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Moon TJ, Blackburn CW, Du JY, Marcus RE. What Are the Differences in Hospital Cost Associated With the Use of Cemented Versus Cementless Femoral Stems in Hemiarthroplasty and Total Hip Arthroplasty for the Treatment of Femoral Neck Fracture? J Arthroplasty 2024; 39:313-319.e1. [PMID: 37572717 DOI: 10.1016/j.arth.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 05/29/2023] [Accepted: 08/03/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND The purpose of this study was to determine if there is a difference in hospital costs associated with the use of cemented versus cementless femoral stems in hemiarthroplasty (HA) and total hip arthroplasty (THA) for the treatment of femoral neck fracture (FNF). METHODS This retrospective cohort study utilizes the 2019 Medicare Provider Analysis and Review Limited Data Set. Patients undergoing arthroplasty for the treatment of FNF were identified. Patients were grouped by cemented or cementless femoral stem fixation. There were 16,148 patients who underwent arthroplasty for FNF available: 4,913 THAs (3,705 patients who had cementless femoral stems and 1,208 patients who had cemented femoral stems) and 11,235 HAs (6,099 patients who had cementless femoral stems and 5,136 who had cemented femoral stems). Index hospital costs were estimated by multiplying total charges by cost-to-charge ratios. Costs were analyzed using univariable and multivariable generalized linear models. RESULTS Cemented femoral stem THA generated 1.080 times (95% confidence interval, 1.06 to 1.10; P < .001), or 8.0%, greater index hospital costs than cementless femoral stem THA, and cemented femoral stem HA generated 1.042 times (95% confidence interval, 1.03 to 1.05; P < .001), or 4.2%, greater index hospital costs than cementless femoral stem HA. CONCLUSIONS Cemented femoral stems for FNF treated with either THA or HA are associated with only a small portion of increased cost compared to cementless femoral stems. Providers may choose the method of arthroplasty stem fixation for the treatment of FNF based on what they deem most appropriate for the specific patient.
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Affiliation(s)
- Tyler J Moon
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Collin W Blackburn
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jerry Y Du
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Randall E Marcus
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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Kheir MM, Dilley JE, Speybroeck J, Kuyl EV, Ochenjele G, McLawhorn AS, Meneghini RM. The Influence of Dorr Type and Femoral Fixation on Outcomes Following Total Hip Arthroplasty for Acute Femoral Neck Fractures: A Multicenter Study. J Arthroplasty 2023; 38:719-725. [PMID: 36283515 DOI: 10.1016/j.arth.2022.10.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The American Academy of Orthopaedic Surgeons guidelines report moderate evidence for cementing femoral stems for hip fractures, mainly derived from hemiarthroplasty literature. This is the first large, nonregistry study examining the influence of femoral fixation, implant type, patient characteristics, and radiographic factors on outcomes after total hip arthroplasty (THA) for acute femoral neck fractures. METHODS A multicenter retrospective study was performed of 709 THA cases (199 cemented, 510 cementless) for femoral neck fractures from 2006 to 2020 at three large academic institutions. Demographics, perioperative characteristics, and radiographs were reviewed. Kaplan-Meier survivorship curves were generated for multiple outcomes. Univariate and multivariate analyses were performed with P ≤ .05 denoting significance. RESULTS Cementless stems had a higher all-cause aseptic femoral revision rate (5.1 versus 0.5%, P = .002) and periprosthetic femoral fracture rate (4.3 versus 0%, P = .001). Each successive Dorr type had a higher fracture rate with cementless implants: 2.3%, 3.7%, and 15.9% in Dorr A, B, and C, respectively (P < .001). Logistic regression analyses confirmed that cementless stems (P = .02) and Dorr C bone (P = .001) are associated with periprosthetic fractures; collared implants and prophylactic cables did not protect against fractures. There was no difference in rates of dislocation, septic revision, or mortality between groups. CONCLUSION Cementless stems during THA for femoral neck fractures have a higher aseptic femoral revision rate, specifically for periprosthetic fractures. Dorr C bone was particularly prone with an alarmingly high fracture rate. All fractures occurred in cementless cases, suggesting that cemented stems may minimize this complication. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Michael M Kheir
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Julian E Dilley
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jacob Speybroeck
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Emile-Victor Kuyl
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - George Ochenjele
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Bloch BV, White JJE, Matar HE, Berber R, Manktelow ARJ. Should patient age thresholds dictate fixation strategy in total hip arthroplasty? Bone Joint J 2022; 104-B:206-211. [PMID: 35094580 DOI: 10.1302/0301-620x.104b2.bjj-2021-1199.r1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Total hip arthroplasty (THA) is a very successful and cost-effective operation, yet debate continues about the optimum fixation philosophy in different age groups. The concept of the 'cementless paradox' and the UK 'Getting it Right First Time' initiative encourage increased use of cemented fixation due to purported lower revision rates, especially in elderly patients, and decreased cost. METHODS In a high-volume, tertiary referral centre, we identified 10,112 THAs from a prospectively collected database, including 1,699 cemented THAs, 5,782 hybrid THAs, and 2,631 cementless THAs. The endpoint was revision for any reason. Secondary analysis included examination of implant survivorship in patients aged over 70 years, over 75 years, and over 80 years at primary THA. RESULTS Cemented fixation had the lowest implant survival in all age groups, with a total ten-year survivorship of 97.0% (95% confidence interval (CI) 95.8 to 97.8) in the cemented group, 97.6% (95% CI 96.9 to 98.1) in the hybrid group, and 97.9% (95% CI 96.9 to 98.6) in the cementless group. This was not statistically significant (p = 0.092). There was no age group where cemented fixation outperformed hybrid or cementless fixation. CONCLUSION While all fixation techniques performed well at long-term follow-up, cemented fixation was associated with the lowest implant survival in all age groups, including in more elderly patients. We recommend that surgeons should carefully monitor their own outcomes and use fixation techniques that they are familiar with, and deliver the best outcomes in their own hands. Cite this article: Bone Joint J 2022;104-B(2):206-211.
