Trends in Revenue, Cost, and Contribution Margin of Patients Who Have a High Comorbidity Burden Undergoing Total Hip Arthroplasty From 2013 to 2021.

BACKGROUND: With the increasing utilization of total hip arthroplasty (THA) in patients who have a high comorbidity burden (HCB), coinciding with modifications to reimbursement models over the past decade, an evaluation of the financial impact of HCB on THA over time is warranted. This study aimed to investigate trends in revenue and cost associated with THA in HCB patients. METHODS: Of 13,439 patients who had primary, elective THA between 2013 and 2021 at our institution, we retrospectively reviewed 978 patients considered to have HCB (Charlson comorbidity index ≥ 5 and American Society of Anesthesiology scores 3 or 4). We collected patient demographics, perioperative data, revenue, cost, and contribution margin (CM) of the inpatient episode. We analyzed changes as a percentage of 2013 values over time for these financial markers. Linear regression determined trend significance. The final analysis included 978 HCB patients who had complete financial data. RESULTS: Between 2013 and 2021, direct costs increased significantly (P = .002), along with a nonsignificant increase in total costs (P = .056). While revenue remained steady during the study period (P = .486), the CM decreased markedly to 38.0% of 2013 values, although not statistically significant (P = .222). Rates of 90-day complications and home discharge remained steady throughout the study period. CONCLUSIONS: Increasing costs for HCB patients undergoing THA were not matched by an equivalent increase in revenue, leading to dwindling CMs throughout the past decade. Re-evaluation of reimbursement models for THA that account for patients' HCB may be necessary to preserve broad access to care. LEVEL OF EVIDENCE: III.

Trends in Extended Oral Antibiotic Prophylaxis Utilization Following Primary and Revision Total Hip Arthroplasty From 2010 to 2022.

BACKGROUND: In patients considered high-risk for infection, extended oral antibiotic (EOA) prophylaxis has been demonstrated to reduce rates of prosthetic joint infection following total hip arthroplasty (THA). Although national guidelines regarding their use have not yet been created, the increase in literature surrounding EOA prophylaxis suggests a potential change in practice patterns. The purpose of this study was to investigate the trends in utilization of EOA prophylaxis following THA from 2010 to 2022 and identify prescription patterns. METHODS: A total of 646,059 primary THA and 51,879 aseptic revision THA patients were included in this study. Patients who underwent primary or aseptic revision THA between 2010 and 2022 were identified in a national administrative claims database. Rates and duration of EOA prescriptions were calculated. A secondary analysis examined rates of utilization across demographics, including patients considered high risk for infection. RESULTS: From 2010 to 2022, utilization of EOA increased by 366% and 298% following primary and revision THA, respectively. Of patients prescribed postoperative antibiotics, 30% and 59% were prescribed antibiotics for more than 7 days following primary and revision THA, respectively. Rates of utilization were similar between high-risk individuals and the general population. CONCLUSIONS: Rates of utilization of EOA prophylaxis after THA have increased significantly since 2010. As current trends demonstrate a wide variation in prescription patterns, including in length of antibiotic duration and in patient population prescribed, guidelines surrounding the use of EOA prophylaxis after THA are necessary to promote antibiotic stewardship while preventing rates of periprosthetic joint infection.

Time trends in case-mix and risk of revision following hip and knee arthroplasty in public and private hospitals: a cross-sectional analysis based on 476,312 procedures from the Dutch Arthroplasty Register.

