Comparative outcomes of total joint arthroplasty

A prospective pre- and postoperative general health/quality-of-life factor comparison, using the Rand SF-36 Health Status Questionnaire (TyPE Specification, Quality Quest [Health Outcomes Institute, Minneapolis, MN]), was carried out on a consecutive series of patients with diagnosed osteoarthritis undergoing total hip and knee arthroplasty between March 1991 and March 1994. Study groups consisted of 85 total hip arthroplasty patients, 93 total knee arthroplasty patients, and 65 single-stage bilateral total knee arthroplasty patients, all treated at the same specialty hospital, under the care of three senior orthopaedic surgeons. The average patient age was 69 years. Significant improvements in quality-of-life measures including physical functioning, social functioning, role functioning/physical problem, role functioning/emotional problem, mental health, energy/fatigue, pain, and change in health were noted in all hip and knee arthroplasty patients 6 months, 1 year, and 2 years after surgery (P < .05). There appeared to be no significant differences in quality-of-life measures between hip and knee arthroplasty patients. Results therefore indicate that total hip and knee arthroplasty significantly improve the functional status and quality of life among patients suffering from osteoarthritis.     

Treatment of femoral neck fractures in elderly patients over 60 years of age - which is the ideal modality of primary joint replacement?

Background  

Femoral neck fractures in the elderly are frequent, represent a great health care problem, and have a significant impact on health insurance costs. Reconstruction options using hip arthroplasty include unipolar or bipolar hemiarthroplasty (HA), and total hip arthroplasty (THA). The purpose of this review is to discuss the indications, limitations, and pitfalls of each of these techniques.     

Do Commonly Reported Outcome Measures Reflect Patient Satisfaction After Revision Hip Arthroplasty?

The purpose of this study was to determine which commonly reported outcome measures best correlated with patient satisfaction after revision hip arthroplasty and to identify factors unrelated to hip status that may also play a role. From our institutional database, we identified 78 patients (80 hips) who underwent revision total hip arthroplasty and collected follow-up data. Patients with moderate or severe pain and those with limited walking ability reported significantly lower satisfaction scores. Harris hip score and patient-rated general health status were independently associated with patient satisfaction. Patient-rated anxiety and depression correlated inversely with satisfaction. Commonly reported outcome measures do reflect patient satisfaction after revision hip arthroplasty. However, satisfaction also appears to be influenced by psychologic factors.     

Obesity and long term functional outcomes following elective total hip replacement

ABSTRACT: INTRODUCTION: Obesity rates continue to rise and more total hip arthroplasty procedures are being performed in progressively younger, obese patients. Hence, maintenance of long term physical function will become very important for quality of life, functional independence and hip prosthesis survival. Presently, there are no reviews of the long term efficacy of total hip arthroplasty on physical function. This review: 1) synopsized available data regarding obesity effects on long term functional outcomes after total hip arthroplasty, and 2) suggested future directions for research. METHODS: A literature search was conducted from 1965 to January of 2011 for studies that evaluated long term functional outcomes at one year or longer after THA in obese (body mass index values [greater than or equal to]30 kg/m2) and non-obese patients (body mass index <30 kg/m2). RESULTS: Five retrospective studies and 18 prospective studies were identified as those that assessed physical function before surgery out to [greater than or equal to] one year after total hip arthroplasty. Study sample sizes ranged from 108-18,968 and followed patients from one to twenty years. Total hip arthroplasty confers significant pain reduction and improvement in quality of life irrespective of body mass index. Functional improvement occurred after total hip arthroplasty among all studies, but obese patients generally did not attain the same level of physical function by the follow-up time point. DISCUSSION: Uncontrolled obesity after total hip arthroplasty is related to worsening of comorbidities and excessive health care costs over the long term. Aggressive and sustainable rehabilitation strategies that include physical exercise, psychosocial components and behavior modification may be highly useful in maximizing and maintaining weight loss after total hip arthroplasty.     

Health and quality of life before and after hip or knee arthroplasty

The impact of hip and knee arthroplasty based on the patients' own evaluations of their health, quality of life, and physical ability was assessed using a cross-sectional study design. The eligibility criteria were a diagnosis of primary arthrosis, primary operation, and total joint arthroplasty. Preoperative hip and knee patient groups were compared with similar groups who underwent arthroplasty 2 or 5 years previously. Subjective health outcome was assessed with the Nottingham health profile and a 15-dimensional, health-related quality of life measure. Patients' physical ability was assessed using a measure of activities of daily living. Major improvements were observed for pain, sleep, range of motion, and physical ability. However, after surgery, patients were less healthy than the general population of the same age. The health status of patients operated on 2 or 5 years ago was similar, suggesting that health gains persist for several years.     