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Affiliation(s)
- Benjamin V Bloch
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jonathan J E White
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Hosam E Matar
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Reshid Berber
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew R J Manktelow
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, UK
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GUIMARÃES RODRIGOPEREIRA, VIAMONT-GUERRA MARÍAROXANA, ANTONIOLI ELIANE, LENZA MARIO. TOTAL HIP ARTHROPLASTY IN THE PUBLIC HEALTH SYSTEM OF SÃO PAULO: COMPARING TYPES OF FIXATION. ACTA ORTOPÉDICA BRASILEIRA 2022; 30:e251150. [DOI: 10.1590/1413-785220223005e251150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 09/22/2021] [Indexed: 11/13/2022]
Abstract
ABSTRACT Brazil lacks registries on the prevalence of primary total hip arthroplasty (THA) fixation methods. Objective: (i) to describe the demographic profile of patients who underwent THA in the public health system of the municipality of São Paulo during the last 12 years and (ii) to compare fixation methods regarding costs, hospital stay length, and death rates. Methods: This is an ecological study conducted with data available on TabNet, a platform belonging to DATASUS. Public data (from the government health system) on THA procedures performed in São Paulo from 2008 to 2019 were extracted. Gender, age, city region, THA fixation method, number of surgeries, costs, hospital stay length, and death rates were analyzed. Results: We analyzed 7,673 THA, of which 6220 (81%) were performed via cementless/hybrid fixation and 1453 (19%), via the cemented technique. Cementless/hybrid fixation had a higher cost (US$ 495.27) than the cemented one (p < 0.001). Nevertheless, hospital stay length was 0.87 days longer for cemented fixation than the cementless/hybrid one. We found no significant difference in death rates between THA fixation methods. Conclusion: THA cementless/hybrid fixation is prevalent in the municipality of São Paulo, which had higher total costs and shorter hospitalizations than cemented fixation. We found no difference between THA fixation methods and death rates. Level of Evidence IV, Case Series.
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Accelerometer-based, hand-held navigation for improved knee alignment in total knee arthroplasty: An observational study. J Clin Orthop Trauma 2021; 24:101689. [PMID: 34840947 PMCID: PMC8605332 DOI: 10.1016/j.jcot.2021.101689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Malalignment in total knee arthroplasty has been associated with poor implant longevity and clinical outcomes. The aim of this study was to investigate the accuracy of accelerometer-based navigation in restoring the mechanical axis. METHODS 106 primary total knee arthroplasties performed during February 2016 to September 2017 at a tertiary care centre in India were enrolled in this observational study. We noted the intra-op tourniquet time. Two separate blinded observers measured the preoperative mechanical axis and the post operative radiological results (mechanical axis, coronal and sagittal alignment of femoral and tibial components) and the mean value was taken as final data. Interclass correlation was done to look for variability between the two observers. RESULTS The mean pre operative mechanical axis was 13.74 ± 10.44. The mean tourniquet time was 53.14 ± 7.42 min 91.5% (96/106) knees were within ±3° of neutral mechanical axis with a mean of 1.00° ± 2.68°. The femoral and tibial components with coronal alignment within ±3° perpendicular to the mechanical axis were 93.39% (99/106) and 89.62% (95/106) respectively. In the sagittal plane 89.62% of the femoral components and 87.73% of the tibial components were within ±3° perpendicular to the axis of tibia. CONCLUSION The Accelerometer based portable navigation system effectively reduces the coronal and sagittal alignment outliers in total knee arthroplasty and has no role in rotational alignment of components.
