Trends in Incidence of Hip Fracture and Hip Replacement in Denmark, 1996 to 2018

Importance

The past several decades have witnessed substantial changes in treatments that are particularly relevant for older patients.

Objectives

To assess changes in national-level incidence rates of fracture- and musculoskeletal-related (ie, arthritis-related) hip replacement procedures for individuals aged 40 to 104 years over a 23-year period in Denmark.

Design, Setting, and Participants

This cohort study used national Danish health registers to include the Danish population aged 40 to 104 years from January 1, 1996, to December 31, 2018. Data were analyzed from May 31, 2022, to February 14, 2024.

Main Outcomes and Measures

Age- and period-specific incidence rates of hip fracture and hip replacement stratified on fracture-related vs arthritis-related indication.

Results

From 1996 to 2018, a total of 3 664 979 individuals were followed up for a mean (SD) of 14.6 (7.7) years, resulting in a follow-up time of 53 517 861 person-years and 158 982 (first) hip fractures, of which 42 825 involved fracture-related hip replacement procedures. A further 104 422 individuals underwent arthritis-related hip replacement. During the first 2 decades of the 21st century, hip fracture rates declined by 35% to 40% for individuals aged 70 to 104 years, and the proportion of the population undergoing fracture-related hip replacement increased by 50% to 70%, with modest variation across those aged 75 to 99 years. Rates of arthritis-related hip replacements peaked for individuals aged 75 to 79 years, but with the largest relative rate increase (75%-100%) occurring for those aged 80 to 94 years, primarily from 2001 to 2015, whereafter it remained nearly unchanged. The decline in rates of arthritis-related hip replacement after 75 to 79 years of age was gradual and did not suggest an upper age limit for access to arthritis-related hip replacement.

Conclusions and Relevance

The findings of this cohort study suggest that during the past several decades in Denmark, the incidence of hip fractures declined by 35% to 40% among patients aged 80 to 104 years, while the proportion receiving fracture-related hip replacement remained relatively constant after 75 years of age. During the first decades of the 21st century, arthritis-related hip replacement incidence increased by 50% to 100% among older patients and stabilized hereafter, with no apparent cutoff age for this type of procedure. These patterns indicate a positive overall trend with declining hip fracture incidence over the last decades in Denmark, and the observed hip replacement incidence suggests that age is currently not a major determining factor guiding this type of surgery.

Procedure-specific acute pain trajectory after elective total hip arthroplasty: systematic review and data synthesis

BACKGROUND

For most procedures, there is insufficient evidence to guide clinicians in the optimal timing of advanced analgesic methods, which should be based on the expected time course of acute postoperative pain severity and aimed at time points where basic analgesia has proven insufficient.

METHODS

We conducted a systematic search of the literature of analgesic trials for total hip arthroplasty (THA), extracting and pooling pain scores across studies, weighted for study size. Patients were grouped according to basic anaesthetic method used (general, spinal), and adjuvant analgesic interventions such as nerve blocks, local infiltration analgesia, and multimodal analgesia. Special consideration was given to high-risk populations such as chronic pain or opioid-dependent patients.

RESULTS

We identified and analysed 71 trials with 5973 patients and constructed pain trajectories from the available pain scores. In most patients undergoing THA under general anaesthesia on a basic analgesic regimen, postoperative acute pain recedes to a mild level (<4/10) by 4 h after surgery. We note substantial variability in pain intensity even in patients subjected to similar analgesic regimens. Chronic pain or opioid-dependent patients were most often actively excluded from studies, and never analysed separately.

CONCLUSIONS

We have demonstrated that it is feasible to construct procedure-specific pain curves to guide clinicians on the timing of advanced analgesic measures. Acute intense postoperative pain after THA should have resolved by 4-6 h after surgery in most patients. However, there is a substantial gap in knowledge on the management of patients with chronic pain and opioid-dependent patients.

Closing the Socioeconomic Gap in Massachusetts: Trends in Total Hip Arthroplasty From 2013 to 2015

To extend insurance coverage to all residents, Massachusetts legislation expanded Medicaid eligibility and added new private insurance categories. To date, no one has analyzed the effect of these changes and compared recent trends in total hip arthroplasty (THA) utilization. Therefore, this study sought to update the current trends of THA utilization in Massachusetts from 2013 to 2015. The Massachusetts State Inpatient Database was queried for all patients who underwent primary THA between 2013 and 2015, and 30,308 patients were identified. Analyzed variables included age, sex, race, Charlson Comorbidity Index, median household income, primary payer, discharge disposition, length of stay, hospital charges, hospital costs, and complications. Categorical and continuous variables were assessed using chi-square analyses and analyses of variance, respectively. Between 2013 and 2015, annual THAs increased from 9361 to 10,562. Race did not vary significantly (P=.447), although an increase in patients using Medicaid and a decrease in patients using other insurance was observed (P<.001). Patients with an income quartile of 1 increased, whereas the number of THA patients in quartile 3 decreased (P<.001). There was a decrease in both hospital charges (P<.001) and costs (P<.001). Mean length of stay decreased (P<.001), and the number of patients with complications decreased (P<.001). Massachusetts has been successful in increasing access to THA procedures for low-income patients and increasing the number of patients who use Medicaid for THAs. The current delivery of health care in Massachusetts has shown improvement for its residents, serving as an example that other states can learn from. [Orthopedics. 2021;44(2):e167-e172.].

The incidence of shoulder arthroplasty: rise and future projections compared with hip and knee arthroplasty

BACKGROUND

There remains a paucity of epidemiologic data from recent years on the incidence of shoulder arthroplasty. We aimed to examine the recent trends and predict future projections of hemiarthroplasty (HA), anatomic (aTSA), and reverse shoulder arthroplasty (RSA), as well as compare these predictions to those for total hip (THA) and knee arthroplasty (TKA).

METHODS

The National Inpatient Sample was queried from 2011 to 2017 for HA, aTSA, and RSA, as well as TKA and THA. Linear and Poisson regression was performed to project annual procedural incidence and volume to the year 2025.

RESULTS

Between 2011 and 2017, the number of primary shoulder arthroplasties increased by 103.7%. In particular, RSA increased by 191.3%, with 63,845 RSAs performed in 2017. All projection models demonstrated significant increases in shoulder arthroplasty volume and incidence from 2017 to 2025. By 2025, the linear model predicts that shoulder arthroplasty volume will increase by 67.2% to 174,810 procedures whereas the Poisson model predicts a 235.2% increase, to 350,558 procedures by 2025. These growth rate projections outpace those of THA and TKA.

CONCLUSIONS

The number of shoulder arthroplasties has been increasing in recent years, largely because of the exponential increases in RSA. The overall incidence is increasing at a greater rate than TKA or THA, with projections continuing to rise over the next decade. These data and projections can be used by policy makers and hospitals to drive initiatives aimed at meeting these projected future demands.

Trends in the utilisation rates and acute hospital capacity needs for total hip replacements: results of an analysis of administrative data

Total hip replacement surgery is the mainstay of treatment for end-stage hip arthritis. In 2014, there were 28227 procedures (incidence rate 252/100000 population). Using administrative data, we projected the future volume of total hip replacement procedures and incidence rates using two models. The constant rate model fixes utilisation rates at 2014 levels and adjusts for demographic changes. Projections indicate 32248 admissions by 2025 or an annual growth of 1.22% (incidence rate 273). The time trend model additionally projects the evolution in age-specific utilisation rates. 34895 admissions are projected by 2025 or an annual growth of 1.95% (incidence rate 296). The projections show a shift in performing procedures at younger age. Forecasts of length of stay indicate a substantial shortening. By 2025, the required number of hospital beds will be halved. Despite more procedures, capacity can be reduced, leading to organisational change (e.g. elective orthopaedic clinics) and more labour intensive stays.

