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Bone Infections Increase After S. aureus Bacteremia in Patients With Rheumatoid Arthritis
TOPLINE:
After Staphylococcus aureus bacteremia, patients with rheumatoid arthritis (RA) face nearly double the risk for osteoarticular infections compared with those without RA, with similar mortality risks in both groups.
METHODOLOGY:
- The contraction of S aureus bacteremia is linked to poor clinical outcomes in patients with RA; however, no well-sized studies have evaluated the risk for osteoarticular infections and mortality outcomes in patients with RA following S aureus bacteremia.
- This Danish nationwide cohort study aimed to explore whether the cumulative incidence of osteoarticular infections and death would be higher in patients with RA than in those without RA after contracting S aureus bacteremia.
- The study cohort included 18,274 patients with a first episode of S aureus bacteremia between 2006 and 2018, of whom 367 had been diagnosed with RA before contracting S aureus bacteremia.
- The RA cohort had more women (62%) and a higher median age of participants (73 years) than the non-RA cohort (37% women; median age of participants, 70 years).
TAKEAWAY:
- The 90-day cumulative incidence of osteoarticular infections (septic arthritis, spondylitis, osteomyelitis, psoas muscle abscess, or prosthetic joint infection) was nearly double in patients with RA compared with in those without RA (23.1% vs 12.5%; hazard ratio [HR], 1.93; 95% CI, 1.54-2.41).
- In patients with RA, the risk for osteoarticular infections increased with tumor necrosis factor inhibitor use (HR, 2.27; 95% CI, 1.29-3.98) and orthopedic implants (HR, 1.75; 95% CI, 1.08-2.85).
- Moreover, 90-day all-cause mortality was comparable in the RA (35.4%) and non-RA cohorts (33.9%).
IN PRACTICE:
“Our findings stress the need for vigilance in patients with RA who present with S aureus bacteremia to ensure timely identification and treatment of osteoarticular infections, especially in current TNFi [tumor necrosis factor inhibitor] users and patients with orthopedic implants,” the authors wrote.
SOURCE:
This study, led by Sabine S. Dieperink, MD, of the Centre of Head and Orthopaedics, Copenhagen University Rigshospitalet Glostrup, Denmark, was published online March 9 in Rheumatology (Oxford).
LIMITATIONS:
There might have been chances of misclassification of metastatic S aureus infections owing to the lack of specificity in diagnoses or procedure codes. This study relied on administrative data to record osteoarticular infections, which might have led investigators to underestimate the true cumulative incidence of osteoarticular infections. Also, some patients might have passed away before being diagnosed with osteoarticular infection owing to the high mortality.
DISCLOSURES:
This work was supported by grants from The Danish Rheumatism Association and Beckett Fonden. Some of the authors, including the lead author, declared receiving grants from various funding agencies and other sources, including pharmaceutical companies.
A version of this article appeared on Medscape.com.
TOPLINE:
After Staphylococcus aureus bacteremia, patients with rheumatoid arthritis (RA) face nearly double the risk for osteoarticular infections compared with those without RA, with similar mortality risks in both groups.
METHODOLOGY:
- The contraction of S aureus bacteremia is linked to poor clinical outcomes in patients with RA; however, no well-sized studies have evaluated the risk for osteoarticular infections and mortality outcomes in patients with RA following S aureus bacteremia.
- This Danish nationwide cohort study aimed to explore whether the cumulative incidence of osteoarticular infections and death would be higher in patients with RA than in those without RA after contracting S aureus bacteremia.
- The study cohort included 18,274 patients with a first episode of S aureus bacteremia between 2006 and 2018, of whom 367 had been diagnosed with RA before contracting S aureus bacteremia.
- The RA cohort had more women (62%) and a higher median age of participants (73 years) than the non-RA cohort (37% women; median age of participants, 70 years).
TAKEAWAY:
- The 90-day cumulative incidence of osteoarticular infections (septic arthritis, spondylitis, osteomyelitis, psoas muscle abscess, or prosthetic joint infection) was nearly double in patients with RA compared with in those without RA (23.1% vs 12.5%; hazard ratio [HR], 1.93; 95% CI, 1.54-2.41).
- In patients with RA, the risk for osteoarticular infections increased with tumor necrosis factor inhibitor use (HR, 2.27; 95% CI, 1.29-3.98) and orthopedic implants (HR, 1.75; 95% CI, 1.08-2.85).
- Moreover, 90-day all-cause mortality was comparable in the RA (35.4%) and non-RA cohorts (33.9%).
IN PRACTICE:
“Our findings stress the need for vigilance in patients with RA who present with S aureus bacteremia to ensure timely identification and treatment of osteoarticular infections, especially in current TNFi [tumor necrosis factor inhibitor] users and patients with orthopedic implants,” the authors wrote.
SOURCE:
This study, led by Sabine S. Dieperink, MD, of the Centre of Head and Orthopaedics, Copenhagen University Rigshospitalet Glostrup, Denmark, was published online March 9 in Rheumatology (Oxford).
LIMITATIONS:
There might have been chances of misclassification of metastatic S aureus infections owing to the lack of specificity in diagnoses or procedure codes. This study relied on administrative data to record osteoarticular infections, which might have led investigators to underestimate the true cumulative incidence of osteoarticular infections. Also, some patients might have passed away before being diagnosed with osteoarticular infection owing to the high mortality.
DISCLOSURES:
This work was supported by grants from The Danish Rheumatism Association and Beckett Fonden. Some of the authors, including the lead author, declared receiving grants from various funding agencies and other sources, including pharmaceutical companies.
A version of this article appeared on Medscape.com.
TOPLINE:
After Staphylococcus aureus bacteremia, patients with rheumatoid arthritis (RA) face nearly double the risk for osteoarticular infections compared with those without RA, with similar mortality risks in both groups.
METHODOLOGY:
- The contraction of S aureus bacteremia is linked to poor clinical outcomes in patients with RA; however, no well-sized studies have evaluated the risk for osteoarticular infections and mortality outcomes in patients with RA following S aureus bacteremia.
- This Danish nationwide cohort study aimed to explore whether the cumulative incidence of osteoarticular infections and death would be higher in patients with RA than in those without RA after contracting S aureus bacteremia.
- The study cohort included 18,274 patients with a first episode of S aureus bacteremia between 2006 and 2018, of whom 367 had been diagnosed with RA before contracting S aureus bacteremia.
- The RA cohort had more women (62%) and a higher median age of participants (73 years) than the non-RA cohort (37% women; median age of participants, 70 years).
TAKEAWAY:
- The 90-day cumulative incidence of osteoarticular infections (septic arthritis, spondylitis, osteomyelitis, psoas muscle abscess, or prosthetic joint infection) was nearly double in patients with RA compared with in those without RA (23.1% vs 12.5%; hazard ratio [HR], 1.93; 95% CI, 1.54-2.41).
- In patients with RA, the risk for osteoarticular infections increased with tumor necrosis factor inhibitor use (HR, 2.27; 95% CI, 1.29-3.98) and orthopedic implants (HR, 1.75; 95% CI, 1.08-2.85).
- Moreover, 90-day all-cause mortality was comparable in the RA (35.4%) and non-RA cohorts (33.9%).
IN PRACTICE:
“Our findings stress the need for vigilance in patients with RA who present with S aureus bacteremia to ensure timely identification and treatment of osteoarticular infections, especially in current TNFi [tumor necrosis factor inhibitor] users and patients with orthopedic implants,” the authors wrote.
SOURCE:
This study, led by Sabine S. Dieperink, MD, of the Centre of Head and Orthopaedics, Copenhagen University Rigshospitalet Glostrup, Denmark, was published online March 9 in Rheumatology (Oxford).
LIMITATIONS:
There might have been chances of misclassification of metastatic S aureus infections owing to the lack of specificity in diagnoses or procedure codes. This study relied on administrative data to record osteoarticular infections, which might have led investigators to underestimate the true cumulative incidence of osteoarticular infections. Also, some patients might have passed away before being diagnosed with osteoarticular infection owing to the high mortality.
DISCLOSURES:
This work was supported by grants from The Danish Rheumatism Association and Beckett Fonden. Some of the authors, including the lead author, declared receiving grants from various funding agencies and other sources, including pharmaceutical companies.
A version of this article appeared on Medscape.com.
New ESC guidelines for cutting CV risk in noncardiac surgery
The European Society of Cardiology guidelines on cardiovascular assessment and management of patients undergoing noncardiac surgery have seen extensive revision since the 2014 version.
They still have the same aim – to prevent surgery-related bleeding complications, perioperative myocardial infarction/injury (PMI), stent thrombosis, acute heart failure, arrhythmias, pulmonary embolism, ischemic stroke, and cardiovascular (CV) death.
Cochairpersons Sigrun Halvorsen, MD, PhD, and Julinda Mehilli, MD, presented highlights from the guidelines at the annual congress of the European Society of Cardiology and the document was simultaneously published online in the European Heart Journal.
The document classifies noncardiac surgery into three levels of 30-day risk of CV death, MI, or stroke. Low (< 1%) risk includes eye or thyroid surgery; intermediate (1%-5%) risk includes knee or hip replacement or renal transplant; and high (> 5%) risk includes aortic aneurysm, lung transplant, or pancreatic or bladder cancer surgery (see more examples below).
It classifies patients as low risk if they are younger than 65 without CV disease or CV risk factors (smoking, hypertension, diabetes, dyslipidemia, family history); intermediate risk if they are 65 or older or have CV risk factors; and high risk if they have CVD.
In an interview, Dr. Halvorsen, professor in cardiology, University of Oslo, zeroed in on three important revisions:
First, recommendations for preoperative ECG and biomarkers are more specific, he noted.
The guidelines advise that before intermediate- or high-risk noncardiac surgery, in patients who have known CVD, CV risk factors (including age 65 or older), or symptoms suggestive of CVD:
- It is recommended to obtain a preoperative 12-lead ECG (class I).
- It is recommended to measure high-sensitivity cardiac troponin T (hs-cTn T) or high-sensitivity cardiac troponin I (hs-cTn I). It is also recommended to measure these biomarkers at 24 hours and 48 hours post surgery (class I).
- It should be considered to measure B-type natriuretic peptide or N-terminal of the prohormone BNP (NT-proBNP).
However, for low-risk patients undergoing low- and intermediate-risk noncardiac surgery, it is not recommended to routinely obtain preoperative ECG, hs-cTn T/I, or BNP/NT-proBNP concentrations (class III).
Troponins have a stronger class I recommendation, compared with the IIA recommendation for BNP, because they are useful for preoperative risk stratification and for diagnosis of PMI, Dr. Halvorsen explained. “Patients receive painkillers after surgery and may have no pain,” she noted, but they may have PMI, which has a bad prognosis.
Second, the guidelines recommend that “all patients should stop smoking 4 weeks before noncardiac surgery [class I],” she noted. Clinicians should also “measure hemoglobin, and if the patient is anemic, treat the anemia.”
Third, the sections on antithrombotic treatment have been significantly revised. “Bridging – stopping an oral antithrombotic drug and switching to a subcutaneous or IV drug – has been common,” Dr. Halvorsen said, “but recently we have new evidence that in most cases that increases the risk of bleeding.”
“We are [now] much more restrictive with respect to bridging” with unfractionated heparin or low-molecular-weight heparin, she said. “We recommend against bridging in patients with low to moderate thrombotic risk,” and bridging should only be considered in patients with mechanical prosthetic heart valves or with very high thrombotic risk.
More preoperative recommendations
In the guideline overview session at the congress, Dr. Halverson highlighted some of the new recommendations for preoperative risk assessment.
If time allows, it is recommended to optimize guideline-recommended treatment of CVD and control of CV risk factors including blood pressure, dyslipidemia, and diabetes, before noncardiac surgery (class I).
Patients commonly have “murmurs, chest pain, dyspnea, and edema that may suggest severe CVD, but may also be caused by noncardiac disease,” she noted. The guidelines state that “for patients with a newly detected murmur and symptoms or signs of CVD, transthoracic echocardiography is recommended before noncardiac surgery (class I).
“Many studies have been performed to try to find out if initiation of specific drugs before surgery could reduce the risk of complications,” Dr. Halvorsen noted. However, few have shown any benefit and “the question of presurgery initiation of beta-blockers has been greatly debated,” she said. “We have again reviewed the literature and concluded ‘Routine initiation of beta-blockers perioperatively is not recommended (class IIIA).’ “
“We adhere to the guidelines on acute and chronic coronary syndrome recommending 6-12 months of dual antiplatelet treatment as a standard before elective surgery,” she said. “However, in case of time-sensitive surgery, the duration of that treatment can be shortened down to a minimum of 1 month after elective PCI and a minimum of 3 months after PCI and ACS.”
Patients with specific types of CVD
Dr. Mehilli, a professor at Landshut-Achdorf (Germany) Hospital, highlighted some new guideline recommendations for patients who have specific types of cardiovascular disease.
Coronary artery disease (CAD). “For chronic coronary syndrome, a cardiac workup is recommended only for patients undergoing intermediate risk or high-risk noncardiac surgery.”
“Stress imaging should be considered before any high risk, noncardiac surgery in asymptomatic patients with poor functional capacity and prior PCI or coronary artery bypass graft (new recommendation, class IIa).”
Mitral valve regurgitation. For patients undergoing scheduled noncardiac surgery, who remain symptomatic despite guideline-directed medical treatment for mitral valve regurgitation (including resynchronization and myocardial revascularization), consider a valve intervention – either transcatheter or surgical – before noncardiac surgery in eligible patients with acceptable procedural risk (new recommendation).
Cardiac implantable electronic devices (CIED). For high-risk patients with CIEDs undergoing noncardiac surgery with high probability of electromagnetic interference, a CIED checkup and necessary reprogramming immediately before the procedure should be considered (new recommendation).
Arrhythmias. “I want only to stress,” Dr. Mehilli said, “in patients with atrial fibrillation with acute or worsening hemodynamic instability undergoing noncardiac surgery, an emergency electrical cardioversion is recommended (class I).”
Peripheral artery disease (PAD) and abdominal aortic aneurysm. For these patients “we do not recommend a routine referral for a cardiac workup. But we recommend it for patients with poor functional capacity or with significant risk factors or symptoms (new recommendations).”
Chronic arterial hypertension. “We have modified the recommendation, recommending avoidance of large perioperative fluctuations in blood pressure, and we do not recommend deferring noncardiac surgery in patients with stage 1 or 2 hypertension,” she said.
Postoperative cardiovascular complications
The most frequent postoperative cardiovascular complication is PMI, Dr. Mehilli noted.
“In the BASEL-PMI registry, the incidence of this complication around intermediate or high-risk noncardiac surgery was up to 15% among patients older than 65 years or with a history of CAD or PAD, which makes this kind of complication really important to prevent, to assess, and to know how to treat.”
“It is recommended to have a high awareness for perioperative cardiovascular complications, combined with surveillance for PMI in patients undergoing intermediate- or high-risk noncardiac surgery” based on serial measurements of high-sensitivity cardiac troponin.
The guidelines define PMI as “an increase in the delta of high-sensitivity troponin more than the upper level of normal,” Dr. Mehilli said. “It’s different from the one used in a rule-in algorithm for non-STEMI acute coronary syndrome.”
Postoperative atrial fibrillation (AFib) is observed in 2%-30% of noncardiac surgery patients in different registries, particularly in patients undergoing intermediate or high-risk noncardiac surgery, she noted.
“We propose an algorithm on how to prevent and treat this complication. I want to highlight that in patients with hemodynamic unstable postoperative AF[ib], an emergency cardioversion is indicated. For the others, a rate control with the target heart rate of less than 110 beats per minute is indicated.”
In patients with postoperative AFib, long-term oral anticoagulation therapy should be considered in all patients at risk for stroke, considering the anticipated net clinical benefit of oral anticoagulation therapy as well as informed patient preference (new recommendations).
Routine use of beta-blockers to prevent postoperative AFib in patients undergoing noncardiac surgery is not recommended.
The document also covers the management of patients with kidney disease, diabetes, cancer, obesity, and COVID-19. In general, elective noncardiac surgery should be postponed after a patient has COVID-19, until he or she recovers completely, and coexisting conditions are optimized.
The guidelines are available from the ESC website in several formats: pocket guidelines, pocket guidelines smartphone app, guidelines slide set, essential messages, and the European Heart Journal article.
Noncardiac surgery risk categories
The guideline includes a table that classifies noncardiac surgeries into three groups, based on the associated 30-day risk of death, MI, or stroke:
- Low (< 1%): breast, dental, eye, thyroid, and minor gynecologic, orthopedic, and urologic surgery.
- Intermediate (1%-5%): carotid surgery, endovascular aortic aneurysm repair, gallbladder surgery, head or neck surgery, hernia repair, peripheral arterial angioplasty, renal transplant, major gynecologic, orthopedic, or neurologic (hip or spine) surgery, or urologic surgery
- High (> 5%): aortic and major vascular surgery (including aortic aneurysm), bladder removal (usually as a result of cancer), limb amputation, lung or liver transplant, pancreatic surgery, or perforated bowel repair.
The guidelines were endorsed by the European Society of Anaesthesiology and Intensive Care. The guideline authors reported numerous disclosures.
A version of this article first appeared on Medscape.com.
The European Society of Cardiology guidelines on cardiovascular assessment and management of patients undergoing noncardiac surgery have seen extensive revision since the 2014 version.
They still have the same aim – to prevent surgery-related bleeding complications, perioperative myocardial infarction/injury (PMI), stent thrombosis, acute heart failure, arrhythmias, pulmonary embolism, ischemic stroke, and cardiovascular (CV) death.
Cochairpersons Sigrun Halvorsen, MD, PhD, and Julinda Mehilli, MD, presented highlights from the guidelines at the annual congress of the European Society of Cardiology and the document was simultaneously published online in the European Heart Journal.
The document classifies noncardiac surgery into three levels of 30-day risk of CV death, MI, or stroke. Low (< 1%) risk includes eye or thyroid surgery; intermediate (1%-5%) risk includes knee or hip replacement or renal transplant; and high (> 5%) risk includes aortic aneurysm, lung transplant, or pancreatic or bladder cancer surgery (see more examples below).
It classifies patients as low risk if they are younger than 65 without CV disease or CV risk factors (smoking, hypertension, diabetes, dyslipidemia, family history); intermediate risk if they are 65 or older or have CV risk factors; and high risk if they have CVD.
In an interview, Dr. Halvorsen, professor in cardiology, University of Oslo, zeroed in on three important revisions:
First, recommendations for preoperative ECG and biomarkers are more specific, he noted.
The guidelines advise that before intermediate- or high-risk noncardiac surgery, in patients who have known CVD, CV risk factors (including age 65 or older), or symptoms suggestive of CVD:
- It is recommended to obtain a preoperative 12-lead ECG (class I).
- It is recommended to measure high-sensitivity cardiac troponin T (hs-cTn T) or high-sensitivity cardiac troponin I (hs-cTn I). It is also recommended to measure these biomarkers at 24 hours and 48 hours post surgery (class I).
- It should be considered to measure B-type natriuretic peptide or N-terminal of the prohormone BNP (NT-proBNP).
However, for low-risk patients undergoing low- and intermediate-risk noncardiac surgery, it is not recommended to routinely obtain preoperative ECG, hs-cTn T/I, or BNP/NT-proBNP concentrations (class III).
Troponins have a stronger class I recommendation, compared with the IIA recommendation for BNP, because they are useful for preoperative risk stratification and for diagnosis of PMI, Dr. Halvorsen explained. “Patients receive painkillers after surgery and may have no pain,” she noted, but they may have PMI, which has a bad prognosis.
Second, the guidelines recommend that “all patients should stop smoking 4 weeks before noncardiac surgery [class I],” she noted. Clinicians should also “measure hemoglobin, and if the patient is anemic, treat the anemia.”
Third, the sections on antithrombotic treatment have been significantly revised. “Bridging – stopping an oral antithrombotic drug and switching to a subcutaneous or IV drug – has been common,” Dr. Halvorsen said, “but recently we have new evidence that in most cases that increases the risk of bleeding.”
“We are [now] much more restrictive with respect to bridging” with unfractionated heparin or low-molecular-weight heparin, she said. “We recommend against bridging in patients with low to moderate thrombotic risk,” and bridging should only be considered in patients with mechanical prosthetic heart valves or with very high thrombotic risk.
More preoperative recommendations
In the guideline overview session at the congress, Dr. Halverson highlighted some of the new recommendations for preoperative risk assessment.
If time allows, it is recommended to optimize guideline-recommended treatment of CVD and control of CV risk factors including blood pressure, dyslipidemia, and diabetes, before noncardiac surgery (class I).
Patients commonly have “murmurs, chest pain, dyspnea, and edema that may suggest severe CVD, but may also be caused by noncardiac disease,” she noted. The guidelines state that “for patients with a newly detected murmur and symptoms or signs of CVD, transthoracic echocardiography is recommended before noncardiac surgery (class I).
“Many studies have been performed to try to find out if initiation of specific drugs before surgery could reduce the risk of complications,” Dr. Halvorsen noted. However, few have shown any benefit and “the question of presurgery initiation of beta-blockers has been greatly debated,” she said. “We have again reviewed the literature and concluded ‘Routine initiation of beta-blockers perioperatively is not recommended (class IIIA).’ “
“We adhere to the guidelines on acute and chronic coronary syndrome recommending 6-12 months of dual antiplatelet treatment as a standard before elective surgery,” she said. “However, in case of time-sensitive surgery, the duration of that treatment can be shortened down to a minimum of 1 month after elective PCI and a minimum of 3 months after PCI and ACS.”
Patients with specific types of CVD
Dr. Mehilli, a professor at Landshut-Achdorf (Germany) Hospital, highlighted some new guideline recommendations for patients who have specific types of cardiovascular disease.
Coronary artery disease (CAD). “For chronic coronary syndrome, a cardiac workup is recommended only for patients undergoing intermediate risk or high-risk noncardiac surgery.”
“Stress imaging should be considered before any high risk, noncardiac surgery in asymptomatic patients with poor functional capacity and prior PCI or coronary artery bypass graft (new recommendation, class IIa).”
Mitral valve regurgitation. For patients undergoing scheduled noncardiac surgery, who remain symptomatic despite guideline-directed medical treatment for mitral valve regurgitation (including resynchronization and myocardial revascularization), consider a valve intervention – either transcatheter or surgical – before noncardiac surgery in eligible patients with acceptable procedural risk (new recommendation).
Cardiac implantable electronic devices (CIED). For high-risk patients with CIEDs undergoing noncardiac surgery with high probability of electromagnetic interference, a CIED checkup and necessary reprogramming immediately before the procedure should be considered (new recommendation).
Arrhythmias. “I want only to stress,” Dr. Mehilli said, “in patients with atrial fibrillation with acute or worsening hemodynamic instability undergoing noncardiac surgery, an emergency electrical cardioversion is recommended (class I).”
Peripheral artery disease (PAD) and abdominal aortic aneurysm. For these patients “we do not recommend a routine referral for a cardiac workup. But we recommend it for patients with poor functional capacity or with significant risk factors or symptoms (new recommendations).”
Chronic arterial hypertension. “We have modified the recommendation, recommending avoidance of large perioperative fluctuations in blood pressure, and we do not recommend deferring noncardiac surgery in patients with stage 1 or 2 hypertension,” she said.
Postoperative cardiovascular complications
The most frequent postoperative cardiovascular complication is PMI, Dr. Mehilli noted.
“In the BASEL-PMI registry, the incidence of this complication around intermediate or high-risk noncardiac surgery was up to 15% among patients older than 65 years or with a history of CAD or PAD, which makes this kind of complication really important to prevent, to assess, and to know how to treat.”
“It is recommended to have a high awareness for perioperative cardiovascular complications, combined with surveillance for PMI in patients undergoing intermediate- or high-risk noncardiac surgery” based on serial measurements of high-sensitivity cardiac troponin.
The guidelines define PMI as “an increase in the delta of high-sensitivity troponin more than the upper level of normal,” Dr. Mehilli said. “It’s different from the one used in a rule-in algorithm for non-STEMI acute coronary syndrome.”
Postoperative atrial fibrillation (AFib) is observed in 2%-30% of noncardiac surgery patients in different registries, particularly in patients undergoing intermediate or high-risk noncardiac surgery, she noted.
“We propose an algorithm on how to prevent and treat this complication. I want to highlight that in patients with hemodynamic unstable postoperative AF[ib], an emergency cardioversion is indicated. For the others, a rate control with the target heart rate of less than 110 beats per minute is indicated.”
In patients with postoperative AFib, long-term oral anticoagulation therapy should be considered in all patients at risk for stroke, considering the anticipated net clinical benefit of oral anticoagulation therapy as well as informed patient preference (new recommendations).
Routine use of beta-blockers to prevent postoperative AFib in patients undergoing noncardiac surgery is not recommended.
The document also covers the management of patients with kidney disease, diabetes, cancer, obesity, and COVID-19. In general, elective noncardiac surgery should be postponed after a patient has COVID-19, until he or she recovers completely, and coexisting conditions are optimized.
The guidelines are available from the ESC website in several formats: pocket guidelines, pocket guidelines smartphone app, guidelines slide set, essential messages, and the European Heart Journal article.
Noncardiac surgery risk categories
The guideline includes a table that classifies noncardiac surgeries into three groups, based on the associated 30-day risk of death, MI, or stroke:
- Low (< 1%): breast, dental, eye, thyroid, and minor gynecologic, orthopedic, and urologic surgery.
- Intermediate (1%-5%): carotid surgery, endovascular aortic aneurysm repair, gallbladder surgery, head or neck surgery, hernia repair, peripheral arterial angioplasty, renal transplant, major gynecologic, orthopedic, or neurologic (hip or spine) surgery, or urologic surgery
- High (> 5%): aortic and major vascular surgery (including aortic aneurysm), bladder removal (usually as a result of cancer), limb amputation, lung or liver transplant, pancreatic surgery, or perforated bowel repair.
The guidelines were endorsed by the European Society of Anaesthesiology and Intensive Care. The guideline authors reported numerous disclosures.
A version of this article first appeared on Medscape.com.
The European Society of Cardiology guidelines on cardiovascular assessment and management of patients undergoing noncardiac surgery have seen extensive revision since the 2014 version.
They still have the same aim – to prevent surgery-related bleeding complications, perioperative myocardial infarction/injury (PMI), stent thrombosis, acute heart failure, arrhythmias, pulmonary embolism, ischemic stroke, and cardiovascular (CV) death.
Cochairpersons Sigrun Halvorsen, MD, PhD, and Julinda Mehilli, MD, presented highlights from the guidelines at the annual congress of the European Society of Cardiology and the document was simultaneously published online in the European Heart Journal.
The document classifies noncardiac surgery into three levels of 30-day risk of CV death, MI, or stroke. Low (< 1%) risk includes eye or thyroid surgery; intermediate (1%-5%) risk includes knee or hip replacement or renal transplant; and high (> 5%) risk includes aortic aneurysm, lung transplant, or pancreatic or bladder cancer surgery (see more examples below).
It classifies patients as low risk if they are younger than 65 without CV disease or CV risk factors (smoking, hypertension, diabetes, dyslipidemia, family history); intermediate risk if they are 65 or older or have CV risk factors; and high risk if they have CVD.
In an interview, Dr. Halvorsen, professor in cardiology, University of Oslo, zeroed in on three important revisions:
First, recommendations for preoperative ECG and biomarkers are more specific, he noted.
The guidelines advise that before intermediate- or high-risk noncardiac surgery, in patients who have known CVD, CV risk factors (including age 65 or older), or symptoms suggestive of CVD:
- It is recommended to obtain a preoperative 12-lead ECG (class I).
- It is recommended to measure high-sensitivity cardiac troponin T (hs-cTn T) or high-sensitivity cardiac troponin I (hs-cTn I). It is also recommended to measure these biomarkers at 24 hours and 48 hours post surgery (class I).
- It should be considered to measure B-type natriuretic peptide or N-terminal of the prohormone BNP (NT-proBNP).