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Funk GA, Menuey EM, Cole KA, Schuman TP, Kilway KV, McIff TE. Radical scavenging of poly(methyl methacrylate) bone cement by rifampin and clinically relevant properties of the rifampin-loaded cement. Bone Joint Res 2019; 8:81-89. [PMID: 30915214 PMCID: PMC6397418 DOI: 10.1302/2046-3758.82.bjr-2018-0170.r2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Objectives The objective of this study was to characterize the effect of rifampin incorporation into poly(methyl methacrylate) (PMMA) bone cement. While incompatibilities between the two materials have been previously noted, we sought to identify and quantify the cause of rifampin’s effects, including alterations in curing properties, mechanical strength, and residual monomer content. Methods Four cement groups were prepared using commercial PMMA bone cement: a control; one with 1 g of rifampin; and one each with equimolar amounts of ascorbic acid or hydroquinone relative to the amount of rifampin added. The handling properties, setting time, exothermic output, and monomer loss were measured throughout curing. The mechanical strength of each group was tested over 14 days. A radical scavenging assay was used to assess the scavenging abilities of rifampin and its individual moieties. Results Compared with control, the rifampin-incorporated cement had a prolonged setting time and a reduction in exothermic output during polymerization. The rifampin cement showed significantly reduced strength and was below the orthopaedic weight-bearing threshold of 70 MPa. Based on the radical scavenging assay and strength tests, the hydroquinone structure within rifampin was identified as the polymerization inhibitor. Conclusion The incorporation of rifampin into PMMA bone cement interferes with the cement’s radical polymerization. This interference is due to the hydroquinone moiety within rifampin. This combination alters the cement’s handling and curing properties, and lowers the strength below the threshold for weight-bearing applications. Additionally, the incomplete polymerization leads to increased toxic monomer output, which discourages its use even in non-weight-bearing applications. Cite this article: G. A. Funk, E. M. Menuey, K. A. Cole, T. P. Schuman, K. V. Kilway, T. E. McIff. Radical scavenging of poly(methyl methacrylate) bone cement by rifampin and clinically relevant properties of the rifampin-loaded cement. Bone Joint Res 2019;8:81–89. DOI: 10.1302/2046-3758.82.BJR-2018-0170.R2.
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Affiliation(s)
- G A Funk
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - E M Menuey
- Department of Chemistry, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - K A Cole
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - T P Schuman
- Department of Chemistry, Missouri University of Science and Technology, Rolla, Missouri, USA
| | - K V Kilway
- Department of Chemistry, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - T E McIff
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
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Caraan NA, Windhager R, Webb J, Zentgraf N, Kuehn KD. Role of fast-setting cements in arthroplasty: A comparative analysis of characteristics. World J Orthop 2017; 8:881-890. [PMID: 29312846 PMCID: PMC5745430 DOI: 10.5312/wjo.v8.i12.881] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 10/09/2017] [Accepted: 11/08/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the behaviour of two fast-setting polymethylmethacrylate (PMMA) cements CMW® 2G and Palacos® fast R + G, as reference: Standard-setting Palacos® R + G.
METHODS The fast-setting cements CMW® 2G and Palacos® fast R + G were studied, using standard-setting high viscosity Palacos® R + G as a reference. Eleven units (of two batch numbers) of each cement were tested. All cements were mixed as specified by the manufacturer and analysed on the following parameters: Handling properties (mixing, waiting, working and hardening phase) according to Kuehn, Mechanical properties according to ISO 5833 and DIN 53435, Fatigue strength according to ISO 16402, Benzoyl Peroxide (BPO) - Content by titration, powder/liquid-ratio by weighing, antibiotic elution profile by High Performance Liquid Chromatography. All tests were done in an acclimatised laboratory with temperatures set at 23.5 °C ± 0.5 °C and a humidity of > 40%.
RESULTS Palacos® fast R + G showed slightly shorter handling properties (doughing, hardening phase, n = 12) than CMW® 2G, allowing to reduce operative time and to optimise cemented cup implantation. Data of the quasistatic properties of ISO 5833 and DIN 53435 of both cements tested was comparable. The ISO compressive strength (MPa) of Palacos® fast R + G was significantly higher than CMW® 2G, resulting in ANOVA (P < 0.01) and two sample t-test (P < 0.01) at 0.05 level of significance (n = 20). Palacos® fast R + G showed a higher fatigue strength of about 18% mean (ISO 16402) of 15.3 MPa instead of 13.0 MPa for CMW® 2G (n = 5 × 106 cycles). Palacos® fast R + G and CMW® 2G differed only by 0.11% (n = 6) with the former having the higher content. The BPO-content of both cements were therefore comparable. CMW® 2G had a powder/liquid ratio of 2:1, Palacos® fast R + G of 2.550:1 due to a higher powder content. Despite its higher gentamicin content, CMW® 2G showed a significantly lower antibiotic elution over time than Palacos® fast R + G (n = 3).
CONCLUSION Both cements are compliant with international standards and are highly suitable for their specified surgical indications, affording a time-saving measure without detriment to the mechanical properties.
