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J Hip Surg
DOI: 10.1055/s-0039-1688505

The incidence of total hip arthroplasty (THA) is dramatically increasing, placing a financial burden on the health care system as a whole. These economic challenges have inspired innovation in health care and spurred the implementation of value-based-care models. In this new health care environment, it is imperative to develop strategies that reduce cost while maintaining quality. The authors developed an implant selection guideline system for THA based upon a ratio of patient body mass index (BMI) to age. Patients are divided into either a high, medium, or standard demand category based on a BMI/age ratio of > 0.60, 0.60–0.41, and < 0.40, respectively. Retrospectively, the authors reviewed surgical reports of 1,990 patients who underwent primary THA at their institution from January 2012 to March 2014 to identify the type of implants utilized and analyze the potential cost impact of implementing this standardization system into clinical practice. Of 701 standard demand patients, 31.2% received higher cost implants than their demand necessitates under their model. A 16.5% of the 892 medium demand patients received high demand implants. High and medium demand implants cost 21.1 and 10.5% more than standard demand, respectively. Collectively, application of the BMI/age ratio would have resulted in a 2.2% reduction in overall THA implant cost and 15% if high demand implants had been used in every patient. Implementation of a BMI/age ratio for THA implant selection will reduce costs. This strategy may allow hospitals to more accurately predict and control future costs which is of growing importance in today's bundled payment and value-based-care environment.
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J Hip Surg
DOI: 10.1055/s-0039-1687849

Unplanned readmissions are associated with increased financial burdens. It is important to understand why they occur and how to reduce them. This study identifies incidences, trends, causes, and timing of 30-day readmissions after total hip arthroplasty (THA). Primary THA cases from 2012 to 2016 in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database were identified (n = 122,451). Fractures (n = 3,990), nonelective surgery (n = 1,715), and bilateral THA (n = 730) were excluded, leaving 116,016 cases. Linear regression analysis determined readmission trends overtime. The readmission rate after THA from 2012 to 16 was 3.32%, which significantly decreased during this time (p = 0.022). The top five causes of readmission included musculoskeletal complications (14.8%), deep surgical site infections (SSI; 11.1%), non-SSI infections (10.8%), gastrointestinal complications (GI; 7.5%), and cardiovascular complications (CV; 7.0%). The most common cause of readmission during week 1 was non-SSI infections (13.0%), week 2 was musculoskeletal complications (16%), week 3 was deep SSI (18.4%), and week 4 was deep SSI (18.6%). Causes of readmission that significantly decreased (p < 0.05) from week 1 to 4 include CV complications, GI complications, non-SSI infections, pain, and respiratory complications. In contrast, causes that significantly increased during this time included deep SSI, prosthesis complications, superficial SSI, and wound complications. Readmissions following THA significantly declined from 2012 to 2016. The most common causes of readmission were musculoskeletal complications, deep SSI, non-SSI infections, GI complications, and CV complications. Interestingly, the most common causes of readmission changed from week to week. These findings may help to develop policies to prevent readmissions following THA.
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J Hip Surg
DOI: 10.1055/s-0039-1687850

Clostridium difficile-associated diarrhea (CDAD) is a well-known cause of complications and increased hospital cost following surgery. As CDAD rates continue to be adopted as a quality metric by institutions, it is important to detect high-risk patients prior to surgery, including revision total hip arthroplasty (rTHA). This study was performed to identify the incidence and risk factors of CDAD within 30 days of rTHA. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was accessed from 2015 to 2016 to identify rTHA procedures. Overall, 4,178 patients were included. Preoperative and perioperative variables were analyzed as potential risk factors for the development of CDAD. To compare categorical variables, Chi-square and Fisher's exact tests were used, while t-tests were used to detect differences in continuous variables. Independent risk factors for CDAD were identified using stepwise logistic regression. The rate of CDAD was found to be 0.5% (20/4,178) within 30 days of rTHA. Preoperative functional dependence (odds ratio [OR] = 3.34; p = 0.035) and dyspnea (OR = 3.80; p = 0.019), were statistically significant risk factors for the development of CDAD after rTHA. Septic revision was not a significant risk factor for CDAD (OR = 2.50; p = 0.082). The incidence of CDAD after rTHA in the United States is approximately 0.5%. Independent risk factors for CDAD include preoperative functional dependence and dyspnea. High-risk patients must be identified prior to surgery and antibiotic selection for other infections should be managed judiciously.
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J Hip Surg
DOI: 10.1055/s-0039-1687844

