918]; p = 0.035), increased number of surgical procedures (coefficient, 0.067 [95% CI, 0.005 to 0.129]; p = 0.035), and prior medical or student loans (coefficient, 0.769 [95% CI, 0.523 to 1.016]; p < 0.001).

CONCLUSIONS

Despite a high rate of insurance, patients with orthopaedic trauma in our study had high rates of worry and financial distress. Asking about financial hardship may help to identify those patients with a higher personal financial burden and may promote allocation of additional social support and services.

Who Cares for Total Hip Arthroplasty Complications? Rates of Readmission to a Hospital Different From the Location of the Index Procedure

INTRODUCTION

While the number of total hip arthroplasties (THAs) performed increases, so is the number of postoperative readmissions, resulting in costly episodes of care that may disproportionately affect certain hospitals. This study examines the rates of readmission of patients to the same hospital at which they underwent index THA, compared with readmission to a different hospital.

METHODS

Data for all hospital discharges from 1995 to 2010 were obtained from the California Office of Statewide Health Planning and Development database. Patient outcomes, readmission data, demographic information, hospital teaching status, and location were analyzed. Regression modeling was used to evaluate the effect of hospital teaching status, location, and individual complications on the risk of readmission to the same hospital as opposed to a different hospital following the index procedure.

RESULTS

The overall postoperative readmission rate for specific defined complications or all-cause 30-day readmissions was 3.92%, with 75.17% readmitted to the same hospital. Following index THA at a nonacademic or academic hospital, 95.9% and 84.6% of patients were readmitted to the same type of hospital, respectively. Patients who had their index procedure at an academic hospital had lower odds for readmission to the same hospital (odds ratio, 0.734; P < 0.0001) compared with nonacademic centers. Hospitals in midsize towns had higher odds of readmission to the same hospital (odds ratio, 1.735; P = 0.0012) compared with those in large metropolitan areas.

DISCUSSION

Although more than 75% of patients with unplanned readmissions went to the same hospital as their index THA, academic and larger metropolitan hospitals had higher odds of postoperative readmissions to a different hospital.

A cost-effectiveness analysis of mupirocin and chlorhexidine gluconate for Staphylococcus aureus decolonization prior to hip and knee arthroplasty in Alberta, Canada compared to standard of care

Background

While decolonization of Staphylococcus aureus reduces surgical site infection (SSI) rates following hip and knee arthroplasty, its cost-effectiveness is uncertain. We sought to examine the cost-effectiveness of a decolonization protocol for Staphylococcus aureus prior to hip and knee replacement in Alberta compared to standard care – no decolonization.

Methods

Decision analytic models and a probabilistic sensitivity analysis were used for a cost-effectiveness analysis, with the effectiveness of decolonization based on a large published pre- and post- intervention trial. The primary outcomes of the models were infections prevented and health care costs. We modelled the cost-effectiveness of decolonization in a hypothetical cohort of adult patients undergoing hip and knee replacement in Alberta, Canada. Information on the incidence of complex surgical site infections (SSIs), as well as the cost of care for patients with and without SSIs was taken from a provincial infection control database, and health administrative data.

Results

Use of the decolonization bundle was cost saving compared to usual care ($153/person), and resulted in 16 complex Staphylococcus aureus SSIs annually as opposed to 32 (with approximately 8000 hip or knee arthroplasties performed). The probabilistic sensitivity analysis demonstrated that the majority (84%) of the time the decolonization bundle was cost saving. The model was robust to one-way sensitivity analyses conducted within plausible ranges. There were small upfront costs associated with using a decolonization protocol, however, this model demonstrated cost savings over one year. In a Markov model that considered the impact of a decolonization bundle over a lifetime as it pertained to the need for subsequent joint replacements and patient quality of life, the bundle still resulted in cost savings ($161/person).

Conclusions

Decolonization for Staphylococcus aureus prior to hip and knee replacements resulted in cost savings and fewer SSIs, and should be considered prior to these procedures.

Electronic supplementary material

The online version of this article (10.1186/s13756-019-0568-5) contains supplementary material, which is available to authorized users.