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Affiliation(s)
- Neil Ayron Caraan
- Department of Orthopaedics and Orthopaedic Surgery, Medical University of Vienna, Vienna 1090, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Orthopaedic Surgery, Medical University of Vienna, Vienna 1090, Austria
| | - Jason Webb
- Avon Orthopaedic Centre, North Bristol NHS Trust, Southmead Hospital, Bristol BS10 5NB, United Kingdom
| | - Nadine Zentgraf
- Heraeus Medical GmbH, Wehrheim 61273, Germany
- Medical University of Vienna, Vienna 1090, Austria
| | - Klaus-Dieter Kuehn
- Heraeus Medical GmbH, Wehrheim 61273, Germany
- Medical University of Vienna, Vienna 1090, Austria
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Hanstein T, Kumpe O, Mittelmeier W, Skripitz R. [Hybrid and uncemented hip arthroplasty: Contribution margin in the German lump sum reimbursement system]. DER ORTHOPADE 2016. [PMID: 26215628 DOI: 10.1007/s00132-015-3139-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND The economization of inpatient care began when lump sum reimbursement was introduced into the hospital sector. Since then, total hip arthroplasty (THA) has experienced a rapid development in terms of annual procedures and the optimization of the clinical pathway. Therefore, it is obvious to highlight THA as one of the most common procedures in the German health care system. In this work, the two most common techniques for the fixation of THA are investigated with regard to their cost structure and their influence on the clinical result. OBJECTIVES In Germany, uncemented and hybrid fixation are used for THA. In this study we investigated the differences in material costs, the duration of surgery, and the length of stay. MATERIALS AND METHODS For each fixation technique a retrospective cost analysis was carried out, based on the data from the treatment documentation of the University Hospital for Orthopedics, Rostock (OUK). The mean values of the parameters and expenses have been reviewed with descriptive statistics for differences. RESULTS With regard to total costs and the contribution margin there was no statistically significant difference. CONCLUSIONS Although there are differences in individual cost areas, in total costs, cost advantages and disadvantages cancel each other out. Thus, from an economic perspective no particular technique can be recommended.
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Affiliation(s)
- Tim Hanstein
- Hochschule Ludwigshafen am Rhein, Ernst-Boehe-Str. 4, 67059, Ludwigshafen am Rhein, Deutschland,
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Papanicolas I, McGuire A. Do financial incentives trump clinical guidance? Hip Replacement in England and Scotland. JOURNAL OF HEALTH ECONOMICS 2015; 44:25-36. [PMID: 26359587 DOI: 10.1016/j.jhealeco.2015.08.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 05/01/2015] [Accepted: 08/02/2015] [Indexed: 06/05/2023]
Abstract
Following devolution in 1999 England and Scotland's National Health Services diverged, resulting in major differences in hospital payment. England introduced a case payment mechanism from 2003/4, while Scotland continued to pay through global budgets. We investigate the impact this change had on activity for Hip Replacement. We examine the financial reimbursement attached to uncemented Hip Replacement in England, which has been more generous than for its cemented counterpart, although clinical guidance from the National Institute for Clinical Excellence recommends the later. In Scotland this financial differential does not exist. We use a difference-in-difference estimator, using Scotland as a control, to test whether the change in reimbursement across the two countries had an influence on treatment. Our results indicate that financial incentives are directly linked to the faster uptake of the more expensive, uncemented Hip Replacement in England, which ran against the clinical guidance.
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Affiliation(s)
- Irene Papanicolas
- Department of Social Policy, London School of Economics, Houghton Street, London, UK.