However, for low-risk patients undergoing low- and intermediate-risk noncardiac surgery, it is not recommended to routinely obtain preoperative ECG, hs-cTn T/I, or BNP/NT-proBNP concentrations (class III).
Troponins have a stronger class I recommendation, compared with the IIA recommendation for BNP, because they are useful for preoperative risk stratification and for diagnosis of PMI, Dr. Halvorsen explained. “Patients receive painkillers after surgery and may have no pain,” she noted, but they may have PMI, which has a bad prognosis.
Second, the guidelines recommend that “all patients should stop smoking 4 weeks before noncardiac surgery [class I],” she noted. Clinicians should also “measure hemoglobin, and if the patient is anemic, treat the anemia.”
Third, the sections on antithrombotic treatment have been significantly revised. “Bridging – stopping an oral antithrombotic drug and switching to a subcutaneous or IV drug – has been common,” Dr. Halvorsen said, “but recently we have new evidence that in most cases that increases the risk of bleeding.”
“We are [now] much more restrictive with respect to bridging” with unfractionated heparin or low-molecular-weight heparin, she said. “We recommend against bridging in patients with low to moderate thrombotic risk,” and bridging should only be considered in patients with mechanical prosthetic heart valves or with very high thrombotic risk.
More preoperative recommendations
In the guideline overview session at the congress, Dr. Halverson highlighted some of the new recommendations for preoperative risk assessment.
If time allows, it is recommended to optimize guideline-recommended treatment of CVD and control of CV risk factors including blood pressure, dyslipidemia, and diabetes, before noncardiac surgery (class I).
Patients commonly have “murmurs, chest pain, dyspnea, and edema that may suggest severe CVD, but may also be caused by noncardiac disease,” she noted. The guidelines state that “for patients with a newly detected murmur and symptoms or signs of CVD, transthoracic echocardiography is recommended before noncardiac surgery (class I).
“Many studies have been performed to try to find out if initiation of specific drugs before surgery could reduce the risk of complications,” Dr. Halvorsen noted. However, few have shown any benefit and “the question of presurgery initiation of beta-blockers has been greatly debated,” she said. “We have again reviewed the literature and concluded ‘Routine initiation of beta-blockers perioperatively is not recommended (class IIIA).’ “
“We adhere to the guidelines on acute and chronic coronary syndrome recommending 6-12 months of dual antiplatelet treatment as a standard before elective surgery,” she said. “However, in case of time-sensitive surgery, the duration of that treatment can be shortened down to a minimum of 1 month after elective PCI and a minimum of 3 months after PCI and ACS.”
Patients with specific types of CVD
Dr. Mehilli, a professor at Landshut-Achdorf (Germany) Hospital, highlighted some new guideline recommendations for patients who have specific types of cardiovascular disease.
Coronary artery disease (CAD). “For chronic coronary syndrome, a cardiac workup is recommended only for patients undergoing intermediate risk or high-risk noncardiac surgery.”
“Stress imaging should be considered before any high risk, noncardiac surgery in asymptomatic patients with poor functional capacity and prior PCI or coronary artery bypass graft (new recommendation, class IIa).”
Mitral valve regurgitation. For patients undergoing scheduled noncardiac surgery, who remain symptomatic despite guideline-directed medical treatment for mitral valve regurgitation (including resynchronization and myocardial revascularization), consider a valve intervention – either transcatheter or surgical – before noncardiac surgery in eligible patients with acceptable procedural risk (new recommendation).
Cardiac implantable electronic devices (CIED). For high-risk patients with CIEDs undergoing noncardiac surgery with high probability of electromagnetic interference, a CIED checkup and necessary reprogramming immediately before the procedure should be considered (new recommendation).
Arrhythmias. “I want only to stress,” Dr. Mehilli said, “in patients with atrial fibrillation with acute or worsening hemodynamic instability undergoing noncardiac surgery, an emergency electrical cardioversion is recommended (class I).”
Peripheral artery disease (PAD) and abdominal aortic aneurysm. For these patients “we do not recommend a routine referral for a cardiac workup. But we recommend it for patients with poor functional capacity or with significant risk factors or symptoms (new recommendations).”
Chronic arterial hypertension. “We have modified the recommendation, recommending avoidance of large perioperative fluctuations in blood pressure, and we do not recommend deferring noncardiac surgery in patients with stage 1 or 2 hypertension,” she said.
Postoperative cardiovascular complications
The most frequent postoperative cardiovascular complication is PMI, Dr. Mehilli noted.
“In the BASEL-PMI registry, the incidence of this complication around intermediate or high-risk noncardiac surgery was up to 15% among patients older than 65 years or with a history of CAD or PAD, which makes this kind of complication really important to prevent, to assess, and to know how to treat.”
“It is recommended to have a high awareness for perioperative cardiovascular complications, combined with surveillance for PMI in patients undergoing intermediate- or high-risk noncardiac surgery” based on serial measurements of high-sensitivity cardiac troponin.
The guidelines define PMI as “an increase in the delta of high-sensitivity troponin more than the upper level of normal,” Dr. Mehilli said. “It’s different from the one used in a rule-in algorithm for non-STEMI acute coronary syndrome.”
Postoperative atrial fibrillation (AFib) is observed in 2%-30% of noncardiac surgery patients in different registries, particularly in patients undergoing intermediate or high-risk noncardiac surgery, she noted.
“We propose an algorithm on how to prevent and treat this complication. I want to highlight that in patients with hemodynamic unstable postoperative AF[ib], an emergency cardioversion is indicated. For the others, a rate control with the target heart rate of less than 110 beats per minute is indicated.”
In patients with postoperative AFib, long-term oral anticoagulation therapy should be considered in all patients at risk for stroke, considering the anticipated net clinical benefit of oral anticoagulation therapy as well as informed patient preference (new recommendations).
Routine use of beta-blockers to prevent postoperative AFib in patients undergoing noncardiac surgery is not recommended.
The document also covers the management of patients with kidney disease, diabetes, cancer, obesity, and COVID-19. In general, elective noncardiac surgery should be postponed after a patient has COVID-19, until he or she recovers completely, and coexisting conditions are optimized.
The guidelines are available from the ESC website in several formats: pocket guidelines, pocket guidelines smartphone app, guidelines slide set, essential messages, and the European Heart Journal article.
Noncardiac surgery risk categories
The guideline includes a table that classifies noncardiac surgeries into three groups, based on the associated 30-day risk of death, MI, or stroke:
- Low (< 1%): breast, dental, eye, thyroid, and minor gynecologic, orthopedic, and urologic surgery.
- Intermediate (1%-5%): carotid surgery, endovascular aortic aneurysm repair, gallbladder surgery, head or neck surgery, hernia repair, peripheral arterial angioplasty, renal transplant, major gynecologic, orthopedic, or neurologic (hip or spine) surgery, or urologic surgery
- High (> 5%): aortic and major vascular surgery (including aortic aneurysm), bladder removal (usually as a result of cancer), limb amputation, lung or liver transplant, pancreatic surgery, or perforated bowel repair.
The guidelines were endorsed by the European Society of Anaesthesiology and Intensive Care. The guideline authors reported numerous disclosures.
A version of this article first appeared on Medscape.com.
FROM ESC CONGRESS 2022
Add AFib to noncardiac surgery risk evaluation: New support
Practice has gone back and forth on whether atrial fibrillation (AFib) should be considered in the preoperative cardiovascular risk (CV) evaluation of patients slated for noncardiac surgery, and the Revised Cardiac Risk Index (RCRI), currently widely used as an assessment tool, doesn’t include the arrhythmia.
But consideration of preexisting AFib along with the RCRI predicted 30-day mortality more sharply than the RCRI alone in an analysis of data covering several million patients slated for such procedures.
Indeed, AFib emerged as a significant, independent risk factor for a number of bad postoperative outcomes. Mortality within a month of the procedure climbed about 30% for patients with AFib before the noncardiac surgery. Their 30-day risks for stroke and for heart failure hospitalization went up similarly.
The addition of AFib to the RCRI significantly improved its ability to discriminate 30-day postoperative risk levels regardless of age, sex, and type of noncardiac surgery, Amgad Mentias, MD, Cleveland Clinic, told this news organization. And “it was able to correctly up-classify patients to high risk, if AFib was there, and it was able to down-classify some patients to lower risk if it wasn’t there.”
“I think [the findings] are convincing evidence that atrial fib should at least be part of the thought process for the surgical team and the medical team taking care of the patient,” said Dr. Mentias, who is senior author on the study published in the Journal of the American College of Cardiology, with lead author Sameer Prasada, MD, also of the Cleveland Clinic.
The results “call for incorporating AFib as a risk factor in perioperative risk scores for cardiovascular morbidity and mortality,” the published report states.
Supraventricular arrhythmias had been part of the Goldman Risk Index once widely used preoperatively to assess cardiac risk before practice adopted the RCRI in the past decade, observe Anne B. Curtis, MD, and Sai Krishna C. Korada, MD, University at Buffalo, New York, in an accompanying editorial.
The current findings “demonstrate improved prediction of adverse postsurgical outcomes” from supplementing the RCRI with AFib, they write. Given associations between preexisting AFib and serious cardiac events, “it is time to ‘re-revise’ the RCRI and acknowledge the importance of AFib in predicting adverse outcomes” after noncardiac surgery.
The new findings, however, aren’t all straightforward. In one result that remains a bit of a head-scratcher, postoperative risk of myocardial infarction (MI) in patients with preexisting AFib went in the opposite direction of risk for death and other CV outcomes, falling by almost 20%.
That is “hard to explain with the available data,” the report states, but “the use of anticoagulation, whether oral or parenteral (as a bridge therapy in the perioperative period), is a plausible explanation” given the frequent role of thrombosis in triggering MIs.
Consistent with such a mechanism, the group argues, the MI risk reduction was seen primarily among patients with AFib and a CHA2DS2-VASc score of 2 or higher – that is, those at highest risk for stroke and therefore most likely to be on oral anticoagulation. The MI risk reduction wasn’t seen in such patients with a CHA2DS2-VASc score of 0 or 1.
“I think that’s part of the explanation, that anticoagulation can reduce risk of MI. But it’s not the whole explanation,” Dr. Mentias said in an interview. If it were the sole mechanism, he said, then the same oral anticoagulation that protected against MI should have also cut the postoperative stroke risk. Yet that risk climbed 40% among patients with preexisting AFib.
The analysis started with 8.6 million Medicare patients with planned noncardiac surgery, seen from 2015 to 2019, of whom 16.4% had preexisting AFib. Propensity matching for demographics, urgency and type of surgery, CHA2DS2-VASc score, and RCRI index created two cohorts for comparison: 1.13 million patients with and 1.92 million without preexisting AFib.
Preexisting AFib was associated with a higher 30-day risk for death from any cause, the primary endpoint being 8.3% versus 5.8% for those without such AFib (P < .001), for an odds ratio of 1.31 (95% confidence interval, 1.30-1.32).
Corresponding 30-day ORs for other events, all significant at P < .001, were:
- 1.31 (95% CI, 1.30-1.33) for heart failure
- 1.40 (95% CI, 1.37-1.43) for stroke
- 1.59 (95% CI, 1.43-1.75) for systemic embolism
- 1.14 (95% CI, 1.13-1.16) for major bleeding
- 0.81 (95% CI, 0.79-0.82) for MI
Those with preexisting AFib also had longer hospitalizations at a median 5 days, compared with 4 days for those without such AFib (P < .001).
The study has the limitations of most any retrospective cohort analysis. Other limitations, the report notes, include lack of information on any antiarrhythmic meds given during hospitalization or type of AFib.
For example, AFib that is permanent – compared with paroxysmal or persistent – may be associated with more atrial fibrosis, greater atrial dilatation, “and probably higher pressures inside the heart,” Dr. Mentias observed.
“That’s not always the case, but that’s the notion. So presumably people with persistent or permanent atrial fib would have more advanced heart disease, and that could imply more risk. But we did not have that kind of data.”
Dr. Mentias and Dr. Prasada report no relevant financial relationships; disclosures for the other authors are in the report. Dr. Curtis discloses serving on advisory boards for Abbott, Janssen Pharmaceuticals, Sanofi, and Milestone Pharmaceuticals; receiving honoraria for speaking from Medtronic and Zoll; and serving on a data-monitoring board for Medtronic. Dr. Korada reports he has no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Practice has gone back and forth on whether atrial fibrillation (AFib) should be considered in the preoperative cardiovascular risk (CV) evaluation of patients slated for noncardiac surgery, and the Revised Cardiac Risk Index (RCRI), currently widely used as an assessment tool, doesn’t include the arrhythmia.
But consideration of preexisting AFib along with the RCRI predicted 30-day mortality more sharply than the RCRI alone in an analysis of data covering several million patients slated for such procedures.
Indeed, AFib emerged as a significant, independent risk factor for a number of bad postoperative outcomes. Mortality within a month of the procedure climbed about 30% for patients with AFib before the noncardiac surgery. Their 30-day risks for stroke and for heart failure hospitalization went up similarly.
The addition of AFib to the RCRI significantly improved its ability to discriminate 30-day postoperative risk levels regardless of age, sex, and type of noncardiac surgery, Amgad Mentias, MD, Cleveland Clinic, told this news organization. And “it was able to correctly up-classify patients to high risk, if AFib was there, and it was able to down-classify some patients to lower risk if it wasn’t there.”
“I think [the findings] are convincing evidence that atrial fib should at least be part of the thought process for the surgical team and the medical team taking care of the patient,” said Dr. Mentias, who is senior author on the study published in the Journal of the American College of Cardiology, with lead author Sameer Prasada, MD, also of the Cleveland Clinic.
The results “call for incorporating AFib as a risk factor in perioperative risk scores for cardiovascular morbidity and mortality,” the published report states.
Supraventricular arrhythmias had been part of the Goldman Risk Index once widely used preoperatively to assess cardiac risk before practice adopted the RCRI in the past decade, observe Anne B. Curtis, MD, and Sai Krishna C. Korada, MD, University at Buffalo, New York, in an accompanying editorial.
The current findings “demonstrate improved prediction of adverse postsurgical outcomes” from supplementing the RCRI with AFib, they write. Given associations between preexisting AFib and serious cardiac events, “it is time to ‘re-revise’ the RCRI and acknowledge the importance of AFib in predicting adverse outcomes” after noncardiac surgery.
The new findings, however, aren’t all straightforward. In one result that remains a bit of a head-scratcher, postoperative risk of myocardial infarction (MI) in patients with preexisting AFib went in the opposite direction of risk for death and other CV outcomes, falling by almost 20%.
That is “hard to explain with the available data,” the report states, but “the use of anticoagulation, whether oral or parenteral (as a bridge therapy in the perioperative period), is a plausible explanation” given the frequent role of thrombosis in triggering MIs.
Consistent with such a mechanism, the group argues, the MI risk reduction was seen primarily among patients with AFib and a CHA2DS2-VASc score of 2 or higher – that is, those at highest risk for stroke and therefore most likely to be on oral anticoagulation. The MI risk reduction wasn’t seen in such patients with a CHA2DS2-VASc score of 0 or 1.
“I think that’s part of the explanation, that anticoagulation can reduce risk of MI. But it’s not the whole explanation,” Dr. Mentias said in an interview. If it were the sole mechanism, he said, then the same oral anticoagulation that protected against MI should have also cut the postoperative stroke risk. Yet that risk climbed 40% among patients with preexisting AFib.
The analysis started with 8.6 million Medicare patients with planned noncardiac surgery, seen from 2015 to 2019, of whom 16.4% had preexisting AFib. Propensity matching for demographics, urgency and type of surgery, CHA2DS2-VASc score, and RCRI index created two cohorts for comparison: 1.13 million patients with and 1.92 million without preexisting AFib.
Preexisting AFib was associated with a higher 30-day risk for death from any cause, the primary endpoint being 8.3% versus 5.8% for those without such AFib (P < .001), for an odds ratio of 1.31 (95% confidence interval, 1.30-1.32).
Corresponding 30-day ORs for other events, all significant at P < .001, were:
- 1.31 (95% CI, 1.30-1.33) for heart failure
- 1.40 (95% CI, 1.37-1.43) for stroke
- 1.59 (95% CI, 1.43-1.75) for systemic embolism
- 1.14 (95% CI, 1.13-1.16) for major bleeding
- 0.81 (95% CI, 0.79-0.82) for MI
Those with preexisting AFib also had longer hospitalizations at a median 5 days, compared with 4 days for those without such AFib (P < .001).
The study has the limitations of most any retrospective cohort analysis. Other limitations, the report notes, include lack of information on any antiarrhythmic meds given during hospitalization or type of AFib.
For example, AFib that is permanent – compared with paroxysmal or persistent – may be associated with more atrial fibrosis, greater atrial dilatation, “and probably higher pressures inside the heart,” Dr. Mentias observed.
“That’s not always the case, but that’s the notion. So presumably people with persistent or permanent atrial fib would have more advanced heart disease, and that could imply more risk. But we did not have that kind of data.”
Dr. Mentias and Dr. Prasada report no relevant financial relationships; disclosures for the other authors are in the report. Dr. Curtis discloses serving on advisory boards for Abbott, Janssen Pharmaceuticals, Sanofi, and Milestone Pharmaceuticals; receiving honoraria for speaking from Medtronic and Zoll; and serving on a data-monitoring board for Medtronic. Dr. Korada reports he has no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Practice has gone back and forth on whether atrial fibrillation (AFib) should be considered in the preoperative cardiovascular risk (CV) evaluation of patients slated for noncardiac surgery, and the Revised Cardiac Risk Index (RCRI), currently widely used as an assessment tool, doesn’t include the arrhythmia.
But consideration of preexisting AFib along with the RCRI predicted 30-day mortality more sharply than the RCRI alone in an analysis of data covering several million patients slated for such procedures.
Indeed, AFib emerged as a significant, independent risk factor for a number of bad postoperative outcomes. Mortality within a month of the procedure climbed about 30% for patients with AFib before the noncardiac surgery. Their 30-day risks for stroke and for heart failure hospitalization went up similarly.
The addition of AFib to the RCRI significantly improved its ability to discriminate 30-day postoperative risk levels regardless of age, sex, and type of noncardiac surgery, Amgad Mentias, MD, Cleveland Clinic, told this news organization. And “it was able to correctly up-classify patients to high risk, if AFib was there, and it was able to down-classify some patients to lower risk if it wasn’t there.”
“I think [the findings] are convincing evidence that atrial fib should at least be part of the thought process for the surgical team and the medical team taking care of the patient,” said Dr. Mentias, who is senior author on the study published in the Journal of the American College of Cardiology, with lead author Sameer Prasada, MD, also of the Cleveland Clinic.
The results “call for incorporating AFib as a risk factor in perioperative risk scores for cardiovascular morbidity and mortality,” the published report states.
Supraventricular arrhythmias had been part of the Goldman Risk Index once widely used preoperatively to assess cardiac risk before practice adopted the RCRI in the past decade, observe Anne B. Curtis, MD, and Sai Krishna C. Korada, MD, University at Buffalo, New York, in an accompanying editorial.
The current findings “demonstrate improved prediction of adverse postsurgical outcomes” from supplementing the RCRI with AFib, they write. Given associations between preexisting AFib and serious cardiac events, “it is time to ‘re-revise’ the RCRI and acknowledge the importance of AFib in predicting adverse outcomes” after noncardiac surgery.
The new findings, however, aren’t all straightforward. In one result that remains a bit of a head-scratcher, postoperative risk of myocardial infarction (MI) in patients with preexisting AFib went in the opposite direction of risk for death and other CV outcomes, falling by almost 20%.
That is “hard to explain with the available data,” the report states, but “the use of anticoagulation, whether oral or parenteral (as a bridge therapy in the perioperative period), is a plausible explanation” given the frequent role of thrombosis in triggering MIs.
Consistent with such a mechanism, the group argues, the MI risk reduction was seen primarily among patients with AFib and a CHA2DS2-VASc score of 2 or higher – that is, those at highest risk for stroke and therefore most likely to be on oral anticoagulation. The MI risk reduction wasn’t seen in such patients with a CHA2DS2-VASc score of 0 or 1.
“I think that’s part of the explanation, that anticoagulation can reduce risk of MI. But it’s not the whole explanation,” Dr. Mentias said in an interview. If it were the sole mechanism, he said, then the same oral anticoagulation that protected against MI should have also cut the postoperative stroke risk. Yet that risk climbed 40% among patients with preexisting AFib.
The analysis started with 8.6 million Medicare patients with planned noncardiac surgery, seen from 2015 to 2019, of whom 16.4% had preexisting AFib. Propensity matching for demographics, urgency and type of surgery, CHA2DS2-VASc score, and RCRI index created two cohorts for comparison: 1.13 million patients with and 1.92 million without preexisting AFib.
Preexisting AFib was associated with a higher 30-day risk for death from any cause, the primary endpoint being 8.3% versus 5.8% for those without such AFib (P < .001), for an odds ratio of 1.31 (95% confidence interval, 1.30-1.32).
Corresponding 30-day ORs for other events, all significant at P < .001, were:
- 1.31 (95% CI, 1.30-1.33) for heart failure
- 1.40 (95% CI, 1.37-1.43) for stroke
- 1.59 (95% CI, 1.43-1.75) for systemic embolism
- 1.14 (95% CI, 1.13-1.16) for major bleeding
- 0.81 (95% CI, 0.79-0.82) for MI
Those with preexisting AFib also had longer hospitalizations at a median 5 days, compared with 4 days for those without such AFib (P < .001).
The study has the limitations of most any retrospective cohort analysis. Other limitations, the report notes, include lack of information on any antiarrhythmic meds given during hospitalization or type of AFib.
For example, AFib that is permanent – compared with paroxysmal or persistent – may be associated with more atrial fibrosis, greater atrial dilatation, “and probably higher pressures inside the heart,” Dr. Mentias observed.
“That’s not always the case, but that’s the notion. So presumably people with persistent or permanent atrial fib would have more advanced heart disease, and that could imply more risk. But we did not have that kind of data.”
Dr. Mentias and Dr. Prasada report no relevant financial relationships; disclosures for the other authors are in the report. Dr. Curtis discloses serving on advisory boards for Abbott, Janssen Pharmaceuticals, Sanofi, and Milestone Pharmaceuticals; receiving honoraria for speaking from Medtronic and Zoll; and serving on a data-monitoring board for Medtronic. Dr. Korada reports he has no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Is aspirin the best way to prevent blood clots after THA/TKA?
CHICAGO – Patients discharged to facilities rather than to home after total hip arthroplasty (THA) or total knee arthroplasty (TKA) may need more potent chemoprophylaxis than aspirin to prevent blood clots, new data suggest.
Researchers led by Stefano Muscatelli, MD, an orthopedist at Michigan Medicine, Ann Arbor, first aimed to determine whether there was an increase in risk of venous thromboembolism (VTE) in patients who were discharged to facilities such as a skilled nursing facility or inpatient rehabilitation facility, compared with those discharged to home after THA or TKA.
The second aim was to determine whether VTE risk differed between home- and non–home-discharge patients when stratified by the chemoprophylaxis prescribed to prevent VTE.
Findings were presented at the annual meeting of the American Academy of Orthopaedic Surgeons by coauthor Michael McHugh, MD, also an orthopedist at Michigan Medicine in Ann Arbor.
The agents were categorized in three groups: aspirin only; more aggressive anticoagulants, including warfarin, factor Xa inhibitor, direct thrombin inhibitor, low-molecular-weight heparin, pentasaccharide, or antiplatelet agents, with or without concurrent aspirin; and other regimens.
The researchers found that rates of VTE were higher among patients discharged to facilities.
Of 6,411 patients included in the study, the overall rate of VTE was 1.05%. Among home-discharge patients (n = 5445), rates of VTE were significantly lower than among patients discharged to facilities (n = 966) (0.83% vs. 2.26%; P < .001).
However, the researchers found there was no difference in VTE rates between non-home and home discharge in patients who received more aggressive chemoprophylaxis.
Among discharged patients who received only aspirin, rates of VTE among those discharged to home were significantly lower compared to those discharged to facilities (0.76% vs. 3.83%; P < .001).
“Smoking, BMI [body mass index], procedure type, and preoperative anticoagulation were not associated with the outcome of VTE,” Dr. McHugh said.
“Although we found VTE to continue to be an uncommon complication, non-home discharge is independently associated with higher rates of VTE. Patients should be encouraged to discharge home, but those discharged to non-home facilities after total joint arthroplasty should be considered for more potent chemoprophylaxis than aspirin,” he concluded.
Stuart J. Fischer, MD, with Summit (N.J.) Orthopaedics and Sports Medicine, who was not part of the study, told this news organization that he found the results inconclusive.
He said there is the potential for confounding because “the people who are sent to a facility after total hip or total knee are inherently less mobile and less able to take care of themselves, so they are at a higher risk for VTE. They are going to be more static.”
Dr. Fischer noted that over the past few years, there has been a movement away from anticoagulation with more aggressive agents toward aspirin, for several reasons. Providers don’t have to monitor aspirin use and can instruct patients to take it once or twice a day. Initial data seem to show that it protects well against VTE.
“The question is, in certain population of patients, is it enough? And that’s where the data are unclear,” Dr. Fischer said.
“It’s certainly a useful study, and we need to find out which methods of anticoagulation are most effective in each setting,” he said.
Limitations include that it was a retrospective review and that adverse events from more aggressive chemoprophylaxis agents were not assessed. Prophylactic regimens were chosen at the discretion of the treating surgeon.
The researchers excluded bilateral cases, conversion arthroplasty, hip hemiarthroplasty, unicompartmental knee arthroplasty, and deaths.
Dr. Muscatelli and Dr. McHugh reported no relevant financial relationships. A coauthor reported being a paid consultant for DePuy and Zimmer. Dr. Fischer reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
CHICAGO – Patients discharged to facilities rather than to home after total hip arthroplasty (THA) or total knee arthroplasty (TKA) may need more potent chemoprophylaxis than aspirin to prevent blood clots, new data suggest.
Researchers led by Stefano Muscatelli, MD, an orthopedist at Michigan Medicine, Ann Arbor, first aimed to determine whether there was an increase in risk of venous thromboembolism (VTE) in patients who were discharged to facilities such as a skilled nursing facility or inpatient rehabilitation facility, compared with those discharged to home after THA or TKA.
The second aim was to determine whether VTE risk differed between home- and non–home-discharge patients when stratified by the chemoprophylaxis prescribed to prevent VTE.
Findings were presented at the annual meeting of the American Academy of Orthopaedic Surgeons by coauthor Michael McHugh, MD, also an orthopedist at Michigan Medicine in Ann Arbor.
The agents were categorized in three groups: aspirin only; more aggressive anticoagulants, including warfarin, factor Xa inhibitor, direct thrombin inhibitor, low-molecular-weight heparin, pentasaccharide, or antiplatelet agents, with or without concurrent aspirin; and other regimens.
The researchers found that rates of VTE were higher among patients discharged to facilities.
Of 6,411 patients included in the study, the overall rate of VTE was 1.05%. Among home-discharge patients (n = 5445), rates of VTE were significantly lower than among patients discharged to facilities (n = 966) (0.83% vs. 2.26%; P < .001).
However, the researchers found there was no difference in VTE rates between non-home and home discharge in patients who received more aggressive chemoprophylaxis.
Among discharged patients who received only aspirin, rates of VTE among those discharged to home were significantly lower compared to those discharged to facilities (0.76% vs. 3.83%; P < .001).
“Smoking, BMI [body mass index], procedure type, and preoperative anticoagulation were not associated with the outcome of VTE,” Dr. McHugh said.
“Although we found VTE to continue to be an uncommon complication, non-home discharge is independently associated with higher rates of VTE. Patients should be encouraged to discharge home, but those discharged to non-home facilities after total joint arthroplasty should be considered for more potent chemoprophylaxis than aspirin,” he concluded.
Stuart J. Fischer, MD, with Summit (N.J.) Orthopaedics and Sports Medicine, who was not part of the study, told this news organization that he found the results inconclusive.
