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    Rate of Revision THA Declines in All Age Groups Except Middle Age

    As more patients undergo total hip arthroplasty (THA) before age 65, the rate of revisions due to complications has risen sharply in this younger age group, according to a study published in The Journal of Bone & Joint Surgery.

    The research from Cedars-Sinai Medical Center in Los Angeles, California, shows that between 2007 and 2013, the rate of THA revision surgery increased in adults age 45 to 64 while it decreased in all other age groups. Other findings, based on analysis of nationwide data, suggest “a trend in the right direction” toward better outcomes over time for patients undergoing THA revision surgery.

    “Hip arthroplasty revision is a lot safer and more successful than 20 years ago, but still occurs too frequently,” said senior author Guy Paiement, MD. “We need to continue improving techniques and implants.”

    The researchers analyzed nearly 320,500 THA revision procedures in the Agency for Healthcare Research & Quality’s Nationwide Inpatient Sample. Although THA is a highly successful procedure, failure can occur for a variety of reasons, such as implant loosening, infection, or dislocation. In these cases, revision surgery may be needed to remove or replace all of part of the hip implant.

    The data showed a 12% increase in the overall estimated THA revision rate during the 6-year study period, after adjustment for population growth. The increase was driven exclusively by patients age 45 to 64: In this group, the THA revision rate increased by more than 30%. In all other age groups, the revision rate decreased.

    The reasons for revision surgery also changed between 2007 and 2013, with about a 14% decrease in revisions due to dislocation. This gain was offset by an increase in revision surgery due to “other mechanical complications.” That trend likely reflects complications related to the increased use of “metal-on-metal” hip implants during the study period, according to the authors.

    The data also showed improved outcomes for patients undergoing THA revision surgery. Rates of several serious inpatient complications decreased significantly, including venous thromboembolic events, myocardial infarction, pneumonia, and urinary tract infections.

    The mortality rate decreased significantly, as did the percentage of patients discharged from the hospital to a skilled nursing facility. There was also a 19% decrease in inflation-adjusted cost per THA revision – perhaps reflecting a reduction in length of hospital stays resulting from lower inpatient complication rates.

    “Over the last several decades, there have been substantial advancements in both surgical technique and implant design that have improved patient outcomes” after THA, the authors write. Although THA provides excellent long-term outcomes, high rates and costs of revision surgery continue to be a problem.

    Even if they do not undergo revision surgery, most hip arthroplasty patients age 45 to 64 have a life expectancy of 20 years or longer after THA. “A large proportion of these patients will outlive their implants” the authors observe. “This presents a challenge to the orthopaedic and scientific communities as the need for longer-lasting implants in these relatively young patients is critical.” The researchers note that in the 1990s and 2000s, metal-on-metal hip implants were widely used in younger patients. More recently, use of these types of implants has decreased due to concerns about adverse outcomes.

    Meanwhile, for patients who require THA revision, the procedure is safer today and associated with fewer complications, even after adjusting for all health problems. The study authors conclude, “This improving patient safety profile is encouraging and validates the efforts made to improve patient outcomes after THA revision.”

    Source

    Rajaee SS, Campbell JC, Mirocha J, Paiement GD. Increasing Burden of Total Hip Arthroplasty Revisions in Patients Between 45 and 64 Years of Age. J Bone Joint Surg Am. 2018;100(6):449-58. doi: 10.2106/JBJS.17.00470.