| | - Alistair McGuire
- Department of Social Policy, London School of Economics, Houghton Street, London, UK
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Jameson SS, Mason J, Baker PN, Gregg PJ, Deehan DJ, Reed MR. Implant Optimisation for Primary Hip Replacement in Patients over 60 Years with Osteoarthritis: A Cohort Study of Clinical Outcomes and Implant Costs Using Data from England and Wales. PLoS One 2015; 10:e0140309. [PMID: 26561859 PMCID: PMC4643061 DOI: 10.1371/journal.pone.0140309] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 09/24/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Hip replacement is one of the most commonly performed surgical procedures worldwide; hundreds of implant configurations provide options for femoral head size, joint surface material and fixation method with dramatically varying costs. Robust comparative evidence to inform the choice of implant is needed. This retrospective cohort study uses linked national databases from England and Wales to determine the optimal type of replacement for patients over 60 years undergoing hip replacement for osteoarthritis. METHODS AND FINDINGS Implants included were the commonest brand from each of the four types of replacement (cemented, cementless, hybrid and resurfacing); the reference prosthesis was the cemented hip procedure. Patient reported outcome scores (PROMs), costs and risk of repeat (revision) surgery were examined. Multivariable analyses included analysis of covariance to assess improvement in PROMs (Oxford hip score, OHS, and EQ5D index) (9159 linked episodes) and competing risks modelling of implant survival (79,775 procedures). Cost of implants and ancillary equipment were obtained from National Health Service procurement data. RESULTS EQ5D score improvements (at 6 months) were similar for all hip replacement types. In females, revision risk was significantly higher in cementless hip prostheses (hazard ratio, HR = 2.22, p<0.001), when compared to the reference hip. Although improvement in OHS was statistically higher (22.1 versus 20.5, p<0.001) for cementless implants, this small difference is unlikely to be clinically important. In males, revision risk was significantly higher in cementless (HR = 1.95, p = 0.003) and resurfacing implants, HR = 3.46, p<0.001), with no differences in OHS. Material costs were lowest with the reference implant (cemented, range £1103 to £1524) and highest with cementless implants (£1928 to £4285). Limitations include the design of the study, which is intrinsically vulnerable to omitted variables, a paucity of long-term implant survival data (reflecting the duration of data collection), the possibility of revision under-reporting, response bias within PROMs data, and issues associated with current outcome scoring systems, which may not accurately reflect level of improvement in some patients. CONCLUSIONS Cement fixation, using a polyethylene cup and a standard sized head offers good outcomes, with the lowest risks and at the lowest costs. The most commonly used cementless and resurfacing implants were associated with higher risk of revision and were more costly, while perceptions of improved function and longevity were unsupported.
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Affiliation(s)
- Simon S. Jameson
- School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, University Boulevard, Stockton-on-Tees, TS17 6BH, United Kingdom
- The National Joint Registry for England and Wales, London, United Kingdom
- Department of Orthopaedic Surgery, South Tees Hospitals NHS Foundation Trust, Marton Road, Middlesbrough, TS4 3BW, United Kingdom
| | - James Mason
- School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, University Boulevard, Stockton-on-Tees, TS17 6BH, United Kingdom
| | - Paul N. Baker
- The National Joint Registry for England and Wales, London, United Kingdom
- Department of Orthopaedic Surgery, South Tees Hospitals NHS Foundation Trust, Marton Road, Middlesbrough, TS4 3BW, United Kingdom
| | - Paul J. Gregg
- The National Joint Registry for England and Wales, London, United Kingdom
- Department of Orthopaedic Surgery, South Tees Hospitals NHS Foundation Trust, Marton Road, Middlesbrough, TS4 3BW, United Kingdom
| | - David J. Deehan
- Department of Orthopaedic Surgery, Newcastle Hospitals NHS Foundation Trust, Freeman Road, High Heaton, Newcastle upon Tyne, NE7 7DN, United Kingdom
| | - Mike R. Reed
- Department of Orthopaedic Surgery, Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, Ashington, Northumberland, NE63 9JJ, United Kingdom
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Uncemented fully hydroxyapatite-coated hip stem for intracapsular femoral neck fractures in osteoporotic elderly patients: a multicenter study. Arthroplast Today 2015; 1:81-84. [PMID: 28326377 PMCID: PMC4956684 DOI: 10.1016/j.artd.2015.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 02/22/2015] [Accepted: 02/24/2015] [Indexed: 11/28/2022] Open
Abstract
There is still debate over the limits of age and bone stock quality of patients on whom to use an un-cemented straight stem coated with hydroxyapatite (HA). We studied a group of 244 patients with a displaced intracapsular fracture of the femoral neck who underwent cementless hemiarthroplasty or total hip arthroplasty. 143 patients were reviewed at the two-year follow up. A fully HA-coated stem for intracapsular hip fracture results in a satisfactory return to pre-injury mobility and a low complications rate. The advantage reported in the literature of a low mortality rate with use of an un-cemented implant in elderly patients was shown to be greater still on finding an immediate primary stability and rapid osteointegration of the implant.
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Kallala R, Anderson P, Morris S, Haddad FS. The cost analysis of cemented versus cementless total hip replacement operations on the NHS. Bone Joint J 2013; 95-B:874-6. [PMID: 23814235 DOI: 10.1302/0301-620x.95b7.26931] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In a time of limited resources, the debate continues over which types of hip prosthesis are clinically superior and more cost-effective. Orthopaedic surgeons increasingly need robust economic evidence to understand the full value of the operation, and to aid decision making on the 'package' of procedures that are available and to justify their practice beyond traditional clinical preference. In this paper we explore the current economic debate about the merits of cemented and cementless total hip replacement, an issue that continues to divide the orthopaedic community.