BACKGROUND AND PURPOSE: This study aims to assess time trends in case-mix and to evaluate the risk of revision and causes following primary THA, TKA, and UKA in private and public hospitals in the Netherlands. METHODS: We retrospectively analyzed 476,312 primary arthroplasties (public: n = 413,560 and private n = 62,752) implanted between 2014 and 2023 using Dutch Arthroplasty Register data. We explored patient demographics, procedure details, trends over time, and revisions per hospital type. Adjusted revision risk was calculated for comparable subgroups (ASA I/II, age ≤ 75, BMI ≤ 30, osteoarthritis diagnosis, and moderate-high socioeconomic status (SES). RESULTS: The volume of THAs and TKAs in private hospitals increased from 4% and 9% in 2014, to 18% and 21% in 2022. Patients in private hospitals were younger, had lower ASA classification, lower BMI, and higher SES compared with public hospital patients. In private hospitals, age and ASA II proportion increased over time. Multivariable Cox regression demonstrated a lower revision risk for primary THA (HR 0.7, CI 0.7-0.8), TKA (HR 0.8, CI 0.7-0.9), and UKA (HR 0.8, CI 0.7-0.9) in private hospitals. After initial arthroplasty in private hospitals, 49% of THA and 37% of TKA revisions were performed in public hospitals. CONCLUSION: Patients in private hospitals were younger, had lower ASA classification, lower BMI, and higher SES com-pared with public hospital patients. The number of arthroplasties increased in private hospitals, with a lower revision risk compared with public hospitals.

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.

Postoperative Morbidity and Mortality in Diabetic Patients After Fast-Track Hip and Knee Arthroplasty: A Prospective Follow-up Cohort of 36,762 Procedures.

BACKGROUND: Diabetes increases the risk of adverse outcomes in surgical procedures, including total hip and knee arthroplasty (THA/TKA), and the prevalence of diabetic patients undergoing these procedures is high, ranging from approximately 8% to 20%. However, there is still a need to clarify the role of diabetes and antihyperglycemic treatment in a fast-track THA/TKA setting, which otherwise may decrease morbidity. Consequently, we investigated the association between diabetes and antihyperglycemic treatment on length of stay (LOS) and complications following fast-track THA/TKA within a multicenter fast-track collaboration. METHODS: We used an observational study design on data from a prospective multicenter fast-track collaboration on unselected elective primary THA/TKA from 2010 to 2017. Complete follow-up (>99%) was achieved through The Danish National Patient Registry, antihyperglycemic treatment established through the Danish National Database of Reimbursed Prescriptions and types of complications leading to LOS >4 days, 90-day readmission or mortality obtained by scrutinizing health records and discharge summaries. Patients were categorized as nondiabetic and if diabetic into insulin-, orally, and dietary-treated diabetic patients. RESULTS: A total of 36,762 procedures were included, of which 837 (2.3%) had insulin-treated diabetes, 2615 (7.1%) orally treated diabetes, and 566 (1.5%) dietary-treated diabetes. Overall median LOS was 2 (interquartile range [IQR]: 1-3) days, and mean LOS was 2.4 (standard deviation [SD], 2.5) days. The proportion of patients with LOS >4 days was 6.0% for nondiabetic patients, 14.7% for insulin-treated, 9.4% for orally treated, and 9.5% for dietary-treated diabetic patients. Pharmacologically treated diabetes (versus nondiabetes) was independently associated with increased odds of LOS >4 days (insulin-treated: odds ratio [OR], 2.2 [99.6% confidence interval {CI}, 1.3-3.7], P < .001; orally treated: OR, 1.5 [99.6% CI, 1.0-2.1]; P = .002). Insulin-treated diabetes was independently associated with increased odds of "diabetes-related" morbidity (OR, 2.3 [99.6% CI, 1.2-4.2]; P < .001). Diabetic patients had increased renal complications regardless of antihyperglycemic treatment, but only insulin-treated patients suffered significantly more cardiac complications than nondiabetic patients. There was no increase in periprosthetic joint infections or mortality associated with diabetes. CONCLUSIONS: Patients with pharmacologically treated diabetes undergoing fast-track THA/TKA were at increased odds of LOS >4 days. Although complication rates were low, patients with insulin-treated diabetes were at increased odds of postoperative complications compared to nondiabetic patients and to their orally treated counterparts. Further investigation into the pathogenesis of postoperative complications differentiated by antihyperglycemic treatment is needed.

Factors associated with implant survival following total hip replacement surgery: A registry study of data from the National Joint Registry of England, Wales, Northern Ireland and the Isle of Man.