Periprosthetic proximal femoral fractures in cemented and uncemented stems according to Vancouver classification: observation of a new fracture pattern

BACKGROUND

Periprosthetic fractures are increasingly encountered in hip arthroplasty. The Vancouver classification system is widely used. Little knowledge exists regarding the association of the Vancouver classification with either cemented or uncemented stems. The aim was to analyse a series of fractures and determine associations.

METHODS

A series of consecutive patients over 8 years was identified including only post-operative fractures of primary hip arthroplasties. Baseline and radiographic characteristics were recorded including the type of stem fixation (cemented or uncemented) and Vancouver classification. Statistical analysis was performed to determine the association of the Vancouver classification between cemented and uncemented stems.

RESULTS

A total of 172 patients were identified (84 cemented stems, 88 uncemented stems). There were 30 Vancouver A fractures (12 cemented vs.18 uncemented, p > 0.05), 125 Vancouver B fractures (63 cemented vs. 62 uncemented, p > 0.05) and 17 Vancouver C fractures (9 cemented vs. 8 uncemented, p > 0.05). The Vancouver B2 fracture occurred most frequently (N = 95; 44 cemented vs. 51 uncemented, p > 0.05) and consists of four distinct fracture patterns: the previously described comminuted 'burst', clamshell and spiral patterns and the newly observed 'reverse' clamshell. The burst and spiral fracture patterns are significantly associated with cemented stems, and the clamshell pattern is significantly associated with uncemented stems.

CONCLUSIONS

Vancouver A, B and C fractures occur equally in cemented and uncemented stems. Awareness of four distinct Vancouver B2 fracture patterns, including the newly observed reverse clamshell, will aid surgeons in predicting stem instability.

The efficacy and safety of selective COX-2 inhibitors for postoperative pain management in patients after total knee/hip arthroplasty: a meta-analysis

BACKGROUND

Many selective cyclooxygenase (COX-2) inhibitors are currently used in clinical practice. COX-2 inhibitors have good anti-inflammatory, analgesic, antipyretic effects, and gastrointestinal safety. However, the analgesic effects and adverse reactions of COX-2 after total knee/hip arthroplasty (TKA/THA) are not fully known.

OBJECTIVE

To evaluate the efficacy and safety of selective COX-2 inhibitors in postoperative pain management in patients receiving TKA/THA.

METHODS

Randomized controlled trials (RCTs) were retrieved from medical literature databases. Risk ratios (RR) Std mean difference (SMD) and 95% confidence intervals (CI) were calculated to analyze the primary and safety endpoints.

RESULTS

In total, 18 articles (23 trial comparisons) were retrieved comprising 3104 patients. Among them, 1910 patients (61.5%) were randomized to the experimental group whereas 1194 patients (38.5%) were randomized to the control group. The primary endpoints were the patients' VAS score at rest or on ambulation (within 3 days). We found that VAS score in patients that received selective COX-2 inhibitor was significantly lower compared to those of the control group.

CONCLUSION

This meta-analysis shows that selective COX-2 inhibitor therapy is effective, safe, and reliable in relieving postoperative pain of THA/TKA.

The evolution of robotic arm-assisted arthroplasty in Greece

BACKGROUND

The robotic arm-assisted (Mako) arthroplasty was introduced in Greece in January 2014, through the years of financial crisis. The purpose of this study is to demonstrate its evolution per procedure throughout the years.

MATERIALS AND METHODS

Data regarding type of procedure: partial knee arthroplasty (PKA), total knee arthroplasty (TKA) and total hip arthroplasty (THA) were collected from the official distributor of the Mako platform in Greece. The number of Mako arthroplasties were calculated annually and monthly per procedure type from January 2014 to December 2018.

RESULTS

A total of 1081 robotic arm-assisted arthroplasties have been performed in Greece in two private hospitals. Mako cases showed overall 163.06% increase, while THA showed 235.1% increase, during the study period. On the other hand PKA showed 61% decrease, while in during one year (2017-2018) TKA showed 402% increase.

CONCLUSIONS

Introducing robots into the orthopedic operating theater may improve precision, could lead to lower complication rates and finally may offer higher patient satisfaction scores. However, the total growth of robotic arm-assisted arthroplasties in Greece should be interpreted with caution, since all surgeries were performed in private institutions and, therefore, the economic burden of these procedures may have been withstood by specific social class patients.

Impact of Local Infiltration Analgesia on the Quality of Recovery After Anterior Total Hip Arthroplasty: A Randomized, Triple-Blind, Placebo-Controlled Trial

BACKGROUND

Local infiltration analgesia (LIA) is commonly used in anterior total hip arthroplasty (THA) surgery; however, evidence for its efficacy is lacking. We hypothesized that LIA with 0.2% ropivacaine when compared with injection of placebo (0.9% saline) would improve patient quality of recovery on postoperative day (POD) 1, as measured by the Quality of Recovery-15 (QoR-15) score.

METHODS

Patients scheduled to have a primary unilateral anterior THA with a single surgeon in a tertiary level metropolitan hospital were randomized to receive LIA with either 2.5 mL/kg of 0.2% ropivacaine or 0.9% saline as placebo. Patients and clinical and study personnel were blinded to group allocation. Perioperative care was standardized and this included spinal anesthesia and oral multimodal analgesia. The primary outcome was a multidimensional (pain, physical comfort, physical independence, emotions, and psychological support) patient-reported quality of recovery scale, QoR-15, measured on POD 1.

RESULTS

One hundred sixty patients were randomized; 6 patients were withdrawn after randomization and 2 patients had incomplete outcome data. The intention-to-treat analysis included 152 patients. The median (interquartile range [IQR]) QoR-15 score on POD 1 of the ropivacaine group was 119.5 (102-124), compared with the placebo group which had a median (IQR) of 115 (98-126). The median difference of 2 (95% confidence interval [CI], -4 to 7; P = .56) was not statistically or clinically significant. An as-per-protocol sensitivity analysis of 146 patients who received spinal anesthesia without general anesthesia, and the allocated intervention, also showed no evidence of a significant difference between groups. Secondary outcomes (worst pain numerical rating scale at rest and with movement on POD 1, opioid consumption on PODs 1 and 2, mobilization on POD 1, Brief Pain Inventory severity and interference on POD 90, and length of stay) were similar in both groups.

CONCLUSIONS

LIA with 0.2% ropivacaine when compared with 0.9% saline as placebo did not improve quality of recovery 1 day after anterior THA.

Technology-assisted rehabilitation following total knee or hip replacement for people with osteoarthritis: a systematic review and meta-analysis

BACKGROUND

To evaluate the effectiveness and safety of technology-assisted rehabilitation following total hip/knee replacement (THR/TKR).