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Affiliation(s)
- R Kallala
- University College London Hospital, 235 Euston Road, London NW1 2BU, UK
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Radiographic results of fully uncemented trabecular metal reverse shoulder system at 1 and 2 years' follow-up. J Shoulder Elbow Surg 2013; 22:e20-5. [PMID: 23246277 DOI: 10.1016/j.jse.2012.08.019] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 07/24/2012] [Accepted: 08/16/2012] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to assess the short-term radiographic outcome of a fully uncemented reverse total shoulder arthroplasty (RTSA) system. MATERIALS AND METHODS We reviewed the radiographs of 98 consecutive patients undergoing uncemented RTSA. All patients had a standardized series of radiographs taken at 2 weeks, 1 year, and 2 years postoperatively. Humeral stems were evaluated for radiolucent lines by zone and component subsidence. Evaluation for scapular notching and radiolucency surrounding the baseplate implant within the glenoid vault was also performed. RESULTS At 1 year, 93.9% of humeral stems had no lucent lines and 6.1% had less than 2 mm of lucency. Of the scapulae, 76.6% showed no evidence of notching, 21.4% had type 1 scapular notching, and 2.0% had type 2 notching at 1 year. At 2 years, 89.5% of humeral stem components had no lucent lines and 10.5% had less than 2 mm of lucency. Fifty-seven percent of scapulae had no notching, 34.2% had type 1 notching, 5.3% had type 2 notching, and 2.6% had type 3 notching. No stems had lucency in more than 1 zone or lucency ≥ 2 mm; 9.2% had subsidence of 2 mm or less. No glenoid components had any lucency around the baseplate or screws. CONCLUSIONS Cementless trabecular metal porous-coated implants for RTSA are associated with secure glenoid fixation and minimal radiographic evidence of humeral stem loosening or subsidence at short-term follow-up. The rates of scapular notching found in our study are comparable to previous studies and did not affect implant stability.
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Röttger J, Scheller-Kreinsen D, Busse R. Patient-level hospital costs and length of stay after conventional versus minimally invasive total hip replacement: a propensity-matched analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2012; 15:999-1004. [PMID: 23244800 DOI: 10.1016/j.jval.2012.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Revised: 06/05/2012] [Accepted: 06/15/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES A current trend in total hip replacement (THR) is the use of minimally invasive surgery. Little is known, however, about the impact of minimally invasive THR on resource use and length of stay. This study analyzed the effect of minimally invasive surgery on hospital costs and length of stay in German hospitals compared with conventional treatment in THR. METHODS We used patient-level administrative hospital data from three German hospitals participating in the national cost data study. We conducted a propensity score matching to account for baseline differences between minimally invasively and conventionally treated patients. Subsequently, we estimated the treatment effect on costs and length of stay by conducting group comparisons, via paired t tests and Wilcoxon signed-rank tests, and regression analyses. RESULTS The three hospitals provided data from 2886 THR patients. The propensity score matching led to 812 matched pairs. Length of stay was significantly higher for conventionally treated patients (11.49 days vs. 10.90 days; P < 0.05), but total costs did not differ significantly (€6018 vs. €5986; P = 0.67). We found a difference in the allocation of costs, with significantly higher implant costs for minimally invasively treated patients (€1514 vs. €1375; P < 0.001) in contrast to significantly higher staff and overhead costs for conventionally treated patients. CONCLUSIONS Minimally invasive surgery was compared with conventional THR and was found to be associated with a reduced length of stay. Total hospital costs, however, did not differ between the two treatment groups, because of higher implant costs for minimally invasively treated patients.
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Affiliation(s)
- Julia Röttger
- Department of Health Care Management, Berlin University of Technology, Germany, Berlin, Germany.
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Griffiths EJ, Stevenson D, Porteous MJ. Cost savings of using a cemented total hip replacement: an analysis of the National Joint Registry data. ACTA ACUST UNITED AC 2012; 94:1032-5. [PMID: 22844042 DOI: 10.1302/0301-620x.94b8.28717] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The debate whether to use cemented or uncemented components in primary total hip replacement (THR) has not yet been considered with reference to the cost implications to the National Health Service. We obtained the number of cemented and uncemented components implanted in 2009 from the National Joint Registry for England and Wales. The cost of each component was established. The initial financial saving if all were cemented was then calculated. Subsequently the five-year rates of revision for each type of component were reviewed and the predicted number of revisions at five years for the actual components used was compared with the predicted number of revisions for a cemented THR. This was then multiplied by the mean cost of revision surgery to provide an indication of the savings over the first five years if all primary THRs were cemented. The saving at primary THR was calculated to be £10 million with an additional saving during the first five years of between £5 million and £8.5 million. The use of cemented components in routine primary THR in the NHS as a whole can be justified on a financial level but we recognise individual patient factors must be considered when deciding which components to use.
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Affiliation(s)
- E J Griffiths
- West Suffolk NHS Trust, Hardwick Lane, Bury St Edmunds, Suffolk IP33 2QZ, UK.