He said there is the potential for confounding because “the people who are sent to a facility after total hip or total knee are inherently less mobile and less able to take care of themselves, so they are at a higher risk for VTE. They are going to be more static.”
Dr. Fischer noted that over the past few years, there has been a movement away from anticoagulation with more aggressive agents toward aspirin, for several reasons. Providers don’t have to monitor aspirin use and can instruct patients to take it once or twice a day. Initial data seem to show that it protects well against VTE.
“The question is, in certain population of patients, is it enough? And that’s where the data are unclear,” Dr. Fischer said.
“It’s certainly a useful study, and we need to find out which methods of anticoagulation are most effective in each setting,” he said.
Limitations include that it was a retrospective review and that adverse events from more aggressive chemoprophylaxis agents were not assessed. Prophylactic regimens were chosen at the discretion of the treating surgeon.
The researchers excluded bilateral cases, conversion arthroplasty, hip hemiarthroplasty, unicompartmental knee arthroplasty, and deaths.
Dr. Muscatelli and Dr. McHugh reported no relevant financial relationships. A coauthor reported being a paid consultant for DePuy and Zimmer. Dr. Fischer reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
CHICAGO – Patients discharged to facilities rather than to home after total hip arthroplasty (THA) or total knee arthroplasty (TKA) may need more potent chemoprophylaxis than aspirin to prevent blood clots, new data suggest.
Researchers led by Stefano Muscatelli, MD, an orthopedist at Michigan Medicine, Ann Arbor, first aimed to determine whether there was an increase in risk of venous thromboembolism (VTE) in patients who were discharged to facilities such as a skilled nursing facility or inpatient rehabilitation facility, compared with those discharged to home after THA or TKA.
The second aim was to determine whether VTE risk differed between home- and non–home-discharge patients when stratified by the chemoprophylaxis prescribed to prevent VTE.
Findings were presented at the annual meeting of the American Academy of Orthopaedic Surgeons by coauthor Michael McHugh, MD, also an orthopedist at Michigan Medicine in Ann Arbor.
The agents were categorized in three groups: aspirin only; more aggressive anticoagulants, including warfarin, factor Xa inhibitor, direct thrombin inhibitor, low-molecular-weight heparin, pentasaccharide, or antiplatelet agents, with or without concurrent aspirin; and other regimens.
The researchers found that rates of VTE were higher among patients discharged to facilities.
Of 6,411 patients included in the study, the overall rate of VTE was 1.05%. Among home-discharge patients (n = 5445), rates of VTE were significantly lower than among patients discharged to facilities (n = 966) (0.83% vs. 2.26%; P < .001).
However, the researchers found there was no difference in VTE rates between non-home and home discharge in patients who received more aggressive chemoprophylaxis.
Among discharged patients who received only aspirin, rates of VTE among those discharged to home were significantly lower compared to those discharged to facilities (0.76% vs. 3.83%; P < .001).
“Smoking, BMI [body mass index], procedure type, and preoperative anticoagulation were not associated with the outcome of VTE,” Dr. McHugh said.
“Although we found VTE to continue to be an uncommon complication, non-home discharge is independently associated with higher rates of VTE. Patients should be encouraged to discharge home, but those discharged to non-home facilities after total joint arthroplasty should be considered for more potent chemoprophylaxis than aspirin,” he concluded.
Stuart J. Fischer, MD, with Summit (N.J.) Orthopaedics and Sports Medicine, who was not part of the study, told this news organization that he found the results inconclusive.
He said there is the potential for confounding because “the people who are sent to a facility after total hip or total knee are inherently less mobile and less able to take care of themselves, so they are at a higher risk for VTE. They are going to be more static.”
Dr. Fischer noted that over the past few years, there has been a movement away from anticoagulation with more aggressive agents toward aspirin, for several reasons. Providers don’t have to monitor aspirin use and can instruct patients to take it once or twice a day. Initial data seem to show that it protects well against VTE.
“The question is, in certain population of patients, is it enough? And that’s where the data are unclear,” Dr. Fischer said.
“It’s certainly a useful study, and we need to find out which methods of anticoagulation are most effective in each setting,” he said.
Limitations include that it was a retrospective review and that adverse events from more aggressive chemoprophylaxis agents were not assessed. Prophylactic regimens were chosen at the discretion of the treating surgeon.
The researchers excluded bilateral cases, conversion arthroplasty, hip hemiarthroplasty, unicompartmental knee arthroplasty, and deaths.
Dr. Muscatelli and Dr. McHugh reported no relevant financial relationships. A coauthor reported being a paid consultant for DePuy and Zimmer. Dr. Fischer reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
AT AAOS 2022
Simple prevention strategies can lessen postoperative delirium after orthopedic surgery
A new study has found that and a prevention program can help improve staff education and outcomes.
“In an aging society, it is very important to develop and implement a strategy for POD prevention to ensure that aging patients are treated as safely and effectively as possible,” wrote Jung-Yeon Choi of Seoul (South Korea) National University Bundang Hospital and coauthors. The study was published in BMC Geriatrics.
To determine how to better identify and treat high-risk patients for POD after orthopedic surgery, the researchers led a retrospective cohort study that included an intervention group of participants who were aged at least 65 years (n = 275) and a control group from a year prior (n = 274). Patients in the intervention group had their risk of delirium assessed and categorized using a simple screening tool, and those deemed at risk were entered into a multicomponent delirium prevention program.
Of the 275 patients in the intervention group, 144 required screening for delirium. Ninety-nine were classified as low risk, 29 were classified as high risk, and 16 missed the screening. Fifty-three additional patients were classified as high risk because they were aged 80 years or older. During the study, 17 participants experienced POD, 16 of whom were classified as high risk. In regard to estimating POD risk, the sensitivity and specificity of the delirium screening tool were 94.1% and 72.7%, respectively. Incidence rates of POD were 10.2% in the control group and 6.2% in the intervention group.
The authors noted their study’s limitations, including its design as a retrospective review of medical records rather than a prospective randomized controlled trial. In addition, because it was conducted in just one teaching hospital, they deemed it “not possible to determine the generalizability and long-term effect of our findings.”
The authors reported no conflicts of interest.
SOURCE: Choi JY et al. BMC Geriatr. 2019 Oct 26. doi: 10.1186/s12877-019-1303-z.
A new study has found that and a prevention program can help improve staff education and outcomes.
“In an aging society, it is very important to develop and implement a strategy for POD prevention to ensure that aging patients are treated as safely and effectively as possible,” wrote Jung-Yeon Choi of Seoul (South Korea) National University Bundang Hospital and coauthors. The study was published in BMC Geriatrics.
To determine how to better identify and treat high-risk patients for POD after orthopedic surgery, the researchers led a retrospective cohort study that included an intervention group of participants who were aged at least 65 years (n = 275) and a control group from a year prior (n = 274). Patients in the intervention group had their risk of delirium assessed and categorized using a simple screening tool, and those deemed at risk were entered into a multicomponent delirium prevention program.
Of the 275 patients in the intervention group, 144 required screening for delirium. Ninety-nine were classified as low risk, 29 were classified as high risk, and 16 missed the screening. Fifty-three additional patients were classified as high risk because they were aged 80 years or older. During the study, 17 participants experienced POD, 16 of whom were classified as high risk. In regard to estimating POD risk, the sensitivity and specificity of the delirium screening tool were 94.1% and 72.7%, respectively. Incidence rates of POD were 10.2% in the control group and 6.2% in the intervention group.
The authors noted their study’s limitations, including its design as a retrospective review of medical records rather than a prospective randomized controlled trial. In addition, because it was conducted in just one teaching hospital, they deemed it “not possible to determine the generalizability and long-term effect of our findings.”
The authors reported no conflicts of interest.
SOURCE: Choi JY et al. BMC Geriatr. 2019 Oct 26. doi: 10.1186/s12877-019-1303-z.
A new study has found that and a prevention program can help improve staff education and outcomes.
“In an aging society, it is very important to develop and implement a strategy for POD prevention to ensure that aging patients are treated as safely and effectively as possible,” wrote Jung-Yeon Choi of Seoul (South Korea) National University Bundang Hospital and coauthors. The study was published in BMC Geriatrics.
To determine how to better identify and treat high-risk patients for POD after orthopedic surgery, the researchers led a retrospective cohort study that included an intervention group of participants who were aged at least 65 years (n = 275) and a control group from a year prior (n = 274). Patients in the intervention group had their risk of delirium assessed and categorized using a simple screening tool, and those deemed at risk were entered into a multicomponent delirium prevention program.
Of the 275 patients in the intervention group, 144 required screening for delirium. Ninety-nine were classified as low risk, 29 were classified as high risk, and 16 missed the screening. Fifty-three additional patients were classified as high risk because they were aged 80 years or older. During the study, 17 participants experienced POD, 16 of whom were classified as high risk. In regard to estimating POD risk, the sensitivity and specificity of the delirium screening tool were 94.1% and 72.7%, respectively. Incidence rates of POD were 10.2% in the control group and 6.2% in the intervention group.
The authors noted their study’s limitations, including its design as a retrospective review of medical records rather than a prospective randomized controlled trial. In addition, because it was conducted in just one teaching hospital, they deemed it “not possible to determine the generalizability and long-term effect of our findings.”
The authors reported no conflicts of interest.
SOURCE: Choi JY et al. BMC Geriatr. 2019 Oct 26. doi: 10.1186/s12877-019-1303-z.
FROM BMC GERIATRICS
Minor surgeries appear safe for hemophilia patients on emicizumab
MELBOURNE – A majority of minor surgeries can be performed in hemophilia A patients receiving emicizumab therapy without requiring prophylactic treatment with coagulation factors, according to data presented at the International Society on Thrombosis and Haemostasis congress.
Elena Santagostino, MD, PhD, from the Hemophilia and Thrombosis Center at Ospedale Maggiore Policlinico in Milan presented data from 399 patients involved in the four HAVEN trials of the humanized bispecific monoclonal antibody emicizumab (Hemlibra), which is Food and Drug Administration–approved for the prevention of bleeding episodes in individuals with hemophilia A, with or without inhibitors.
The analysis focused on the 126 patients (31.6%) who underwent at least one surgical procedure during the studies. Of the 233 surgeries, there were 215 minor procedures performed in 115 patients, and 18 major surgeries in 18 patients. All patients were receiving ongoing treatment with emicizumab, and there was no change to that treatment regimen during surgery.
“It is clear that surgery is a challenge for hemophilia,” Dr. Santagostino said. “It is a challenge for bleeding, it is a challenge for thrombosis, it is a challenge for any new drug, and this is why there is a lot of interest around this topic.”
Overall, 65.6% of minor surgeries were performed without any prophylactic coagulation factor treatment, and 90.8% of minor surgeries were conducted without postoperative bleeds requiring treatment. There were no cases of thrombosis reported.
The surgeries that did not require prophylactic coagulation factor included 42 dental procedures, 25 central venous access devices, 17 endoscopic procedures, and 12 joint procedures.
While the HAVEN studies did not allow for elective major surgery, there were still 18 unplanned major surgical situations that arose during the course of the studies. These included three hip, one knee, and one ankle arthroplasties; three synovectomies; and some dental, central venous line, and endoscopic biopsy procedures.
Of these, 15 involved prophylactic coagulant factor administration, but three procedures – including one synovectomy – were performed without prophylaxis and none resulted in a bleed.
There was one complicated bleed that occurred in a patient undergoing multiple procedures including a synovectomy, joint debridement and chondroplasty, who received prolonged treatment with recombinant Factor VIIa.
Dr. Santagostino said the findings showed surgery could be safely performed in patients who were being treated with emicizumab, both with and without inhibitors.
“A large number of minor procedures can be done without adding coagulation factors,” she said in an interview. “This is true for less invasive surgeries, such as catheter-related central venous line procedures. Even several endoscopic procedures, like a single biopsy, can be done reasonably safely.”
However she said there was still a lack of experience in dealing with hemophilia A patients who were undergoing cancer surgery, or who had significant comorbidities that might put them at higher risk of thrombosis.
“These are special patients populations that are still not investigated in the trial setting,” she said.
Commenting on the data, session cochair Liane Khoo, MD, from the Haemophilia Treatment Centre at Royal Prince Alfred Hospital in Sydney, said the results showed surgery could be performed in hemophilia A patients with and without inhibitors.
“The more we have the medication and the more experience we have, then we become more confident in using it,” she said.
The study was funded by F. Hoffman-La Roche and Chugai Pharmaceutical. Dr. Santagostino reported consultancies and speakers bureau engagements with the pharmaceutical sector.
SOURCE: Santagostino E et al. 2019 ISTH Congress, Abstract OC 60.1.
MELBOURNE – A majority of minor surgeries can be performed in hemophilia A patients receiving emicizumab therapy without requiring prophylactic treatment with coagulation factors, according to data presented at the International Society on Thrombosis and Haemostasis congress.
Elena Santagostino, MD, PhD, from the Hemophilia and Thrombosis Center at Ospedale Maggiore Policlinico in Milan presented data from 399 patients involved in the four HAVEN trials of the humanized bispecific monoclonal antibody emicizumab (Hemlibra), which is Food and Drug Administration–approved for the prevention of bleeding episodes in individuals with hemophilia A, with or without inhibitors.
The analysis focused on the 126 patients (31.6%) who underwent at least one surgical procedure during the studies. Of the 233 surgeries, there were 215 minor procedures performed in 115 patients, and 18 major surgeries in 18 patients. All patients were receiving ongoing treatment with emicizumab, and there was no change to that treatment regimen during surgery.
“It is clear that surgery is a challenge for hemophilia,” Dr. Santagostino said. “It is a challenge for bleeding, it is a challenge for thrombosis, it is a challenge for any new drug, and this is why there is a lot of interest around this topic.”
Overall, 65.6% of minor surgeries were performed without any prophylactic coagulation factor treatment, and 90.8% of minor surgeries were conducted without postoperative bleeds requiring treatment. There were no cases of thrombosis reported.
The surgeries that did not require prophylactic coagulation factor included 42 dental procedures, 25 central venous access devices, 17 endoscopic procedures, and 12 joint procedures.
While the HAVEN studies did not allow for elective major surgery, there were still 18 unplanned major surgical situations that arose during the course of the studies. These included three hip, one knee, and one ankle arthroplasties; three synovectomies; and some dental, central venous line, and endoscopic biopsy procedures.
Of these, 15 involved prophylactic coagulant factor administration, but three procedures – including one synovectomy – were performed without prophylaxis and none resulted in a bleed.
There was one complicated bleed that occurred in a patient undergoing multiple procedures including a synovectomy, joint debridement and chondroplasty, who received prolonged treatment with recombinant Factor VIIa.
Dr. Santagostino said the findings showed surgery could be safely performed in patients who were being treated with emicizumab, both with and without inhibitors.
“A large number of minor procedures can be done without adding coagulation factors,” she said in an interview. “This is true for less invasive surgeries, such as catheter-related central venous line procedures. Even several endoscopic procedures, like a single biopsy, can be done reasonably safely.”
However she said there was still a lack of experience in dealing with hemophilia A patients who were undergoing cancer surgery, or who had significant comorbidities that might put them at higher risk of thrombosis.
“These are special patients populations that are still not investigated in the trial setting,” she said.
Commenting on the data, session cochair Liane Khoo, MD, from the Haemophilia Treatment Centre at Royal Prince Alfred Hospital in Sydney, said the results showed surgery could be performed in hemophilia A patients with and without inhibitors.
“The more we have the medication and the more experience we have, then we become more confident in using it,” she said.
The study was funded by F. Hoffman-La Roche and Chugai Pharmaceutical. Dr. Santagostino reported consultancies and speakers bureau engagements with the pharmaceutical sector.
SOURCE: Santagostino E et al. 2019 ISTH Congress, Abstract OC 60.1.
MELBOURNE – A majority of minor surgeries can be performed in hemophilia A patients receiving emicizumab therapy without requiring prophylactic treatment with coagulation factors, according to data presented at the International Society on Thrombosis and Haemostasis congress.
Elena Santagostino, MD, PhD, from the Hemophilia and Thrombosis Center at Ospedale Maggiore Policlinico in Milan presented data from 399 patients involved in the four HAVEN trials of the humanized bispecific monoclonal antibody emicizumab (Hemlibra), which is Food and Drug Administration–approved for the prevention of bleeding episodes in individuals with hemophilia A, with or without inhibitors.
The analysis focused on the 126 patients (31.6%) who underwent at least one surgical procedure during the studies. Of the 233 surgeries, there were 215 minor procedures performed in 115 patients, and 18 major surgeries in 18 patients. All patients were receiving ongoing treatment with emicizumab, and there was no change to that treatment regimen during surgery.
“It is clear that surgery is a challenge for hemophilia,” Dr. Santagostino said. “It is a challenge for bleeding, it is a challenge for thrombosis, it is a challenge for any new drug, and this is why there is a lot of interest around this topic.”
Overall, 65.6% of minor surgeries were performed without any prophylactic coagulation factor treatment, and 90.8% of minor surgeries were conducted without postoperative bleeds requiring treatment. There were no cases of thrombosis reported.
The surgeries that did not require prophylactic coagulation factor included 42 dental procedures, 25 central venous access devices, 17 endoscopic procedures, and 12 joint procedures.
While the HAVEN studies did not allow for elective major surgery, there were still 18 unplanned major surgical situations that arose during the course of the studies. These included three hip, one knee, and one ankle arthroplasties; three synovectomies; and some dental, central venous line, and endoscopic biopsy procedures.
Of these, 15 involved prophylactic coagulant factor administration, but three procedures – including one synovectomy – were performed without prophylaxis and none resulted in a bleed.
There was one complicated bleed that occurred in a patient undergoing multiple procedures including a synovectomy, joint debridement and chondroplasty, who received prolonged treatment with recombinant Factor VIIa.
Dr. Santagostino said the findings showed surgery could be safely performed in patients who were being treated with emicizumab, both with and without inhibitors.
“A large number of minor procedures can be done without adding coagulation factors,” she said in an interview. “This is true for less invasive surgeries, such as catheter-related central venous line procedures. Even several endoscopic procedures, like a single biopsy, can be done reasonably safely.”
However she said there was still a lack of experience in dealing with hemophilia A patients who were undergoing cancer surgery, or who had significant comorbidities that might put them at higher risk of thrombosis.
“These are special patients populations that are still not investigated in the trial setting,” she said.
Commenting on the data, session cochair Liane Khoo, MD, from the Haemophilia Treatment Centre at Royal Prince Alfred Hospital in Sydney, said the results showed surgery could be performed in hemophilia A patients with and without inhibitors.
“The more we have the medication and the more experience we have, then we become more confident in using it,” she said.
The study was funded by F. Hoffman-La Roche and Chugai Pharmaceutical. Dr. Santagostino reported consultancies and speakers bureau engagements with the pharmaceutical sector.
SOURCE: Santagostino E et al. 2019 ISTH Congress, Abstract OC 60.1.
REPORTING FROM 2019 ISTH CONGRESS
Evaluation of the American Academy of Orthopaedic Surgeons Appropriate Use Criteria for the Nonarthroplasty Treatment of Knee Osteoarthritis in Veterans
Knee osteoarthritis (OA) affects almost 9.3 million adults in the US and accounts for $27 billion in annual health care expenses.1,2 Due to the increasing cost of health care and an aging population, there has been renewed interest in establishing criteria for nonarthroplasty treatment of knee OA.
In 2013, using the RAND/UCLA Appropriateness method, the American Academy of Orthopaedic Surgeons (AAOS) developed an appropriate use criteria (AUC) for nonarthroplasty management of primary OA of the knee, based on orthopaedic literature and expert opinion.3 Interventions such as activity modification, weight loss, prescribed physical therapy, nonsteroidal anti-inflammatory drugs, tramadol, prescribed oral or transcutaneous opioids, acetaminophen, intra-articular corticosteroids, hinged or unloading knee braces, arthroscopic partial menisectomy or loose body removal, and realignment osteotomy were assessed. An algorithm was developed for 576 patients scenarios that incorporated patient-specific, prognostic/predictor variables to assign designations of “appropriate,” “may be appropriate,” or “rarely appropriate,” to treatment interventions.4,5 An online version of the algorithm (orthoguidelines.org) is available for physicians and surgeons to judge appropriateness of nonarthroplasty treatments; however, it is not intended to mandate candidacy for treatment or intervention.
Clinical evaluation of the AAOS AUC is necessary to determine how treatment recommendations correlate with current practice. A recent examination of the AAOS Appropriateness System for Surgical Management of Knee OA found that prognostic/predictor variables, such as patient age, OA severity, and pattern of knee OA involvement were more heavily weighted when determining arthroplasty appropriateness than was pain severity or functional loss.6 Furthermore, non-AAOS AUC prognostic/predictor variables, such as race and gender, have been linked to disparities in utilization of knee OA interventions.7-9 Such disparities can be costly not just from a patient perceptive, but also employer and societal perspectives.10
The Department of Veterans Affairs (VA) health care system represents a model of equal-access-to care system in the US that is ideal for examination of issues about health care utilization and any disparities within the AAOS AUC model and has previously been used to assess utilization of total knee arthroplasty.9 The aim of this study was to characterize utilization of the AAOS AUC for nonarthroplasty treatment of knee OA in a VA patient population. We asked the following questions: (1) What variables are predictive of receiving a greater number of AAOS AUC evaluated nonarthroplasty treatments? (2) What variables are predictive of receiving “rarely appropriate” AAOS AUC evaluated nonarthroplasty treatment? (3) What factors are predictive of duration of nonarthroplasty care until total knee arthroplasty (TKA)?
Methods
The institutional review board at the Louis Stokes Cleveland VA Medical Center in Ohio approved a retrospective chart review of nonarthroplasty treatments utilized by patients presenting to its orthopaedic section who subsequently underwent knee arthroplasty between 2013 and 2016. Eligibility criteria included patients aged ≥ 30 years with a diagnosis of unilateral or bilateral primary knee OA. Patients with posttraumatic OA, inflammatory arthritis, and a history of infectious arthritis or Charcot arthropathy of the knee were excluded. Patients with a body mass index (BMI) > 40 or a hemoglobin A1c > 8.0 at presentation were excluded as nonarthroplasty care was the recommended course of treatment above these thresholds.
Data collected included race, gender, duration of nonarthroplasty treatment, BMI, and Kellgren-Lawrence classification of knee OA at time of presentation for symptomatic knee OA.11 All AAOS AUC-evaluated nonarthroplasty treatments utilized prior to arthroplasty intervention also were recorded (Table 1). 
Statistical Analysis
Statistical analysis was completed with GraphPad Software Prism 7.0a (La Jolla, CA) and Mathworks MatLab R2016b software (Natick, MA). Univariate analysis with Student t tests with Welch corrections in the setting of unequal variance, Mann-Whitney nonparametric tests, and Fisher exact test were generated in the appropriate setting. Multivariable analyses also were conducted. For continuous outcomes, stepwise multiple linear regression was used to generate predictive models; for binary outcomes, binomial logistic regression was used.
Factors analyzed in regression modeling for the total number of AAOS AUC evaluated nonarthroplasty treatments utilized and the likelihood of receiving a rarely appropriate treatment included gender, race, function-limiting pain, range of motion (ROM), ligamentous instability, arthritis pattern, limb alignment, mechanical symptoms, BMI, age, and Kellgren-Lawrence grade. Factors analyzed in timing of TKA included the above variables plus the total number of AUC interventions, whether the patient received an inappropriate intervention, and average appropriateness of the interventions received. Residual analysis with Cook’s distance was used to identify outliers in regression. Observations with Cook’s distance > 3 times the mean Cook’s distance were identified as potential outliers, and models were adjusted accordingly. All statistical analyses were 2-tailed. Statistical significance was set to P ≤ .05 for all outputs.
Results
In the study, 97.8% of participants identified as male, and the mean age was 62.8 years (Table 3). 
Appropriate Use Criteria Interventions
Patients received a mean of 5.2 AAOS AUC evaluated interventions before undergoing arthroplasty management at a mean of 32.3 months (range 2-181 months) from initial presentation. The majority of these interventions were classified as either appropriate or may be appropriate, according to the AUC definitions (95.1%). Self-management and physical therapy programs were widely utilized (100% and 90.1%, respectively), with all use of these interventions classified as appropriate.
Hinged or unloader knee braces were utilized in about half the study patients; this intervention was classified as rarely appropriate in 4.4% of these patients. Medical therapy was also widely used, with all use of NSAIDs, acetaminophen, and tramadol classified as appropriate or may be appropriate. Oral or transcutaneous opioid medications were prescribed in 14.3% of patients, with 92.3% of this use classified as rarely appropriate. Although the opioid medication prescribing provider was not specifically evaluated, there were no instances in which the orthopaedic service provided an oral or transcutaneous opioid prescriptions. Procedural interventions, with the exception of corticosteroid injections, were uncommon; no patient received realignment osteotomy, and only 12.1% of patients underwent arthroscopy. The use of arthroscopy was deemed rarely appropriate in 72.7% of these cases.
Factors Associated With AAOS AUC Intervention Use
There was no difference in the number of AAOS AUC evaluated interventions received based on BMI (mean [SD] BMI < 35, 5.2 [1.0] vs BMI ≥ 35, 5.3 [1.1], P = .49), age (mean [SD] aged < 60 years, 5.4 [1.0] vs aged ≥ 60 years, 5.1 [1.2], P = .23), or Kellgren-Lawrence arthritic grade (mean [SD] grade ≤ 2, 5.5 [1.0] vs grade > 2, 5.1 [1.1], P = .06). These variables also were not associated with receiving a rarely appropriate intervention (mean [SD] BMI < 35, 0.27 [0.5] vs BMI > 35, 0.2 [0.4], P = .81; aged > 60 years, 0.3 [0.5] vs aged < 60 years, 0.2 [0.4], P = .26; Kellgren-Lawrence grade < 2, 0.4 [0.6] vs grade > 2, 0.2 [0.4], P = .1).
Regression modeling to predict total number of AAOS AUC evaluated interventions received produced a significant model (R2 = 0.111, P = .006). The presence of ligamentous instability (β coefficient, -1.61) and the absence of mechanical symptoms (β coefficient, -0.67) were negative predictors of number of AUC interventions received. Variance inflation factors were 1.014 and 1.012, respectively. Likewise, regression modeling to identify factors predictive of receiving a rarely appropriate intervention also produced a significant model (pseudo R2= 0.06, P = .025), with lower Kellgren-Lawrence grade the only significant predictor of receiving a rarely appropriate intervention (odds ratio [OR] 0.54; 95% CI, 0.42 -0.72, per unit increase).
Timing from presentation to arthroplasty intervention was also evaluated. Age was a negative predictor (β coefficient -1.61), while positive predictors were reduced ROM (β coefficient 15.72) and having more AUC interventions (β coefficient 7.31) (model R2= 0.29, P = < .001). Age was the most significant predictor. Variance inflations factors were 1.02, 1.01, and 1.03, respectively. Receiving a rarely appropriate intervention was not associated with TKA timing.
Discussion
This single-center retrospective study examined the utilization of AAOS AUC-evaluated nonarthroplasty interventions for symptomatic knee OA prior to TKA. The aims of this study were to validate the AAOS AUC in a clinical setting and identify predictors of AAOS AUC utilization. In particular, this study focused on the number of interventions utilized prior to knee arthroplasty, whether interventions receiving a designation of rarely appropriate were used, and the duration of nonarthroplasty treatment.