METHODS

Six electronic databases were searched without language or time restrictions for relevant studies: MEDLINE, EMBASE, Cochrane Library, CINAHL, SPORTDiscus, Physiotherapy Evidence Database (PEDro); from inception to November 7th, 2018. Two reviewers independently applied inclusion criteria to select eligible randomised controlled trials (RCTs) that investigated the effectiveness of technology-based interventions, compared with usual care or no intervention for people undergoing THR/TKR. Two reviewers independently extracted trial details (e.g. patients' profile, intervention, outcomes, attrition and adverse events). Study methodological quality was assessed using the PEDro scale. Quality of evidence was critically appraised using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

We identified 21 eligible studies assessing telerehabilitation, game- or web-based therapy. There were 17 studies (N = 2188) in post-TKR rehabilitation and 4 studies (N = 783) in post-THR rehabilitation. Compared to usual care, technology-based intervention was more effective in reducing pain (mean difference (MD): - 0.25; 95% confidence interval (CI): - 0.48, - 0.02; moderate evidence) and improving function measured with the timed up-and-go test (MD: -7.03; 95% CI: - 11.18, - 2.88) in people undergoing TKR. No between-group differences were observed in rates of hospital readmissions or treatment-related adverse events (AEs) in those studies.

CONCLUSION

There is moderate-quality of evidence showed technology-assisted rehabilitation, in particular, telerehabilitation, results in a statistically significant improvement in pain; and low-quality of evidence for the improvement in functional mobility in people undergoing TKR. The effects were however too small to be clinically significant. For THR, there is very limited low-quality evidence shows no significant effects.

Population Pharmacokinetics of Periarticular Ketorolac in Adult Patients Undergoing Total Hip or Total Knee Replacement Surgery

BACKGROUND

Ketorolac tromethamine has been used for joint infiltration by the orthopedic surgeons as a part of postoperative multimodal analgesia. The objective of this study is to investigate the pharmacokinetic properties of S (-) and R (+) enantiomers of ketorolac in adult patients undergoing total hip (THA) and knee arthroplasty (TKA).

METHODS

Adult patients with normal preoperative renal function received a periarticular infiltration of 30 mg of ketorolac tromethamine along with 100 mL of 0.2% ropivacaine and 1 mg of epinephrine at the end of their THA or TKA surgery. Blood samples were taken from a venous cannula at various time points after infiltration. Pharmacokinetic modeling was performed using PMetrics 1.5.0.

RESULTS

From 18 participants, 104 samples were analyzed. The peak plasma concentration for S (-) ketorolac was found to be lower than that of R (+) ketorolac, for both THA (0.19-1.22 mg/L vs 0.39-1.63 mg/L, respectively) and TKA (0.28-0.60 mg/L vs 0.48-0.88 mg/L, respectively). The clearance of the S (-) ketorolac enantiomer was higher than R (+) ketorolac (4.50 ± 2.27 vs 1.40 ± 0.694 L/h, respectively).

CONCLUSIONS

Our study demonstrates that with periarticular infiltration, S (-) ketorolac was observed to have increased clearance rate and highly variable volume of distribution and lower peak plasma concentration compared to R (+) ketorolac.

Current Trends in Clinical Practice for the Direct Anterior Approach Total Hip Arthroplasty

BACKGROUND

Despite increased popularity of the direct anterior approach (DAA) for total hip arthroplasty (THA), current practice trends and specific driving factors leading to adoption are not well established.

METHODS

We conducted an electronic e-mail survey of members of the American Association of Hip and Knee Surgeons inquiring into the choice of THA surgical approach, perceptions of clinical outcomes, and economic implications associated with the DAA.

RESULTS

Of 996 total respondents (44.3% American Association of Hip and Knee Surgeons member response rate), 56.2% currently perform the DAA. DAA performers have been in practice for statistically less time than non-performers (17.0 years vs 20.9 years, P < .001). Similarly, high-volume DAA surgeons have been in practice for less time than low-volume surgeons. DAA performers felt that revision case status (79.3%), complex anatomy (65.0%), and body habitus (53.0%) were factors leading to preferential use of the posterior approach. We also provide comprehensive data for perceived outcomes comparing the DAA and posterior approach. For current non-performers, the top reasons for not utilizing the DAA were feelings of worse outcomes, no clinical benefit, and concern for the learning curve. Economically, 76.1% of DAA performers reported increased patient market share by performing the DAA while 65.8% of non-performers endorsed lost patient market share. Only 3.0% of current non-performers plan to adopt the DAA in the future.

CONCLUSION

This is the first study of its kind to highlight current trends and clinical practices from a surgeon perspective regarding the DAA. Specifically, it provides comprehensive data regarding perceptions of clinical outcomes, practice economics, and driving factors for choice of surgical approach for surgeons who do and do not perform the DAA.

Current Practice Trends in Primary Hip and Knee Arthroplasties Among Members of the American Association of Hip and Knee Surgeons: A Long-Term Update

At the 2018 Annual Meeting of the American Association of Hip and Knee Surgeons, an audience response poll was conducted to determine current practice patterns among its members. The poll pertained to primary total hip arthroplasties and primary total knee arthroplasties, and results were compared to the findings from similar polls completed at previous annual meetings of the American Association of Hip and Knee Surgeons. This article summarizes the current findings and compares trends over time from the previous polls.

Comparison of Hospital Readmission After Total Hip and Total Knee Arthroplasty vs Spinal Surgery After Implementation of the Hospital Readmissions Reduction Program

IMPORTANCE

The Hospital Readmissions Reduction Program (HRRP) was recently expanded to penalize excessive readmissions after total hip arthroplasty (THA) and total knee arthroplasty (TKA). These are the first surgical procedures to be included in the HRRP.

OBJECTIVE

To determine whether the HRRP was associated with a greater decrease in readmissions after targeted procedures (THA and TKA) compared with similar nontargeted procedures (lumbar spine fusion and laminectomy).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted of patients 50 years or older among all payers in the Nationwide Readmissions Database who underwent THA, TKA, lumbar spine fusion, or laminectomy between January 1, 2010, and September 30, 2015. Multivariable logistic regression and interrupted time-series models were used to calculate and compare 30-day readmission trends in 3 periods associated with the HRRP: preimplementation (January 2010-September 2012), implementation (October 2012-September 2014), and penalty (October 2014-September 2015). Statistical analysis was performed from January 1, 2010, to September 30, 2015.

EXPOSURES

Announcement and implementation of the HRRP.

MAIN OUTCOMES AND MEASURES

Readmission within 30 days after hospitalization for THA, TKA, lumbar spine fusion, or laminectomy surgery.

RESULTS

The study included 6 687 077 (58.3% women and 41.7% men; mean age, 66.7 years; 95% CI, 66.7-66.8 years) weighted hospitalizations for THA, TKA, lumbar spine fusion, and laminectomy surgery: 4 765 466 hospitalizations for targeted conditions and 1 921 611 for nontargeted conditions. After passage of the Patient Protection and Affordable Care Act, the risk-adjusted rates of readmission after all procedures decreased in a similar fashion. Implementation of the HRRP was associated with a 0.018% per month decrease in the rate of readmission (95% CI, -0.025% to -0.010%) after targeted procedures, which was not observed after nontargeted procedures (slope per month, -0.003%; 95% CI, -0.016% to 0.010%). Penalties were not associated with a greater decrease in readmission for either targeted or nontargeted procedures.

CONCLUSIONS AND RELEVANCE

These results appear to be consistent with hospitals responding to the future possibility of penalties by reducing readmissions after surgical procedures targeted by the HRRP.

Clinical efficacy of orthopilot navigation system versus conventional manual of total hip arthroplasty: A systematic review and meta-analysis

BACKGROUND

To compare the clinical efficacy between Orthopilot navigation system and conventional manual surgery in total hip arthroplasty (THA).