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17
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Kim YH, Kim JS, Park JW, Joo JH. Total hip replacement with a short metaphyseal-fitting anatomical cementless femoral component in patients aged 70 years or older. ACTA ACUST UNITED AC 2011; 93:587-92. [DOI: 10.1302/0301-620x.93b5.25994] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
We reviewed the results of 84 total hip replacements performed with a short metaphyseal-fitting anatomical cementless femoral component in 84 unselected consecutive patients with a mean age of 78.9 years (70 to 88). The mean follow-up was 4.6 years (4 to 5). The mean pre-operative Harris hip score was 26 points (0 to 56), which improved to 89 (61 to 100) at the final follow-up. No patient had thigh pain. The mean pre-operative Western Ontario and McMaster Universities osteoarthritis index score was 61 points (48 to 75), which improved to 21 (6 to 46). The mean University of California, Los Angeles activity score was 5.5 points (3 to 7) at the final follow-up. Osseointegration was seen in all femoral and acetabular components. All hips had grade 1 stress shielding of the proximal femur. No acetabular or femoral osteolysis was identified. These results demonstrate that a short metaphyseal-fitting femoral component achieves optimal fixation without diaphyseal anchorage in elderly patients.
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Affiliation(s)
- Y.-H. Kim
- The Joint Replacement Center of Korea, Ewha Women’s University, MokDong Hospital, 911-1, Mokdong, YangChun-Gu, Seoul 158-710, Korea
| | - J.-S. Kim
- The Joint Replacement Center of Korea, Ewha Women’s University, MokDong Hospital, 911-1, Mokdong, YangChun-Gu, Seoul 158-710, Korea
| | - J.-W. Park
- The Joint Replacement Center of Korea, Ewha Women’s University, MokDong Hospital, 911-1, Mokdong, YangChun-Gu, Seoul 158-710, Korea
| | - J.-H. Joo
- The Joint Replacement Center of Korea, Ewha Women’s University, MokDong Hospital, 911-1, Mokdong, YangChun-Gu, Seoul 158-710, Korea
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Davies C, Lorgelly P, Shemilt I, Mugford M, Tucker K, Macgregor A. Can choices between alternative hip prostheses be evidence based? a review of the economic evaluation literature. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2010; 8:20. [PMID: 21034434 PMCID: PMC2984411 DOI: 10.1186/1478-7547-8-20] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Accepted: 10/29/2010] [Indexed: 11/10/2022] Open
Abstract
Background Total hip replacement surgery places a considerable financial burden on health services and society. Given the large number of hip prostheses available to surgeons, reliable economic evidence is crucial to inform resource allocation decisions. This review summarises published economic evidence on alternative hip prostheses to examine the potential for the literature to inform resource allocation decisions in the UK. Methods We searched nine medical and economics electronic databases. 3,270 studies were initially identified, 17 studies were included in the review. Studies were critically appraised using three separate guidelines. Results Several methodological problems were identified including a lack of observed long term prosthesis survival data, limited up-to-date and UK based evidence and exclusion of patient and societal perspectives. Conclusions More clinical trials including long term follow-up and economic evaluation are needed. These should compare the cost-effectiveness of different prostheses with longer-term follow-up and including a wider perspective.
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Affiliation(s)
- Charlotte Davies
- School of Medicine, Health Policy and Practice, University of East Anglia, UK.
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Abstract
Acrylic bone cements are in extensive use in joint replacement surgery. They are weight bearing and load transferring in the bone-cement-prosthesis complex and therefore, inter alia, their mechanical properties are deemed to be crucial for the overall outcome. In spite of adequate preclinical test results according to the current specifications (ISO, ASTM), cements with inferior clinical results have appeared on the market. The aim of this study was to investigate whether it is possible to predict the long term clinical performance of acrylic bone cement on the basis of mechanical in vitro testing. We performed in vitro quasistatic testing of cement after aging in different media and at different temperatures for up to 5 years. Dynamic creep testing and testing of retrieved cement were also performed. Testing under dry conditions, as required in current standards, always gave higher values for mechanical properties than did storage and testing under more physiological conditions. We could demonstrate a continuous increase in mechanical properties when testing in air, while testing in water resulted in a slight decrease in mechanical properties after 1 week and then levelled out. Palacos bone cement showed a higher creep than CMW3G and the retrieved Boneloc specimens showed a higher creep than retrieved Palacos. The strength of a bone cement develops more slowly than the apparent high initial setting rate indicates and there are changes in mechanical properties over a period of five years. The effect of water absorption is important for the physical properties but the mechanical changes caused by physical aging are still present after immersion in water. The established standards are in need of more clinically relevant test methods and their associated requirements need better definition. We recommend that testing of bone cements should be performed after extended aging under simulated physiological conditions. Simple quasistatic and dynamic creep tests seem unable to predict clinical performance of acrylic bone cements when the products under test are chemically very similar. However, such testing might be clinically relevant if the cements exhibit substantial differences.
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Affiliation(s)
- Markus Nottrott
- Centre for Bone- and Soft tissue Tumours, Department of Orthopaedic Surgery, Haukeland University Hospital, NO-5021 Bergen, Norway.