Patients with knee instability used fewer total AAOS AUC evaluated interventions prior to TKA. Subjective instability has been reported as high as 27% in patients with OA and has been associated with fear of falling, poor balance confidence, activity limitations, and lower Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function scores.12 However, it has not been found to correlate with knee laxity.13 Nevertheless, significant functional impairment with the risk of falling may reduce the number of nonarthroplasty interventions attempted. On the other hand, the presence of mechanical symptoms resulted in greater utilization of nonarthroplasty interventions. This is likely due to the greater utilization of arthroscopic partial menisectomy or loose body removal in this group of patients. Despite its inclusion as an AAOS AUC evaluated intervention, arthroscopy remains a contentious treatment for symptomatic knee pain in the setting of OA.14,15
For every unit decrease in Kellgren-Lawrence OA grade, patients were 54% more likely to receive a rarely appropriate intervention prior to knee arthroplasty. This is supported by the recent literature examining the AAOS AUC for surgical management of knee OA. Riddle and colleagues developed a classification tree to determine the contributions of various prognostic variables in final classifications of the 864 clinical vignettes used to develop the appropriateness algorithm and found that OA severity was strongly favored, with only 4 of the 432 vignettes with severe knee OA judged as rarely appropriate for surgical intervention.6
Our findings, too, may be explained by an AAOS AUC system that too heavily weighs radiographic severity of knee OA, resulting in more frequent rarely appropriate interventions in patients with less severe arthritis, including nonarthroplasty treatments. It is likely that rarely appropriate interventions were attempted in this subset of our study cohort based on patient’s subjective symptoms and functional status, both of which have been shown to be discordant with radiographic severity of knee OA.16
Oral or transcutaneous prescribed opioid medications were the most frequent intervention that received a rarely appropriate designation. Patients with preoperative opioid use undergoing TKA have been shown to have a greater risk for postoperative complications and longer hospital stay, particularly those patients aged < 75 years. Younger age, use of more interventions, and decreased knee ROM at presentation were predictive of longer duration of nonarthroplasty treatment. The use of more AAOS AUC evaluated interventions in these patients suggests that the AAOS AUC model may effectively be used to manage symptomatic OA, increasing the time from presentation to knee arthroplasty.
Interestingly, the use of rarely appropriate interventions did not affect TKA timing, as would be expected in a clinically effective nonarthroplasty treatment model. The reasons for rarely appropriate nonsurgical interventions are complex and require further investigation. One possible explanation is that decreased ROM was a marker for mechanical symptoms that necessitated additional intervention in the form of knee arthroscopy, delaying time to TKA.
Limitations
There are several limitations of this study. First, the small sample size (N = 90) requires acknowledgment; however, this limitation reflects the difficulty in following patients for years prior to an operative intervention. Second, the study population consists of veterans using the VA system and may not be reflective of the general population, differing with respect to gender, racial, and socioeconomic factors. Nevertheless, studies examining TKA utilization found, aside from racial and ethnic variability, patient gender and age do not affect arthroplasty utilization rate in the VA system.17
Additional limitations stem from the retrospective nature of this study. While the Computerized Patient Record System and centralized care of the VA system allows for review of all physical therapy consultations, orthotic consultations, and medications within the VA system, any treatments and intervention delivered by non-VA providers were not captured. Furthermore, the ability to assess for confounding variables limiting the prescription of certain medications, such as chronic kidney disease with NSAIDs or liver disease with acetaminophen, was limited by our study design.
Although our study suffers from selection bias with respect to examination of nonarthroplasty treatment in patients who have ultimately undergone TKA, we feel that this subset of patients with symptomatic knee OA represents the majority of patients evaluated for knee OA by orthopaedic surgeons in the clinic setting. It should be noted that although realignment osteotomies were sometimes indicated as appropriate by AAOS AUC model in our study population, this intervention was never performed due to patient and surgeon preference. Additionally, although it is not an AAOS AUC evaluated intervention, viscosupplementation was sporadically used during the study period; however, it is now off formulary at the investigation institution.
Conclusion
Our study suggests that patients without knee instability use more nonarthroplasty treatments over a longer period before TKA, and those patients with less severe knee OA are at risk of receiving an intervention judged to be rarely appropriate by the AAOS AUC. Such interventions do not affect timing of TKA. Nonarthroplasty care should be individualized to patients’ needs, and the decision to proceed with arthroplasty should be considered only after exhausting appropriate conservative measures. We recommend that providers use the AAOS AUC, especially when treating younger patients with less severe knee OA, particularly if considering opiate therapy or knee arthroscopy.
Acknowledgments
The authors would like to acknowledge Patrick Getty, MD, for his surgical care of some of the study patients. This material is the result of work supported with resources and the use of facilities at the Louis Stokes Cleveland VA Medical Center in Ohio.
1. Cross M, Smith E, Hoy D, et al. The global burden of hip and knee osteoarthritis: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73(7):1323-1330.
2. Losina E, Walensky RP, Kessler CL, et al. Cost-effectiveness of total knee arthroplasty in the United States: patient risk and hospital volume. Arch Intern Med. 2009;169(12):1113-1121; discussion 1121-1122.
3. Members of the Writing, Review, and Voting Panels of the AUC on the Non-Arthroplasty Treatment of Osteoarthritis of the Knee, Sanders JO, Heggeness MH, Murray J, Pezold R, Donnelly P. The American Academy of Orthopaedic Surgeons Appropriate Use Criteria on the Non-Arthroplasty Treatment of Osteoarthritis of the Knee. J Bone Joint Surg Am. 2014;96(14):1220-1221.
4. Sanders JO, Murray J, Gross L. Non-arthroplasty treatment of osteoarthritis of the knee. J Am Acad Orthop Surg. 2014;22(4):256-260.
5. Yates AJ Jr, McGrory BJ, Starz TW, Vincent KR, McCardel B, Golightly YM. AAOS appropriate use criteria: optimizing the non-arthroplasty management of osteoarthritis of the knee. J Am Acad Orthop Surg. 2014;22(4):261-267.
6. Riddle DL, Perera RA. Appropriateness and total knee arthroplasty: an examination of the American Academy of Orthopaedic Surgeons appropriateness rating system. Osteoarthritis Cartilage. 2017;25(12):1994-1998.
7. Morgan RC Jr, Slover J. Breakout session: ethnic and racial disparities in joint arthroplasty. Clin Orthop Relat Res. 2011;469(7):1886-1890.
8. O’Connor MI, Hooten EG. Breakout session: gender disparities in knee osteoarthritis and TKA. Clin Orthop Relat Res. 2011;469(7):1883-1885.
9. Ibrahim SA. Racial and ethnic disparities in hip and knee joint replacement: a review of research in the Veterans Affairs Health Care System. J Am Acad Orthop Surg. 2007;15(suppl 1):S87-S94.
10. Karmarkar TD, Maurer A, Parks ML, et al. A fresh perspective on a familiar problem: examining disparities in knee osteoarthritis using a Markov model. Med Care. 2017;55(12):993-1000.
11. Kohn MD, Sassoon AA, Fernando ND. Classifications in brief: Kellgren-Lawrence Classification of Osteoarthritis. Clin Orthop Relat Res. 2016;474(8):1886-1893.
12. Nguyen U, Felson DT, Niu J, et al. The impact of knee instability with and without buckling on balance confidence, fear of falling and physical function: the Multicenter Osteoarthritis Study. Osteoarthritis Cartilage. 2014;22(4):527-534.
13. Schmitt LC, Fitzgerald GK, Reisman AS, Rudolph KS. Instability, laxity, and physical function in patients with medial knee osteoarthritis. Phys Ther. 2008;88(12):1506-1516.
14. Laupattarakasem W, Laopaiboon M, Laupattarakasem P, Sumananont C. Arthroscopic debridement for knee osteoarthritis. Cochrane Database Syst Rev. 2008;(1):CD005118.
15. Lamplot JD, Brophy RH. The role for arthroscopic partial meniscectomy in knees with degenerative changes: a systematic review. Bone Joint J. 2016;98-B(7):934-938.
16. Whittle R, Jordan KP, Thomas E, Peat G. Average symptom trajectories following incident radiographic knee osteoarthritis: data from the Osteoarthritis Initiative. RMD Open. 2016;2(2):e000281.
17. Jones A, Kwoh CK, Kelley ME, Ibrahim SA. Racial disparity in knee arthroplasty utilization in the Veterans Health Administration. Arthritis Rheum. 2005;53(6):979-981.
Knee osteoarthritis (OA) affects almost 9.3 million adults in the US and accounts for $27 billion in annual health care expenses.1,2 Due to the increasing cost of health care and an aging population, there has been renewed interest in establishing criteria for nonarthroplasty treatment of knee OA.
In 2013, using the RAND/UCLA Appropriateness method, the American Academy of Orthopaedic Surgeons (AAOS) developed an appropriate use criteria (AUC) for nonarthroplasty management of primary OA of the knee, based on orthopaedic literature and expert opinion.3 Interventions such as activity modification, weight loss, prescribed physical therapy, nonsteroidal anti-inflammatory drugs, tramadol, prescribed oral or transcutaneous opioids, acetaminophen, intra-articular corticosteroids, hinged or unloading knee braces, arthroscopic partial menisectomy or loose body removal, and realignment osteotomy were assessed. An algorithm was developed for 576 patients scenarios that incorporated patient-specific, prognostic/predictor variables to assign designations of “appropriate,” “may be appropriate,” or “rarely appropriate,” to treatment interventions.4,5 An online version of the algorithm (orthoguidelines.org) is available for physicians and surgeons to judge appropriateness of nonarthroplasty treatments; however, it is not intended to mandate candidacy for treatment or intervention.
Clinical evaluation of the AAOS AUC is necessary to determine how treatment recommendations correlate with current practice. A recent examination of the AAOS Appropriateness System for Surgical Management of Knee OA found that prognostic/predictor variables, such as patient age, OA severity, and pattern of knee OA involvement were more heavily weighted when determining arthroplasty appropriateness than was pain severity or functional loss.6 Furthermore, non-AAOS AUC prognostic/predictor variables, such as race and gender, have been linked to disparities in utilization of knee OA interventions.7-9 Such disparities can be costly not just from a patient perceptive, but also employer and societal perspectives.10
The Department of Veterans Affairs (VA) health care system represents a model of equal-access-to care system in the US that is ideal for examination of issues about health care utilization and any disparities within the AAOS AUC model and has previously been used to assess utilization of total knee arthroplasty.9 The aim of this study was to characterize utilization of the AAOS AUC for nonarthroplasty treatment of knee OA in a VA patient population. We asked the following questions: (1) What variables are predictive of receiving a greater number of AAOS AUC evaluated nonarthroplasty treatments? (2) What variables are predictive of receiving “rarely appropriate” AAOS AUC evaluated nonarthroplasty treatment? (3) What factors are predictive of duration of nonarthroplasty care until total knee arthroplasty (TKA)?
Methods
The institutional review board at the Louis Stokes Cleveland VA Medical Center in Ohio approved a retrospective chart review of nonarthroplasty treatments utilized by patients presenting to its orthopaedic section who subsequently underwent knee arthroplasty between 2013 and 2016. Eligibility criteria included patients aged ≥ 30 years with a diagnosis of unilateral or bilateral primary knee OA. Patients with posttraumatic OA, inflammatory arthritis, and a history of infectious arthritis or Charcot arthropathy of the knee were excluded. Patients with a body mass index (BMI) > 40 or a hemoglobin A1c > 8.0 at presentation were excluded as nonarthroplasty care was the recommended course of treatment above these thresholds.
Data collected included race, gender, duration of nonarthroplasty treatment, BMI, and Kellgren-Lawrence classification of knee OA at time of presentation for symptomatic knee OA.11 All AAOS AUC-evaluated nonarthroplasty treatments utilized prior to arthroplasty intervention also were recorded (Table 1).
Statistical Analysis
Statistical analysis was completed with GraphPad Software Prism 7.0a (La Jolla, CA) and Mathworks MatLab R2016b software (Natick, MA). Univariate analysis with Student t tests with Welch corrections in the setting of unequal variance, Mann-Whitney nonparametric tests, and Fisher exact test were generated in the appropriate setting. Multivariable analyses also were conducted. For continuous outcomes, stepwise multiple linear regression was used to generate predictive models; for binary outcomes, binomial logistic regression was used.
Factors analyzed in regression modeling for the total number of AAOS AUC evaluated nonarthroplasty treatments utilized and the likelihood of receiving a rarely appropriate treatment included gender, race, function-limiting pain, range of motion (ROM), ligamentous instability, arthritis pattern, limb alignment, mechanical symptoms, BMI, age, and Kellgren-Lawrence grade. Factors analyzed in timing of TKA included the above variables plus the total number of AUC interventions, whether the patient received an inappropriate intervention, and average appropriateness of the interventions received. Residual analysis with Cook’s distance was used to identify outliers in regression. Observations with Cook’s distance > 3 times the mean Cook’s distance were identified as potential outliers, and models were adjusted accordingly. All statistical analyses were 2-tailed. Statistical significance was set to P ≤ .05 for all outputs.
Results
In the study, 97.8% of participants identified as male, and the mean age was 62.8 years (Table 3).
Appropriate Use Criteria Interventions
Patients received a mean of 5.2 AAOS AUC evaluated interventions before undergoing arthroplasty management at a mean of 32.3 months (range 2-181 months) from initial presentation. The majority of these interventions were classified as either appropriate or may be appropriate, according to the AUC definitions (95.1%). Self-management and physical therapy programs were widely utilized (100% and 90.1%, respectively), with all use of these interventions classified as appropriate.
Hinged or unloader knee braces were utilized in about half the study patients; this intervention was classified as rarely appropriate in 4.4% of these patients. Medical therapy was also widely used, with all use of NSAIDs, acetaminophen, and tramadol classified as appropriate or may be appropriate. Oral or transcutaneous opioid medications were prescribed in 14.3% of patients, with 92.3% of this use classified as rarely appropriate. Although the opioid medication prescribing provider was not specifically evaluated, there were no instances in which the orthopaedic service provided an oral or transcutaneous opioid prescriptions. Procedural interventions, with the exception of corticosteroid injections, were uncommon; no patient received realignment osteotomy, and only 12.1% of patients underwent arthroscopy. The use of arthroscopy was deemed rarely appropriate in 72.7% of these cases.
Factors Associated With AAOS AUC Intervention Use
There was no difference in the number of AAOS AUC evaluated interventions received based on BMI (mean [SD] BMI < 35, 5.2 [1.0] vs BMI ≥ 35, 5.3 [1.1], P = .49), age (mean [SD] aged < 60 years, 5.4 [1.0] vs aged ≥ 60 years, 5.1 [1.2], P = .23), or Kellgren-Lawrence arthritic grade (mean [SD] grade ≤ 2, 5.5 [1.0] vs grade > 2, 5.1 [1.1], P = .06). These variables also were not associated with receiving a rarely appropriate intervention (mean [SD] BMI < 35, 0.27 [0.5] vs BMI > 35, 0.2 [0.4], P = .81; aged > 60 years, 0.3 [0.5] vs aged < 60 years, 0.2 [0.4], P = .26; Kellgren-Lawrence grade < 2, 0.4 [0.6] vs grade > 2, 0.2 [0.4], P = .1).
Regression modeling to predict total number of AAOS AUC evaluated interventions received produced a significant model (R2 = 0.111, P = .006). The presence of ligamentous instability (β coefficient, -1.61) and the absence of mechanical symptoms (β coefficient, -0.67) were negative predictors of number of AUC interventions received. Variance inflation factors were 1.014 and 1.012, respectively. Likewise, regression modeling to identify factors predictive of receiving a rarely appropriate intervention also produced a significant model (pseudo R2= 0.06, P = .025), with lower Kellgren-Lawrence grade the only significant predictor of receiving a rarely appropriate intervention (odds ratio [OR] 0.54; 95% CI, 0.42 -0.72, per unit increase).
Timing from presentation to arthroplasty intervention was also evaluated. Age was a negative predictor (β coefficient -1.61), while positive predictors were reduced ROM (β coefficient 15.72) and having more AUC interventions (β coefficient 7.31) (model R2= 0.29, P = < .001). Age was the most significant predictor. Variance inflations factors were 1.02, 1.01, and 1.03, respectively. Receiving a rarely appropriate intervention was not associated with TKA timing.
Discussion
This single-center retrospective study examined the utilization of AAOS AUC-evaluated nonarthroplasty interventions for symptomatic knee OA prior to TKA. The aims of this study were to validate the AAOS AUC in a clinical setting and identify predictors of AAOS AUC utilization. In particular, this study focused on the number of interventions utilized prior to knee arthroplasty, whether interventions receiving a designation of rarely appropriate were used, and the duration of nonarthroplasty treatment.
Patients with knee instability used fewer total AAOS AUC evaluated interventions prior to TKA. Subjective instability has been reported as high as 27% in patients with OA and has been associated with fear of falling, poor balance confidence, activity limitations, and lower Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function scores.12 However, it has not been found to correlate with knee laxity.13 Nevertheless, significant functional impairment with the risk of falling may reduce the number of nonarthroplasty interventions attempted. On the other hand, the presence of mechanical symptoms resulted in greater utilization of nonarthroplasty interventions. This is likely due to the greater utilization of arthroscopic partial menisectomy or loose body removal in this group of patients. Despite its inclusion as an AAOS AUC evaluated intervention, arthroscopy remains a contentious treatment for symptomatic knee pain in the setting of OA.14,15
For every unit decrease in Kellgren-Lawrence OA grade, patients were 54% more likely to receive a rarely appropriate intervention prior to knee arthroplasty. This is supported by the recent literature examining the AAOS AUC for surgical management of knee OA. Riddle and colleagues developed a classification tree to determine the contributions of various prognostic variables in final classifications of the 864 clinical vignettes used to develop the appropriateness algorithm and found that OA severity was strongly favored, with only 4 of the 432 vignettes with severe knee OA judged as rarely appropriate for surgical intervention.6
Our findings, too, may be explained by an AAOS AUC system that too heavily weighs radiographic severity of knee OA, resulting in more frequent rarely appropriate interventions in patients with less severe arthritis, including nonarthroplasty treatments. It is likely that rarely appropriate interventions were attempted in this subset of our study cohort based on patient’s subjective symptoms and functional status, both of which have been shown to be discordant with radiographic severity of knee OA.16
Oral or transcutaneous prescribed opioid medications were the most frequent intervention that received a rarely appropriate designation. Patients with preoperative opioid use undergoing TKA have been shown to have a greater risk for postoperative complications and longer hospital stay, particularly those patients aged < 75 years. Younger age, use of more interventions, and decreased knee ROM at presentation were predictive of longer duration of nonarthroplasty treatment. The use of more AAOS AUC evaluated interventions in these patients suggests that the AAOS AUC model may effectively be used to manage symptomatic OA, increasing the time from presentation to knee arthroplasty.
Interestingly, the use of rarely appropriate interventions did not affect TKA timing, as would be expected in a clinically effective nonarthroplasty treatment model. The reasons for rarely appropriate nonsurgical interventions are complex and require further investigation. One possible explanation is that decreased ROM was a marker for mechanical symptoms that necessitated additional intervention in the form of knee arthroscopy, delaying time to TKA.
Limitations
There are several limitations of this study. First, the small sample size (N = 90) requires acknowledgment; however, this limitation reflects the difficulty in following patients for years prior to an operative intervention. Second, the study population consists of veterans using the VA system and may not be reflective of the general population, differing with respect to gender, racial, and socioeconomic factors. Nevertheless, studies examining TKA utilization found, aside from racial and ethnic variability, patient gender and age do not affect arthroplasty utilization rate in the VA system.17
Additional limitations stem from the retrospective nature of this study. While the Computerized Patient Record System and centralized care of the VA system allows for review of all physical therapy consultations, orthotic consultations, and medications within the VA system, any treatments and intervention delivered by non-VA providers were not captured. Furthermore, the ability to assess for confounding variables limiting the prescription of certain medications, such as chronic kidney disease with NSAIDs or liver disease with acetaminophen, was limited by our study design.
Although our study suffers from selection bias with respect to examination of nonarthroplasty treatment in patients who have ultimately undergone TKA, we feel that this subset of patients with symptomatic knee OA represents the majority of patients evaluated for knee OA by orthopaedic surgeons in the clinic setting. It should be noted that although realignment osteotomies were sometimes indicated as appropriate by AAOS AUC model in our study population, this intervention was never performed due to patient and surgeon preference. Additionally, although it is not an AAOS AUC evaluated intervention, viscosupplementation was sporadically used during the study period; however, it is now off formulary at the investigation institution.
Conclusion
Our study suggests that patients without knee instability use more nonarthroplasty treatments over a longer period before TKA, and those patients with less severe knee OA are at risk of receiving an intervention judged to be rarely appropriate by the AAOS AUC. Such interventions do not affect timing of TKA. Nonarthroplasty care should be individualized to patients’ needs, and the decision to proceed with arthroplasty should be considered only after exhausting appropriate conservative measures. We recommend that providers use the AAOS AUC, especially when treating younger patients with less severe knee OA, particularly if considering opiate therapy or knee arthroscopy.
Acknowledgments
The authors would like to acknowledge Patrick Getty, MD, for his surgical care of some of the study patients. This material is the result of work supported with resources and the use of facilities at the Louis Stokes Cleveland VA Medical Center in Ohio.
Knee osteoarthritis (OA) affects almost 9.3 million adults in the US and accounts for $27 billion in annual health care expenses.1,2 Due to the increasing cost of health care and an aging population, there has been renewed interest in establishing criteria for nonarthroplasty treatment of knee OA.
In 2013, using the RAND/UCLA Appropriateness method, the American Academy of Orthopaedic Surgeons (AAOS) developed an appropriate use criteria (AUC) for nonarthroplasty management of primary OA of the knee, based on orthopaedic literature and expert opinion.3 Interventions such as activity modification, weight loss, prescribed physical therapy, nonsteroidal anti-inflammatory drugs, tramadol, prescribed oral or transcutaneous opioids, acetaminophen, intra-articular corticosteroids, hinged or unloading knee braces, arthroscopic partial menisectomy or loose body removal, and realignment osteotomy were assessed. An algorithm was developed for 576 patients scenarios that incorporated patient-specific, prognostic/predictor variables to assign designations of “appropriate,” “may be appropriate,” or “rarely appropriate,” to treatment interventions.4,5 An online version of the algorithm (orthoguidelines.org) is available for physicians and surgeons to judge appropriateness of nonarthroplasty treatments; however, it is not intended to mandate candidacy for treatment or intervention.
Clinical evaluation of the AAOS AUC is necessary to determine how treatment recommendations correlate with current practice. A recent examination of the AAOS Appropriateness System for Surgical Management of Knee OA found that prognostic/predictor variables, such as patient age, OA severity, and pattern of knee OA involvement were more heavily weighted when determining arthroplasty appropriateness than was pain severity or functional loss.6 Furthermore, non-AAOS AUC prognostic/predictor variables, such as race and gender, have been linked to disparities in utilization of knee OA interventions.7-9 Such disparities can be costly not just from a patient perceptive, but also employer and societal perspectives.10
The Department of Veterans Affairs (VA) health care system represents a model of equal-access-to care system in the US that is ideal for examination of issues about health care utilization and any disparities within the AAOS AUC model and has previously been used to assess utilization of total knee arthroplasty.9 The aim of this study was to characterize utilization of the AAOS AUC for nonarthroplasty treatment of knee OA in a VA patient population. We asked the following questions: (1) What variables are predictive of receiving a greater number of AAOS AUC evaluated nonarthroplasty treatments? (2) What variables are predictive of receiving “rarely appropriate” AAOS AUC evaluated nonarthroplasty treatment? (3) What factors are predictive of duration of nonarthroplasty care until total knee arthroplasty (TKA)?
Methods
The institutional review board at the Louis Stokes Cleveland VA Medical Center in Ohio approved a retrospective chart review of nonarthroplasty treatments utilized by patients presenting to its orthopaedic section who subsequently underwent knee arthroplasty between 2013 and 2016. Eligibility criteria included patients aged ≥ 30 years with a diagnosis of unilateral or bilateral primary knee OA. Patients with posttraumatic OA, inflammatory arthritis, and a history of infectious arthritis or Charcot arthropathy of the knee were excluded. Patients with a body mass index (BMI) > 40 or a hemoglobin A1c > 8.0 at presentation were excluded as nonarthroplasty care was the recommended course of treatment above these thresholds.
Data collected included race, gender, duration of nonarthroplasty treatment, BMI, and Kellgren-Lawrence classification of knee OA at time of presentation for symptomatic knee OA.11 All AAOS AUC-evaluated nonarthroplasty treatments utilized prior to arthroplasty intervention also were recorded (Table 1).
Statistical Analysis
Statistical analysis was completed with GraphPad Software Prism 7.0a (La Jolla, CA) and Mathworks MatLab R2016b software (Natick, MA). Univariate analysis with Student t tests with Welch corrections in the setting of unequal variance, Mann-Whitney nonparametric tests, and Fisher exact test were generated in the appropriate setting. Multivariable analyses also were conducted. For continuous outcomes, stepwise multiple linear regression was used to generate predictive models; for binary outcomes, binomial logistic regression was used.
Factors analyzed in regression modeling for the total number of AAOS AUC evaluated nonarthroplasty treatments utilized and the likelihood of receiving a rarely appropriate treatment included gender, race, function-limiting pain, range of motion (ROM), ligamentous instability, arthritis pattern, limb alignment, mechanical symptoms, BMI, age, and Kellgren-Lawrence grade. Factors analyzed in timing of TKA included the above variables plus the total number of AUC interventions, whether the patient received an inappropriate intervention, and average appropriateness of the interventions received. Residual analysis with Cook’s distance was used to identify outliers in regression. Observations with Cook’s distance > 3 times the mean Cook’s distance were identified as potential outliers, and models were adjusted accordingly. All statistical analyses were 2-tailed. Statistical significance was set to P ≤ .05 for all outputs.
Results
In the study, 97.8% of participants identified as male, and the mean age was 62.8 years (Table 3).
Appropriate Use Criteria Interventions
Patients received a mean of 5.2 AAOS AUC evaluated interventions before undergoing arthroplasty management at a mean of 32.3 months (range 2-181 months) from initial presentation. The majority of these interventions were classified as either appropriate or may be appropriate, according to the AUC definitions (95.1%). Self-management and physical therapy programs were widely utilized (100% and 90.1%, respectively), with all use of these interventions classified as appropriate.
Hinged or unloader knee braces were utilized in about half the study patients; this intervention was classified as rarely appropriate in 4.4% of these patients. Medical therapy was also widely used, with all use of NSAIDs, acetaminophen, and tramadol classified as appropriate or may be appropriate. Oral or transcutaneous opioid medications were prescribed in 14.3% of patients, with 92.3% of this use classified as rarely appropriate. Although the opioid medication prescribing provider was not specifically evaluated, there were no instances in which the orthopaedic service provided an oral or transcutaneous opioid prescriptions. Procedural interventions, with the exception of corticosteroid injections, were uncommon; no patient received realignment osteotomy, and only 12.1% of patients underwent arthroscopy. The use of arthroscopy was deemed rarely appropriate in 72.7% of these cases.
Factors Associated With AAOS AUC Intervention Use
There was no difference in the number of AAOS AUC evaluated interventions received based on BMI (mean [SD] BMI < 35, 5.2 [1.0] vs BMI ≥ 35, 5.3 [1.1], P = .49), age (mean [SD] aged < 60 years, 5.4 [1.0] vs aged ≥ 60 years, 5.1 [1.2], P = .23), or Kellgren-Lawrence arthritic grade (mean [SD] grade ≤ 2, 5.5 [1.0] vs grade > 2, 5.1 [1.1], P = .06). These variables also were not associated with receiving a rarely appropriate intervention (mean [SD] BMI < 35, 0.27 [0.5] vs BMI > 35, 0.2 [0.4], P = .81; aged > 60 years, 0.3 [0.5] vs aged < 60 years, 0.2 [0.4], P = .26; Kellgren-Lawrence grade < 2, 0.4 [0.6] vs grade > 2, 0.2 [0.4], P = .1).
Regression modeling to predict total number of AAOS AUC evaluated interventions received produced a significant model (R2 = 0.111, P = .006). The presence of ligamentous instability (β coefficient, -1.61) and the absence of mechanical symptoms (β coefficient, -0.67) were negative predictors of number of AUC interventions received. Variance inflation factors were 1.014 and 1.012, respectively. Likewise, regression modeling to identify factors predictive of receiving a rarely appropriate intervention also produced a significant model (pseudo R2= 0.06, P = .025), with lower Kellgren-Lawrence grade the only significant predictor of receiving a rarely appropriate intervention (odds ratio [OR] 0.54; 95% CI, 0.42 -0.72, per unit increase).