METHODS

Electronic databases were searched to identify randomized controlled trials (RCTs) investigating Orthopilot navigation system versus conventional manual in patients undergoing THA. Outcome measurements include anteversion angle, inclination angle, preoperative leg length discrepancy, postoperative leg length discrepancy and femoral offset. Statistical software Stata 12.0 was used for data-analysis.

RESULTS

A total of 5 studies were finally included in this meta-analysis. The results showed that the conventional manual group have a less anteversion angle than that in Orthopilot navigation system group (weighted mean difference (WMD) = 4.67, 95% confidence interval (CI) = 3.53, 5.82, P = .000). And pooled analysis showed that the inclination angle in Orthopilot navigation group was less than that in conventional manual group (WMD = -4.19, 95% CI = -8.00, -0.37, P = .031). There was no significant difference between the preoperative leg length discrepancy and postoperative leg length discrepancy (P > .05). Orthopilot navigation system compared with conventional manual procedure was associated with decreased of femoral offset by 2.76 (WMD = -2.76, 95%CI = -3.90, -1.62, P = .000).

CONCLUSION

Both Orthopilot navigation system and conventional THA result in significant improvements in patient function with similar overall complication rates and have their own edges in cup position.

[Management of infection associated with prosthetic arthroplasty : What's new ?]

Total hip and knee arthroplasties are associated with a risk of infection ranging between 0.5 and 2 %, and pose a difficult diagnosis and prolonged treatment for the infected patient. The treatment must be multidisciplinary, consisting of orthopaedic surgeons, infectious diseases specialists, and radiologists, aiming at an accurate diagnosis and appropriate decisions, adapted to the clinical situation of the patient. We review the latest consensus on the diagnosis and management of these infections.

Relative survival following hemi-and total hip arthroplasty for hip fractures in Sweden

BACKGROUND

Hip fractures are a common problem in the ageing population. Hip arthroplasty is the common treatment option for displaced intracapsular neck of femur fractures. Even though hip replacements are successful in restoring mobility, reducing pain and diminishing loss of health-related quality of life, the potential impact of a hip fracture on life expectancy as well as the postoperative mortality need consideration. The purpose of this study was to describe the mid-term relative survival rate for a cohort of Swedish patients whom underwent total- or hemiarthroplasty surgery following hip fracture. We also explored whether the survival rate is prosthesis-type specific and influenced by comorbidities, sex, socioeconomic and surgical factors.

METHODS

Using prospectively collected information of the Swedish Hip Arthroplasty Register-linked database we identified 43,891 patients operated between 2005 and 2012. Patient- and surgery-specific data in combination with socio-economic data were available for this analysis. We studied relative survival rate and used multivariable modelling with Cox Proportional Hazards Model in Transformed Time.

RESULTS

Compared to the Swedish general population the baseline excess hazard was very high in the first half year after the operation, thereafter the excess hazard decreased but remained non-negligible through the 8 years' follow-up period. The mortality rate of males was higher compared to women. Higher Elixhauser comorbidity index (ECI) was associated with worsening survival. However, patients who had ECI = 0 had higher mortality than patients with ECI =1 the first 420 days post fracture. Patients with a hemiarthroplasty had a worse survival than patients with a total hip arthroplasty. Of the hospital types considered university hospitals had lower survival rate. Younger patients had a greater loss of expected life span than patients who suffer hip fracture in their more advanced ages.

CONCLUSIONS

Swedish hip fracture patients who undergo arthroplasty surgery had a high excess hazard of dying in the first half year following surgery, and this excess hazard never subsided to negligible levels at least up to 8 years after surgery. Interestingly having no prior record of illnesses worsened the initial mortality. Men living alone had the highest long-term excess mortality.

Bone microarchitecture, biomechanical properties, and advanced glycation end-products in the proximal femur of adults with type 2 diabetes

Skeletal fragility is a major complication of type 2 diabetes mellitus (T2D), but there is a poor understanding of mechanisms underlying T2D skeletal fragility. The increased fracture risk has been suggested to result from deteriorated bone microarchitecture or poor bone quality due to accumulation of advanced glycation end-products (AGEs). We conducted a clinical study to determine whether: 1) bone microarchitecture, AGEs, and bone biomechanical properties are altered in T2D bone, 2) bone AGEs are related to bone biomechanical properties, and 3) serum AGE levels reflect those in bone. To do so, we collected serum and proximal femur specimens from T2D (n = 20) and non-diabetic (n = 33) subjects undergoing total hip replacement surgery. A section from the femoral neck was imaged by microcomputed tomography (microCT), tested by cyclic reference point indentation, and quantified for AGE content. A trabecular core taken from the femoral head was imaged by microCT and subjected to uniaxial unconfined compression tests. T2D subjects had greater HbA₁c (+23%, p ≤ 0.0001), but no difference in cortical tissue mineral density, cortical porosity, or trabecular microarchitecture compared to non-diabetics. Cyclic reference point indentation revealed that creep indentation distance (+18%, p ≤ 0.05) and indentation distance increase (+20%, p ≤ 0.05) were greater in cortical bone from T2D than in non-diabetics, but no other indentation variables differed. Trabecular bone mechanical properties were similar in both groups, except for yield stress, which tended to be lower in T2D than in non-diabetics. Neither serum pentosidine nor serum total AGEs were different between groups. Cortical, but not trabecular, bone AGEs tended to be higher in T2D subjects (21%, p = 0.09). Serum AGEs and pentosidine were positively correlated with cortical and trabecular bone AGEs. Our study presents new data on biomechanical properties and AGEs in adults with T2D, which are needed to better understand mechanisms contributing to diabetic skeletal fragility.

Trends in Total Hip Arthroplasty Under the Patient Protection and Affordable Care Act: A National Database Analysis Between 2008 and 2015

The Patient Protection and Affordable Care Act expanded health coverage for low-earning individuals and families. With more Americans having access to care, the use of elective procedures, such as total hip arthroplasty (THA), was expected to increase. Therefore, the aim of this study was to evaluate trends in THA before and after the initiation of the Patient Protection and Affordable Care Act regarding race, age, body mass index, and sex between 2008 and 2015. The National Surgical Quality Improvement Program database was queried for all individuals who had undergone primary THA between 2008 and 2015. This yielded a total of 104,209 patients. Descriptive statistics were used to analyze patient-level data. A Cochran-Armitage test assessed trends in categorical data points over time. Analysis indicated an increased percentage of blacks or African Americans undergoing THA (7.8% vs 9.2%, P<.001), followed by Native Americans or Pacific Islanders (0.0% vs 0.4%, P<.001), American Indians or Alaskan Natives (0.3% vs 0.5%, P=.016), and Asians (1.4% vs 1.5%, P=.002). An increased percentage of patients 55 to 80 years old received THAs (68.6% vs 74.1%, P<.001). The percentage of patients with a body mass index of 25.0 to 29.9 kg/m², 30.0 to 34.9 kg/m², and 35.0 to 39.9 kg/m² increased (32.9% vs 33.1%, 24.2% vs 25.6%, 12.6% vs 13.3%, respectively, P<.001 for all). These findings may provide insight on the changing patient characteristics for orthopedic surgeons performing THA. Furthermore, these findings may inform health policy makers interested in increasing access to procedures underutilized by specific patient populations and the creation of strategies to meet increased demand. [Orthopedics. 2018; 41(4):e534-e540.].

A systematic review of psychological interventions in total hip and knee arthroplasty

BACKGROUND

The current practice in elective orthopaedics does not routinely include psychological interventions despite evidence that psychological factors such as personality, anxiety, depression and negative thinking styles can influence outcomes and recovery from surgery. The objective of this paper was to review the effectiveness of psychological interventions used in conjunction with total hip (THA) and knee arthroplasty (TKA), in improving patient reported joint outcomes.