Acetabular implant placement: How do we place it in the 21st century?

Hip instability is one of the major complications after total hip arthroplasty (THA) and carries a significant financial burden on the health system. Implant malpositioning is among the most important risk factors for this complication. The optimal component position has been investigated since the inception of total hip arthroplasty, but it is not completely defined. In this paper, we review the historical “safe zone” for the acetabular implant and current optimal techniques for implant positioning, including the use of available technologies.     

The value of patient activity level in the outcome of total hip arthroplasty

Commonly used total hip arthroplasty scores take into account pain, function, walking, and range of motion. The purpose of this study was to evaluate the value of patient activity level as part of the outcome of total hip arthroplasty. Using linear regression analysis, the relationship between patient activity level (University of California Los Angeles activity score), the Harris Hip Score, and the Short Form-12 health survey was evaluated in 152 patients (mean age, 58.7 years) with a mean follow-up 5.2 years (range, 2-21 years). The University of California Los Angeles activity scale had an R(2) value of 0.39 and 0.19 to the Short Form-12 physical and mental components, respectively, and 0.32 to the Harris Hip Score. By evaluating patient activity level, one obtains important qualitative information in assessing the clinical outcome after total hip arthroplasty.     

Change in pain and function while waiting for major joint arthroplasty

The objective of this study was to examine the change in pain and physical function that occurs while waiting for major arthroplasty. Data were collected prospectively from a cohort of 313 patients who were waiting > 1 month for total hip arthroplasty or total knee arthroplasty. The WOMAC and the SF-36 health status instruments were administered at the time the patient was placed on the waiting list and again just before surgery. Minimal amounts of change in pain and physical and psychosocial function occurred for hip and knee arthroplasty patients while they waited. Overall, waiting time did not appear to have a negative impact on the amount of pain and dysfunction experienced.     

髋关节置换术后病人下肢关节运动功能锻炼

目的 探讨人工髋关节置换术后病人康复期下肢关节的运动功能锻炼方法与效果.方法 2011年7月至2015年1月于湖北医药学院附属东风医院骨科择期行人工髋关节置换术病人104例,病人均顺利完成人工髋关节置换术.根据随机数字表法的平行对照原则分为常规组和改进组各52例,常规组给予常规护理,改进组在常规护理基础上采用流程化运动功能锻炼.比较两组病人首次下地时间、最长步行距离、髋关节Harris评分、并发症和36条目健康调查量表(36-item short-form health survey questionnaire,SF-36)的情况.结果 改进组病人首次下地时间明显早于常规组,术后2周改进组的最长步行距离比常规组长(均P<0.05).康复后,改进组病人的髋关节功能Harris评分优良率为86.5%优于常规组的61.5%(P<0.05).改进组康复期间的尿潴留、便秘、感染、褥疮、肌肉萎缩等并发症发生情况明显低于常规组(P<0.05).康复后在总体健康、躯体疼痛、生理职能、生理功能等方面,改进组的得分均高于常规组(P<0.05).结论 人工髋关节置换术病人康复期下肢关节的运动功能锻炼能减少病人术后卧床时间,提高髋关节康复的速度,降低并发症出现的概率,术后病人康复更好,病人的生活质量得到更好的改善.     

The expectations of patients undergoing revision hip arthroplasty

Sixty patients were prospectively assessed using the Western Ontario and McMaster Osteoarthritis Index (WOMAC) scale for osteoarthritis of the hip and the Short Form 36 (SF-36) general health status scale as well as the expectation WOMAC, which asked patients to estimate how they expected to feel 6 months after revision hip arthroplasty. There was a wide range of expectations, but we were unable to find any significant correlation between the patients' preoperative pain and stiffness levels and their expectations for pain and stiffness after revision hip arthroplasty. There was no significant correlation between the SF-36 scores and the patients' expectations. Our findings suggest that the expectations of patients awaiting revision hip arthroplasties are high and are not related closely to the level of preoperative disability.     