Timing from presentation to arthroplasty intervention was also evaluated. Age was a negative predictor (β coefficient -1.61), while positive predictors were reduced ROM (β coefficient 15.72) and having more AUC interventions (β coefficient 7.31) (model R2= 0.29, P = < .001). Age was the most significant predictor. Variance inflations factors were 1.02, 1.01, and 1.03, respectively. Receiving a rarely appropriate intervention was not associated with TKA timing.
Discussion
This single-center retrospective study examined the utilization of AAOS AUC-evaluated nonarthroplasty interventions for symptomatic knee OA prior to TKA. The aims of this study were to validate the AAOS AUC in a clinical setting and identify predictors of AAOS AUC utilization. In particular, this study focused on the number of interventions utilized prior to knee arthroplasty, whether interventions receiving a designation of rarely appropriate were used, and the duration of nonarthroplasty treatment.
Patients with knee instability used fewer total AAOS AUC evaluated interventions prior to TKA. Subjective instability has been reported as high as 27% in patients with OA and has been associated with fear of falling, poor balance confidence, activity limitations, and lower Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function scores.12 However, it has not been found to correlate with knee laxity.13 Nevertheless, significant functional impairment with the risk of falling may reduce the number of nonarthroplasty interventions attempted. On the other hand, the presence of mechanical symptoms resulted in greater utilization of nonarthroplasty interventions. This is likely due to the greater utilization of arthroscopic partial menisectomy or loose body removal in this group of patients. Despite its inclusion as an AAOS AUC evaluated intervention, arthroscopy remains a contentious treatment for symptomatic knee pain in the setting of OA.14,15
For every unit decrease in Kellgren-Lawrence OA grade, patients were 54% more likely to receive a rarely appropriate intervention prior to knee arthroplasty. This is supported by the recent literature examining the AAOS AUC for surgical management of knee OA. Riddle and colleagues developed a classification tree to determine the contributions of various prognostic variables in final classifications of the 864 clinical vignettes used to develop the appropriateness algorithm and found that OA severity was strongly favored, with only 4 of the 432 vignettes with severe knee OA judged as rarely appropriate for surgical intervention.6
Our findings, too, may be explained by an AAOS AUC system that too heavily weighs radiographic severity of knee OA, resulting in more frequent rarely appropriate interventions in patients with less severe arthritis, including nonarthroplasty treatments. It is likely that rarely appropriate interventions were attempted in this subset of our study cohort based on patient’s subjective symptoms and functional status, both of which have been shown to be discordant with radiographic severity of knee OA.16
Oral or transcutaneous prescribed opioid medications were the most frequent intervention that received a rarely appropriate designation. Patients with preoperative opioid use undergoing TKA have been shown to have a greater risk for postoperative complications and longer hospital stay, particularly those patients aged < 75 years. Younger age, use of more interventions, and decreased knee ROM at presentation were predictive of longer duration of nonarthroplasty treatment. The use of more AAOS AUC evaluated interventions in these patients suggests that the AAOS AUC model may effectively be used to manage symptomatic OA, increasing the time from presentation to knee arthroplasty.
Interestingly, the use of rarely appropriate interventions did not affect TKA timing, as would be expected in a clinically effective nonarthroplasty treatment model. The reasons for rarely appropriate nonsurgical interventions are complex and require further investigation. One possible explanation is that decreased ROM was a marker for mechanical symptoms that necessitated additional intervention in the form of knee arthroscopy, delaying time to TKA.
Limitations
There are several limitations of this study. First, the small sample size (N = 90) requires acknowledgment; however, this limitation reflects the difficulty in following patients for years prior to an operative intervention. Second, the study population consists of veterans using the VA system and may not be reflective of the general population, differing with respect to gender, racial, and socioeconomic factors. Nevertheless, studies examining TKA utilization found, aside from racial and ethnic variability, patient gender and age do not affect arthroplasty utilization rate in the VA system.17
Additional limitations stem from the retrospective nature of this study. While the Computerized Patient Record System and centralized care of the VA system allows for review of all physical therapy consultations, orthotic consultations, and medications within the VA system, any treatments and intervention delivered by non-VA providers were not captured. Furthermore, the ability to assess for confounding variables limiting the prescription of certain medications, such as chronic kidney disease with NSAIDs or liver disease with acetaminophen, was limited by our study design.
Although our study suffers from selection bias with respect to examination of nonarthroplasty treatment in patients who have ultimately undergone TKA, we feel that this subset of patients with symptomatic knee OA represents the majority of patients evaluated for knee OA by orthopaedic surgeons in the clinic setting. It should be noted that although realignment osteotomies were sometimes indicated as appropriate by AAOS AUC model in our study population, this intervention was never performed due to patient and surgeon preference. Additionally, although it is not an AAOS AUC evaluated intervention, viscosupplementation was sporadically used during the study period; however, it is now off formulary at the investigation institution.
Conclusion
Our study suggests that patients without knee instability use more nonarthroplasty treatments over a longer period before TKA, and those patients with less severe knee OA are at risk of receiving an intervention judged to be rarely appropriate by the AAOS AUC. Such interventions do not affect timing of TKA. Nonarthroplasty care should be individualized to patients’ needs, and the decision to proceed with arthroplasty should be considered only after exhausting appropriate conservative measures. We recommend that providers use the AAOS AUC, especially when treating younger patients with less severe knee OA, particularly if considering opiate therapy or knee arthroscopy.
Acknowledgments
The authors would like to acknowledge Patrick Getty, MD, for his surgical care of some of the study patients. This material is the result of work supported with resources and the use of facilities at the Louis Stokes Cleveland VA Medical Center in Ohio.
1. Cross M, Smith E, Hoy D, et al. The global burden of hip and knee osteoarthritis: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73(7):1323-1330.
2. Losina E, Walensky RP, Kessler CL, et al. Cost-effectiveness of total knee arthroplasty in the United States: patient risk and hospital volume. Arch Intern Med. 2009;169(12):1113-1121; discussion 1121-1122.
3. Members of the Writing, Review, and Voting Panels of the AUC on the Non-Arthroplasty Treatment of Osteoarthritis of the Knee, Sanders JO, Heggeness MH, Murray J, Pezold R, Donnelly P. The American Academy of Orthopaedic Surgeons Appropriate Use Criteria on the Non-Arthroplasty Treatment of Osteoarthritis of the Knee. J Bone Joint Surg Am. 2014;96(14):1220-1221.
4. Sanders JO, Murray J, Gross L. Non-arthroplasty treatment of osteoarthritis of the knee. J Am Acad Orthop Surg. 2014;22(4):256-260.
5. Yates AJ Jr, McGrory BJ, Starz TW, Vincent KR, McCardel B, Golightly YM. AAOS appropriate use criteria: optimizing the non-arthroplasty management of osteoarthritis of the knee. J Am Acad Orthop Surg. 2014;22(4):261-267.
6. Riddle DL, Perera RA. Appropriateness and total knee arthroplasty: an examination of the American Academy of Orthopaedic Surgeons appropriateness rating system. Osteoarthritis Cartilage. 2017;25(12):1994-1998.
7. Morgan RC Jr, Slover J. Breakout session: ethnic and racial disparities in joint arthroplasty. Clin Orthop Relat Res. 2011;469(7):1886-1890.
8. O’Connor MI, Hooten EG. Breakout session: gender disparities in knee osteoarthritis and TKA. Clin Orthop Relat Res. 2011;469(7):1883-1885.
9. Ibrahim SA. Racial and ethnic disparities in hip and knee joint replacement: a review of research in the Veterans Affairs Health Care System. J Am Acad Orthop Surg. 2007;15(suppl 1):S87-S94.
10. Karmarkar TD, Maurer A, Parks ML, et al. A fresh perspective on a familiar problem: examining disparities in knee osteoarthritis using a Markov model. Med Care. 2017;55(12):993-1000.
11. Kohn MD, Sassoon AA, Fernando ND. Classifications in brief: Kellgren-Lawrence Classification of Osteoarthritis. Clin Orthop Relat Res. 2016;474(8):1886-1893.
12. Nguyen U, Felson DT, Niu J, et al. The impact of knee instability with and without buckling on balance confidence, fear of falling and physical function: the Multicenter Osteoarthritis Study. Osteoarthritis Cartilage. 2014;22(4):527-534.
13. Schmitt LC, Fitzgerald GK, Reisman AS, Rudolph KS. Instability, laxity, and physical function in patients with medial knee osteoarthritis. Phys Ther. 2008;88(12):1506-1516.
14. Laupattarakasem W, Laopaiboon M, Laupattarakasem P, Sumananont C. Arthroscopic debridement for knee osteoarthritis. Cochrane Database Syst Rev. 2008;(1):CD005118.
15. Lamplot JD, Brophy RH. The role for arthroscopic partial meniscectomy in knees with degenerative changes: a systematic review. Bone Joint J. 2016;98-B(7):934-938.
16. Whittle R, Jordan KP, Thomas E, Peat G. Average symptom trajectories following incident radiographic knee osteoarthritis: data from the Osteoarthritis Initiative. RMD Open. 2016;2(2):e000281.
17. Jones A, Kwoh CK, Kelley ME, Ibrahim SA. Racial disparity in knee arthroplasty utilization in the Veterans Health Administration. Arthritis Rheum. 2005;53(6):979-981.
1. Cross M, Smith E, Hoy D, et al. The global burden of hip and knee osteoarthritis: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73(7):1323-1330.
2. Losina E, Walensky RP, Kessler CL, et al. Cost-effectiveness of total knee arthroplasty in the United States: patient risk and hospital volume. Arch Intern Med. 2009;169(12):1113-1121; discussion 1121-1122.
3. Members of the Writing, Review, and Voting Panels of the AUC on the Non-Arthroplasty Treatment of Osteoarthritis of the Knee, Sanders JO, Heggeness MH, Murray J, Pezold R, Donnelly P. The American Academy of Orthopaedic Surgeons Appropriate Use Criteria on the Non-Arthroplasty Treatment of Osteoarthritis of the Knee. J Bone Joint Surg Am. 2014;96(14):1220-1221.
4. Sanders JO, Murray J, Gross L. Non-arthroplasty treatment of osteoarthritis of the knee. J Am Acad Orthop Surg. 2014;22(4):256-260.
5. Yates AJ Jr, McGrory BJ, Starz TW, Vincent KR, McCardel B, Golightly YM. AAOS appropriate use criteria: optimizing the non-arthroplasty management of osteoarthritis of the knee. J Am Acad Orthop Surg. 2014;22(4):261-267.
6. Riddle DL, Perera RA. Appropriateness and total knee arthroplasty: an examination of the American Academy of Orthopaedic Surgeons appropriateness rating system. Osteoarthritis Cartilage. 2017;25(12):1994-1998.
7. Morgan RC Jr, Slover J. Breakout session: ethnic and racial disparities in joint arthroplasty. Clin Orthop Relat Res. 2011;469(7):1886-1890.
8. O’Connor MI, Hooten EG. Breakout session: gender disparities in knee osteoarthritis and TKA. Clin Orthop Relat Res. 2011;469(7):1883-1885.
9. Ibrahim SA. Racial and ethnic disparities in hip and knee joint replacement: a review of research in the Veterans Affairs Health Care System. J Am Acad Orthop Surg. 2007;15(suppl 1):S87-S94.
10. Karmarkar TD, Maurer A, Parks ML, et al. A fresh perspective on a familiar problem: examining disparities in knee osteoarthritis using a Markov model. Med Care. 2017;55(12):993-1000.
11. Kohn MD, Sassoon AA, Fernando ND. Classifications in brief: Kellgren-Lawrence Classification of Osteoarthritis. Clin Orthop Relat Res. 2016;474(8):1886-1893.
12. Nguyen U, Felson DT, Niu J, et al. The impact of knee instability with and without buckling on balance confidence, fear of falling and physical function: the Multicenter Osteoarthritis Study. Osteoarthritis Cartilage. 2014;22(4):527-534.
13. Schmitt LC, Fitzgerald GK, Reisman AS, Rudolph KS. Instability, laxity, and physical function in patients with medial knee osteoarthritis. Phys Ther. 2008;88(12):1506-1516.
14. Laupattarakasem W, Laopaiboon M, Laupattarakasem P, Sumananont C. Arthroscopic debridement for knee osteoarthritis. Cochrane Database Syst Rev. 2008;(1):CD005118.
15. Lamplot JD, Brophy RH. The role for arthroscopic partial meniscectomy in knees with degenerative changes: a systematic review. Bone Joint J. 2016;98-B(7):934-938.
16. Whittle R, Jordan KP, Thomas E, Peat G. Average symptom trajectories following incident radiographic knee osteoarthritis: data from the Osteoarthritis Initiative. RMD Open. 2016;2(2):e000281.
17. Jones A, Kwoh CK, Kelley ME, Ibrahim SA. Racial disparity in knee arthroplasty utilization in the Veterans Health Administration. Arthritis Rheum. 2005;53(6):979-981.
Unicondylar Knee Arthroplasty in the U.S. Patient Population: Prevalence and Epidemiology
ABSTRACT
Publications on the prevalence of unicompartmental knee arthroplasty in the United States using a single database may have underestimated the “true” number of cases performed, given that several unicondylar knee arthroplasty (UKA) patients are <65 years and have private insurance. The prevalence of UKA in elderly (≥65 years) and younger (<65 years) populations was evaluated using the 2002 to 2011 5% sample of the Medicare data (Part B) and the 2004 to June 2012 MarketScan Commercial and Medicare Supplemental databases, respectively. The prevalence of UKA was stratified by age, gender, census region, Charlson comorbidity index, Medicare buy-in status, and diagnosis. The annual rate of change in the UKA rate was examined using Poisson regression to evaluate temporal changes considering year as a covariate.
A total of 5235 and 23,310 UKA procedures were identified from the 5% Medicare and MarketScan databases, respectively. The rates of UKA generally increased until 2008, after which there was a decline. In both cohorts, gender and year of operation were found to be significantly associated with UKA rate. Analysis of data obtained over the past few years revealed that males 55 to 64 years, 65 to 69 years, and 70 to 74 years were the only age-gender groups whose UKA rates appeared to be trending upward.
From 2002 to 2011, the rate of UKAs performed in the United States has increased, and a significant proportion of the surgeries were performed in younger (<65 years) patients.
Continue to: Unicondylar knee arthroplasty...
Unicondylar knee arthroplasty (UKA) is an effective surgical treatment for symptomatic degenerative joint disease of a single compartment of the knee, providing improved functional outcomes compared with total knee arthroplasty (TKA).1-3 It has been estimated that the proportion of patients undergoing TKA, who meet the criteria for UKA, varies between 21% and 47%.4,5 However, it has been variably estimated that the usage of UKA ranges from 0% to 50% (mean, 8%) of all primary knee arthroplasties.5-8 It is believed that this discrepancy between the percentage of patients who meet indications for the surgery and those who receive it is associated with various factors, including surgeon training and experiences, diverse indications, economic factors, as well as acknowledgment of the reportedly higher revision rates of UKA than those of TKA in national joint registries.7,9-11
According to their classic article, Kozinn and Scott12 outlined the indications for UKA that, in their experience, led to the most successful outcomes, including age >60 years, weight <82 kg, low physical demand, localized arthritis with no full-thickness chondromalacia elsewhere in the joint, intact anterior cruciate ligament, minimal deformity, and flexion >90°. More recently, indications have been expanded to include younger and more active patients, higher body mass index, and some patterns of patellofemoral chondromalacia, with an increasing number of publications reporting successful clinical outcomes in these cohorts as well.13-17 Taken together, it is clear that the “classic” strict indications for UKA can be safely expanded, which have and will result in an increased number of these procedures being performed above and beyond that which might be predicted based on demographic trends alone.
A growing body of literature has been published on the prevalence and projections of orthopedic procedures in the United States.18-20 Several studies have focused their analysis on 1 of several large administrative databases, including the Nationwide Inpatient Sample, the 5% Medicare Part B database, and the National Hospital Discharge Survey.18,20-23 A concern with limiting an analysis of the prevalence of unicompartmental knee arthroplasty to these particular databases is that it may underestimate the “true” number of cases performed in the United States, given that several UKA patients are <65 years and have private insurance, and therefore, would not be captured statistically by a database that collects data on patients ≥65 years.
The purpose of this study was to quantify the current prevalence and epidemiology of UKA in the U.S. patient population. Our hypothesis was that the number of procedures and the procedural rate of UKA are increasing over time. Furthermore, this increase may be attributed to an increase in select age- or gender-based segments of the population. To test this hypothesis, we analyzed 2 separate large claims databases to capture patients over a spectrum of age and inclusive of both private and public payers, including the 5% Medicare Part B database (2002–2011) for patients ≥65 years and the MarketScan database (2004 to June 2011) for patients <65 years. Understanding the accurate trends in the use of UKA on a national scale is important for legislative bodies, healthcare administrators, and physicians.
MATERIALS AND METHODS
The 2002 to 2011 5% sample of the Medicare data (Part B) and the 2004 to June 2012 MarketScan Commercial and Medicare Supplemental databases were used to evaluate the prevalence of UKA in elderly (≥65 years) and younger (<65 years) populations, respectively. The UKA procedures were identified using the CPT code 27446.
The prevalence of UKA was stratified by age, gender, census region, Charlson Comorbidity Index, Medicare buy-in status, and diagnosis. The buy-in status is a proxy for the socioeconomic status as it reflects the state subsidizing the health insurance premium for the beneficiary. The Charlson Comorbidity Index is a composite score that has been used to assess the comorbidity level of a patient by taking into account the number and the severity of comorbid conditions.24 For the elderly population, the rate of UKA was subsequently evaluated based on the number of beneficiaries for that particular age-gender group and year in both databases. Poisson regression was used to evaluate the annual rate of change in the UKA rate for assessing temporal changes considering year as a covariate. Age and gender, as well as 2-way interaction terms for age, gender, and year, were also considered as covariates.
Continue to: RESULTS...
RESULTS
For the time periods analyzed, a total of 5235 and 23,310 UKA procedures were identified from the 5% Medicare and MarketScan databases, respectively. A peak in the prevalence appeared around 2008 for the elderly population and in 2009 for the younger population (Figure 1). When normalized by the size of the population segment, the rate of UKA was found to be approximately 5 times greater in the elderly population, increasing from 369 in 2002 to 639 in 2008, but plateauing to 561 in 2011. Extrapolating to the 100% Medicare population, these numbers increased to 7380, 12,780, and 11,220, respectively. Temporal changes in the UKA rate were significant, increasing from 24.5 UKAs per 100,000 persons in 2002 to 43.1 UKAs in 2008, followed by a decline to 36.5 in 2011 (P < .0001) (Figure 2). The rates of UKA generally increased from 2002 to 2008 for both males and females in the Medicare cohort; however, the rates of UKA in female patients continuously declined from 2008 onward, whereas the UKA rates in male patients decreased in 2009, followed by an increase in 2010 and 2011 (Figure 2). For the younger population, there was a slight increase in the rate of UKA from 2004 to approximately 2009, after which the rates for both males and females remained relatively steady. When put in the context of the prevalence of TKA, the prevalence of UKA fluctuated during the same time period. In the Medicare population, the prevalence of UKA ranged from 4.3% (2005) to 5.9% (2008) of the TKA prevalence between 2002 and 2011. In the younger MarketScan population, the prevalence of UKA ranged from 6.7% (2005) to 8.9% (2008) between 2004 and June 2012.
The UKA rate differed significantly according to gender (P = .0209), with higher rates for males. Although there were no age-related differences (P = .3723), age–gender interactions were found to be significant (P < .0001). For males, the largest rate of UKA in the most recent year of data was observed in the 70- to 74-year-old group, followed by the 75- to 79- and the 65- to 69-year-old groups (Figure 3). For females, those in the 65- to 69- and the 70- to 74-year-old groups had the highest rate of UKA. In the younger cohort, there were increases in the UKA rates since 2004. These rates appeared to be relatively stable from the 2008 or 2009 period onward, except for females 55–64 years, which demonstrated a steady decline since 2008. Analysis of data obtained over the past few years showed that males 55–64, 65–69, and 70–74 years were the only age–gender groups whose UKA rates appeared to be trending upward.
The vast majority of elderly UKA patients were white (95.5%), and when stratified by census region, the highest proportion of UKA procedures was observed in the South and the Midwest (Figure 4). Furthermore, among patients <65 years, 64.2% had a Charlson score of 0 compared to 40.8% in the elderly group (Figure 5). For the Medicare population, based on their receipt of state subsidies for their insurance premiums, 5.1% of patients were of lower socioeconomic status. Osteoarthritis was diagnosed in 99.4% and 97.3% of the MarketScan and Medicare cohorts, respectively.
In the Medicare cohort, gender (P = .0209) and year of operation (P < .0001) were found to be significantly associated with the rate of UKA, along with age-gender (P < .0001) and gender-year (P = .0202) interaction terms. In the MarketScan cohort, age (P = .0173), gender (P = .0017), and year of operation (P = .0002) were found to be significantly associated with UKA rate. Two-way interactions between age-gender (P = .0018), age–year (P = .0207), and gender-year (P = .0017) were also found to be statistically significant factors.
Continue to: DISCUSSION...
DISCUSSION
The results of our study indicate that between 2002 and 2011, a steadily increasing number of UKA procedures was performed in the United States, and a significant proportion of the surgeries was performed on patients <65 years. Without the MarketScan database data, we would have missed more than 23,000 UKA cases performed during this 10-year time period. This finding validates our research methodology that incorporated data on privately insured younger (<65 years) patients, which is something that has not been done when examining the epidemiology of UKA.
To our knowledge, there are only 2 other publications attempting to quantify the incidence of UKA procedures performed in the United States. Bolognesi and colleagues23 used the Medicare 5% sample to assess trends in the use of knee arthroplasty from 2000 to 2009. The authors reported that a total of 68,603 patients underwent unilateral total knee arthroplasty (n = 65,505) or unicompartmental knee arthroplasty (n = 3098) over this 10-year time period. Given that there is substantial overlap of our time periods, it is not surprising that our Medicare numbers are similar (3098 vs 5235). In their study, the use of TKA increased 1.7-fold, whereas the use of UKA increased 6.2-fold23. In our analysis of the Medicare (2011 vs 2002) and MarketScan (2011 vs 2004) databases, there was a 1.3-fold and a 3.4-fold increase in the number of TKAs performed. Concomitantly, the use of UKA increased 1.5-fold and 2.8-fold, respectively, in these databases over the same time periods. The reason for the slight discrepancy in the numbers may be attributable to the peak occurring in 2008. The other publication on the subject by Riddle and colleagues8 focused on the time period 1998 to 2005 and used implant manufacturer’s sales data cross-referenced to a database of 44 hospitals to derive their national estimates. Using their unique methodology, the authors calculated an incidence of UKA, ranging from 6570 implants in 1998 to 44,990 in 2005. They reported that UKA use during the study period increased by 3 times the rate of TKA in the United States, with an average yearly percentage increase in the number of UKA procedures of 32.5% compared to 9.4% for TKA procedures. It is difficult to account for the discrepancy in the number of UKAs performed reported between our current study and that of Riddle and colleagues;8 however, the fact that the authors used implant manufacturer’s individual sales numbers may indicate that a portion of UKA patients was not captured in either the Medicare 5% or the MarketScan database. Nonetheless, in our analysis, the annual increase in the number of UKA procedures performed during the time periods studied averaged 5.8% in the older population and 25.4% in the younger population compared to the increase in the number of TKA procedures, which averaged 3.6% and 33.9% in the older and younger populations, respectively. In addition, in our study, the percentage of UKAs performed relative to the number of TKAs during the time intervals studied varied from a low of 4.3% to a high of 5.9% in the older population and from a low of 6.7% to a high of 8.9% in the younger population.
During the 10-year period of this study, a general upward trend appeared in the total number of unicompartmental knee arthroplasties performed in both the Medicare and the MarketScan databases. The rate at which the procedure was performed increased in the Medicare population from 24.5 to 36.5 (per 100,000 persons) over a 10-year time period and in the MarketScan cohort from 5.9 to 7.4 (per 100,000 persons) over an 8.5-year time period. This indicates both a larger absolute and a relative rate increase in UKA procedures in the elderly population. Around 2008 and 2009, the data showed a slight dip in the rate of UKA in the Medicare population and a plateau in the rate in the MarketScan database. Although this may be a spurious finding in the data that would be smoothed out with a longer time period investigated, it is interesting that this finding coincided with a national economic downturn. Although it might be expected that macroeconomics may affect the utilization of elective surgery such as total joint replacement, Kurtz and colleagues25 investigated this particular question and found that neither the economic downturns of 2001 or those of 2008 and 2009 had a significant impact on the incidence of total joint replacement surgeries.
Incorporation of the MarketScan database data indicated that a significant proportion of patients undergoing UKA were <65 years and that there was a slight but increasing rate of procedures performed on this age cohort over the past decade. A similar finding has been reported in the Finnish Arthroplasty Registry. Leskinen and colleagues26 reported that the incidence of UKAs among individuals 30 to 59 years increased from 0.2 (per 100,000 persons) to 10 (per 100,000 persons) from 1980 to 2006 and that most of the increase occurred among patients 50 to 59 years. The fact that younger age is no longer observed as a relative contraindication to this procedure is supported by several clinical investigations. Cartier and colleagues27 reported 93% survival at 10 years in patients with a mean age of 65 years, but included patients as young as 28 years, claiming that the results for younger patients were no worse than those for older patients in the series. Pandit and colleagues17 compared the results of 245 young patients (<60 years) to those of 755 older patients (>60 years) and found a survival rate of 97% at 10 years, with no significant difference in mean functional outcomes, failure rate, or survival between the groups at >5 years of follow-up. Given that patients <65 years now account for approximately half of the TKAs performed each year, with the greatest increase in volume among patients between 45 and 54, it is clear that investigations on the epidemiology of UKA must take into account this increasingly relevant younger patient cohort.28
Continue to: Our data indicate...
Our data indicate that only approximately 5% of UKA patients were non-white and another 5% were from lower socioeconomic status. These findings have been observed in multiple other studies looking at the epidemiology of total joint replacement in the United States.29 Bolognesi and colleagues23 reported that although “non-white race” patients made up 12% of the general Medicare sample they were analyzing, these patients accounted for only 5% and 3% of the total knee arthroplasty and unicompartmental knee arthroplasty populations, respectively. Although it is beyond the scope of this paper to delve into the reasons for this discrepancy, it may be related to differences in access to care, healthcare literacy, and trust of patients in the healthcare system.30,31
Our study, like all those based on administrative claims, has several notable inherent limitations. Coding inaccuracies as well as the potential for systematic bias (eg, underreporting) may affect the accuracy of our results. Although the MarketScan Commercial Research Database (Truven Health Analytics) includes nationally representative information for >180 million patients covered with private insurance, it is possible that we have missed some patients who underwent UKA during the time period investigated. However, we feel that the number missed is probably small and does not affect our conclusions in any meaningful manner.
CONCLUSION
This novel analysis of 2 separate administrative claims databases, which more accurately captures all patients undergoing UKA, indicates that there has been a steady increase in the rate of the procedure over the past decade and that a significant proportion of the surgeries were performed in younger (<65 years) patients. Understanding the accurate trends in the use of UKA on a national scale is important for legislative bodies, healthcare administrators, as well as physicians. Furthermore, given the increasing rates of UKA in patients <65 years old, and the increased burden on implants for withstanding increased activities and repetitive loads, it remains imperative to strive to optimize materials, implant designs, and surgical techniques to enhance implant durability.
- Hopper GP, Leach WJ. Participation in sporting activities following knee replacement: total versus unicompartmental. Knee Surg Sports Traumatol Arthrosc. 2008;16(10):973-979. doi: 10.1007/s00167-008-0596-9.