METHODS

An extensive literature search was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Search terms included psychology, interventions, and orthopaedics. Articles were included if they were randomised controlled trials (RCTs) of psychological interventions involving active patient participation measured with patient reported joint outcomes in patients undergoing hip or knee arthroplasty.

RESULTS

A total of 19,489 titles were screened. Seven studies met the inclusion criteria and were included. Five of seven studies did not show improvements in patient reported outcomes after surgery. Specifically, psycho-education alone was not effective at improving patient reported joint outcomes in two out of two studies.

CONCLUSION

The current literature does not support routine psychological interventions for TKA and THA. However, it should be noted that the literature for psychological interventions in conjunction with TKA and THA is still in its infancy. This gap in the literature is surprising, considering the importance of the role of psychological factors in recovery. Further RCTs with long term follow ups, multidisciplinary involvement, and more comprehensive and focused interventions that go beyond educating patients are needed. Future studies should account for the demand effect, include measures of psychological variables to determine whether psychological interventions are more beneficial for some patients compared to others, and compare the different modes of delivery and timing of interventions to determine the optimal nature and duration of psychological interventions for TKA and THA.

Outpatient-Focused Joint Arthroplasty Is the Future: The Midwest Center for Joint Replacement Experience

BACKGROUND

Perhaps, the most significant developments in joint arthroplasty in the past decade have been in the area of multimodal perioperative management reducing pain, nausea, and length of stay leading to outpatient arthroplasty.

METHODS

Over a 2-year period, we performed 1230 arthroplasty cases including partial knee, total hip, total knee, and selected revision cases.

RESULTS

Patient satisfaction ranged from 98% to 100% great/good. Ninety-eight percent of patients were discharged the same day. There were no readmissions for pain control and an overall readmission rate of 2%.

CONCLUSION

The outpatient program centers on the patient needs, family engagement, essentials of home recovery, preoperative education, efficient surgery, and a surgeon-controlled environment with a highly standardized care. This is a distinct shift in today's health-care environment, which has seen the expansion of regulatory demands; focus on Electronic Health Record, and distractions from real discussions of demonstrated value creation. The future is bright for both ambulatory surgery center and hospital development of successful outpatient joint arthroplasty program for patients and surgeons alike.

Total hip arthroplasty to treat acetabular protrusions secondary to rheumatoid arthritis

BACKGROUND

The treatment of acetabular protrusions during total hip arthroplasty of patients with rheumatoid arthritis is difficult. A lack of bone stock, deficient medial cup support, and medialization of the joint center in those with protrusio acetabuli must be addressed during acetabular reconstruction. The purpose of this study was to assess the short-term clinical results of total hip arthroplasty in patients with severe acetabular protrusions secondary to rheumatoid arthritis.

METHODS

From January 2011 to November 2014, 18 patients (20 hips) with severe acetabular protrusions secondary to rheumatoid arthritis underwent total hip arthroplasties using a non-cement impaction and auto-bone-grafting method with resection of the femoral head to treat the acetabular protrusion. The Harris hip scoring system was used to evaluate hip function during follow-up; X-rays were taken to assess the extent of prosthesis loosening and bone graft healing.

RESULTS

The operation time ranged from 55 to 131 min, averaging 89.5 ± 8.1 min. The blood loss was 165-480 mL (295 ± 10.9 mL). No blood vessel or nerve damage and no acetabular or femoral fracture occurred. The follow-up duration was 4.5 ± 1.7 years. Postoperative X-rays revealed autologous bone graft/acetabular fusion at 4.5 months post-surgery. The Harris hip scores increased significantly, from 55.3 ± 9.5 to 92.2 ± 12.7, after the operation (P < 0.01). The distance from the center of the femoral head to Kohler's line increased from 19.87 ± 3.9 mm to 21.5 ± 3.5 mm after the operation (P < 0.01). During follow-up, no hip acetabular prosthesis loosening was evident.

CONCLUSIONS

For patients with protrusio acetabuli secondary to rheumatoid arthritis, the use of a cementless, trabecular, metal modular cup allowing peripheral press fitting and restoration of bone stock via impacted autologous bone grafting are both technically straightforward and appear to yield satisfactory short-term results.

Trends in Medicare Reimbursement for Orthopedic Procedures: 2000 to 2016

Understanding trends in reimbursement is critical to the financial sustainability of orthopedic practices. Little research has examined physician fee trends over time for orthopedic procedures. This study evaluated trends in Medicare reimbursements for orthopedic surgical procedures. The Medicare Physician Fee Schedule was examined for Current Procedural Terminology code values for the most common orthopedic and nonorthopedic procedures between 2000 and 2016. Prices were adjusted for inflation to 2016-dollar values. To assess mean growth rate for each procedure and subspecialty, compound annual growth rates were calculated. Year-to-year dollar amount changes were calculated for each procedure and subspecialty. Reimbursement trends for individual procedures and across subspecialties were compared. Between 2000 and 2016, annual reimbursements decreased for all orthopedic procedures examined except removal of orthopedic implant. The orthopedic procedures with the greatest mean annual decreases in reimbursement were shoulder arthroscopy/decompression, total knee replacement, and total hip replacement. The orthopedic procedures with the least annual reimbursement decreases were carpal tunnel release and repair of ankle fracture. Rate of Medicare procedure reimbursement change varied between subspecialties. Trauma had the smallest decrease in annual change compared with spine, sports, and hand. Annual reimbursement decreased at a significantly greater rate for adult reconstruction procedures than for any of the other subspecialties. These findings indicate that reimbursement for procedures has steadily decreased, with the most rapid decrease seen in adult reconstruction. [Orthopedics. 2018; 41(2):95-102.].

Variation in Prosthetic Joint Infection and treatment strategies during 4.5 years of follow-up after primary joint arthroplasty using administrative data of 41397 patients across Australian, European and United States hospitals

BACKGROUND

To identify best practices and quality improvement initiatives, we aimed to assess whether the incidence of Periprosthetic Joint Infection (PJI) and treatment strategies differed across patients treated in Australian, European and United States (US) hospitals.

METHODS

Routinely collected administrative data for 41397 patients undergoing a primary total hip or knee arthroplasty between July 2007-December 2010 across 22 hospitals were included. Patients were followed for 2 years looking for PJI occurrence, defined as early (within 4 weeks) and late PJI, and surgical treatment during 2.5 years after PJI diagnosis. Logistic and Poisson regression models were used to test for differences in PJI occurrence and treatment strategies across the three geographical regions, adjusted for age, sex, joint and Elixhauser comorbidity groups.

RESULTS

PJI occurrence varied from 1.4% in European to 1.7% in Australian patients, which were significantly higher than US patients after adjustment for patient characteristics (OR 1.24 [1.01-1.52] and 1.40 [1.03-1.91] respectively). Early PJIs varied between 0.3% in European to 0.6% in Australian patients, but adjusted rates were similar. Revision following PJI was significantly lower in Australian than in US patients (OR 0.46 [0.25-0.86]) as were the total number of revisions (RR 0.51 [0.36-0.71]) and number of surgical procedures (RR 0.60 [0.44-0.81]) used to treat PJI.

CONCLUSION

The overall PJI rate was significantly higher in Australian patients, but fewer procedures were needed to treat these PJIs. Future research should reveal whether this reflects PJIs caught earlier or less severe when diagnosed, and whether this is associated with the longer length of stay after primary arthroplasty in Australian hospitals.