A common concern for patients undergoing joint replacement is that the implant will increase their body weight. In an effort to determine if in fact the joint implant is heavier than the bone removed during surgery, the authors conducted a 3-year review from 11/2014 to 11/2017 of 339 patients who underwent total hip arthroplasty (THA) procedures performed by a single surgeon. In the 339 patients, the bone and tissue removed from the patient was weighed. Using the known weights of each component (cup, head, and stem), the authors calculated the total mass of the hip prosthetic implant. Using deidentified patient data, they reviewed only the weight of bone and tissue removed and the calculated weight of the implant placed in each THA performed by the single surgeon. They subtracted the mass of the bone and tissue removed during surgery from the total mass of the hip implant to determine the net weight differential in the patient following surgery and calculated an average net weight gain of 124.84 g in the 339 patients who underwent THA. This weight gain of 124.84 g is equivalent to 0.275 lbs. Previous studies have only looked at weight gain or loss following total joint replacement with respect to natural weight loss/gain that may be associated with improved mobility following surgery. This is the first study to measure the actual quantifiable net weight differential due to the joint replacement itself. The authors concluded that no appreciable weight gain following THA can be attributed to the weight of the implant.
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J Hip Surg
DOI: 10.1055/s-0039-1683963

Ileus following total hip arthroplasty (THA) is a clinically and financially significant postoperative complication that has not been extensively described in the orthopaedic joint literature. Ileus has been found to occur in 0.7 to 4.0% of patients after total joint arthroplasty and as high as 5.6% in patients after revision THA.1,2,3 In a 17-year period (2001 Fiscal Year through 2017 Fiscal Year) at one institution, the authors found an incidence of 0.674% (213/31619) following THA. In addition, the incidence of ileus following THA has drastically declined over this 17-year period, from 1.822% (19/1043) in 2001 to 0.099% (3/3036) in 2017. This decrease may be attributed to a reduction in narcotic use postoperatively, earlier ambulation following surgery, and reduction in length of hospital stay. Though postoperative ileus is not yet a preventable complication, recognition of risk factors may permit earlier intervention to ameliorate some of the morbidity associated with this condition.
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J Hip Surg 2019; 03: 001-001
DOI: 10.1055/s-0039-1683937



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J Hip Surg
DOI: 10.1055/s-0039-1679953

Obtaining appropriate prosthetic fit in cementless total hip arthroplasty can be challenging in cases with disparity between the femoral and metaphyseal diameters of the femur or cases of complex deformity. One solution has been to utilize a custom femoral component in total hip arthroplasty. The long-term results of this option with respect to femoral morphology are limited. This cohort was analyzed to determine the survivorship, functional results using Harris Hip Scores (HHSs), and complication rates using these implants. Survivorship and complications were evaluated based on the proximal femoral anatomy and severity of arthritis. The authors retrospectively reviewed 73 cases of custom femoral implants in total hip arthroplasties by a single surgeon. The average age of patients at index surgery was 58.06 years (range, 36.00–73.75 years). The mean follow-up was 8.59 years (range, 0.17–20.33 years) with a minimum of 2-year follow-up required for analysis of HHS data. There were 8 failures at a mean of 67.68 months (range, 2.04–135 months). The reasons for revision were infection (2), osteolysis (1), periprosthetic fracture (3), osteolysis and aseptic loosening (1), and polyethylene wear (1). The mean preoperative HHS was 55.38 (range, 31–90). The mean follow-up HHS was 93.10 (range, 38–100) with a mean improvement of 37.44 (p < 0.0001). Complications included infection (3), fracture (6), and dislocation (3). Preoperative Dorr classification A (n = 44), B (n = 24), and C (n = 1) and Kellgren–Lawrence grades I (n = 0), II (n = 2), III (n = 7), and IV (n = 60) were not predictive of failure or revision (p = 0.45, p = 0.6). There was a near significant association between Dorr classification B femur fractures requiring revision (p < 0.053). Kaplan–Meier predicted survivorship was 20.33 years with revision for any reason as the endpoint and total overall survivorship of 81.7%. Custom cementless femoral stems provide satisfactory survivorship and improvement in hip scores in a variety of patients undergoing cementless total hip arthroplasty. Fracture rates are higher in Dorr class B femurs. The level of evidence was IV.
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J Hip Surg
DOI: 10.1055/s-0039-1681081