- Lygre SH, Espehaug B, Havelin LI, Furnes O, Vollset SE. Pain and function in patients after primary unicompartmental and total knee arthroplasty. J Bone Joint Surg, (Am). 2010;92(18):2890-2897. doi: 10.2106/JBJS.I.00917.
- Liddle AD, Pandit H, Judge A, Murray DW. Patient-reported outcomes after total and unicompartmental knee arthroplasty: a study of 14,076 matched patients from the National Joint Registry for England and Wales. Bone Joint J. 2015;97-B(6):793-801. doi: 10.1302/0301-620X.97B6.35155.
- Arno S, Maffei D, Walker PS, Schwarzkopf R, Desai P, Steiner GC. Retrospective analysis of total knee arthroplasty cases for visual, histological, and clinical eligibility of unicompartmental knee arthroplasties. J Arthroplast. 2011;26(8):1396-1403. doi: 10.1016/j.arth.2010.12.023.
- Willis-Owen CA, Brust K, Alsop H, Miraldo M, Cobb JP. Unicondylar knee arthroplasty in the UK National Health Service: an analysis of candidacy, outcome and cost efficacy. Knee. 2009;16(6):473-478. doi: 10.1016/j.knee.2009.04.006.
- Murray DW, Liddle AD, Dodd CA, Pandit H. Unicompartmental knee arthroplasty: is the glass half full or half empty? Bone Joint J. 2015;97-B(10 Suppl. A):3-8. doi: 10.1302/0301-620X.97B10.36542.
- Liddle AD, Judge A, Pandit H, Murray DW. Adverse outcomes after total and unicompartmental knee replacement in 101,330 matched patients: a study of data from the National Joint Registry for England and Wales. Lancet. 2014;384(9952):1437-1445. doi: 10.1016/S0140-6736(14)60419-0.
- Riddle DL, Jiranek WA, McGlynn FJ. Yearly incidence of unicompartmental knee arthroplasty in the United States. J Arthroplast. 2008;23(3):408-412. doi: 10.1016/j.arth.2007.04.012.
- Argenson JN, Blanc G, Aubaniac JM, Parratte S. Modern unicompartmental knee arthroplasty with cement: a concise follow-up, at a mean of twenty years, of a previous report. J Bone Joint Surg, (Am). 2013;95(10):905-909. doi: 10.2106/JBJS.L.00963.
- Koskinen E, Eskelinen A, Paavolainen P, Pulkkinen P, Remes V. Comparison of survival and cost-effectiveness between unicondylar arthroplasty and total knee arthroplasty in patients with primary osteoarthritis: a follow-up study of 50,493 knee replacements from the Finnish Arthroplasty Register. Acta Orthop. 2008;79(4):499-507. doi: 10.1080/17453670710015490.
- Knutson K, Lewold S, Robertsson O, Lidgren L. The Swedish knee arthroplasty register. A nation-wide study of 30,003 knees 1976-1992. Acta Orthop Scand. 1994;65(4):375-386. doi: 10.3109/17453679408995475.
- Kozinn SC, Scott R. Unicondylar knee arthroplasty. J Bone Joint Surg, (Am). 1989;71(1):145-150. doi: 10.2106/00004623-198971010-00023.
- Pennington DW. Unicompartmental knee arthroplasty in patients sixty years of age or younger. J Bone Joint Surg, (Am). 2003;85-A(10):1968-1973. doi: 10.2106/00004623-200310000-00016.
- Biswas D, Van Thiel GS, Wetters NG, Pack BJ, Berger RA, Della Valle CJ. Medial unicompartmental knee arthroplasty in patients less than 55 years old: minimum of two years of follow-up. J Arthroplast. 2014;29(1):101-105. doi: 10.1016/j.arth.2013.04.046.
- Murray DW, Pandit H, Weston-Simons JS, et al. Does body mass index affect the outcome of unicompartmental knee replacement? Knee. 2013;20(6):461-465. doi: 10.1016/j.knee.2012.09.017.
- Kang SN, Smith TO, Sprenger De Rover WB, Walton NP. Pre-operative patellofemoral degenerative changes do not affect the outcome after medial Oxford unicompartmental knee replacement: a report from an independent centre. J Bone Joint Surg Br. 2011;93(4):476-478. doi: 10.1302/0301-620X.93B4.25562.
- Pandit H, Jenkins C, Gill HS, et al. Unnecessary contraindications for mobile-bearing unicompartmental knee replacement. J Bone Joint Surg Br. 2011;93(5):622-628. doi: 10.1302/0301-620X.93B5.26214.
- Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005;87(7):1487-1497. doi: 10.2106/JBJS.D.02441.
- Kurtz SM, Ong KL, Schmier J, et al. Future clinical and economic impact of revision total hip and knee arthroplasty. J Bone Joint Surg, (Am). 2007;89(Suppl. 3):144-151. doi: 10.2106/JBJS.G.00587.
- Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg. 2010;19(8):1115-1120. doi: 10.1016/j.jse.2010.02.009.
- Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg, (Am). 2007;89(4):780-785. doi: 10.2106/JBJS.F.00222.
- Kamath AF, Ong KL, Lau E, et al. Quantifying the burden of revision total joint arthroplasty for periprosthetic infection. J Arthroplast. 2015;30(9):1492-1497. doi: 10.1016/j.arth.2015.03.035.
- Bolognesi MP, Greiner MA, Attarian DE, et al. Unicompartmental knee arthroplasty and total knee arthroplasty among Medicare beneficiaries, 2000 to 2009. J Bone Joint Surg, (Am). 2013;95(22):e174. doi: 10.2106/JBJS.L.00652.
- Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373-383. doi: 10.1016/0021-9681(87)90171-8.
- Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. J Bone Joint Surg, (Am). 2014;96(8):624-630. doi: 10.2106/JBJS.M.00285.
- Leskinen J, Eskelinen A, Huhtala H, Paavolainen P, Remes V. The incidence of knee arthroplasty for primary osteoarthritis grows rapidly among baby boomers: a population-based study in Finland. Arthritis Rheum. 2012;64(2):423-428. doi: 10.1002/art.33367.
- Cartier P, Sanouiller JL, Grelsamer RP. Unicompartmental knee arthroplasty surgery. 10-year minimum follow-up period. J Arthroplast. 1996;11(7):782-788. doi: 10.1016/S0883-5403(96)80177-X.
- Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res. 2009;467(10):2606-2612. doi: 10.1007/s11999-009-0834-6.
- Singh JA, Lu X, Rosenthal GE, Ibrahim S, Cram P. Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national Medicare data. Ann Rheum Dis. 2014;73(12):2107-2115. doi: 10.1136/annrheumdis-2013-203494.
- Pierce TP, Elmallah RK, Lavernia CJ, et al. Racial disparities in lower extremity arthroplasty outcomes and use. Orthopedics. 2015;38(12): e1139-e1146. doi: 10.3928/01477447-20151123-05.
- Irgit K, Nelson CL. Defining racial and ethnic disparities in THA and TKA. Clin Orthop Relat Res. 2011;469(7):1817-1823. doi: 10.1007/s11999-011-1885-z.
ABSTRACT
Publications on the prevalence of unicompartmental knee arthroplasty in the United States using a single database may have underestimated the “true” number of cases performed, given that several unicondylar knee arthroplasty (UKA) patients are <65 years and have private insurance. The prevalence of UKA in elderly (≥65 years) and younger (<65 years) populations was evaluated using the 2002 to 2011 5% sample of the Medicare data (Part B) and the 2004 to June 2012 MarketScan Commercial and Medicare Supplemental databases, respectively. The prevalence of UKA was stratified by age, gender, census region, Charlson comorbidity index, Medicare buy-in status, and diagnosis. The annual rate of change in the UKA rate was examined using Poisson regression to evaluate temporal changes considering year as a covariate.
A total of 5235 and 23,310 UKA procedures were identified from the 5% Medicare and MarketScan databases, respectively. The rates of UKA generally increased until 2008, after which there was a decline. In both cohorts, gender and year of operation were found to be significantly associated with UKA rate. Analysis of data obtained over the past few years revealed that males 55 to 64 years, 65 to 69 years, and 70 to 74 years were the only age-gender groups whose UKA rates appeared to be trending upward.
From 2002 to 2011, the rate of UKAs performed in the United States has increased, and a significant proportion of the surgeries were performed in younger (<65 years) patients.
Continue to: Unicondylar knee arthroplasty...
Unicondylar knee arthroplasty (UKA) is an effective surgical treatment for symptomatic degenerative joint disease of a single compartment of the knee, providing improved functional outcomes compared with total knee arthroplasty (TKA).1-3 It has been estimated that the proportion of patients undergoing TKA, who meet the criteria for UKA, varies between 21% and 47%.4,5 However, it has been variably estimated that the usage of UKA ranges from 0% to 50% (mean, 8%) of all primary knee arthroplasties.5-8 It is believed that this discrepancy between the percentage of patients who meet indications for the surgery and those who receive it is associated with various factors, including surgeon training and experiences, diverse indications, economic factors, as well as acknowledgment of the reportedly higher revision rates of UKA than those of TKA in national joint registries.7,9-11
According to their classic article, Kozinn and Scott12 outlined the indications for UKA that, in their experience, led to the most successful outcomes, including age >60 years, weight <82 kg, low physical demand, localized arthritis with no full-thickness chondromalacia elsewhere in the joint, intact anterior cruciate ligament, minimal deformity, and flexion >90°. More recently, indications have been expanded to include younger and more active patients, higher body mass index, and some patterns of patellofemoral chondromalacia, with an increasing number of publications reporting successful clinical outcomes in these cohorts as well.13-17 Taken together, it is clear that the “classic” strict indications for UKA can be safely expanded, which have and will result in an increased number of these procedures being performed above and beyond that which might be predicted based on demographic trends alone.
A growing body of literature has been published on the prevalence and projections of orthopedic procedures in the United States.18-20 Several studies have focused their analysis on 1 of several large administrative databases, including the Nationwide Inpatient Sample, the 5% Medicare Part B database, and the National Hospital Discharge Survey.18,20-23 A concern with limiting an analysis of the prevalence of unicompartmental knee arthroplasty to these particular databases is that it may underestimate the “true” number of cases performed in the United States, given that several UKA patients are <65 years and have private insurance, and therefore, would not be captured statistically by a database that collects data on patients ≥65 years.
The purpose of this study was to quantify the current prevalence and epidemiology of UKA in the U.S. patient population. Our hypothesis was that the number of procedures and the procedural rate of UKA are increasing over time. Furthermore, this increase may be attributed to an increase in select age- or gender-based segments of the population. To test this hypothesis, we analyzed 2 separate large claims databases to capture patients over a spectrum of age and inclusive of both private and public payers, including the 5% Medicare Part B database (2002–2011) for patients ≥65 years and the MarketScan database (2004 to June 2011) for patients <65 years. Understanding the accurate trends in the use of UKA on a national scale is important for legislative bodies, healthcare administrators, and physicians.
MATERIALS AND METHODS
The 2002 to 2011 5% sample of the Medicare data (Part B) and the 2004 to June 2012 MarketScan Commercial and Medicare Supplemental databases were used to evaluate the prevalence of UKA in elderly (≥65 years) and younger (<65 years) populations, respectively. The UKA procedures were identified using the CPT code 27446.
The prevalence of UKA was stratified by age, gender, census region, Charlson Comorbidity Index, Medicare buy-in status, and diagnosis. The buy-in status is a proxy for the socioeconomic status as it reflects the state subsidizing the health insurance premium for the beneficiary. The Charlson Comorbidity Index is a composite score that has been used to assess the comorbidity level of a patient by taking into account the number and the severity of comorbid conditions.24 For the elderly population, the rate of UKA was subsequently evaluated based on the number of beneficiaries for that particular age-gender group and year in both databases. Poisson regression was used to evaluate the annual rate of change in the UKA rate for assessing temporal changes considering year as a covariate. Age and gender, as well as 2-way interaction terms for age, gender, and year, were also considered as covariates.
Continue to: RESULTS...
RESULTS
For the time periods analyzed, a total of 5235 and 23,310 UKA procedures were identified from the 5% Medicare and MarketScan databases, respectively. A peak in the prevalence appeared around 2008 for the elderly population and in 2009 for the younger population (Figure 1). When normalized by the size of the population segment, the rate of UKA was found to be approximately 5 times greater in the elderly population, increasing from 369 in 2002 to 639 in 2008, but plateauing to 561 in 2011. Extrapolating to the 100% Medicare population, these numbers increased to 7380, 12,780, and 11,220, respectively. Temporal changes in the UKA rate were significant, increasing from 24.5 UKAs per 100,000 persons in 2002 to 43.1 UKAs in 2008, followed by a decline to 36.5 in 2011 (P < .0001) (Figure 2). The rates of UKA generally increased from 2002 to 2008 for both males and females in the Medicare cohort; however, the rates of UKA in female patients continuously declined from 2008 onward, whereas the UKA rates in male patients decreased in 2009, followed by an increase in 2010 and 2011 (Figure 2). For the younger population, there was a slight increase in the rate of UKA from 2004 to approximately 2009, after which the rates for both males and females remained relatively steady. When put in the context of the prevalence of TKA, the prevalence of UKA fluctuated during the same time period. In the Medicare population, the prevalence of UKA ranged from 4.3% (2005) to 5.9% (2008) of the TKA prevalence between 2002 and 2011. In the younger MarketScan population, the prevalence of UKA ranged from 6.7% (2005) to 8.9% (2008) between 2004 and June 2012.
The UKA rate differed significantly according to gender (P = .0209), with higher rates for males. Although there were no age-related differences (P = .3723), age–gender interactions were found to be significant (P < .0001). For males, the largest rate of UKA in the most recent year of data was observed in the 70- to 74-year-old group, followed by the 75- to 79- and the 65- to 69-year-old groups (Figure 3). For females, those in the 65- to 69- and the 70- to 74-year-old groups had the highest rate of UKA. In the younger cohort, there were increases in the UKA rates since 2004. These rates appeared to be relatively stable from the 2008 or 2009 period onward, except for females 55–64 years, which demonstrated a steady decline since 2008. Analysis of data obtained over the past few years showed that males 55–64, 65–69, and 70–74 years were the only age–gender groups whose UKA rates appeared to be trending upward.
The vast majority of elderly UKA patients were white (95.5%), and when stratified by census region, the highest proportion of UKA procedures was observed in the South and the Midwest (Figure 4). Furthermore, among patients <65 years, 64.2% had a Charlson score of 0 compared to 40.8% in the elderly group (Figure 5). For the Medicare population, based on their receipt of state subsidies for their insurance premiums, 5.1% of patients were of lower socioeconomic status. Osteoarthritis was diagnosed in 99.4% and 97.3% of the MarketScan and Medicare cohorts, respectively.
In the Medicare cohort, gender (P = .0209) and year of operation (P < .0001) were found to be significantly associated with the rate of UKA, along with age-gender (P < .0001) and gender-year (P = .0202) interaction terms. In the MarketScan cohort, age (P = .0173), gender (P = .0017), and year of operation (P = .0002) were found to be significantly associated with UKA rate. Two-way interactions between age-gender (P = .0018), age–year (P = .0207), and gender-year (P = .0017) were also found to be statistically significant factors.
Continue to: DISCUSSION...
DISCUSSION
The results of our study indicate that between 2002 and 2011, a steadily increasing number of UKA procedures was performed in the United States, and a significant proportion of the surgeries was performed on patients <65 years. Without the MarketScan database data, we would have missed more than 23,000 UKA cases performed during this 10-year time period. This finding validates our research methodology that incorporated data on privately insured younger (<65 years) patients, which is something that has not been done when examining the epidemiology of UKA.
To our knowledge, there are only 2 other publications attempting to quantify the incidence of UKA procedures performed in the United States. Bolognesi and colleagues23 used the Medicare 5% sample to assess trends in the use of knee arthroplasty from 2000 to 2009. The authors reported that a total of 68,603 patients underwent unilateral total knee arthroplasty (n = 65,505) or unicompartmental knee arthroplasty (n = 3098) over this 10-year time period. Given that there is substantial overlap of our time periods, it is not surprising that our Medicare numbers are similar (3098 vs 5235). In their study, the use of TKA increased 1.7-fold, whereas the use of UKA increased 6.2-fold23. In our analysis of the Medicare (2011 vs 2002) and MarketScan (2011 vs 2004) databases, there was a 1.3-fold and a 3.4-fold increase in the number of TKAs performed. Concomitantly, the use of UKA increased 1.5-fold and 2.8-fold, respectively, in these databases over the same time periods. The reason for the slight discrepancy in the numbers may be attributable to the peak occurring in 2008. The other publication on the subject by Riddle and colleagues8 focused on the time period 1998 to 2005 and used implant manufacturer’s sales data cross-referenced to a database of 44 hospitals to derive their national estimates. Using their unique methodology, the authors calculated an incidence of UKA, ranging from 6570 implants in 1998 to 44,990 in 2005. They reported that UKA use during the study period increased by 3 times the rate of TKA in the United States, with an average yearly percentage increase in the number of UKA procedures of 32.5% compared to 9.4% for TKA procedures. It is difficult to account for the discrepancy in the number of UKAs performed reported between our current study and that of Riddle and colleagues;8 however, the fact that the authors used implant manufacturer’s individual sales numbers may indicate that a portion of UKA patients was not captured in either the Medicare 5% or the MarketScan database. Nonetheless, in our analysis, the annual increase in the number of UKA procedures performed during the time periods studied averaged 5.8% in the older population and 25.4% in the younger population compared to the increase in the number of TKA procedures, which averaged 3.6% and 33.9% in the older and younger populations, respectively. In addition, in our study, the percentage of UKAs performed relative to the number of TKAs during the time intervals studied varied from a low of 4.3% to a high of 5.9% in the older population and from a low of 6.7% to a high of 8.9% in the younger population.
During the 10-year period of this study, a general upward trend appeared in the total number of unicompartmental knee arthroplasties performed in both the Medicare and the MarketScan databases. The rate at which the procedure was performed increased in the Medicare population from 24.5 to 36.5 (per 100,000 persons) over a 10-year time period and in the MarketScan cohort from 5.9 to 7.4 (per 100,000 persons) over an 8.5-year time period. This indicates both a larger absolute and a relative rate increase in UKA procedures in the elderly population. Around 2008 and 2009, the data showed a slight dip in the rate of UKA in the Medicare population and a plateau in the rate in the MarketScan database. Although this may be a spurious finding in the data that would be smoothed out with a longer time period investigated, it is interesting that this finding coincided with a national economic downturn. Although it might be expected that macroeconomics may affect the utilization of elective surgery such as total joint replacement, Kurtz and colleagues25 investigated this particular question and found that neither the economic downturns of 2001 or those of 2008 and 2009 had a significant impact on the incidence of total joint replacement surgeries.
Incorporation of the MarketScan database data indicated that a significant proportion of patients undergoing UKA were <65 years and that there was a slight but increasing rate of procedures performed on this age cohort over the past decade. A similar finding has been reported in the Finnish Arthroplasty Registry. Leskinen and colleagues26 reported that the incidence of UKAs among individuals 30 to 59 years increased from 0.2 (per 100,000 persons) to 10 (per 100,000 persons) from 1980 to 2006 and that most of the increase occurred among patients 50 to 59 years. The fact that younger age is no longer observed as a relative contraindication to this procedure is supported by several clinical investigations. Cartier and colleagues27 reported 93% survival at 10 years in patients with a mean age of 65 years, but included patients as young as 28 years, claiming that the results for younger patients were no worse than those for older patients in the series. Pandit and colleagues17 compared the results of 245 young patients (<60 years) to those of 755 older patients (>60 years) and found a survival rate of 97% at 10 years, with no significant difference in mean functional outcomes, failure rate, or survival between the groups at >5 years of follow-up. Given that patients <65 years now account for approximately half of the TKAs performed each year, with the greatest increase in volume among patients between 45 and 54, it is clear that investigations on the epidemiology of UKA must take into account this increasingly relevant younger patient cohort.28
Continue to: Our data indicate...
Our data indicate that only approximately 5% of UKA patients were non-white and another 5% were from lower socioeconomic status. These findings have been observed in multiple other studies looking at the epidemiology of total joint replacement in the United States.29 Bolognesi and colleagues23 reported that although “non-white race” patients made up 12% of the general Medicare sample they were analyzing, these patients accounted for only 5% and 3% of the total knee arthroplasty and unicompartmental knee arthroplasty populations, respectively. Although it is beyond the scope of this paper to delve into the reasons for this discrepancy, it may be related to differences in access to care, healthcare literacy, and trust of patients in the healthcare system.30,31
Our study, like all those based on administrative claims, has several notable inherent limitations. Coding inaccuracies as well as the potential for systematic bias (eg, underreporting) may affect the accuracy of our results. Although the MarketScan Commercial Research Database (Truven Health Analytics) includes nationally representative information for >180 million patients covered with private insurance, it is possible that we have missed some patients who underwent UKA during the time period investigated. However, we feel that the number missed is probably small and does not affect our conclusions in any meaningful manner.
CONCLUSION
This novel analysis of 2 separate administrative claims databases, which more accurately captures all patients undergoing UKA, indicates that there has been a steady increase in the rate of the procedure over the past decade and that a significant proportion of the surgeries were performed in younger (<65 years) patients. Understanding the accurate trends in the use of UKA on a national scale is important for legislative bodies, healthcare administrators, as well as physicians. Furthermore, given the increasing rates of UKA in patients <65 years old, and the increased burden on implants for withstanding increased activities and repetitive loads, it remains imperative to strive to optimize materials, implant designs, and surgical techniques to enhance implant durability.
ABSTRACT
Publications on the prevalence of unicompartmental knee arthroplasty in the United States using a single database may have underestimated the “true” number of cases performed, given that several unicondylar knee arthroplasty (UKA) patients are <65 years and have private insurance. The prevalence of UKA in elderly (≥65 years) and younger (<65 years) populations was evaluated using the 2002 to 2011 5% sample of the Medicare data (Part B) and the 2004 to June 2012 MarketScan Commercial and Medicare Supplemental databases, respectively. The prevalence of UKA was stratified by age, gender, census region, Charlson comorbidity index, Medicare buy-in status, and diagnosis. The annual rate of change in the UKA rate was examined using Poisson regression to evaluate temporal changes considering year as a covariate.
A total of 5235 and 23,310 UKA procedures were identified from the 5% Medicare and MarketScan databases, respectively. The rates of UKA generally increased until 2008, after which there was a decline. In both cohorts, gender and year of operation were found to be significantly associated with UKA rate. Analysis of data obtained over the past few years revealed that males 55 to 64 years, 65 to 69 years, and 70 to 74 years were the only age-gender groups whose UKA rates appeared to be trending upward.
From 2002 to 2011, the rate of UKAs performed in the United States has increased, and a significant proportion of the surgeries were performed in younger (<65 years) patients.
Continue to: Unicondylar knee arthroplasty...
Unicondylar knee arthroplasty (UKA) is an effective surgical treatment for symptomatic degenerative joint disease of a single compartment of the knee, providing improved functional outcomes compared with total knee arthroplasty (TKA).1-3 It has been estimated that the proportion of patients undergoing TKA, who meet the criteria for UKA, varies between 21% and 47%.4,5 However, it has been variably estimated that the usage of UKA ranges from 0% to 50% (mean, 8%) of all primary knee arthroplasties.5-8 It is believed that this discrepancy between the percentage of patients who meet indications for the surgery and those who receive it is associated with various factors, including surgeon training and experiences, diverse indications, economic factors, as well as acknowledgment of the reportedly higher revision rates of UKA than those of TKA in national joint registries.7,9-11
According to their classic article, Kozinn and Scott12 outlined the indications for UKA that, in their experience, led to the most successful outcomes, including age >60 years, weight <82 kg, low physical demand, localized arthritis with no full-thickness chondromalacia elsewhere in the joint, intact anterior cruciate ligament, minimal deformity, and flexion >90°. More recently, indications have been expanded to include younger and more active patients, higher body mass index, and some patterns of patellofemoral chondromalacia, with an increasing number of publications reporting successful clinical outcomes in these cohorts as well.13-17 Taken together, it is clear that the “classic” strict indications for UKA can be safely expanded, which have and will result in an increased number of these procedures being performed above and beyond that which might be predicted based on demographic trends alone.
A growing body of literature has been published on the prevalence and projections of orthopedic procedures in the United States.18-20 Several studies have focused their analysis on 1 of several large administrative databases, including the Nationwide Inpatient Sample, the 5% Medicare Part B database, and the National Hospital Discharge Survey.18,20-23 A concern with limiting an analysis of the prevalence of unicompartmental knee arthroplasty to these particular databases is that it may underestimate the “true” number of cases performed in the United States, given that several UKA patients are <65 years and have private insurance, and therefore, would not be captured statistically by a database that collects data on patients ≥65 years.
The purpose of this study was to quantify the current prevalence and epidemiology of UKA in the U.S. patient population. Our hypothesis was that the number of procedures and the procedural rate of UKA are increasing over time. Furthermore, this increase may be attributed to an increase in select age- or gender-based segments of the population. To test this hypothesis, we analyzed 2 separate large claims databases to capture patients over a spectrum of age and inclusive of both private and public payers, including the 5% Medicare Part B database (2002–2011) for patients ≥65 years and the MarketScan database (2004 to June 2011) for patients <65 years. Understanding the accurate trends in the use of UKA on a national scale is important for legislative bodies, healthcare administrators, and physicians.
MATERIALS AND METHODS
The 2002 to 2011 5% sample of the Medicare data (Part B) and the 2004 to June 2012 MarketScan Commercial and Medicare Supplemental databases were used to evaluate the prevalence of UKA in elderly (≥65 years) and younger (<65 years) populations, respectively. The UKA procedures were identified using the CPT code 27446.
The prevalence of UKA was stratified by age, gender, census region, Charlson Comorbidity Index, Medicare buy-in status, and diagnosis. The buy-in status is a proxy for the socioeconomic status as it reflects the state subsidizing the health insurance premium for the beneficiary. The Charlson Comorbidity Index is a composite score that has been used to assess the comorbidity level of a patient by taking into account the number and the severity of comorbid conditions.24 For the elderly population, the rate of UKA was subsequently evaluated based on the number of beneficiaries for that particular age-gender group and year in both databases. Poisson regression was used to evaluate the annual rate of change in the UKA rate for assessing temporal changes considering year as a covariate. Age and gender, as well as 2-way interaction terms for age, gender, and year, were also considered as covariates.
Continue to: RESULTS...
RESULTS
For the time periods analyzed, a total of 5235 and 23,310 UKA procedures were identified from the 5% Medicare and MarketScan databases, respectively. A peak in the prevalence appeared around 2008 for the elderly population and in 2009 for the younger population (Figure 1). When normalized by the size of the population segment, the rate of UKA was found to be approximately 5 times greater in the elderly population, increasing from 369 in 2002 to 639 in 2008, but plateauing to 561 in 2011. Extrapolating to the 100% Medicare population, these numbers increased to 7380, 12,780, and 11,220, respectively. Temporal changes in the UKA rate were significant, increasing from 24.5 UKAs per 100,000 persons in 2002 to 43.1 UKAs in 2008, followed by a decline to 36.5 in 2011 (P < .0001) (Figure 2). The rates of UKA generally increased from 2002 to 2008 for both males and females in the Medicare cohort; however, the rates of UKA in female patients continuously declined from 2008 onward, whereas the UKA rates in male patients decreased in 2009, followed by an increase in 2010 and 2011 (Figure 2). For the younger population, there was a slight increase in the rate of UKA from 2004 to approximately 2009, after which the rates for both males and females remained relatively steady. When put in the context of the prevalence of TKA, the prevalence of UKA fluctuated during the same time period. In the Medicare population, the prevalence of UKA ranged from 4.3% (2005) to 5.9% (2008) of the TKA prevalence between 2002 and 2011. In the younger MarketScan population, the prevalence of UKA ranged from 6.7% (2005) to 8.9% (2008) between 2004 and June 2012.