Total Hip Arthroplasty and Hemiarthroplasty: US National Trends in the Treatment of Femoral Neck Fractures

There is controversy regarding whether total hip arthroplasty (THA) or hemiarthroplasty (HA) is the treatment preferred for displaced intracapsular femoral neck fractures (FNFs). Using the US National Hospital Discharge Survey, we found that, of 12,757 patients admitted for FNF between 2001 and 2010, 4.6% underwent THA and 52.5% underwent HA. More of both procedures were performed over time. Mean age was higher for HA patients. Hospitalization duration and blood transfusion rates were higher for THA. There were region-based differences in frequency of THA and significant hospital-size-based differences in frequency of HA, possibly because of differences in regional training and subspecialist availability. In addition, a larger proportion of THA patients was covered by private insurance.

The Centralization of Total Joint Arthroplasty in New York State An Analysis of 168,247 Cases

We identified 168,247 total hip and total knee arthroplasties performed in New York State between 2010 and 2012 to examine the evidence for increased geographical and institutional centralization of these procedures. We measured the increased growth of high volume institutions as compared to lower volume hospitals in New York State. We found a high proportion of total arthroplasties already performed in the dozen biggest hospitals in New York back in 2010 and a significant higher growth of these high volume, "centers of excellence," hospitals when compared to low volume hospitals.

Equity of publicly-funded hip and knee joint replacement surgery in New Zealand: results from a national observational study

AIM

This study examines equity in the provision of publicly-funded hip and knee total joint replacement (TJR) surgery in New Zealand between 2006 and 2013 to: 1) investigate national rates by demographic characteristics; 2) describe changes in national rates over time; and 3) compare rates of provision between District Health Boards (DHBs).

METHODS

Hospital discharge data for people aged 20 years or over who had at least one hip or knee TJR between 2006 and 2013 was obtained from the Ministry of Health's National Minimum Dataset.

RESULTS

Higher TJR rates were observed among those aged 75-84 years, females, those of Māori ethnicity, those not living in rural or main urban areas and those in the most deprived socio-economic groups. TJRs increased from 7,053 in 2006 to 8,429 in 2013, however the rate was highest in 2007. In 2012-13, age-ethnicity-standardised rates varied between DHBs from 196 to 419/100,000 person years, with larger DHBs having lower rates than smaller DHBs.

CONCLUSION

There was evidence of geographic inequity in TJR provision across New Zealand. Despite increased numbers of procedures, rates of publicly-funded TJR surgery are barely keeping up with population increases. Reasons behind differences in provision should be examined.

The Effects of Hospital Closure on the Local Utilization of Total Joint Replacement The Queens Experience

Since 2000, 31 hospitals have closed in New York State. This has primarily been due to the financial difficulties endured by these institutions, many of which were located in areas inhabited predominantly by patients of lower socioeconomic status. Additionally, recommendations by the NYS Depart- ment of Health (Berger Commission) cited excess hospital capacity as a driver for the struggles of the healthcare delivery system in New York, forcing financially stable in - stitutions to close their doors as well. Data has shown that outcomes are improved when complex procedures, such as joint arthroplasty, are performed at high volume hospitals. However, for patients in the outer boroughs of NYC, travel to these specialized centers may be too expensive and physi- cally difficult for poor patients with severe osteoarthritis. Using the SPARCS database, we identified a temporary decrease in utilization of lower extremity total joint replace - ment in the areas immediately adjacent to closed hospitals. This does not appear to have a lasting effect as illustrated by quick return back to pre-closure trends and further in- crease when compared with regional trends. This effect is more pronounced in urban areas where public transportation and traffic are more of an issue for patients, making it more difficult to travel with the goal of seeking care elsewhere.

Changes in Payment Regulation and Acute Care Use for Total Hip Replacement: Trends in Length of Stay, Costs, and Discharge, 1997-2012

PURPOSE

To describe trends in the length of stay (LOS), costs, mortality, and discharge destination among a national sample of total hip replacement (THR) patients between 1997 and 2012.

DESIGN

Longitudinal retrospective design

METHODS

Descriptive analysis of the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample data.

FINDINGS

A total of 3,516,636 procedures were performed over the study period. Most THR patients were women, and the proportion aged 44-65 years increased. LOS decreased from 5 to 3 days. Charges more than doubled, from $22,184 to $53,901. Deaths decreased from 43 to 12 deaths per 10,000 patients. THR patients discharged to an institutional setting declined, while those discharged to the community increased.

CONCLUSION

We found an increase in THR patients, who were younger, women, had private insurance, and among those discharged to community-based settings.

CLINICAL RELEVANCE

Findings have implications for patient profiles, workplace environments, quality improvement, and educational preparation of nurses in acute and postacute settings.

Incidence, surgical procedures, and outcomes of hip fracture among elderly type 2 diabetic and non-diabetic patients in Spain (2004-2013)

Hip fracture is a serious public health problem. We used Spanish hospital discharge data to examine trends in 2004-2013 in the incidence of hip fracture among elderly patients. We found that hip fracture incidence is higher in subjects with than without diabetes and is much higher among women than men.

INTRODUCTION

This study aimed to describe trends in the incidence of hip fracture hospitalizations, use of surgical procedures, and hospital outcomes among elderly patients with and without type 2 diabetes mellitus (T2DM) in Spain, 2004-2013.

METHODS

We selected all patients with a discharge primary diagnosis of hip fracture using the Spanish national hospital discharge database. Discharges were grouped by diabetes status: Incidences were calculated overall and stratified by diabetes status and year. We analyzed surgical procedures, length of hospital stay (LOHS), and in-hospital mortality (IHM). Multivariate analysis was adjusted by age, year, comorbidity, and in-hospital complications (IHC).

RESULTS

From 2004 to 2013, 432,760 discharges with hip fracture were identified (21.3 % suffered T2DM). Incidence among diabetic men and women increased until year 2010 and then remained stable. Diabetic women have three times higher incidence than diabetic men. Incidences and IHC were higher among patients with diabetes beside sex. The proportion of patients that underwent internal fixation increased for all groups of patients and the arthroplasty repair decreased. After multivariate analysis, IHM has improved over the study period for all patients. Suffering diabetes was associated to higher IHM in women (odds ratio (OR) 1.12; 95 % confidence interval (CI) 1.07-1.17).

CONCLUSIONS

Hip fracture incidence is higher in subjects with than without diabetes and is much higher among women than men. In diabetic patients, incidence rates increased initially but have leveled from 2010 onwards. For all groups, the use of internal fixation has increased overtime and IHM and LOHS have decreased from 2004 to 2013.

Temporal trends in primary and revision total knee and hip replacement in Taiwan

BACKGROUND

Total joint replacement (TJR) accounts for a substantial proportion of the total expenditures for health care. Efficient utilization of health resources requires information regarding the trends of TJR. This study investigated the association of TJR with the demographic characteristics in Taiwan from 1998 to 2009. It also estimated the demand for total knee replacement (TKR) and total hip replacement (THR) in the next two decades.

METHODS

International Classification of Diseases-9 (ICD-9) procedure codes were used to identify the data for primary and revision TKRs and THRs between the years 1998 and 2009 from Taiwan's National Health Insurance Research Database. Age- and sex-specific rates of such procedures were calculated. The trend in TJR rate and its future estimation were studied with regression analyses.