Hospital resource utilization for primary and revision total hip arthroplasty

BACKGROUND: Previous reports have suggested that hospital resource utilization for revision total hip arthroplasty is substantially higher than that for primary total hip arthroplasty. However, current United States Medicare hospital-reimbursement policy does not distinguish between the two procedures. The purpose of this study was to compare primary and revision total hip arthroplasties with regard to actual hospital resource utilization and to identify clinical and demographic factors that are predictive of higher resource utilization associated with these procedures. METHODS: We evaluated the clinical, demographic, and economic data associated with 491 consecutive unilateral primary or revision total hip arthroplasties performed by two surgeons at a single institution between January 2000 and December 2002. The distributions of various demographic, clinical, and utilization characteristics were compared between the two types of arthroplasty procedures, and multivariable linear regression techniques were used to determine independent patient characteristics that were predictive of higher costs for both the primary and the revision procedures. RESULTS: The mean total hospital cost was $31,341 for the revision procedures compared with $24,170 for the primary procedures (p < 0.0001). The mean operative time was 41% longer for the revisions than for the primary procedures (4.5 hours compared with 3.2 hours, p < 0.0001), the mean estimated blood loss was 160% higher (1348 mL compared with 518 mL, p < 0.0001), the mean complication rate was 32% higher (29% compared with 22%, p = 0.072), and the mean length of the hospital stay was 16% longer (6.5 days compared with 5.6 days, p = 0.0005). A higher severity-of-illness score (a measure of preoperative medical health) was predictive of higher resource utilization for both primary and revision arthroplasty even after adjustment for other factors. Preoperative femoral and ace-tabular bone loss and a diagnosis of periprosthetic fracture were predictive of higher resource utilization associated with revision procedures. CONCLUSIONS: At one institution, hospital resource utilization for revision total hip arthroplasty was found to be significantly higher than that for primary arthroplasty. This information is not reflected by current United States Medicare hospital reimbursement, which is the same for all lower-extremity arthroplasty procedures, regardless of the diagnosis, the complexity of the procedure, or the patient's baseline medical health. If these findings are generalizable to other institutions, appropriate reimbursement formulas should be developed to accurately reflect the true costs of caring for patients with a failed total hip arthroplasty.     

Heterotopic bone formation following hip arthroplasty: A retrospective study of 65 bilateral cases

Heterotopic bone formation after two-stage bilateral cemented total hip arthroplasty was evaluated in 65 patients (23 women and 42 men) who had not received treatment with anti-inflammatory drugs in the immediate postoperative weeks. The mean age at the first operation was 65 years, and the median interval between the two arthroplasties was 3 months. Fifty-two patients developed heterotopic ossification after the initial hip arthroplasty. Of these patients, 40 also developed ossifications after contralateral hip arthroplasty. Out of 11 males developing Grade-III heterotopic ossification after the initial hip arthroplasty, 8 also developed Grade-III ossification after contralateral hip arthroplasty. Two females developed Grade-III ossification after the initial arthroplasty, but neither of them developed a Grade-III lesion after contralateral total hip arthroplasty. Males with Grade-III heterotopic ossification after the initial hip arthroplasty were shown to be at a high risk of developing the same severe lesion after contralateral total hip arthroplasty, making them candidates for postoperative prophylaxis.     

Prospective Randomized Study of Two Surgical Approaches for Total Hip Arthroplasty

The benefits of different surgical approaches for total hip arthroplasty continue to be debated. One hundred patients were prospectively enrolled and randomized into 2 groups. One group underwent total hip arthroplasty through a single-incision modified Smith-Peterson approach, whereas the other group underwent total hip arthroplasty through a direct lateral approach. All patients received the same postoperative protocol. Evaluation included operative time, estimated blood loss, analgesia requirement, transfusions, and length of stay. Functional outcome was assessed preoperatively and postoperatively. Up to 1-year follow-up, the direct anterior group demonstrated significantly better improvement in both the mental and physical health dimensions of Short Form-36 and Western Ontario McMaster Osteoarthritis Index compared with direct lateral approach group. At 2 years, the results in both groups were the same.     