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Cementless femoral prostheses cost more to implant than cemented femoral prostheses. Clin Orthop Relat Res 2009; 467:1546-51. [PMID: 18781368 PMCID: PMC2674154 DOI: 10.1007/s11999-008-0485-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Accepted: 08/15/2008] [Indexed: 01/31/2023]
Abstract
UNLABELLED Prosthetic cost contributes greatly to the overall expense of THA. A key question, therefore, in the selection of implant technique is whether any price difference exists between a cementless and a cemented femoral prosthesis. We evaluated the price difference between the most commonly used cemented and cementless femoral stems at three high-volume academic medical centers. Each hospital's costs for prostheses from the manufacturers were recorded. The average cost of implanting a cementless femoral prosthesis was $296 more than the average cost of implanting a cemented femoral stem, even with the additional expense of two batches of bone cement and the accessories commonly used to achieve a third-generation cementing technique. The price difference was less variable if the cost of the prostheses from only the primary implant supplier for each institution was considered. As the number of THAs performed per year continues to escalate, implantation of a cemented femoral component remains an attractive method of fixation from an economic standpoint. LEVEL OF EVIDENCE Level III, economic and decision analysis. See the Guidelines for Authors for a complete description of levels of evidence.
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Ilizaliturri Sánchez VM, Mangino Pariente G, Camacho Galindo J. [Surgical treatment of hip osteoarthritis: update in total hip arthroplasty]. ACTA ACUST UNITED AC 2007; 3 Suppl 3:S57-62. [PMID: 21794483 DOI: 10.1016/s1699-258x(07)73657-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Total hip replacement is one of the most successful procedures in orthopaedic surgery. There are two different technologies for implant fixation in total hip replacement: cemented and cementless, both can be combined, which is called Hybrid arthroplasty. Long term implant stability results in long term function. The most important factor that limits longevity of well-fixed implants is the wear of the articular surfaces. Wear of the polyethylene from the acetabulum generates particles that access the implant bone or the implant-cement-bone interface. This produces an inflammatory reaction, osteolysis and implant loosening. Polyethylene of higher resistance to wear and prosthetic articulations without polyethylene (hard on hard bearings), have been introduced to improve wear particle generation. Minimally invasive surgical techniques minimize surgical trauma to sort tissue around the hip joint, facilitating a better and more rapid recovery.
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Bordini B, Stea S, De Clerico M, Strazzari S, Sasdelli A, Toni A. Factors affecting aseptic loosening of 4750 total hip arthroplasties: multivariate survival analysis. BMC Musculoskelet Disord 2007; 8:69. [PMID: 17650301 PMCID: PMC1947978 DOI: 10.1186/1471-2474-8-69] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Accepted: 07/24/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Total hip arthroplasty is a successful surgery, that fails at a rate of approximately 10% at ten years from surgery. Causes for failure are mainly aseptic loosening of one or both components partially due to wear of articular surfaces and partially to design. The present analysis aimed to identify risk factors and quantify their effects on aseptic failure. METHODS Multivariate survival analysis was applied to 4,750 primary total hip arthroplasties performed between 1995 and 2000. RESULTS The survival of the prosthesis is affected by gender, age, pathology, type of the prosthesis and skill of the. The worst conditions are male patients, younger than 40 years, affected by sequelae of congenital diseases, operated by a who performed less than 400 total hip artroplasty in the period. Furthermore, cemented cups and stems (less expensive) have a higher risk of failure compared with uncemented ones (more expensive). CONCLUSION The only variable that affects survival and that can be modified by is the type of prosthesis: a lower cost is associated to a higher risk. Results concerning the risk associated with cemented components are partially in disagreement with studies performed in countries where cemented prostheses are used more often than uncemented ones.
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Affiliation(s)
- Barbara Bordini
- Laboratorio di Tecnologia Medica, Istituti Ortopedici Rizzoli Via Barbiano 1/10, 40136 Bologna, Italy
| | - Susanna Stea
- Laboratorio di Tecnologia Medica, Istituti Ortopedici Rizzoli Via Barbiano 1/10, 40136 Bologna, Italy
| | - Manuela De Clerico
- Laboratorio di Tecnologia Medica, Istituti Ortopedici Rizzoli Via Barbiano 1/10, 40136 Bologna, Italy
| | - Sergio Strazzari
- Servizio di Farmacia, Istituti Ortopedici Rizzoli Via Barbiano 1/10, 40136 Bologna, Italy
| | - Antonio Sasdelli
- Direzione Amministrativa, Istituti Ortopedici Rizzoli Via Barbiano 1/10, 40136 Bologna, Italy
| | - Aldo Toni
- Laboratorio di Tecnologia Medica, Istituti Ortopedici Rizzoli Via Barbiano 1/10, 40136 Bologna, Italy
- I Divisione di Ortopedia e Traumatologia, Istituti Ortopedici Rizzoli Via Barbiano 1/10, 40136 Bologna, Italy
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