The UKA rate differed significantly according to gender (P = .0209), with higher rates for males. Although there were no age-related differences (P = .3723), age–gender interactions were found to be significant (P < .0001). For males, the largest rate of UKA in the most recent year of data was observed in the 70- to 74-year-old group, followed by the 75- to 79- and the 65- to 69-year-old groups (Figure 3). For females, those in the 65- to 69- and the 70- to 74-year-old groups had the highest rate of UKA. In the younger cohort, there were increases in the UKA rates since 2004. These rates appeared to be relatively stable from the 2008 or 2009 period onward, except for females 55–64 years, which demonstrated a steady decline since 2008. Analysis of data obtained over the past few years showed that males 55–64, 65–69, and 70–74 years were the only age–gender groups whose UKA rates appeared to be trending upward.
The vast majority of elderly UKA patients were white (95.5%), and when stratified by census region, the highest proportion of UKA procedures was observed in the South and the Midwest (Figure 4). Furthermore, among patients <65 years, 64.2% had a Charlson score of 0 compared to 40.8% in the elderly group (Figure 5). For the Medicare population, based on their receipt of state subsidies for their insurance premiums, 5.1% of patients were of lower socioeconomic status. Osteoarthritis was diagnosed in 99.4% and 97.3% of the MarketScan and Medicare cohorts, respectively.
In the Medicare cohort, gender (P = .0209) and year of operation (P < .0001) were found to be significantly associated with the rate of UKA, along with age-gender (P < .0001) and gender-year (P = .0202) interaction terms. In the MarketScan cohort, age (P = .0173), gender (P = .0017), and year of operation (P = .0002) were found to be significantly associated with UKA rate. Two-way interactions between age-gender (P = .0018), age–year (P = .0207), and gender-year (P = .0017) were also found to be statistically significant factors.
Continue to: DISCUSSION...
DISCUSSION
The results of our study indicate that between 2002 and 2011, a steadily increasing number of UKA procedures was performed in the United States, and a significant proportion of the surgeries was performed on patients <65 years. Without the MarketScan database data, we would have missed more than 23,000 UKA cases performed during this 10-year time period. This finding validates our research methodology that incorporated data on privately insured younger (<65 years) patients, which is something that has not been done when examining the epidemiology of UKA.
To our knowledge, there are only 2 other publications attempting to quantify the incidence of UKA procedures performed in the United States. Bolognesi and colleagues23 used the Medicare 5% sample to assess trends in the use of knee arthroplasty from 2000 to 2009. The authors reported that a total of 68,603 patients underwent unilateral total knee arthroplasty (n = 65,505) or unicompartmental knee arthroplasty (n = 3098) over this 10-year time period. Given that there is substantial overlap of our time periods, it is not surprising that our Medicare numbers are similar (3098 vs 5235). In their study, the use of TKA increased 1.7-fold, whereas the use of UKA increased 6.2-fold23. In our analysis of the Medicare (2011 vs 2002) and MarketScan (2011 vs 2004) databases, there was a 1.3-fold and a 3.4-fold increase in the number of TKAs performed. Concomitantly, the use of UKA increased 1.5-fold and 2.8-fold, respectively, in these databases over the same time periods. The reason for the slight discrepancy in the numbers may be attributable to the peak occurring in 2008. The other publication on the subject by Riddle and colleagues8 focused on the time period 1998 to 2005 and used implant manufacturer’s sales data cross-referenced to a database of 44 hospitals to derive their national estimates. Using their unique methodology, the authors calculated an incidence of UKA, ranging from 6570 implants in 1998 to 44,990 in 2005. They reported that UKA use during the study period increased by 3 times the rate of TKA in the United States, with an average yearly percentage increase in the number of UKA procedures of 32.5% compared to 9.4% for TKA procedures. It is difficult to account for the discrepancy in the number of UKAs performed reported between our current study and that of Riddle and colleagues;8 however, the fact that the authors used implant manufacturer’s individual sales numbers may indicate that a portion of UKA patients was not captured in either the Medicare 5% or the MarketScan database. Nonetheless, in our analysis, the annual increase in the number of UKA procedures performed during the time periods studied averaged 5.8% in the older population and 25.4% in the younger population compared to the increase in the number of TKA procedures, which averaged 3.6% and 33.9% in the older and younger populations, respectively. In addition, in our study, the percentage of UKAs performed relative to the number of TKAs during the time intervals studied varied from a low of 4.3% to a high of 5.9% in the older population and from a low of 6.7% to a high of 8.9% in the younger population.
During the 10-year period of this study, a general upward trend appeared in the total number of unicompartmental knee arthroplasties performed in both the Medicare and the MarketScan databases. The rate at which the procedure was performed increased in the Medicare population from 24.5 to 36.5 (per 100,000 persons) over a 10-year time period and in the MarketScan cohort from 5.9 to 7.4 (per 100,000 persons) over an 8.5-year time period. This indicates both a larger absolute and a relative rate increase in UKA procedures in the elderly population. Around 2008 and 2009, the data showed a slight dip in the rate of UKA in the Medicare population and a plateau in the rate in the MarketScan database. Although this may be a spurious finding in the data that would be smoothed out with a longer time period investigated, it is interesting that this finding coincided with a national economic downturn. Although it might be expected that macroeconomics may affect the utilization of elective surgery such as total joint replacement, Kurtz and colleagues25 investigated this particular question and found that neither the economic downturns of 2001 or those of 2008 and 2009 had a significant impact on the incidence of total joint replacement surgeries.
Incorporation of the MarketScan database data indicated that a significant proportion of patients undergoing UKA were <65 years and that there was a slight but increasing rate of procedures performed on this age cohort over the past decade. A similar finding has been reported in the Finnish Arthroplasty Registry. Leskinen and colleagues26 reported that the incidence of UKAs among individuals 30 to 59 years increased from 0.2 (per 100,000 persons) to 10 (per 100,000 persons) from 1980 to 2006 and that most of the increase occurred among patients 50 to 59 years. The fact that younger age is no longer observed as a relative contraindication to this procedure is supported by several clinical investigations. Cartier and colleagues27 reported 93% survival at 10 years in patients with a mean age of 65 years, but included patients as young as 28 years, claiming that the results for younger patients were no worse than those for older patients in the series. Pandit and colleagues17 compared the results of 245 young patients (<60 years) to those of 755 older patients (>60 years) and found a survival rate of 97% at 10 years, with no significant difference in mean functional outcomes, failure rate, or survival between the groups at >5 years of follow-up. Given that patients <65 years now account for approximately half of the TKAs performed each year, with the greatest increase in volume among patients between 45 and 54, it is clear that investigations on the epidemiology of UKA must take into account this increasingly relevant younger patient cohort.28
Continue to: Our data indicate...
Our data indicate that only approximately 5% of UKA patients were non-white and another 5% were from lower socioeconomic status. These findings have been observed in multiple other studies looking at the epidemiology of total joint replacement in the United States.29 Bolognesi and colleagues23 reported that although “non-white race” patients made up 12% of the general Medicare sample they were analyzing, these patients accounted for only 5% and 3% of the total knee arthroplasty and unicompartmental knee arthroplasty populations, respectively. Although it is beyond the scope of this paper to delve into the reasons for this discrepancy, it may be related to differences in access to care, healthcare literacy, and trust of patients in the healthcare system.30,31
Our study, like all those based on administrative claims, has several notable inherent limitations. Coding inaccuracies as well as the potential for systematic bias (eg, underreporting) may affect the accuracy of our results. Although the MarketScan Commercial Research Database (Truven Health Analytics) includes nationally representative information for >180 million patients covered with private insurance, it is possible that we have missed some patients who underwent UKA during the time period investigated. However, we feel that the number missed is probably small and does not affect our conclusions in any meaningful manner.
CONCLUSION
This novel analysis of 2 separate administrative claims databases, which more accurately captures all patients undergoing UKA, indicates that there has been a steady increase in the rate of the procedure over the past decade and that a significant proportion of the surgeries were performed in younger (<65 years) patients. Understanding the accurate trends in the use of UKA on a national scale is important for legislative bodies, healthcare administrators, as well as physicians. Furthermore, given the increasing rates of UKA in patients <65 years old, and the increased burden on implants for withstanding increased activities and repetitive loads, it remains imperative to strive to optimize materials, implant designs, and surgical techniques to enhance implant durability.
- Hopper GP, Leach WJ. Participation in sporting activities following knee replacement: total versus unicompartmental. Knee Surg Sports Traumatol Arthrosc. 2008;16(10):973-979. doi: 10.1007/s00167-008-0596-9.
- Lygre SH, Espehaug B, Havelin LI, Furnes O, Vollset SE. Pain and function in patients after primary unicompartmental and total knee arthroplasty. J Bone Joint Surg, (Am). 2010;92(18):2890-2897. doi: 10.2106/JBJS.I.00917.
- Liddle AD, Pandit H, Judge A, Murray DW. Patient-reported outcomes after total and unicompartmental knee arthroplasty: a study of 14,076 matched patients from the National Joint Registry for England and Wales. Bone Joint J. 2015;97-B(6):793-801. doi: 10.1302/0301-620X.97B6.35155.
- Arno S, Maffei D, Walker PS, Schwarzkopf R, Desai P, Steiner GC. Retrospective analysis of total knee arthroplasty cases for visual, histological, and clinical eligibility of unicompartmental knee arthroplasties. J Arthroplast. 2011;26(8):1396-1403. doi: 10.1016/j.arth.2010.12.023.
- Willis-Owen CA, Brust K, Alsop H, Miraldo M, Cobb JP. Unicondylar knee arthroplasty in the UK National Health Service: an analysis of candidacy, outcome and cost efficacy. Knee. 2009;16(6):473-478. doi: 10.1016/j.knee.2009.04.006.
- Murray DW, Liddle AD, Dodd CA, Pandit H. Unicompartmental knee arthroplasty: is the glass half full or half empty? Bone Joint J. 2015;97-B(10 Suppl. A):3-8. doi: 10.1302/0301-620X.97B10.36542.
- Liddle AD, Judge A, Pandit H, Murray DW. Adverse outcomes after total and unicompartmental knee replacement in 101,330 matched patients: a study of data from the National Joint Registry for England and Wales. Lancet. 2014;384(9952):1437-1445. doi: 10.1016/S0140-6736(14)60419-0.
- Riddle DL, Jiranek WA, McGlynn FJ. Yearly incidence of unicompartmental knee arthroplasty in the United States. J Arthroplast. 2008;23(3):408-412. doi: 10.1016/j.arth.2007.04.012.
- Argenson JN, Blanc G, Aubaniac JM, Parratte S. Modern unicompartmental knee arthroplasty with cement: a concise follow-up, at a mean of twenty years, of a previous report. J Bone Joint Surg, (Am). 2013;95(10):905-909. doi: 10.2106/JBJS.L.00963.
- Koskinen E, Eskelinen A, Paavolainen P, Pulkkinen P, Remes V. Comparison of survival and cost-effectiveness between unicondylar arthroplasty and total knee arthroplasty in patients with primary osteoarthritis: a follow-up study of 50,493 knee replacements from the Finnish Arthroplasty Register. Acta Orthop. 2008;79(4):499-507. doi: 10.1080/17453670710015490.
- Knutson K, Lewold S, Robertsson O, Lidgren L. The Swedish knee arthroplasty register. A nation-wide study of 30,003 knees 1976-1992. Acta Orthop Scand. 1994;65(4):375-386. doi: 10.3109/17453679408995475.
- Kozinn SC, Scott R. Unicondylar knee arthroplasty. J Bone Joint Surg, (Am). 1989;71(1):145-150. doi: 10.2106/00004623-198971010-00023.
- Pennington DW. Unicompartmental knee arthroplasty in patients sixty years of age or younger. J Bone Joint Surg, (Am). 2003;85-A(10):1968-1973. doi: 10.2106/00004623-200310000-00016.
- Biswas D, Van Thiel GS, Wetters NG, Pack BJ, Berger RA, Della Valle CJ. Medial unicompartmental knee arthroplasty in patients less than 55 years old: minimum of two years of follow-up. J Arthroplast. 2014;29(1):101-105. doi: 10.1016/j.arth.2013.04.046.
- Murray DW, Pandit H, Weston-Simons JS, et al. Does body mass index affect the outcome of unicompartmental knee replacement? Knee. 2013;20(6):461-465. doi: 10.1016/j.knee.2012.09.017.
- Kang SN, Smith TO, Sprenger De Rover WB, Walton NP. Pre-operative patellofemoral degenerative changes do not affect the outcome after medial Oxford unicompartmental knee replacement: a report from an independent centre. J Bone Joint Surg Br. 2011;93(4):476-478. doi: 10.1302/0301-620X.93B4.25562.
- Pandit H, Jenkins C, Gill HS, et al. Unnecessary contraindications for mobile-bearing unicompartmental knee replacement. J Bone Joint Surg Br. 2011;93(5):622-628. doi: 10.1302/0301-620X.93B5.26214.
- Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005;87(7):1487-1497. doi: 10.2106/JBJS.D.02441.
- Kurtz SM, Ong KL, Schmier J, et al. Future clinical and economic impact of revision total hip and knee arthroplasty. J Bone Joint Surg, (Am). 2007;89(Suppl. 3):144-151. doi: 10.2106/JBJS.G.00587.
- Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg. 2010;19(8):1115-1120. doi: 10.1016/j.jse.2010.02.009.
- Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg, (Am). 2007;89(4):780-785. doi: 10.2106/JBJS.F.00222.
- Kamath AF, Ong KL, Lau E, et al. Quantifying the burden of revision total joint arthroplasty for periprosthetic infection. J Arthroplast. 2015;30(9):1492-1497. doi: 10.1016/j.arth.2015.03.035.
- Bolognesi MP, Greiner MA, Attarian DE, et al. Unicompartmental knee arthroplasty and total knee arthroplasty among Medicare beneficiaries, 2000 to 2009. J Bone Joint Surg, (Am). 2013;95(22):e174. doi: 10.2106/JBJS.L.00652.
- Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373-383. doi: 10.1016/0021-9681(87)90171-8.
- Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. J Bone Joint Surg, (Am). 2014;96(8):624-630. doi: 10.2106/JBJS.M.00285.
- Leskinen J, Eskelinen A, Huhtala H, Paavolainen P, Remes V. The incidence of knee arthroplasty for primary osteoarthritis grows rapidly among baby boomers: a population-based study in Finland. Arthritis Rheum. 2012;64(2):423-428. doi: 10.1002/art.33367.
- Cartier P, Sanouiller JL, Grelsamer RP. Unicompartmental knee arthroplasty surgery. 10-year minimum follow-up period. J Arthroplast. 1996;11(7):782-788. doi: 10.1016/S0883-5403(96)80177-X.
- Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res. 2009;467(10):2606-2612. doi: 10.1007/s11999-009-0834-6.
- Singh JA, Lu X, Rosenthal GE, Ibrahim S, Cram P. Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national Medicare data. Ann Rheum Dis. 2014;73(12):2107-2115. doi: 10.1136/annrheumdis-2013-203494.
- Pierce TP, Elmallah RK, Lavernia CJ, et al. Racial disparities in lower extremity arthroplasty outcomes and use. Orthopedics. 2015;38(12): e1139-e1146. doi: 10.3928/01477447-20151123-05.
- Irgit K, Nelson CL. Defining racial and ethnic disparities in THA and TKA. Clin Orthop Relat Res. 2011;469(7):1817-1823. doi: 10.1007/s11999-011-1885-z.
- Hopper GP, Leach WJ. Participation in sporting activities following knee replacement: total versus unicompartmental. Knee Surg Sports Traumatol Arthrosc. 2008;16(10):973-979. doi: 10.1007/s00167-008-0596-9.
- Lygre SH, Espehaug B, Havelin LI, Furnes O, Vollset SE. Pain and function in patients after primary unicompartmental and total knee arthroplasty. J Bone Joint Surg, (Am). 2010;92(18):2890-2897. doi: 10.2106/JBJS.I.00917.
- Liddle AD, Pandit H, Judge A, Murray DW. Patient-reported outcomes after total and unicompartmental knee arthroplasty: a study of 14,076 matched patients from the National Joint Registry for England and Wales. Bone Joint J. 2015;97-B(6):793-801. doi: 10.1302/0301-620X.97B6.35155.
- Arno S, Maffei D, Walker PS, Schwarzkopf R, Desai P, Steiner GC. Retrospective analysis of total knee arthroplasty cases for visual, histological, and clinical eligibility of unicompartmental knee arthroplasties. J Arthroplast. 2011;26(8):1396-1403. doi: 10.1016/j.arth.2010.12.023.
- Willis-Owen CA, Brust K, Alsop H, Miraldo M, Cobb JP. Unicondylar knee arthroplasty in the UK National Health Service: an analysis of candidacy, outcome and cost efficacy. Knee. 2009;16(6):473-478. doi: 10.1016/j.knee.2009.04.006.
- Murray DW, Liddle AD, Dodd CA, Pandit H. Unicompartmental knee arthroplasty: is the glass half full or half empty? Bone Joint J. 2015;97-B(10 Suppl. A):3-8. doi: 10.1302/0301-620X.97B10.36542.
- Liddle AD, Judge A, Pandit H, Murray DW. Adverse outcomes after total and unicompartmental knee replacement in 101,330 matched patients: a study of data from the National Joint Registry for England and Wales. Lancet. 2014;384(9952):1437-1445. doi: 10.1016/S0140-6736(14)60419-0.
- Riddle DL, Jiranek WA, McGlynn FJ. Yearly incidence of unicompartmental knee arthroplasty in the United States. J Arthroplast. 2008;23(3):408-412. doi: 10.1016/j.arth.2007.04.012.
- Argenson JN, Blanc G, Aubaniac JM, Parratte S. Modern unicompartmental knee arthroplasty with cement: a concise follow-up, at a mean of twenty years, of a previous report. J Bone Joint Surg, (Am). 2013;95(10):905-909. doi: 10.2106/JBJS.L.00963.
- Koskinen E, Eskelinen A, Paavolainen P, Pulkkinen P, Remes V. Comparison of survival and cost-effectiveness between unicondylar arthroplasty and total knee arthroplasty in patients with primary osteoarthritis: a follow-up study of 50,493 knee replacements from the Finnish Arthroplasty Register. Acta Orthop. 2008;79(4):499-507. doi: 10.1080/17453670710015490.
- Knutson K, Lewold S, Robertsson O, Lidgren L. The Swedish knee arthroplasty register. A nation-wide study of 30,003 knees 1976-1992. Acta Orthop Scand. 1994;65(4):375-386. doi: 10.3109/17453679408995475.
- Kozinn SC, Scott R. Unicondylar knee arthroplasty. J Bone Joint Surg, (Am). 1989;71(1):145-150. doi: 10.2106/00004623-198971010-00023.
- Pennington DW. Unicompartmental knee arthroplasty in patients sixty years of age or younger. J Bone Joint Surg, (Am). 2003;85-A(10):1968-1973. doi: 10.2106/00004623-200310000-00016.
- Biswas D, Van Thiel GS, Wetters NG, Pack BJ, Berger RA, Della Valle CJ. Medial unicompartmental knee arthroplasty in patients less than 55 years old: minimum of two years of follow-up. J Arthroplast. 2014;29(1):101-105. doi: 10.1016/j.arth.2013.04.046.
- Murray DW, Pandit H, Weston-Simons JS, et al. Does body mass index affect the outcome of unicompartmental knee replacement? Knee. 2013;20(6):461-465. doi: 10.1016/j.knee.2012.09.017.
- Kang SN, Smith TO, Sprenger De Rover WB, Walton NP. Pre-operative patellofemoral degenerative changes do not affect the outcome after medial Oxford unicompartmental knee replacement: a report from an independent centre. J Bone Joint Surg Br. 2011;93(4):476-478. doi: 10.1302/0301-620X.93B4.25562.
- Pandit H, Jenkins C, Gill HS, et al. Unnecessary contraindications for mobile-bearing unicompartmental knee replacement. J Bone Joint Surg Br. 2011;93(5):622-628. doi: 10.1302/0301-620X.93B5.26214.
- Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005;87(7):1487-1497. doi: 10.2106/JBJS.D.02441.
- Kurtz SM, Ong KL, Schmier J, et al. Future clinical and economic impact of revision total hip and knee arthroplasty. J Bone Joint Surg, (Am). 2007;89(Suppl. 3):144-151. doi: 10.2106/JBJS.G.00587.
- Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg. 2010;19(8):1115-1120. doi: 10.1016/j.jse.2010.02.009.
- Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg, (Am). 2007;89(4):780-785. doi: 10.2106/JBJS.F.00222.
- Kamath AF, Ong KL, Lau E, et al. Quantifying the burden of revision total joint arthroplasty for periprosthetic infection. J Arthroplast. 2015;30(9):1492-1497. doi: 10.1016/j.arth.2015.03.035.
- Bolognesi MP, Greiner MA, Attarian DE, et al. Unicompartmental knee arthroplasty and total knee arthroplasty among Medicare beneficiaries, 2000 to 2009. J Bone Joint Surg, (Am). 2013;95(22):e174. doi: 10.2106/JBJS.L.00652.
- Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373-383. doi: 10.1016/0021-9681(87)90171-8.
- Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. J Bone Joint Surg, (Am). 2014;96(8):624-630. doi: 10.2106/JBJS.M.00285.
- Leskinen J, Eskelinen A, Huhtala H, Paavolainen P, Remes V. The incidence of knee arthroplasty for primary osteoarthritis grows rapidly among baby boomers: a population-based study in Finland. Arthritis Rheum. 2012;64(2):423-428. doi: 10.1002/art.33367.
- Cartier P, Sanouiller JL, Grelsamer RP. Unicompartmental knee arthroplasty surgery. 10-year minimum follow-up period. J Arthroplast. 1996;11(7):782-788. doi: 10.1016/S0883-5403(96)80177-X.
- Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res. 2009;467(10):2606-2612. doi: 10.1007/s11999-009-0834-6.
- Singh JA, Lu X, Rosenthal GE, Ibrahim S, Cram P. Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national Medicare data. Ann Rheum Dis. 2014;73(12):2107-2115. doi: 10.1136/annrheumdis-2013-203494.
- Pierce TP, Elmallah RK, Lavernia CJ, et al. Racial disparities in lower extremity arthroplasty outcomes and use. Orthopedics. 2015;38(12): e1139-e1146. doi: 10.3928/01477447-20151123-05.
- Irgit K, Nelson CL. Defining racial and ethnic disparities in THA and TKA. Clin Orthop Relat Res. 2011;469(7):1817-1823. doi: 10.1007/s11999-011-1885-z.
TAKE-HOME POINTS
- Prior publications on prevalence of unicondylar knee arthroplasty (UKA) in the United States using a single database may have underestimated the “true” number of cases performed.
- For the time periods analyzed, a total of 5,235 and 23,310 UKA procedures were identified from the 5% Medicare and MarketScan databases, respectively.
- Rates of UKA generally increased until 2008, after which there was a decline through 2012.
- Gender and year of operation were found to be significantly associated with UKA rate.
- Males ages 55-64, 65-69, and 70-74 were the only age-gender groups whose UKA rates appear to be trending upward.
A Retrospective Analysis of the Modified Intervastus Approach
ABSTRACT
The subvastus (SV) approach is a well-known muscle- and tendon-sparing approach for total knee arthroplasty (TKA), which has been shown in some studies to provide better outcomes in the visual analog pain score (VAS), knee range of motion (ROM), straight-leg raise, as well as faster rehabilitation, compared with the standard medial parapatellar (MP) approach. We previously described a new knee replacement technique known as the modified intervastus (MIV) approach. The MIV approach is a muscle- and tendon-sparing approach that is extensile and simple to perform. It may be used in the majority of complex primary cases and revisions. Here we describe the surgical technique for performing the MIV approach and provide functional outcome measures. A total of 127 patients (mean age, 66.75 years) underwent TKA using the MIV approach with 1-year follow-up. Clinical outcomes were assessed by recording both a VAS and knee ROM preoperatively, and again at several postoperative time points when the length of time required to ambulate independently (without assistive devices) was also measured. The VAS decreased significantly from the preoperative period (3.69 ± 2.22) to postoperative day 1 (3.17 ± 1.97) (P < .05). Although knee ROM decreased 1 week after surgery, the ROM increased by 6 weeks after surgery compared with the preoperative ROM, and the trend continued over the 1-year follow-up. One-third (33%) of patients were able to walk independently (without assistive devices) at 2 weeks and 78% at 8 weeks. The MIV approach to the knee is a muscle- and tendon-sparing approach that offers advantages over the SV approach and may be used for complex primary and revision total knee cases.
Continue to: Total knee arthroplasty...
Total knee arthroplasty (TKA) is one of the most common orthopedic surgical procedures, with more than 600,000 TKAs performed annually in the United States, and by 2030 the number is expected to reach 3.48 million per year.1Several approaches have been described for total TKA, and the medial parapatellar (MP) approach to the knee is considered the workhorse of total knee replacements. It is an extensile approach that is easy to perform but may delay active knee extension and straight-leg raise after surgery.2 Alternative approaches such as the subvastus (SV) and midvastus approaches to the knee (Figure 1A) typically allow a more rapid straight-leg raise but may be more challenging to perform and time-consuming in morbidly obese patients, muscular patients, and patients with severe deformities.3
The intervastus approach (Figure 1A) described by Jojima4 and others utilizes the interval between the quadriceps tendon and vastus medialis. Although it is a simple approach to perform that is extensile, it is not considered tendon-sparing since the vastus medialis inserts onto the medial aspect of the quadriceps tendon (Figure 2).5 Therefore, dissecting through this interval, without elevation of the vastus medialis (Figure 3A), damages the quadriceps tendon, and strangulation of the muscle occurs with repair of the arthrotomy site (Figure 3B). This situation is even more likely in patients with a low-lying vastus medialis.6
The modified intervastus (MIV) approach described previously,7 may be used in the majority of patients undergoing TKA. The advantages of this approach include its extensile nature, similarities to an MP approach, and preservation of both the extensor mechanism and the vastus medialis, leading to a more rapid return to active knee extension than is traditionally observed.2,7 The approach is simple to perform, easy to close, and is compatible with more extensile approaches such as a quadriceps snip if required in revision scenarios.7 However, functional outcomes of the MIV approach have not been quantified. It is unknown whether these outcomes will offer any advantages compared with the SV approach. Therefore, the objective of this study was to measure functional outcomes of the MIV approach and to compare the results with those previously published for the SV approach. We hypothesized that using the MIV approach for TKA surgery would lead to early straight-leg raise and increase in knee range of motion (ROM) postoperatively.
SURGICAL TECHNIQUE
The MIV approach preserves the quadriceps tendon and vastus medialis.7 After exposure of the vastus medialis muscle, the interval between the quadriceps tendon and vastus medialis is identified (Figure 4). The fascia overlying the lateral edge of the vastus medialis is incised where it meets the quadriceps tendon (Figure 5). The muscle is then bluntly elevated off the underlying capsule just enough to allow for a capsular repair later (Figure 6). An arthrotomy is then performed from cephalad to caudal (Figure 7). This interval may be extended proximally between the vastus intermedius and vastus medialis to expose the distal femur if needed. The closure is performed by repairing the capsule with absorbable suture (Figure 8A), and the vastus medialis fascia is repaired back to the medial edge of the quadriceps tendon, restoring the anatomy (Figure 8B).
Continue to: PATIENTS AND METHODS...
PATIENTS AND METHODS
A retrospective review of functional outcomes after TKA using the MIV approach was conducted; the study was approved by the University of Illinois Institutional Review Board. A total of 127 patients of mean age 66.75 years (range, 48–86 years) with primary osteoarthritis of the knee who were indicated for a total knee replacement with 1-year follow-up were included. The patient demographics are shown in Table 1. All patients underwent TKA using the MIV approach described above by 2 experienced orthopedic surgeons at the same institution. Patients received spinal anesthesia and a periarticular pain block intraoperatively. A measured resection technique was used by 1 surgeon, and a gap-balancing technique by the other. Surgeon 1 used the Persona PS cemented knee system (Zimmer Biomet, and Surgeon 2 used the Sigma PS cemented knee system (Depuy). Patellar resurfacing was done in all cases. Patellar tracking was checked intraoperatively using the ‘no-touch’ technique, and the need for a lateral release was noted. Drains were removed on postoperative day 1. Oral opioids were given as needed. Intravenous antibiotics were continued for 24 hours. Oral anticoagulants were used for thromboembolism prophylaxis for 3 weeks. Patients were mobilized on the day of surgery with full weight-bearing under the supervision of an experienced physical therapist. Static and dynamic quadriceps exercises were started on the same day of surgery along with active knee ROM exercises. Pain score, extensor lag, ROM, walking ability, and complications were recorded in all patients.