THE PSYCHOLOGICAL IMPACT OF HIP ARTHROPLASTY

The impact of total hip arthroplasty on psychological functioning was examined in 51 patients; 25 females and 26 males with a mean age of 65 years (range 42–81 years). Assessments of psychological well-being and distress were made with the Mental Health Inventory. Life satisfaction, self-rated health, and pain ratings were also obtained. Assessments were made prior to surgery, immediately after surgery, and at a 2 month follow-up. The operation produced significant improvements in psychological well-being (P < 0.001), psychological distress (P < 0.001). life satisfaction (P < 0.01), self-rated health (P < 0.001), and pain (P < 0.001). It is concluded that the changes in medical and functional status following hip arthroplasty documented in previous research are accompanied by substantial improvements in psychological state, and that the inclusion of psychological factors in hip arthroplasty research will provide a more comprehensive assessment of outcome.     

Fixation Method for Hip Arthroplasty Stem Following Hip Fracture: A Population-Level Cost-Effectiveness Analysis

BackgroundHip arthroplasty is increasing in Australia. The number of procedures for fractured neck of femur was 7500 in 2017. Best practices for fixation method and procedure type require scrutiny. This paper is about the costs and health outcomes of cemented and uncemented hemiarthroplasty and total hip arthroplasty at a national level.MethodsWe created a Markov model for patients <75, aged 75-85, and over 85. Expected costs and health outcomes over 5 years from a decision to change from existing practice to a best practice policy in which all patients with fractured neck of femur received the same fixation method based on age and type of arthroplasty are estimated. The model was populated using prevalence and incidence data from the Australian Orthopedic Association National Joint Replacement Registry, costs from Metro North Hospital and Health Service in Queensland, and probabilities and utilities from the literature. We simulated the uncertainties in outcomes with probabilistic sensitivity analysis.ResultsWe found that uncemented stem procedures were more costly and provided worse health outcomes compared to cemented stem fixation for hemiarthroplasty and total hip arthroplasty for all age groups. Moving from existing practice to cemented stem arthroplasty could save the Australian health system $2.0 million over 5 years with a gain of 203 quality-adjusted life years.ConclusionWe suggest that consideration be given to cemented fixation of the femoral stem for patients receiving both hemiarthroplasty and total hip arthroplasty for fractured neck of femur. Best practice guidelines focused on cost-effectiveness should recommend cemented stem fixation to both save costs and improve patient quality of life.     

Resection arthroplasty in radiation-induced osteonecrosis of the hip

PurposeThe purpose of this study was to evaluate the choice of appropriate surgical procedure through follow-up of postoperative results in patients with radiation-induced osteonecrosis of the hip.Materials and methodsFrom January 1990 to December 2010, 25 patients underwent surgery for hip osteonecrosis after pelvic irradiation, for a total of 31 cases. The mean patient age was 61.6 years and the mean follow-up period was 60.4 months. There were 28 cases of primary total hip arthroplasty, three cases of primary resection arthroplasty, and six cases of secondary resection arthroplasty after total hip arthroplasty failure. The THA group was classified into two groups according to the period of operation: 1990 ∼ 2000 and 2001 ∼ 2010. THA and resection arthroplasty were compared retrospectively.ResultsIn the 16 cases of primary total hip arthroplasty (1990 ∼ 2000), 8 cases (50%) had a failed acetabular component. In 12 cases of primary total hip arthroplasty (2001 ∼ 2010), two cases (16.7%) had a failed acetabular component and two cases (16.7%) had an infection. Six cases underwent resection arthroplasty after total hip arthroplasty. There were no complications in the nine cases of resection arthroplasty. Seven of the nine cases (77.7%) had pain relief. The mean VAS scores of the resection arthroplasty group were lower than those of the total hip arthroplasty group at the time of the latest follow up (P = 0.04).ConclusionsThe failure rate of total hip arthroplasty used in radiation necrosis has decreased. Therefore, total hip arthroplasty should be the primary surgical method in patients with radiation-induced osteonecrosis of the hip. Resection arthroplasty is limited as first-line therapy due to functional problems. It use should be limited to pain control in low-demand elderly patients.     