BACKGROUND: Nearly 100,000 people underwent total hip replacement (THR) in the United Kingdom in 2018, and most can expect it to last at least 25 years. However, some THRs fail and require revision surgery, which results in worse outcomes for the patient and is costly to the health service. Variation in the survival of THR implants has been observed between units and reducing this unwarranted variation is one focus of the "Getting it Right First Time" (GIRFT) program in the UK. We aimed to investigate whether the statistically improved implant survival of THRs in a high-performing unit is associated with the implants used or other factors at that unit, such as surgical skill. METHODS AND FINDINGS: We analyzed a national, mandatory, prospective, cohort study (National Joint Registry for England, Wales, Northern Ireland and the Isle of Man [NJR]) of all THRs performed in England and Wales. We included the 664,761 patients with records in the NJR who have received a stemmed primary THR between 1 April 2003 and 31 December 2017 in one of 461 hospitals, with osteoarthritis as the only indication. The exposure was the unit (hospital) in which the THR was implanted. We compared survival of THRs implanted in the "exemplar" unit with THRs implanted anywhere else in the registry. The outcome was revision surgery of any part of the THR construct for any reason. Net failure was calculated using Kaplan-Meier estimates, and adjusted analyses employed flexible parametric survival analysis. The mean age of patients contributing to our analyses was 69.9 years (SD 10.1), and 61.1% were female. Crude analyses including all THRs demonstrated better implant survival at the exemplar unit with an all-cause construct failure of 1.7% (95% CI 1.3-2.3) compared with 2.9% (95% CI 2.8-3.0) in the rest of the country after 13.9 years (log-rank test P < 0.001). The same was seen in analyses adjusted for age, sex, and American Society of Anesthesiology (ASA) score (difference in restricted mean survival time 0.12 years [95% CI 0.07-0.16; P < 0.001]). Adjusted analyses restricted to the same implants as the exemplar unit show no demonstrable difference in restricted mean survival time between groups after 13.9 years (P = 0.34). A limitation is that this study is observational and conclusions regarding causality cannot be inferred. Our outcome is revision surgery, and although important, we recognize it is not the only marker of success of a THR. CONCLUSIONS: Our results suggest that the "better than expected" implant survival results of this exemplar center are associated with implant choice. The survival results may be replicated by adopting key treatment decisions, such as implant selection. These decisions are easier to replicate than technical skills or system factors.

Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation.

BACKGROUND: Early ambulation after total hip arthroplasty predicts early discharge. Spinal anesthesia is preferred by many practices but can delay ambulation, especially with bupivacaine. Mepivacaine, an intermediate-acting local anesthetic, could enable earlier ambulation than bupivacaine. This study was designed to test the hypothesis that patients who received mepivacaine would ambulate earlier than those who received hyperbaric or isobaric bupivacaine for primary total hip arthroplasty. METHODS: This randomized controlled trial included American Society of Anesthesiologists Physical Status I to III patients undergoing primary total hip arthroplasty. The patients were randomized 1:1:1 to 52.5 mg of mepivacaine, 11.25 mg of hyperbaric bupivacaine, or 12.5 mg of isobaric bupivacaine for spinal anesthesia. The primary outcome was ambulation between 3 and 3.5 h. Secondary outcomes included return of motor and sensory function, postoperative pain, opioid consumption, transient neurologic symptoms, urinary retention, intraoperative hypotension, intraoperative muscle tension, same-day discharge, length of stay, and 30-day readmissions. RESULTS: Of 154 patients, 50 received mepivacaine, 53 received hyperbaric bupivacaine, and 51 received isobaric bupivacaine. Patient characteristics were similar among groups. For ambulation at 3 to 3.5 h, 35 of 50 (70.0%) of patients met this endpoint in the mepivacaine group, followed by 20 of 53 (37.7%) in the hyperbaric bupivacaine group, and 9 of 51 (17.6%) in the isobaric bupivacaine group (P < 0.001). Return of motor function occurred earlier with mepivacaine. Pain and opioid consumption were higher for mepivacaine patients in the early postoperative period only. For ambulatory status, 23 of 50 (46.0%) of mepivacaine, 13 of 53 (24.5%) of hyperbaric bupivacaine, and 11 of 51 (21.5%) of isobaric bupivacaine patients had same-day discharge (P = 0.014). Length of stay was shortest in mepivacaine patients. There were no differences in transient neurologic symptoms, urinary retention, hypotension, muscle tension, or dizziness. CONCLUSIONS: Mepivacaine patients ambulated earlier and were more likely to be discharged the same day than both hyperbaric bupivacaine and isobaric bupivacaine patients. Mepivacaine could be beneficial for outpatient total hip arthroplasty candidates if spinal is the preferred anesthesia type.