Femoral neck-preserving short- (NPS) stem implants for total hip arthroplasty (THA) bear several advantages over longer-stem implants, such as native hip structure preservation and improved physiological loading. However, there still is a gap of knowledge regarding the potential benefits of a short-stem design over conventional neck-sacrificing stems in regards to patient-reported outcomes (PROs). The authors investigated the differences in PROs between a neck-sacrificing stem design and NPS stem design arthroplasty. They hypothesized that PROs of NPS stem THA would be higher in the medium-term in comparison to the neck-sacrificing implant system. Neck-sacrificing implant patients (n = 90, age 57 ± 7.9 years) and a matched (body mass index [BMI], age) cohort group of NPS implant patients (n = 105, age 55.2 ± 9.9 years) reported both preoperative and postoperative hip disability and osteoarthritis outcome scores (HOOS). Average follow-up was 413 ± 207 days (neck sacrificing implant) and 454 ± 226 days (NPS implant). The authors applied multivariate analysis of variance (MANOVA) and Mann–Whitney tests for statistical analyses. Significance levels were Holm–Bonferroni adjusted for multiple comparisons. HOOS Subscores increased significantly after surgery independent of implant type (p < 0.001). There was a significant time by surgery interaction (p = 0.02). Follow-up HOOS subscores were significantly higher in the NPS implant group: symptoms (p < 0.001), pain (p < 0.001), activities of daily living (ADL; p = 0.011), sports and recreation (p = 0.011), and quality of life (QOL; p = 0.007). While long-term studies are required for further investigation, evidence from the current study suggests that NPS implants may provide a significant benefit to primary THA patients, which could be due to physiological loading advantages or retention of bone tissue.
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J Hip Surg
DOI: 10.1055/s-0039-1681091

Metastatic disease to the periacetabular region of the pelvis is a complex and challenging problem to treat. Similar to the proximal femur, this area of the skeleton has a high proportion of involvement when primary tumors metastasize to bone. Surgical intervention to treat this patient population is significantly more difficult than treating lesions of the proximal femur. There tends to be higher rates of intraoperative blood loss and postoperative complications, as well as poorer prognoses. It is important for the operating surgeon to evaluate the patient's medical status using a multidisciplinary approach and fully understand their prognosis before planning and performing surgical intervention. Given the complex nature of these surgeries, they are best performed by orthopaedic oncologists or experienced revision arthroplasty specialists. The clinical evaluation, workup, and perioperative adjuncts to treatment for periacetabular metastatic disease are similar to those for disease of the proximal femur as discussed in part 1 of this article series. This review focuses on aspects specific to acetabular disease and surgical intervention in these patients.
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J Hip Surg
DOI: 10.1055/s-0039-1681080

Evaluation and management of suspected pathologic fractures, secondary to metastatic disease, require a comprehensive understanding of the underlying disease process and a multidisciplinary treatment approach. Recognition of a pathologic fracture can be challenging, and the diagnosis today remains often missed, but is necessary for appropriate care. The incidence of cancer in the United States is on the rise, and with advances in medical and surgical care the prevalence of cancer is increasing as well. This will result in a similar trend of increased incidence and prevalence of metastatic disease requiring treatment from orthopaedic surgeons. The proximal femur is the most common location for metastatic lesions in the appendicular skeleton, and as such sees a disproportionate number of pathologic fractures. This site of injury is particularly challenging to manage due to the transmission of high forces through this region during ambulation. A combination of adjunct therapies and surgical intervention will maximize the outcomes for these patients. Obtaining a tissue diagnosis, especially in the setting of a solitary bone lesion, is a crucial and required early step in this process.
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