Highlights of Papers on Adult Reconstruction Hip Topics
Benchmarking Femoral Neck Fracture Treatment in the US
An analysis of data in the American Joint Replacement Registry (AJRR) shows that total hip arthroplasty (THA) is becoming a more common method of treating femoral neck fractures, increasing from 19.8% of fracture cases in 2012 to 24.4% in 2017.
Hemiarthroplasty remains the treatment of choice – particularly for older patients – however, accounting for 77.2% of procedures for femoral neck fractures. Most surgeons opt for a cementless stem fixation – nearly 60% for hemiarthroplasty and 94% for THA between 2012 and 2017 – but there is a trend toward more cemented implants, increasing from 37.5% in 2012 to 56.5% in 2017 for hemiarthroplasty procedures and from 2.9% to 8.2% for THA.
The study authors note that utilization of cementless stem designs is higher in the AJRR than in other registries worldwide.
Etkin C, Shores P, Gioe TJ, Springer BD, Bozic KJ. Treatment of Femoral Neck Fracture from the American Joint Replacement Registry (Paper 145). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
Complications and Costs for Conversion THA in Femoral Neck Fracture Patients
Converting a hemiarthroplasty to a total hip arthroplasty (THA) in a patient with a femoral neck fracture is as costly as a revision THA and carries similar risks for complications, dislocations, and reoperations. A conversion THA, therefore, should not be included in the same diagnosis related group as primary THA, according to a study from Mayo Clinic.
To better understand outcomes and costs, the researchers identified 389 femoral neck fracture patients who had undergone conversion from a hemiarthroplasty to a THA between 1985 and 2014 at Mayo Clinic and matched them on a 1:2 basis with 778 primary THA patients and 778 first-time revision THA patients.
Compared with primary THA patients, the conversion THA patients had a higher risk of complications, dislocations, and reoperations and a similar risk of needing revision THA. The risk of complications, dislocations, and reoperations was similar for first-time revision and conversion THA patients, but revision THA patients had a higher risk of re-revision.
Inpatient costs for revision and conversion THA were found to be $3000 to $4000 more than for primary THA.
Hernandez N, Maradit-Kremers H, Sierra RJ. Conversion of Failed Hemiarthroplasty to Total Hip Arthroplasty Has Similar Outcomes and Costs as Revision Total Hip Arthroplasty (Paper 193). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
Failures in Revision Total Hip Arthroplasty
Instability was the most common reason for re-revision among patients who underwent revision total hip arthroplasty (THA) at Mayo Clinic between 2005 and 2015, followed by fracture, femoral aseptic loosening, acetabular aseptic loosening, infection, and polyethylene wear.
More than 2500 patients underwent a revision procedure at Mayo Clinic during the study period: 39% isolated acetabular revisions, 22% isolated femoral revisions, 18% both component revisions, and 21% modular component exchanges. There were 211 re-revisions.
The overall survivorship free of re-revision was 94% at 2 years, 92% at 5 years, and 88% at 10 years, which the study authors said represents a substantial improvement when compared with historical controls.
Goldman A, Berry DJ, Abdel MP. Why are Contemporary Revision Total Hip Arthroplasties Failing? An Analysis of 2,500 Cases (Paper 194). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
Goldman AH, Sierra RJ, Trousdale RT, Lewallen DG, Berry DJ, Abdel MP. The Lawrence D. Dorr Surgical Techniques & Technologies Award: Why Are Contemporary Revision Total Hip Arthroplasties Failing? An Analysis of 2500 Cases. J Arthroplasty. 2019 Jan 23. pii: S0883-5403(19)30076-2. doi: 10.1016/j.arth.2019.01.031. [Epub ahead of print]
Returning to Work after Total Joint Arthroplasty
Patients undergoing total hip and total knee arthroplasty may want to know before surgery when they can expect to return to work, but none of the currently used functional outcome measures can provide an answer. Researchers from The Rothman Institute sought to identify patient variables that predict return to work and develop a model that could be used to estimate an individual’s readiness to return to work.
Of the 391 patients surveyed, 95% had returned to work within 12 weeks of surgery. Total hip arthroplasty patients returned sooner than total knee arthroplasty patients: 5.56 weeks vs. 7.79 weeks (P<0.001). The researchers found these independent predictors for faster returns to work:
- Being self-employed
- Availability of light-duty work
- Higher incomes
Predictors for longer returns to work were:
- Having at least 50% physical duties
- Knee arthroplasty
- Longer length of stay
- Job requiring more standing hours
The researchers said surgeons should take these variables into account when talking with patients about returning to work after total joint arthroplasty.
Rondon A, Tan T, Greenky M, Kheir M, Foltz C, Purtill JJ. Return to Work After Total Joint Arthroplasty: A Predictive Model (Paper 581). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
Initiating a Hydration Protocol in Same-Day Surgery Patients
Taking a cue from the anesthesia literature, researchers from NYU Langone Health found that patients scheduled for same-day discharge following primary total hip arthroplasty (THA) can safely consume clear liquids up to 2 hours before surgery without it causing a disruption in the discharge plan.
Patients undergoing primary THA between September 2017 and April 2018 were permitted to drink 32 ounces of clear liquids up to 2 hours before surgery. They were compared with patients who had THA between January 2017 and August 2017 and were NPO after midnight on the day of surgery.
After analyzing prospectively collected data on quality metrics, such as readmissions, length of stay, and program failure, the researchers concluded that their hydration protocol was safe, effective, and non-inferior to the standard NPO protocol. A similar number of patients in both groups had to stay an extra day in the hospital and none of the patients had surgery rescheduled because of failure to comply with the hydration protocol.
The researchers recommend additional studies with larger sample sizes to more fully understand the impact of a hydration protocol on same-day discharge for THA patients.
Anoushiravani A, Feng J, Harris NH, Jean-Louis K, Schwarzkopf R, Davidovitch R. Preoperative Oral Hydration is Safe in Rapid Recovery Total Hip Arthroplasty (Paper 708). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
Cementless Fixation and the Risk of Perioprosthetic Fracture
Cementless fixation has become increasingly common in hemiarthroplasty and total hip arthroplasty (THA). It is also becoming an increasingly common cause of early periprosthetic fracture requiring revision, according to an analysis of data from the American Joint Replacement Registry (AJRR).
Of the more than 10,000 revisions reported to the registry between 2012 and 2017, 622 (6.1%) were done within 3 months of the primary procedure due to perioprosthetic fracture, 522 in THA patients and 100 in hemiarthroplasty patients. With most of the revisions associated with cementless (n=583) versus cemented (n=39) fixation, patients with cementless femoral stems were found to be 2.6 times more likely to require early revision for a periprosthetic fracture than patients with cemented femoral stems.
Springer BD, Etkin C, Shores P, Gioe TJ, Lewallen DG, Bozic KJ. Perioperative Periprosthetic Femur Fractures are Strongly Correlated with Fixation Method: An Analysis from the American Joint Replacement Registry (Paper 878). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
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