Intrathecal Morphine and Pulmonary Complications after Arthroplasty in Patients with Obstructive Sleep Apnea: A Retrospective Cohort Study.

BACKGROUND: Intrathecal morphine is commonly and effectively used for analgesia after joint arthroplasty, but has been associated with delayed respiratory depression. Patients with obstructive sleep apnea may be at higher risk of postoperative pulmonary complications. However, data is limited regarding the safety of intrathecal morphine in this population undergoing arthroplasty. METHODS: This retrospective cohort study aimed to determine the safety of intrathecal morphine in 1,326 patients with documented or suspected obstructive sleep apnea undergoing hip or knee arthroplasty. Chart review was performed to determine clinical characteristics, perioperative events, and postoperative outcomes. All patients received neuraxial anesthesia with low-dose (100 µg) intrathecal morphine (exposure) or without opioids (control). The primary outcome was any postoperative pulmonary complication including: (1) respiratory depression requiring naloxone; (2) pneumonia; (3) acute respiratory event requiring consultation with the critical care response team; (4) respiratory failure requiring intubation/mechanical ventilation; (5) unplanned admission to the intensive care unit for respiratory support; and (6) death from a respiratory cause. The authors hypothesized that intrathecal morphine would be associated with increased postoperative complications. RESULTS: In 1,326 patients, 1,042 (78.6%) received intrathecal morphine. The mean age of patients was 65 ± 9 yr and body mass index was 34.7 ± 7.0 kg/m. Of 1,326 patients, 622 (46.9%) had suspected obstructive sleep apnea (Snoring, Tired, Observed, Pressure, Body Mass Index, Age, Neck size, Gender [STOP-Bang] score greater than 3), while 704 of 1,326 (53.1%) had documented polysomnographic diagnosis. Postoperatively, 20 of 1,322 (1.5%) patients experienced pulmonary complications, including 14 of 1,039 (1.3%) in the exposed and 6 of 283 (2.1%) in the control group (P = 0.345). Overall, there were 6 of 1 322 (0.5%) cases of respiratory depression, 18 of 1,322 (1.4%) respiratory events requiring critical care team consultation, and 4 of 1,322 (0.3%) unplanned intensive care unit admissions; these rates were similar between both groups. After adjustment for confounding, intrathecal morphine was not significantly associated with postoperative pulmonary complication (adjusted odds ratio, 0.60 [95% CI, 0.24 to 1.67]; P = 0.308). CONCLUSIONS: Low-dose intrathecal morphine, in conjunction with multimodal analgesia, was not reliably associated with postoperative pulmonary complications in patients with obstructive sleep apnea undergoing joint arthroplasty.

Has the Use of Fixation Techniques in THA Changed in This Decade? The Uncemented Paradox Revisited.

