What Are Normal Metal Ion Levels After Total Hip Arthroplasty? A Serologic Analysis of Four Bearing Surfaces

Background

The recent experiences with adverse local tissue reactions have highlighted the need to establish what are normal serum levels of cobalt (Co), chromium (Cr), and titanium (Ti) after hip arthroplasty.

The Frank Stinchfield Award

Background

Hip fractures are a major public health concern. For displaced femoral neck fractures, the needs for medical services during hospitalization and extending beyond hospital discharge after total hip arthroplasty (THA) may be different than the needs after THA performed for osteoarthritis (OA), yet these differences are largely uncharacterized, and the Medicare Severity Diagnosis-Related Groups system does not distinguish between THA performed for fracture and OA.

Questions/purposes

(1) What are the differences in in-hospital and 30-day postoperative clinical outcomes for THA performed for femoral neck fracture versus OA? (2) Is a patient’s fracture status, that is whether or not a patient has a femoral neck fracture, associated with differences in in-hospital and 30-day postoperative clinical outcomes after THA?

Methods

The National Surgical Quality Improvement Program (NSQIP) database, which contains outcomes for surgical patients up to 30 days after discharge, was used to identify patients undergoing THA for OA and femoral neck fracture. OA and fracture cohorts were matched one-to-one using propensity scores based on age, gender, American Society of Anesthesiologists grade, and medical comorbidities. Propensity scores represented the conditional probabilities for each patient having a femoral neck fracture based on their individual characteristics, excluding their actual fracture status. Outcomes of interest included operative time, length of stay (LOS), complications, transfusion, discharge destination, and readmission. There were 42,692 patients identified (41,739 OA; 953 femoral neck fractures) with 953 patients in each group for the matched analysis.

Results

For patients with fracture, operative times were slightly longer (98 versus 92 minutes, p = 0.015), they experienced longer LOS (6 versus 4 days, p < 0.001), and the overall frequency of complications was greater compared with patients with OA (16% versus 6%, p < 0.001). Although the frequency of preoperative transfusions was higher in the fracture group (2.0% versus 0.2%, p = 0.002), the frequency of postoperative transfusion was not different between groups (27% versus 24%, p = 0.157). Having a femoral neck fracture versus OA was strongly associated with any postoperative complication (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.1–3.8]; p < 0.001), unplanned readmission (OR, 1.8; 95% CI, 1.0–3.2; p = 0.049), and discharge to an inpatient facility (OR, 1.7; 95% CI, 1.4–2.0; p < 0.001).

Conclusions

Compared with THA for OA, THA for femoral neck fracture is associated with greater rates of complications, longer LOS, more likely discharge to continued inpatient care, and higher rates of unplanned readmission. This implies higher resource utilization for patients with a fracture. These differences exist despite matching of other preoperative risk factors. As healthcare reimbursement moves toward bundled payment models, it would seem important to differentiate patients and procedures based on the resource utilization they represent to healthcare systems. These results show different expected resource utilization in these two fundamentally different groups of patients undergoing hip arthroplasty, suggesting a need to modify healthcare policy to maintain access to THA for all patients.

Level of Evidence

Level III, therapeutic study.

     

Follow the trail: Using insights from the growth of palliative care to propose a roadmap for cancer rehabilitation

Despite research explicating the benefits of cancer rehabilitation interventions to optimize physical, social, emotional, and vocational functioning, many reports document low rates of referral to and uptake of rehabilitation in oncology. Cancer rehabilitation clinicians, researchers, and policy makers could learn from the multidisciplinary specialty of palliative care, which has benefited from a growth strategy and has garnered national recognition as an important and necessary aspect of oncology care. The purpose of this article is to explore the actions that have increased the uptake and integration of palliative care to yield insights and multimodal strategies for the development and growth of cancer rehabilitation. After examining the history of palliative care and its growth, the authors highlight 5 key strategies that may benefit the field of cancer rehabilitation: 1) stimulating the science in specific gap areas; 2) creating clinical practice guidelines; 3) building clinical capacity; 4) ascertaining and responding to public opinion; and 5) advocating for public policy change. Coordinated and simultaneous advances on these 5 strategies may catalyze the growth, utilization, and effectiveness of patient screening, timely referrals, and delivery of appropriate cancer rehabilitation care that reduces disability and improves quality of life for cancer survivors who need these services.     