RESULTS

From 1998 to 2009, the number of primary TKRs increased by 99.1% and that of primary THRs increased by 11.3%. The number of revision TKRs increased by 3.1% and that of revision THRs decreased by 13.2%. Compared with their respective rates in 2005, the rates of primary TKR and primary THR were projected to increase by 508.2% and 69.7%, respectively, in 2030. The rate of revision TKR was predicted to increase by 75.3% and that of revision THR to decrease by 36.1%.

CONCLUSION

This study gives an insight into the current status burden of TJR in Taiwan. TJR rate projection would be useful for future planning of budget and resources for TJR in Taiwan.

Outcome Measures in Total Joint Arthroplasty: Current Status, Challenges, and Future Directions

Total joint arthroplasty (TJA) is the most commonly performed surgical procedure for the treatment of advanced degenerative joint diseases. Numerous outcome measures for TJA have been developed, which can be reported by physicians, patients, or both. Although outcome tools were traditionally centered on morbidity, mortality, and implant survival, the focus has evolved over recent years to joint-specific, disease-specific, activity-specific, general well-being, and quality of life assessments. However, despite the importance of outcome measures in a time of growing demand for TJA and increased government scrutiny fueled by high implant costs, there remains no "gold standard" method to assess the impact of TJA. The aim of this review is to evaluate the currently available literature on outcome measures in joint arthroplasty, highlighting the strengths and limitations of commonly used instruments. Because outcomes are influenced by a multitude of intangible factors, there is an increasing role for assessing patient satisfaction as a simple way to account for the complex aspects of care. Strategies including proper patient selection and establishing realistic expectations preoperatively are critical to optimizing outcomes. In an era of increasing public scrutiny, the current state of conflicting results and variable correlations among outcome measures implores the need for a standardized system that should incorporate a metric for patient satisfaction adjusted for preoperative expectations.

Comparative Epidemiology of Revision Arthroplasty: Failed THA Poses Greater Clinical and Economic Burdens Than Failed TKA

BACKGROUND

Revision THA and TKA are growing and important clinical and economic challenges. Healthcare systems tend to combine revision joint replacement procedures into a single service line, and differences between revision THA and revision TKA remain incompletely characterized. These differences carry implications for guiding care and resource allocation. We therefore evaluated epidemiologic trends associated with revision THAs and TKAs.

QUESTIONS/PURPOSES

We sought to determine differences in (1) the number of patients undergoing revision TKA and THA and respective demographic trends; (2) differences in the indications for and types of revision TKA and THA; (3) differences in patient severity of illness scoring between THA and TKA; and (4) differences in resource utilization (including cost and length of stay [LOS]) between revision THA and TKA.

METHODS

The Nationwide Inpatient Sample (NIS) was used to evaluate 235,857 revision THAs and 301,718 revision TKAs between October 1, 2005 and December 31, 2010. Patient characteristics, procedure information, and resource utilization were compared across revision THAs and TKAs. A revision burden (ratio of number of revisions to total number of revision and primary surgeries) was calculated for hip and knee procedures. Severity of illness scoring and cost calculations were derived from the NIS. As our study was principally descriptive, statistical analyses generally were not performed; however, owing to the large sample size available to us through this NIS analysis, even small observed differences presented are likely to be highly statistically significant.

RESULTS

Revision TKAs increased by 39% (revision burden, 9.1%-9.6%) and THAs increased by 23% (revision burden, 15.4%-14.6%). Revision THAs were performed more often in older patients compared with revision TKAs. Periprosthetic joint infection (25%) and mechanical loosening (19%) were the most common reasons for revision TKA compared with dislocation (22%) and mechanical loosening (20%) for revision THA. Full (all-component) revision was more common in revision THAs (43%) than in TKAs (37%). Patients who underwent revision THA generally were sicker (> 50% major severity of illness score) than patients who underwent revision TKA (65% moderate severity of illness score). Mean LOS was longer for revision THAs than for TKAs. Mean hospitalization costs were slightly higher for revision THA (USD 24,697 +/- USD 40,489 [SD]) than revision TKA (USD 23,130 +/- USD 36,643 [SD]). Periprosthetic joint infection and periprosthetic fracture were associated with the greatest LOS and costs for revision THAs and TKAs.

CONCLUSIONS

These data could prove important for healthcare systems to appropriately allocate resources to hip and knee procedures: the revision burden for THA is 52% greater than for TKA, but revision TKAs are increasing at a faster rate. Likewise, the treating clinician should understand that while both revision THAs and TKAs bear significant clinical and economic costs, patients undergoing revision THA tend to be older, sicker, and have greater costs of care.

[RESEARCH PROGRESS OF OSTEOTOMY IN TOTAL HIP ARTHROPLASTY TO TREAT CROWE TYPE IV DEVELOPMENTAL DYSPLASIA OF THE HIP]

OBJECTIVE

To summarize the methods and complications of osteotomy in total hip arthroplasty (THA) to treat Crowe type IV developmental dysplasia of the hip (DDH) so as to provide the reference for selection of surgical procedures.

METHODS

The literature concerning THA for DDH was reviewed, and the effectiveness and complications were summarized in different methods.

RESULTS

At present, four osteotomies are commonly used in DDH, including transtrochanteric osteotomy, subtrochanteric osteotomy, lesser trochanteric osteotomy, and distal femoral osteotomy. Transtrochanteric osteotomy and subtrochanteric osteotomy can effectively adjust leg length, correct femoral anteversion and avoid nerve injury, but transtrochanteric osteotomy may cause bone fracture and abductor injury. Lesser trochanteric osteotomy is scarcely used because of its poor effectiveness. Distal femoral osteotomy is usually used in patients with knee deformity.

CONCLUSION

For patients with Crowe type IV DDH complicated by severe femoral dislocation and soft tissue spasm, subtrochanteric osteotomy should be selected, whereas it needs an associated standard focusing on how to select the osteotomy shape and length in subtrochanteric ostetomy, which needs an advanced research.

Current trends and projections in the utilisation rates of hip and knee replacement in New Zealand from 2001 to 2026

AIM

This study aimed to estimate the demand for total hip (THR) and knee replacements (TKR) by 2026 within New Zealand (NZ) and show how demographic factors are likely to influence this projection.

METHOD

Yearly population data from the NZ Census was compared to the NZ Joint Register from 2001-2011 and ethnic and gender specific data was organised into 5 year age groups from 35 years to calculate the incidence for each age group. Poisson regression analysis was used to project the incidence for 2026 and to evaluate the independent associations between age, gender and ethnicity.

RESULTS

Between 2001 and 2011 the incidence of THR and TKR increased by 8.20% and 52.20% respectively with a peak incidence in the 70-74 age group. Men were less likely to undergo both THR and TKR (OR 0.91, 95% CI 0.89-0.94 and OR 0.88, 95% CI 0.89-0.90). By 2026 the absolute number of THR and TKR is estimated to increase by 84% (8950 procedures) and 183% (8613 procedures) respectively. Europeans were the most likely to undergo THR compared to Maori, Pacific people or Asians (OR 0.72, 95% CI 0.67-0.74). There was a large increase in the age standardised incidence of TKR for Pacific people and they were more likely to undergo TKR than Europeans (OR 1.00, 95% CI 0.97-1.04).

CONCLUSION

Over the past decade, incidence of THR and TKR have increased, and by 2026, the number of THR and TKR is projected to increase by 84% and 183% respectively. This increase will create a significant socioeconomic burden which will necessitate prudent and focused healthcare strategies to ensure that there are adequate resources to meet this demand.