BACKGROUND: Despite existing studies favoring cemented fixation for patients older than 75 years, a trend toward increased use of uncemented fixation has been described in a 2013 study that used arthroplasty registry data from 2006 to 2010. Updated summarized data are needed beyond 2010 to investigate contemporary trends in the usage of uncemented fixation, especially in patients older than 75 years, and to draw attention to a potential continuing conflict between trends in fixation choice and reported revision risk. Thus, healthcare policy and practice can change and surgeons can make better implant fixation choices. QUESTIONS/PURPOSES: (1) Has the percentage of primary THAs performed with uncemented fixation changed since 2010? (2) Has the percentage of primary THAs performed in patients older than 75 years performed with uncemented fixation changed since 2010? (3) After stratifying by age, which fixation strategy (cemented versus uncemented and hybrid versus uncemented) is associated with the lowest risk of revision? METHODS: National annual reports from hip arthroplasty registers were identified, and data were extracted from registers published in English or a Scandinavian language, with at least 3 years of reported data in the period from 2010 to 2017. These included Australia, Denmark, England-Wales, Finland, the Netherlands, New Zealand, Romania, Norway, Sweden, and Switzerland, which are all countries with high completeness rates. Data regarding rates of revisions (all causes) related to fixation methods and secondary to different age groups, were taken directly from the registers and no re-analysis was done. The risk estimates were presented as either hazard ratios, rate per 100 component years or as Kaplan-Meier estimates of revision. The age groups compared for Denmark were younger than 50, 50-59, 60-69,70-79, and older than 80 years, and for Australia, New Zealand, England-Wales, and Finland, they were younger than 55, 55-64, 65-74, and older than 75 years. No data were pooled across the registers. RESULTS: The current use of uncemented fixation in primary THAs varies between 24% (Sweden) and 71% (Denmark). Increasing use of uncemented fixation has been reported in Norway, Denmark, and Sweden, whereas decreasing use of uncemented fixation has been reported in England-Wales, Australia, New Zealand, and Finland. Examining the group of patients older than 75 years, we found that the use of uncemented fixation has been stable in Netherlands, Sweden, New Zealand, and England-Wales. The use of uncemented fixation is still increasing in Denmark and Australia. In Finland, the use of uncemented fixation has decreased (from 43 % to 24 %) from 2010 to 2017. When compared with uncemented fixation, the risk of revision for hips using cemented fixation was lower in patients older than 75 years for all registers surveyed, except for the oldest males in the Finnish register. In this group, no difference was found between cemented and uncemented fixation. CONCLUSION: Our findings should be used in healthcare policy as feedback on current THAs being performed so as to direct surgeons to choose the right implant fixation, especially in patients older than 75 years, thereby reducing revision risk and increasing the long-term survival of primary THAs. It appears that femoral stem fixation may be the most important revision risk factor in older patients, and future studies should examine this perspective. LEVEL OF EVIDENCE: Level III, therapeutic study.

Projections of Primary TKA and THA in Germany From 2016 Through 2040.

BACKGROUND: Future projections for both TKA and THA in the United States and other countries forecast a further increase of already high numbers of joint replacements. The consensus is that in industrialized countries, this increase is driven by demographic changes with more elderly people being less willing to accept activity limitations. Unlike the United States, Germany and many other countries face a population decline driven by low fertility rates, longer life expectancy, and immigration rates that cannot compensate for population aging. Many developing countries are likely to follow that example in the short or medium term amid global aging. Due to growing healthcare expenditures in a declining and aging population with a smaller available work force, reliable predictions of procedure volume by age groups are requisite for health and fiscal policy makers to maintain high standards in arthroplasty for the future population.Questions/purposes (1) By how much is the usage of primary TKA and THA in Germany expected to increase from 2016 through 2040? (2) How is arthroplasty usage in Germany expected to vary as a function of patient age during this time span? METHODS: The annual number of primary TKAs and THAs were calculated based on population projections and estimates of future healthcare expenditures as a percent of the gross domestic product (GDP) in Germany. For this purpose, a Poisson regression analysis using age, gender, state, healthcare expenditure, and calendar year as covariates was performed. The dependent variable was the historical number of primary TKAs and THAs performed as compiled by the German federal office of statistics for the years 2005 through 2016. RESULTS: Through 2040, the incidence rate for both TKA and THA will continue to increase annually. For TKA, the incidence rate is expected to increase from 245 TKAs per 100,000 inhabitants to 379 (297-484) (55%, 95% CI 21 to 98). The incidence rate of THAs is anticipated to increase from 338 to 437 (357-535) per 100,000 inhabitants (29% [95% CI 6 to 58]) between 2016 and 2040. The total number of TKAs is expected to increase by 45% (95% CI 14 to 8), from 168,772 procedures in 2016 to 244,714 (95% CI 191,920 to 312,551) in 2040. During the same period, the number of primary THAs is expected to increase by 23% (95% CI 0 to 50), from 229,726 to 282,034 (95% CI 230,473 to 345,228). Through 2040, the greatest increase in TKAs is predicted to occur in patients aged 40 to 69 years (40- to 49-year-old patients: 269% (95% CI 179 to 390); 50- to 59-year-old patients: 94% (95% CI 48 to 141); 60- to 69-year-old patients: 43% (95% CI 13 to 82). The largest increase in THAs is expected in the elderly (80- to 89-year-old patients (71% [95% CI 40 to 110]). CONCLUSIONS: Although the total number of TKAs and THAs is projected to increase in Germany between now and 2040, the increase will be smaller than that previously forecast for the United States, due in large part to the German population decreasing over that time, while the American population increases. Much of the projected increase in Germany will be from the use of TKA in younger patients and from the use of THA in elderly patients. Knowledge of these trends may help planning by surgeons, hospitals, stakeholders, and policy makers in countries similar to Germany, where high incidence rates of arthroplasty, aging populations, and overall decreasing populations are present. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