The inflammatory response to social defeat is increased in older mice

KINSEY, S. G., BAILEY, M. T., SHERIDAN, J. F., PADGETT, D. A. The inflammatory response to social defeat is increased in older mice. PHYSIOL BEHAV 91(0) 000-000, 2007. Previous research indicates that repeated social defeat of mice causes increased lymphocyte trafficking to the spleen, elevated proinflammatory cytokine production, and induced glucocorticoid insensitivity in splenocytes. Social defeat also causes increases in anxiety-like behavior. This study investigated whether repeated social defeat results in similar immunoregulatory and behavioral changes in older mice as those seen previously in young adult mice. The data revealed that, regardless of age, defeated mice had significantly more splenic CD11b+ Gr-1+ monocytes and neutrophils than controls. Supernatants harvested from cultured splenocytes from older mice contained comparatively higher IL-6 and TNF-alpha than supernatants from younger animals. In addition, those same cells derived from older defeated mice were hypersensitive to lipopolysaccharide (LPS) and insensitive to glucocorticoids in vitro. As seen previously in young adult mice, social defeat caused an increase in anxiety-like behavior in the open field test, but had no effect on learned helplessness in the forced swim test. These data indicated that repeated social defeat results in a proinflammatory state that is exacerbated in older mice. The implications of these data are noteworthy, given the strong role of inflammation in many age-related diseases.     

Periprosthetic Fractures of the Femur After Hip Arthroplasty: An Analysis of 99 Patients

The medical records and radiographs of 99 patients treated for a periprosthetic femur fracture after total hip arthroplasty over a 17-year period at a single institution were prospectively reviewed. Fractures were classified according to the Vancouver system and stratified as to treatment method. Sixty-six patients had complete records available and a minimum of 12 months follow-up. Overall, 86% of the patients achieved fracture union. The success rate of cemented revision in the B2 and B3 groups was 84%, whereas cement-less revision was 86% successful. The complication rate of surgical treatment was 29%. Fracture union with a stable implant was possible in the majority of cases. Our results support the use of the Vancouver classification as a treatment algorithm.     

Patterns-of-care disparities among uninsured versus insured patients with anorectal carcinoma referred for radiotherapy at an Urban Safety-Net Hospital

BackgroundTo compare patterns-of-care and clinical outcomes among uninsured versus insured patients (IPs) with anorectal malignancies referred for radiotherapy at an urban safety-net hospital. This topic is important because uninsured patients (UPs) in the US often have limited access to health care, which can result in worse health outcomes.MethodsWe reviewed the medical records of 59 patients with biopsy-proven, non-metastatic anal and rectal cancers who received curative-intent primary or neoadjuvant/adjuvant radiotherapy between May 2002 and August 2012. Data regarding patient and disease characteristics, weight loss, insurance status at symptom onset, date of first therapeutic intervention, and survival status at last follow-up, were collected and analyzed.ResultsThe percentage of IPs presenting with T4 tumors was 7% versus 40% among the uninsured (P=0.005). The median interval between first symptom onset and diagnosis date was 89 (range, 0–1,428) days for IPs and 221 (range, 0–1,576) days for UPs (P=0.01). The median interval between first symptom onset and treatment initiation was 172 (range, 9–1,498) days for IPs and 302 (range, 35–1,624 days) days for UPs (P=0.01). The 5-year overall survival rate was 59% for the entire cohort, 62% for the insured patients, and 55% for the uninsured patients (P=0.76)ConclusionsDifferences in health insurance status demonstrated various disparities in patterns-of-care, including significant delay in diagnosis, more advanced-stage disease at presentation, and treatment initiation delays among UPs. Nevertheless, overall survival at 5 years was not statistically significant between the insured and the uninsured.