Heterotopic bone formation following hip arthroplasty. A retrospective study of 65 bilateral cases

Heterotopic bone formation after two-stage bilateral cemented total hip arthroplasty was evaluated in 65 patients (23 women and 42 men) who had not received treatment with antiinflammatory drugs in the immediate postoperative weeks. The mean age at the first operation was 65 years, and the median interval between the two arthroplasties was 3 months. Fifty-two patients developed heterotopic ossification after the initial hip arthroplasty. Of these patients, 40 also developed ossifications after contralateral hip arthroplasty. Out of 11 males developing Grade-III heterotopic ossification after the initial hip arthroplasty, 8 also developed Grade-III ossification after contralateral hip arthroplasty. Two females developed Grade-III ossification after the initial arthroplasty, but neither of them developed a Grade-III lesion after contralateral total hip arthroplasty. Males with Grade-III heterotopic ossification after the initial hip arthroplasty were shown to be at a high risk of developing the same severe lesion after contralateral total hip arthroplasty, making them candidates for postoperative prophylaxis.     

Reducing arthroplasty costs via vendor contracts.

OBJECTIVE: To describe a method of reducing the costs of implants in hip and knee arthroplasty. DESIGN: Implant costs were compared before and after the implementation of a 2-year contract with implant vendors, providing increased volume for decreased implant cost. An additional 20% of arthroplasties could be done outside the contract for research or special purposes. SETTING: A regional health authority involving 2 acute care hospitals. METHOD: Costs were obtained for 942 hip and knee arthroplasties performed in 1993/94 and compared with costs of 1656 hip and knee arthroplasties performed in 1996/97. OUTCOME MEASURES: Implant cost and number of joint arthroplasty procedures performed. RESULTS: A 40% decrease in the cost per implant for primary knee arthroplasty and an 18% decrease in the cost per implant for primary hip arthroplasty were achieved. A rebate, calculated as a percentage of volume used, was received from the vendor to support general orthopedic research and education. A new contract for 3 years has recently been signed with 3 vendors designated as primary vendors for 80% of the volume. CONCLUSION: The vendor-contract economic strategy effectively reduced the cost of hip and knee arthroplasty and may be useful at other centres looking for cost reduction methods that maintain adequate patient care and support clinical research and education.     

Revision Hip Arthroplasty: A Retrospective Survey

A survey of revision hip arthroplasties was performed, using a retrospective review of the patients' case notes and radiographs, and an assessment of the patients, at least 1 year after the revision. The patients were divided into three categories: a) First revision hip arthroplasty (41 patients); b) Second revision hip arthroplasty (8 patients); c) Revision of femoral hemi-arthroplasty (14 patients). The reasons for revision, the type of revision and the final outcome have been identified in each group. This is the first study which allows direct comparison of the final outcome, as assessed by accurate objective criteria, between patients having revision hip arthroplasty for different reasons. Radiographs of the hip arthroplasty after the original operation and after revision have been analysed.

The final outcome of first revision hip arthroplasty and revision of hemi-arthroplasty to total hip replacement was generally good. The outcome of second revision hip arthroplasty was generally poor.     

Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck. A randomized, controlled trial

BACKGROUND: Hemiarthroplasty and total hip arthroplasty are commonly used to treat displaced intracapsular fractures of the femoral neck, but each has disadvantages and the optimal treatment of these fractures remains controversial. METHODS: In the present prospectively randomized study, eighty-one patients who had been mobile and lived independently before they had sustained a displaced fracture of the femoral neck were randomized to receive either a total hip arthroplasty or a hemiarthroplasty. The mean age of the patients was seventy-five years. Outcome was assessed with use of the Oxford hip score, and final radiographs were assessed. RESULTS: After a mean duration of follow-up of three years, the mean walking distance was 1.17 mi (1.9 km) for the hemiarthroplasty group and 2.23 mi (3.6 km) for the total hip arthroplasty group, and the mean Oxford hip score was 22.3 for the hemiarthroplasty group and 18.8 for the total hip arthroplasty group. Patients in the total hip arthroplasty group walked farther (p=0.039) and had a lower (better) Oxford hip score (p=0.033) than those in the hemiarthroplasty group. Twenty of thirty-two living patients in the hemiarthroplasty group had radiographic evidence of acetabular erosion at the time of the final follow-up. None of the hips in the hemiarthroplasty group dislocated, whereas three hips in the total hip arthroplasty group dislocated. In the hemiarthroplasty group, two hips were revised to total hip arthroplasty and three additional hips had acetabular erosion severe enough to indicate revision. In the total hip arthroplasty group, one hip was revised because of subsidence of the femoral component. CONCLUSIONS: Total hip arthroplasty conferred superior short-term clinical results and fewer complications when compared with hemiarthroplasty in this prospectively randomized study of mobile, independent patients who had sustained a displaced fracture of the femoral neck.