The Evolution of Hip Arthroscopy: What Has Changed Since 2008-A Single Surgeon's Experience.

PURPOSE: To compare a single surgeon's first 200 cases of hip arthroscopy with the last 200 cases regarding patient demographic characteristics, indications for surgery, intraoperative findings, procedures performed, and patient-reported outcomes. METHODS: Data were reviewed for all patients undergoing primary hip arthroscopy between February 2008 and August 2016 performed by a single surgeon. Of the 3,319 patients who underwent hip-preservation surgery during the study period, the first 200 (group A) and last 200 (group B) eligible for minimum 2-year follow-up were included in our analysis. RESULTS: Follow-up was available for 187 of 200 patients (93.5%) and 189 of 200 patients (94.5%) in groups A and B, respectively. The groups were similar in age, sex, and body mass index (P > .05). Group A included significantly more patients with Tönnis grade 1 (37% vs 21%, P < .001). Group B consisted of significantly more (P < .001) labral reconstructions (10.2% vs 0%), capsular closures (72.7% vs 26.2%), and gluteus medius repairs (18.2% vs 3.2%). Femoroplasty was performed for smaller cam lesions in group B, resulting in smaller postoperative alpha angles (45.7° ± 7.9° vs 42.4° ± 6.3°, P < .001). Group B exhibited significantly higher patient-reported outcomes at minimum 2-year follow-up (P < .05). In addition, in group B, greater proportions of patients achieved the minimal clinically important difference and patient acceptable symptomatic state (P < .05). CONCLUSIONS: This study shows the noteworthy evolution in the management of the prearthritic adult hip occurring between 2008 and 2016. This includes improvements in preoperative patient evaluation and patient selection. In addition, the proportion of patients undergoing labral reconstruction, capsular plication, and femoroplasty has increased significantly. These developments, as well as increased surgical experience, may have contributed to improved surgical outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Effects of an aging population on hospital costs related to elective hip replacements.

OBJECTIVES: Elective hip replacement is a common procedure for elderly people with osteoarthrosis. With more elderly people in the future, the demand for hip replacements will increase and put additional constraints on hospital services. The objective was to explore the future need for hip replacements and related costs and to investigate if anticipated future efficiency gains might alleviate the strain of increased demand. STUDY DESIGN: Registry-based modelling study. METHODS: Data were obtained from the Irish Central Statistics Office and the national Hospital Inpatient Enquiry system for 2011-2017. We estimated the future demand for hip replacements each year until 2051 and analysed changes in hip replacement rates and the average length of stay. These assumptions were used in our projections. RESULTS: Assuming no change in procedure rates, the annual cost of providing elective hip replacements is expected to increase by 1060 (30%) episodes in 2026 which implies a cost increment of €16M (33%) (vs 2017-level). If the historical increase in the procedure rate is assumed, the cost will increase by €33M (67%). If the observed reduction in length of stay can be maintained, costs will reduce by €14M (29.0%). Such a cost saving may alleviate the effect of the demographic changes and observed increases in procedure rates. CONCLUSIONS: Steady-state assumptions are unrealistic and efficiency gains can alleviate future pressure from population growth. However, this analysis has not addressed the present insufficient capacity of public hospitals to meet population needs, as judged by waiting lists and transfers to private hospitals.