Outcomes following large joint arthroplasty: does socio-economic status matter?

BACKGROUND

We sought to determine whether socio-economic status (SES) is an independent predictor of outcome following total knee (TKR) and hip (THR) replacement in Australians.

METHODS

In this prospective cohort study, we included patients undergoing TKR and THR in a public hospital in whom baseline and 12-month follow-up data were available. SES was determined using the Australian Bureau of Statistics 'Index of Relative Advantage and Disadvantage'. Other independent variables included patients' demographics, comorbidities and procedure-related variables. Outcome measures were the International Knee Society Score and Harris Hip Score pain and function subscales, and the Short Form Health Survey (SF-12) physical and mental component scores.

RESULTS

Among 1,016 patients undergoing TKR and 835 patients undergoing THR, in multiple regression analysis, SES score was not independently associated with pain and functional outcomes. Female sex, older age, being a non-English speaker, higher body mass index and presence of comorbidities were associated with greater post-operative pain and poorer functional outcomes following arthroplasty. Better baseline function, physical and mental health, and lower baseline level of pain were associated with better outcomes at 12 months. In univariate analysis, for TKR, the improvement in SF-12 mental health score post arthroplasty was greater in patients of lower SES (3.8 ± 12.9 versus 1.5 ± 12.2, p=0.008), with a statistically significant inverse association between SES score and post-operative SF-12 mental health score in linear regression analysis (coefficient-0.28, 95% CI: -0.52 to -0.04, p=0.02).

CONCLUSIONS

When adjustments are made for other covariates, SES is not an independent predictor of pain and functional outcome following large joint arthroplasty in Australian patients. However, relative to baseline, patients in lower socioeconomic groups are likely to have greater mental health benefits with TKR than more privileged patients. Large joint arthroplasty should be made accessible to patients of all SES.

Failure rate of cemented and uncemented total hip replacements: register study of combined Nordic database of four nations

OBJECTIVE

To assess the failure rate of cemented, uncemented, hybrid, and reverse hybrid total hip replacements in patients aged 55 years or older.

DESIGN

Register study.

SETTING

Nordic Arthroplasty Register Association database (combined data from Sweden, Norway, Denmark, and Finland).

PARTICIPANTS

347,899 total hip replacements performed during 1995-2011.

MAIN OUTCOME MEASURES

Probability of implant survival (Kaplan-Meier analysis) along with implant survival with revision for any reason as endpoint (Cox multiple regression) adjusted for age, sex, and diagnosis in age groups 55-64, 65-74, and 75 years or older.

RESULTS

The proportion of total hip replacements using uncemented implants increased rapidly towards the end of the study period. The 10 year survival of cemented implants in patients aged 65 to 74 and 75 or older (93.8%, 95% confidence interval 93.6% to 94.0% and 95.9%, 95.8% to 96.1%, respectively) was higher than that of uncemented (92.9%, 92.3% to 93.4% and 93.0%, 91.8% to 94.0%), hybrid (91.6%, 90.9% to 92.2% and 93.9%, 93.1% to 94.5%), and reverse hybrid (90.7%, 87.3% to 93.2% and 93.2%, 90.7% to 95.1%) implants. The survival of cemented (92.2%, 91.8% to 92.5%) and uncemented (91.8%, 91.3% to 92.2%) implants in patients aged 55 to 64 was similar. During the first six months the risk of revision with cemented implants was lower than with all other types of fixation in all age groups.

CONCLUSION

The survival of cemented implants for total hip replacement was higher than that of uncemented implants in patients aged 65 years or older. The increased use of uncemented implants in this age group is not supported by these data. However, because our dataset includes only basic information common to all national registers there is potential for residual confounding.

Which type of exercise therapy is effective after hip arthroplasty? A systematic review of randomized controlled trials

BACKGROUND

Early multidisciplinary rehabilitation can improve the recovery after total hip arthroplasty (THA). However, optimal exercise therapy has not been defined. We aimed to answer the question: "Which type and/or timing of exercise therapy is effective following THA?"

DESIGN

Systematic review.

METHODS

We searched four databases: MEDLINE, PEDro, Cochrane Library, and Cinahl since January 2008 till December 2012. Literature before 2008 was not searched for, because it was previously analyzed by two systematic reviews. Eligible criteria for studies were: Randomized Controlled Trials (RCTs); English language; interventions on type and/or timing of physical exercise initiating after THA; outcome measures including at least one among impairment, activity, participation, quality of life, or length of stay in hospital.

RESULTS

Eleven papers on nine RCTs were identified. Trial quality was mixed. PEDro scores ranged from four to eight. Exercise therapy varied greatly in type and timing. Each of the nine RCTs addressed a specific issue and overall the results were sparse. In the early postoperative phase favorable outcomes were due to ergometer cycling and maximal strength training. Inconclusive results were reported for aquatic exercises, bed exercises without external resistance or without its progressive increase according to the overload principle, and timing. In the late postoperative phase (> 8 weeks postoperatively) advantages were due to weight-bearing exercises.

CONCLUSION

Insufficient evidence exists to build up a detailed evidence-based exercise protocol after THA. Sparse results from few RCTs support specific exercise types which should be added to the usual mobility training in THA patients.

Reduced re-infection rates with postoperative oral antibiotics after two-stage revision hip arthroplasty

BACKGROUND

Surgeons are often trying to decreased reinfection rates following two-stage reimplantation arthroplasty, which range from 3.2% to 13% because multiple staged revision procedures for infection can be costly and have high morbidity. We therefore asked: (1) Did the use of postoperative oral antibiotics reduce reinfection rates after 2-staged revision of THA? And (2) how did this compare with the infection rate after aseptic revision procedures?

METHODS

We identified all patients who underwent two-stage revision THA for a periprosthetic deep hip infection and found 66 patients (67 hips) who had a minimum 24 months' followup. Twenty-two of the 66 procedures (33%) were followed by a minimum of 14 days of postoperative oral antibiotics (mean, 36 days; range, 14 days to lifelong), while 44 were prescribed only immediate parenteral postoperative antibiotic therapy (mean, 1.3 days; range, 1-3 days). We then identified 407 patients (410 hips) who underwent aseptic revision hip arthroplasty and evaluated the infection rate in these patients for comparison; these patients were treated with 24 hours of postoperative parenteral antibiotics. The authors used previously described creteria to establish the presence of infection.

RESULTS

There were no reinfections in the group receiving oral postoperative antibiotics compared to six reinfections (13.6%) in the 44 patients not receiving oral antibiotics. We observed infection in 2 of the 410 hips (0.5%) revised for aseptic reasons.

CONCLUSIONS

We believe that our findings warrant further investigation for using postoperative oral antibiotics after reimplantation for periprosthetic infection in an effort to decrease the likelihood and risks associated with additional revision arthroplasty procedures.

[Total hip arthroplasty through anterior "minimal invasive" approach]

Total hip replacement has seen a tremendous development and has become one of the most successful surgical interventions in orthopaedics. While during the first decades of development of total hip arthroplasty the fixation of the implant into the bone was the main concern, the focus has shifted towards surgical technique and soft tissue handling. In order to avoid permanent soft tissue damage, muscular dysfunction and concerns in regards to cosmetics, minimal invasive and anatomic approaches have been developed. We here provide a short overview on various methods of total hip replacements and we describe our technique through a minimal invasive direct anterior approach. While muscle and nerve damage is minimal, this technique allows for a rapid rehabilitation and is associated with an excellent functional outcome and a minimal risk for dislocation.