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.

Surgery trends for osteonecrosis of the femoral head: a fifteen-year multi-centre study in Japan.

PURPOSE: The most appropriate procedure and at what type and stage of osteonecrosis of the femoral head (ONFH) these procedures had been argued. We attempted to clarify the trend in surgical operations with respect to the age of patients, type classification, and stage of ONFH over a period of 15 years by using the multi-center sentinel monitoring system in Japan. METHODS: We evaluated the hips of 3844 patients using this system in three phases of every five  years from 2003 to 2017. We classified the surgical procedures as osteotomy (OT), hemiarthroplasty (Hemi), and total hip arthroplasty (THA). We assessed the trend in age, type classification, and stage of ONFH over three time periods; "early," and the "late." We calculated the proportion of surgeries for ONFH in each period. We used the Cochran-Armitage test to evaluate trends in proportion of two levels of characteristics across three time periods. RESULTS: The proportion of younger patients significantly decreased. The proportion of OT and Hemi decreased over time, while the proportion of THA increased. The proportion of patients with types C1 and C2 who underwent OT and Hemi decreased over time. In contrast, that of THA increased. The proportion of patients who underwent OT and Hemi significantly decreased; the proportion of patients who underwent THA significantly increased over time at all stages. CONCLUSIONS: In Japan, the younger patients underwent surgery for ONFH decreased. The patients who underwent OT and Hemi for ONFH decreased, while that of THA increased over time.

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.

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.

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.

Cementless short-stem total hip arthroplasty in the elderly patient - is it a safe option?: a prospective multicentre observational study.

BACKGROUND: Due to its bone preserving philosophy, short-stem total hip arthroplasty (THA) has primarily been recommended for young and active patients. However, there may be benefits for elderly patients given a less invasive operative technique due to the short curved implant design. The purpose of this study was to compare the clinical and radiological outcomes as well as perioperative complications of a calcar-guided short stem between a young (< 60 years) and a geriatric (> 75 years) population. METHODS: Data were collected in a total of 5 centers, and 400 short-stems were included as part of a prospective multicentre observational study between 2010 and 2014 with a mean follow-up of 49.2 months. Preoperative femur morphology was analysed using the Dorr classification. Clinical and radiological outcomes were assessed in both groups as well as perioperative complications, rates and reasons for stem revision. RESULTS: No differences were found for the mean visual analogue scale (VAS) values of rest pain, load pain, and satisfaction, whereas Harris Hip Score (HHS) was slightly better in the young group. Comparing both groups, none of the radiological parameters that were assessed (stress-shielding, cortical hypertrophy, radiolucency, osteolysis) reached differences of statistical significance. While in young patients aseptic loosening is the main cause of implant failure, in the elderly group particularly postoperative periprosthetic fractures due to accidental fall have to be considered to be of high risk. The incidence of periprosthetic fractures was found to be 0% in Dorr type A femurs, whereas in Dorr types B and C fractures occurred in 2.1 and 22.2% respectively. CONCLUSIONS: Advanced age alone is not necessarily to be considered as contra-indications for calcar-guided short-stem THA, although further follow-up is needed. However, markedly reduced bone quality with femur morphology of Dorr type C seems to be associated with increased risk for postoperative periprosthetic fractures, thus indication should be limited to Dorr types A and B. TRIAL REGISTRATION: German Clinical Trials Register; DRKS00012634 , 07.07.2017 (retrospectively registered).

Hemolytic reaction in the washed salvaged blood of a patient with paroxysmal nocturnal hemoglobinuria.

BACKGROUND: In patients with paroxysmal nocturnal hemoglobinuria (PNH), the membrane-attack complex (MAC) formed on red blood cells (RBCs) causes hemolysis due to the patient's own activated complement system by an infection, inflammation, or surgical stress. The efficacy of transfusion therapy for patients with PNH has been documented, but no studies have focused on the perioperative use of salvaged autologous blood in patients with PNH. CASE PRESENTATION: A 71-year-old man underwent total hip replacement surgery. An autologous blood salvage device was put in place due to the large bleeding volume and the existence of an irregular antibody. The potassium concentration in the transfer bag of salvaged RBCs after the wash process was high at 6.2 mmol/L, although the washing generally removes > 90% of the potassium from the blood. This may have been caused by continued hemolysis even after the wash process. Once activated, the complement in patients with PNH forms the MAC on the RBCs, and the hemolytic reaction may not be stopped even with RBC washing. CONCLUSIONS: Packed RBCs, instead of salvaged autologous RBCs, should be used for transfusions in patients with PNH. The use of salvaged autologous RBCs in patients with PNH should be limited to critical situations, such as massive bleeding. Physicians should note that the hemolytic reaction may be present inside the transfer bag even after the wash process.

Are Histological Examinations of Arthroplasty Specimens Performed Consistently Across the Country? A Large Database Study.

BACKGROUND: It is currently unknown to what extent routine histological examination of joint arthroplasty specimens occurs across hospitals nationwide. Although this practice is neither supported nor refuted by the available evidence, given the increasing demand for joint arthroplasties, it is crucial to study overall utilization as well as its main drivers. QUESTIONS/PURPOSES: Using national data on joint replacements, we aimed to evaluate: (1) What is the current use of routine histological examination of joint arthroplasty specimens? (2) Does the use vary by geographic location and hospital characteristics? (3) Has use changed over time? METHODS: From the Premier Healthcare database (2006-2016) we included claims data from 87,667 shoulder (595 hospitals, median age 70 years, 16% nonwhite), 564,577 hip (629 hospitals, median age 65 years, 21% nonwhite), and 1,131,323 (630 hospitals, median age 66 years, 24% nonwhite) knee arthroplasties (all elective). Our study group has extensive experience with this data set, which contains information on 20% to 25% of all US hospitalizations. Included hospitals are mainly concentrated in the South (approximately 40%) with equal distributions among the Northeast, West, and Midwest (approximately 20% each). Moreover, the Premier data set has detailed billing information, which allows for evaluations of real-world clinical practice. There was no missing information on the main variables of interest for this specific study. We assessed frequency of histology examination (defined by Current Procedural Terminology codes) overall as well as by hospital characteristics (urban/rural, bed size, teaching status, arthroplasty volume), geographic region (Northeast, South, Midwest, West), and year. Given the large sample size, instead of p values, standardized differences were applied in assessing group differences where a standardized difference of > 0.1 (or 10%) was assumed to represent a meaningful difference between groups. For significance of trends, p values were applied. Percentages provided represent proportions of individual procedures. RESULTS: In most hospitals, histology testing was either rare (1%-10%, used in 187 of 595, 189 of 629, and 254 of 630 hospitals) or ubiquitous (91%-100%, used in 121 of 595, 220 of 629, and 195 of 630 hospitals) for shoulder, hip, and knee arthroplasties, respectively. Overall, histology testing occurred more often in smaller hospitals (37%-53% compared with 26%-45% in larger hospitals) and those located in the Northeast (59%-68% compared with 22%-44% in other regions) and urban areas (32%-49% compared with 20%-31% in rural areas), all with standardized differences > 10%. Histologic examination is slowly decreasing over time: from 2006 to 2016, it decreased from 34% to 30% for shoulder arthroplasty, from 50% to 45% for THAs, and from 43% to 38% for TKAs (all p < 0.001). CONCLUSIONS: Although overall use is decreasing, a substantial number of hospitals still routinely perform histology testing of arthroplasty specimens. Moreover, variation between regions and hospital types suggests that this practice is driven by a variety of factors. This is the first study addressing national utilization, which will be helpful for individual hospitals to assess how they compare with national utilization patterns. Moreover, the findings have clear implications for followup studies, which may be necessary given the exponentially growing demand for arthroplasties. LEVEL OF EVIDENCE: Level III, therapeutic study.