Table 1. Patient Demographics
Total no. of patients | 127 | |
Gender | Male | 44 |
Female | 83 | |
Age (years) | Mean ± Standard deviation | 66.75 ± 9.12 |
Range | 48 – 86 | |
Weight (lb) | Mean ± Standard deviation | 218.38 ± 54.47 |
Range | 125 – 364 | |
BMI (kg/m2) | Mean ± Standard deviation | 34.10 ± 7.22 |
Range | 21.1 – 62.5 | |
The visual analog score (VAS) was obtained preoperatively and recorded on postoperative day 1. Patient walking distance with assistance was measured on the day of surgery, after surgery, and on the day of hospital discharge. Patients were assessed preoperatively and postoperatively at 1 week, 2 weeks, 6 weeks, 3 months, 6 months, and 1 year for knee ROM. A one-way ANOVA was conducted to compare the preoperative and postoperative day 1 VAS with significance set at P < .05 (OriginPro 2015, OriginLab Corporation). Differences in knee ROM between preoperative and postoperative follow-up periods (1 week, 2 weeks, 6 weeks, 3 months, 6 months, and 1 year) were identified using a 1-way ANOVA with a post hoc Tukey test. Significance was set at P < .05.
RESULTS
All patients were able to fully straight-leg raise and demonstrate functional knee ROM by postoperative day 1. The patella tracked centrally in all patients, and none required a lateral retinacular release. The majority of patients were discharged in the first 48 hours after surgery on oral narcotics. None required IV narcotics during their hospital stay or a blood transfusion. Two cases were complicated by severe knee skin blistering postoperatively due to a reaction to an adhesive dressing; one was complicated by skin necrosis leading to a flap reconstruction that became infected, requiring a 2-stage revision. A separate case had an acute postoperative infection that required irrigation and debridement with polyethylene exchange. After a 12-week course of antibiotics, the infection was eradicated. All patients reported a high satisfaction rate during their acute postoperative phase.
Postoperatively, all patients were able to walk on the day of surgery either independently or with some assistance. On the day of surgery, 10% of patients were able to walk >200 feet, and this increased to 65% of patients able to walk >200 feet on the day of discharge (compare Figure 9A and Figure 9B). Within 2 weeks of surgery, 30% of patients could walk independently (without assistive devices), and this number increased to 78% by 8 weeks after surgery (Figure 10).
Pain assessed using the VAS was lower on postoperative day 1 (3.17 ± 1.97) than the preoperative score (3.69 ± 2.22, P< .05). Overall, knee ROM significantly increased during the follow-up after surgery. Initially, the ROM decreased 1 week after surgery (90.82 ± 10.28) compared with preoperative ROM (101.04 ± 19.48, P < .001) (Figure 10). At 2 weeks after surgery, knee ROM returned to the preoperative value (100.70 ± 13.36). By 6 weeks after surgery, knee ROM was 17° greater than the preoperative ROM (118.45 ± 11.89, P < .001). Knee ROM remained stable at 3- and 6-month assessments, and showed further improvement by 1 year (126.62 ± 9.81, P < .001) compared with the preoperative state (Figure 10). The net improvement in knee ROM was 25° of increased knee flexion by 1 year.
Continue to: DISCUSSION...
DISCUSSION
TKA is a successful procedure that restores knee function with pain relief in osteoarthritis patients. The SV approach for TKA has better outcomes in terms of the VAS, ROM, straight-leg raise with faster rehabilitation compared with the standard MP approach;8–12 however, it can be challenging and time-consuming when used in morbidly obese and muscular patients.3 The SV approach can also increase the risk of complications such as patellar tendon avulsion or medial collateral injury because of the difficulty in exposure specifically for knees with limited ROM.13 Here we introduce the MIV approach as an alternative to the SV approach, overcoming most of these difficulties.
With the prevalence of morbid obesity and the market demand for minimally invasive techniques, we believe the MIV approach represents a good approach for surgeons since it is easy to perform, does not require specialized instrumentation, and is a reproducible approach even on the most complex deformities. The minimal time added to ensure blunt elevation of the vastus medialis muscle and an anatomic repair of the underlying knee capsule and vastus medialis fascia to the medial edge of the quadriceps tendon allows restoration of the anatomy and a robust double-layered watertight seal closure with no strangulation of soft tissues. We believe this reproducible muscle- and tendon-sparing approach that allows gentle, soft tissue handling even in the most complex primary total knee cases may lead to less soft tissue swelling, and therefore, less postoperative pain resulting in an accelerated recovery.
The pain level in this group of patients was reduced after the MIV approach as indicated by the VAS. The VAS was significantly decreased on postoperative day 1 compared with the VAS recorded preoperatively (P < .05), indicating patients felt less pain on the day after surgery. The average VAS on postoperative day 1 from other studies for SV approach ranged from 2.1 to 5,9,12,14–19 whereas our MIV approach value was 3.17. Periarticular blocks were available for this study group, and no peripheral nerve blocks were used. Some studies of the SV approach mention the use of peripheral nerve blocks, while others did not describe the method used for treatment or control of postoperative pain. The decreased reported pain levels and the observed increased knee ROM seen in the MIV and SV approach study groups might be attributable to the treatment of postoperative pain.
Patient ambulation also increased from the day of surgery to the day of discharge for the MIV approach. Only 10% of patients were able to walk with assistance >200 feet on the day of surgery; however, this percentage increased to 65% on the discharge day showing an excellent recovery of walking ability within 2 days of surgery. Mehta and colleagues20reported that 95% of patients undergoing subvastus/midvastus approaches could walk >10 blocks at 6 months follow-up. For the MIV approach, 78% of patients were able to walk independently within 8 weeks of surgery.
Continue to: The MIV approach shows improvement...
The MIV approach shows improvement in functional outcomes in terms of knee ROM from preoperative to postoperative. Although knee ROM decreased significantly at postoperative week 1, which is most likely because of a peak in postoperative pain and swelling; the ROM started to increase significantly at postoperative week 6. After 1 year, the knee ROM increased by 25% compared with preoperative ROM for the MIV approach. We found the average knee ROM at postoperative 3 months using the MIV approach to be 120.4°. Knee ROM at postoperative 3 months using the SV approach reported by other studies ranged from 87.1° to 120°.19,21–23 Similarly, after 1 year, the average ROM by MIV approach was 126.62°, whereas average knee ROM from other studies using the SV approach was 114.1°.2,10,19,21 Achieving a knee ROM of 120° allows patients to return to their baseline function and perform activities of daily living without limitation. With the prevalence of knee osteoarthritis in the younger population, the need for increased knee ROM post-TKA becomes more important so patients can return to work and function at their baseline.
In addition to being both a muscle- and tendon-sparing approach, other advantages of the MIV approach are that it is simple to perform and gives similar exposure to the MP approach even in difficult primary cases. It is also as extensile as the medial parapatellar approach, and it can be converted to a quadriceps snip if required. There is also minimal, if any, muscle retraction preventing muscle injury that may be seen with some other muscle-sparing approaches to the knee, especially in more difficult primary total knee cases. Another advantage to this approach, as opposed to the other approaches to the knee described here, is that it allows a double-layered closure, decreasing the possibility of arthrotomy dehiscence. Because of this double-layered closure, there is no muscle strangulation with repair of the arthrotomy site as seen in some other approaches to the knee, and both vascularity and innervation to the vastus medialis are preserved.
One limitation of this study is that it is a retrospective analysis. Future studies of the consequences of using this approach need to include quantitative assessment of muscle function using electromyography or dynamometer measurements, utilization of any number of validated knee score systems to measure functional outcomes, and incorporation of a randomized controlled trial.
In summary, the new MIV approach is easy to perform and is compatible with more extensile approaches such as a quadriceps snip, if required in revision scenarios. The MIV approach preserves the extensor mechanism, vascularity, and innervation to the vastus medialis. Our study documents both safety and good clinical outcomes using the MIV approach in TKA. Therefore, the MIV approach may be used in the majority of patients undergoing TKA.
- Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785. doi:10.2106/JBJS.F.00222.
- Dutka J, Skowronek M, Sosin P, Skowronek P. Subvastus and medial parapatellar approaches in TKA: Comparison of functional results. Orthopedics. 2011;34(6):148-153. doi:10.3928/01477447-20110427-05.
- Hofmann AA, Plaster RL, Murdock LE. Subvastus (Southern) approach for primary total knee arthroplasty. Clin Orthop Relat Res. 1991;(269):70-77.
- Jojima H, Whiteside LA, Ogata K. Anatomic consideration of nerve supply to the vastus medialis in knee surgery. Clin Orthop Relat Res. 2004;423:157-160. doi:10.1097/01.blo.0000128642.61260.b3.
- Chavan SK, Wabale RN. Reviewing morphology of quadriceps femoris muscle. J Morphol Sci. 2016;33(2):112-117. doi:10.4322/jms.053513.
- Holt G, Nunn T, Allen RA, Forrester AW, Gregori A. Variation of the vastus medialis obliquus insertion and its relevance to minimally invasive total knee arthroplasty. J Arthroplasty. 2008;23(4):600-604. doi:10.1016/j.arth.2007.05.053.
- Sartawi M, Kohlman J, Valle C Della. Modified intervastus approach to the knee. J Knee Surg. 2017;31(05):422-424. doi:10.1055/s-0037-1604150.
- Hu X, Wang G, Pei F, et al. A meta-analysis of the sub-vastus approach and medial parapatellar approach in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2013;21(10):2398-2404. doi:10.1007/s00167-012-2080-9.
- Jain S, Wasnik S, Mittal A, Hegde C. Outcome of subvastus approach in elderly nonobese patients undergoing bilateral simultaneous total knee arthroplasty: A randomized controlled study. Indian J Orthop. 2013;47(1):45-49. doi:10.4103/0019-5413.106900.
- Kholeif AM, Radwan YA, Mansour AM, Almoalem HA. Early functional results of the subvastus and medial parapatellar approaches in total knee arthroplasty. Med J Cairo Univ. 2017;85(3):849-854.
- Tzatzairis T, Fiska A, Ververidis A, Tilkeridis K, Kazakos K, Drosos GI. Minimally invasive versus conventional approaches in total knee replacement/arthroplasty: A review of the literature. J Orthop. 2018;15(2):459-466. doi:10.1016/j.jor.2018.03.026.
- Li Z, Cheng W, Sun L, Yao Y, Cao Q, Ye S, et al. Mini-subvastus versus medial parapatellar approach for total knee arthroplasty: a prospective randomized controlled study. Int Orthop. 2018;42(3):543-549. doi:10.1007/s00264-017-3703-z.
- Shah NA, Patil HG, Vaishnav VO, Savale A. Total knee arthroplasty using subvastus approach in stiff knee: a retrospective analysis of 110 cases. Indian J Orthop. 2016;50(2):166-171. doi:10.4103/0019-5413.177582.
- Berstock JR, Murray JR, Whitehouse MR, Blom AW, Beswick AD. Medial subvastus versus the medial parapatellar approach for total knee replacement: A systematic review and meta-analysis of randomized controlled trials. EFORT Open Rev. 2018;3(3):78-84. doi:10.1302/2058-5241.3.170030.
- Pan WM, Li XG, Tang TS, Qian ZL, Zhang Q, Zhang CM. Mini-subvastus versus a standard approach in total knee arthroplasty: A prospective, randomized, controlled study. J Int Med Res. 2010;38(3):890-900. doi:10.1177/147323001003800315.
- Bourke MG, Jull GA, Buttrum PJ, Fitzpatrick PL, Dalton PA, Russell TG. Comparing outcomes of medial parapatellar and subvastus approaches in total knee arthroplasty a randomized controlled trial. J Arthroplasty. 2011;27(3):347-353.e1. doi:10.1016/j.arth.2011.06.005.
- Tomek IM, Kantor SR, Cori LAA, et al. Early patient outcomes after primary total knee arthroplasty with quadriceps-sparing subvastus and medial parapatellar techniques: a randomized, double-blind clinical trial. J Bone Jt Surg Am. 2014;96(11):907-915. doi:10.2106/JBJS.L.01578.
- van Hemert WLW, Senden R, Grimm B, van der Linde MJA, Lataster A, Heyligers IC. Early functional outcome after subvastus or parapatellar approach in knee arthroplasty is comparable. Knee Surg Sports Traumatol Arthrosc. 2011;19(6):943-951. doi:10.1007/s00167-010-1292-0.
- Koh IJ, Kim MW, Kim MS, Jang SW, Park DC, In Y. The patient’s perception does not differ following subvastus and medial parapatellar approaches in total knee arthroplasty: a simultaneous bilateral randomized study. J Arthroplasty. 2016;31(1):112-117. doi:10.1016/j.arth.2015.08.004.
- Mehta N, Bhat MS, Goyal A, Mishra P, Joshi D, Chaudhary D. Quadriceps sparing (subvastus/midvastus) approach versus the conventional medial parapatellar approach in primary knee arthroplasty. J Arthrosc Jt Surg. 2017;4(1):15-20. doi:10.1016/j.jajs.2017.02.004.
- Bridgman SA, Walley G, MacKenzie G, Clement D, Griffiths D, Maffulli N. Sub-vastus approach is more effective than a medial parapatellar approach in primary total knee arthroplasty: A randomized controlled trial. Knee. 2009;16(3):216-222. doi:10.1016/j.knee.2008.11.012.
- Liu HW, Gu WD, Xu NW, Sun JY. Surgical approaches in total knee arthroplasty: A meta-analysis comparing the midvastus and subvastus to the medial peripatellar approach. J Arthroplasty. 2014;29(12):2298-2304. doi:10.1016/j.arth.2013.10.023.
- Varela-Egocheaga JR, Suarez-Suarez MA, Fernandez-Villan M, Gonzalez-Sastre V, Varela-Gomez JR, Rodriguez-Merchan C. Minimally invasive subvastus approach: Improving the results of total knee arthroplasty: a prospective, randomized trial. Clin Orthop Relat Res. 2010;468(5):1200-1208. doi:10.1007/s11999-009-1160-8.
ABSTRACT
The subvastus (SV) approach is a well-known muscle- and tendon-sparing approach for total knee arthroplasty (TKA), which has been shown in some studies to provide better outcomes in the visual analog pain score (VAS), knee range of motion (ROM), straight-leg raise, as well as faster rehabilitation, compared with the standard medial parapatellar (MP) approach. We previously described a new knee replacement technique known as the modified intervastus (MIV) approach. The MIV approach is a muscle- and tendon-sparing approach that is extensile and simple to perform. It may be used in the majority of complex primary cases and revisions. Here we describe the surgical technique for performing the MIV approach and provide functional outcome measures. A total of 127 patients (mean age, 66.75 years) underwent TKA using the MIV approach with 1-year follow-up. Clinical outcomes were assessed by recording both a VAS and knee ROM preoperatively, and again at several postoperative time points when the length of time required to ambulate independently (without assistive devices) was also measured. The VAS decreased significantly from the preoperative period (3.69 ± 2.22) to postoperative day 1 (3.17 ± 1.97) (P < .05). Although knee ROM decreased 1 week after surgery, the ROM increased by 6 weeks after surgery compared with the preoperative ROM, and the trend continued over the 1-year follow-up. One-third (33%) of patients were able to walk independently (without assistive devices) at 2 weeks and 78% at 8 weeks. The MIV approach to the knee is a muscle- and tendon-sparing approach that offers advantages over the SV approach and may be used for complex primary and revision total knee cases.
Continue to: Total knee arthroplasty...
Total knee arthroplasty (TKA) is one of the most common orthopedic surgical procedures, with more than 600,000 TKAs performed annually in the United States, and by 2030 the number is expected to reach 3.48 million per year.1Several approaches have been described for total TKA, and the medial parapatellar (MP) approach to the knee is considered the workhorse of total knee replacements. It is an extensile approach that is easy to perform but may delay active knee extension and straight-leg raise after surgery.2 Alternative approaches such as the subvastus (SV) and midvastus approaches to the knee (Figure 1A) typically allow a more rapid straight-leg raise but may be more challenging to perform and time-consuming in morbidly obese patients, muscular patients, and patients with severe deformities.3
The intervastus approach (Figure 1A) described by Jojima4 and others utilizes the interval between the quadriceps tendon and vastus medialis. Although it is a simple approach to perform that is extensile, it is not considered tendon-sparing since the vastus medialis inserts onto the medial aspect of the quadriceps tendon (Figure 2).5 Therefore, dissecting through this interval, without elevation of the vastus medialis (Figure 3A), damages the quadriceps tendon, and strangulation of the muscle occurs with repair of the arthrotomy site (Figure 3B). This situation is even more likely in patients with a low-lying vastus medialis.6
The modified intervastus (MIV) approach described previously,7 may be used in the majority of patients undergoing TKA. The advantages of this approach include its extensile nature, similarities to an MP approach, and preservation of both the extensor mechanism and the vastus medialis, leading to a more rapid return to active knee extension than is traditionally observed.2,7 The approach is simple to perform, easy to close, and is compatible with more extensile approaches such as a quadriceps snip if required in revision scenarios.7 However, functional outcomes of the MIV approach have not been quantified. It is unknown whether these outcomes will offer any advantages compared with the SV approach. Therefore, the objective of this study was to measure functional outcomes of the MIV approach and to compare the results with those previously published for the SV approach. We hypothesized that using the MIV approach for TKA surgery would lead to early straight-leg raise and increase in knee range of motion (ROM) postoperatively.
SURGICAL TECHNIQUE
The MIV approach preserves the quadriceps tendon and vastus medialis.7 After exposure of the vastus medialis muscle, the interval between the quadriceps tendon and vastus medialis is identified (Figure 4). The fascia overlying the lateral edge of the vastus medialis is incised where it meets the quadriceps tendon (Figure 5). The muscle is then bluntly elevated off the underlying capsule just enough to allow for a capsular repair later (Figure 6). An arthrotomy is then performed from cephalad to caudal (Figure 7). This interval may be extended proximally between the vastus intermedius and vastus medialis to expose the distal femur if needed. The closure is performed by repairing the capsule with absorbable suture (Figure 8A), and the vastus medialis fascia is repaired back to the medial edge of the quadriceps tendon, restoring the anatomy (Figure 8B).
Continue to: PATIENTS AND METHODS...
PATIENTS AND METHODS
A retrospective review of functional outcomes after TKA using the MIV approach was conducted; the study was approved by the University of Illinois Institutional Review Board. A total of 127 patients of mean age 66.75 years (range, 48–86 years) with primary osteoarthritis of the knee who were indicated for a total knee replacement with 1-year follow-up were included. The patient demographics are shown in Table 1. All patients underwent TKA using the MIV approach described above by 2 experienced orthopedic surgeons at the same institution. Patients received spinal anesthesia and a periarticular pain block intraoperatively. A measured resection technique was used by 1 surgeon, and a gap-balancing technique by the other. Surgeon 1 used the Persona PS cemented knee system (Zimmer Biomet, and Surgeon 2 used the Sigma PS cemented knee system (Depuy). Patellar resurfacing was done in all cases. Patellar tracking was checked intraoperatively using the ‘no-touch’ technique, and the need for a lateral release was noted. Drains were removed on postoperative day 1. Oral opioids were given as needed. Intravenous antibiotics were continued for 24 hours. Oral anticoagulants were used for thromboembolism prophylaxis for 3 weeks. Patients were mobilized on the day of surgery with full weight-bearing under the supervision of an experienced physical therapist. Static and dynamic quadriceps exercises were started on the same day of surgery along with active knee ROM exercises. Pain score, extensor lag, ROM, walking ability, and complications were recorded in all patients.
Table 1. Patient Demographics
Total no. of patients | 127 | |
Gender | Male | 44 |
Female | 83 | |
Age (years) | Mean ± Standard deviation | 66.75 ± 9.12 |
Range | 48 – 86 | |
Weight (lb) | Mean ± Standard deviation | 218.38 ± 54.47 |
Range | 125 – 364 | |
BMI (kg/m2) | Mean ± Standard deviation | 34.10 ± 7.22 |
Range | 21.1 – 62.5 | |
The visual analog score (VAS) was obtained preoperatively and recorded on postoperative day 1. Patient walking distance with assistance was measured on the day of surgery, after surgery, and on the day of hospital discharge. Patients were assessed preoperatively and postoperatively at 1 week, 2 weeks, 6 weeks, 3 months, 6 months, and 1 year for knee ROM. A one-way ANOVA was conducted to compare the preoperative and postoperative day 1 VAS with significance set at P < .05 (OriginPro 2015, OriginLab Corporation). Differences in knee ROM between preoperative and postoperative follow-up periods (1 week, 2 weeks, 6 weeks, 3 months, 6 months, and 1 year) were identified using a 1-way ANOVA with a post hoc Tukey test. Significance was set at P < .05.
RESULTS
All patients were able to fully straight-leg raise and demonstrate functional knee ROM by postoperative day 1. The patella tracked centrally in all patients, and none required a lateral retinacular release. The majority of patients were discharged in the first 48 hours after surgery on oral narcotics. None required IV narcotics during their hospital stay or a blood transfusion. Two cases were complicated by severe knee skin blistering postoperatively due to a reaction to an adhesive dressing; one was complicated by skin necrosis leading to a flap reconstruction that became infected, requiring a 2-stage revision. A separate case had an acute postoperative infection that required irrigation and debridement with polyethylene exchange. After a 12-week course of antibiotics, the infection was eradicated. All patients reported a high satisfaction rate during their acute postoperative phase.
Postoperatively, all patients were able to walk on the day of surgery either independently or with some assistance. On the day of surgery, 10% of patients were able to walk >200 feet, and this increased to 65% of patients able to walk >200 feet on the day of discharge (compare Figure 9A and Figure 9B). Within 2 weeks of surgery, 30% of patients could walk independently (without assistive devices), and this number increased to 78% by 8 weeks after surgery (Figure 10).
Pain assessed using the VAS was lower on postoperative day 1 (3.17 ± 1.97) than the preoperative score (3.69 ± 2.22, P< .05). Overall, knee ROM significantly increased during the follow-up after surgery. Initially, the ROM decreased 1 week after surgery (90.82 ± 10.28) compared with preoperative ROM (101.04 ± 19.48, P < .001) (Figure 10). At 2 weeks after surgery, knee ROM returned to the preoperative value (100.70 ± 13.36). By 6 weeks after surgery, knee ROM was 17° greater than the preoperative ROM (118.45 ± 11.89, P < .001). Knee ROM remained stable at 3- and 6-month assessments, and showed further improvement by 1 year (126.62 ± 9.81, P < .001) compared with the preoperative state (Figure 10). The net improvement in knee ROM was 25° of increased knee flexion by 1 year.
Continue to: DISCUSSION...
DISCUSSION
TKA is a successful procedure that restores knee function with pain relief in osteoarthritis patients. The SV approach for TKA has better outcomes in terms of the VAS, ROM, straight-leg raise with faster rehabilitation compared with the standard MP approach;8–12 however, it can be challenging and time-consuming when used in morbidly obese and muscular patients.3 The SV approach can also increase the risk of complications such as patellar tendon avulsion or medial collateral injury because of the difficulty in exposure specifically for knees with limited ROM.13 Here we introduce the MIV approach as an alternative to the SV approach, overcoming most of these difficulties.
With the prevalence of morbid obesity and the market demand for minimally invasive techniques, we believe the MIV approach represents a good approach for surgeons since it is easy to perform, does not require specialized instrumentation, and is a reproducible approach even on the most complex deformities. The minimal time added to ensure blunt elevation of the vastus medialis muscle and an anatomic repair of the underlying knee capsule and vastus medialis fascia to the medial edge of the quadriceps tendon allows restoration of the anatomy and a robust double-layered watertight seal closure with no strangulation of soft tissues. We believe this reproducible muscle- and tendon-sparing approach that allows gentle, soft tissue handling even in the most complex primary total knee cases may lead to less soft tissue swelling, and therefore, less postoperative pain resulting in an accelerated recovery.
The pain level in this group of patients was reduced after the MIV approach as indicated by the VAS. The VAS was significantly decreased on postoperative day 1 compared with the VAS recorded preoperatively (P < .05), indicating patients felt less pain on the day after surgery. The average VAS on postoperative day 1 from other studies for SV approach ranged from 2.1 to 5,9,12,14–19 whereas our MIV approach value was 3.17. Periarticular blocks were available for this study group, and no peripheral nerve blocks were used. Some studies of the SV approach mention the use of peripheral nerve blocks, while others did not describe the method used for treatment or control of postoperative pain. The decreased reported pain levels and the observed increased knee ROM seen in the MIV and SV approach study groups might be attributable to the treatment of postoperative pain.
Patient ambulation also increased from the day of surgery to the day of discharge for the MIV approach. Only 10% of patients were able to walk with assistance >200 feet on the day of surgery; however, this percentage increased to 65% on the discharge day showing an excellent recovery of walking ability within 2 days of surgery. Mehta and colleagues20reported that 95% of patients undergoing subvastus/midvastus approaches could walk >10 blocks at 6 months follow-up. For the MIV approach, 78% of patients were able to walk independently within 8 weeks of surgery.
Continue to: The MIV approach shows improvement...
The MIV approach shows improvement in functional outcomes in terms of knee ROM from preoperative to postoperative. Although knee ROM decreased significantly at postoperative week 1, which is most likely because of a peak in postoperative pain and swelling; the ROM started to increase significantly at postoperative week 6. After 1 year, the knee ROM increased by 25% compared with preoperative ROM for the MIV approach. We found the average knee ROM at postoperative 3 months using the MIV approach to be 120.4°. Knee ROM at postoperative 3 months using the SV approach reported by other studies ranged from 87.1° to 120°.19,21–23 Similarly, after 1 year, the average ROM by MIV approach was 126.62°, whereas average knee ROM from other studies using the SV approach was 114.1°.2,10,19,21 Achieving a knee ROM of 120° allows patients to return to their baseline function and perform activities of daily living without limitation. With the prevalence of knee osteoarthritis in the younger population, the need for increased knee ROM post-TKA becomes more important so patients can return to work and function at their baseline.
In addition to being both a muscle- and tendon-sparing approach, other advantages of the MIV approach are that it is simple to perform and gives similar exposure to the MP approach even in difficult primary cases. It is also as extensile as the medial parapatellar approach, and it can be converted to a quadriceps snip if required. There is also minimal, if any, muscle retraction preventing muscle injury that may be seen with some other muscle-sparing approaches to the knee, especially in more difficult primary total knee cases. Another advantage to this approach, as opposed to the other approaches to the knee described here, is that it allows a double-layered closure, decreasing the possibility of arthrotomy dehiscence. Because of this double-layered closure, there is no muscle strangulation with repair of the arthrotomy site as seen in some other approaches to the knee, and both vascularity and innervation to the vastus medialis are preserved.
One limitation of this study is that it is a retrospective analysis. Future studies of the consequences of using this approach need to include quantitative assessment of muscle function using electromyography or dynamometer measurements, utilization of any number of validated knee score systems to measure functional outcomes, and incorporation of a randomized controlled trial.
In summary, the new MIV approach is easy to perform and is compatible with more extensile approaches such as a quadriceps snip, if required in revision scenarios. The MIV approach preserves the extensor mechanism, vascularity, and innervation to the vastus medialis. Our study documents both safety and good clinical outcomes using the MIV approach in TKA. Therefore, the MIV approach may be used in the majority of patients undergoing TKA.
ABSTRACT
The subvastus (SV) approach is a well-known muscle- and tendon-sparing approach for total knee arthroplasty (TKA), which has been shown in some studies to provide better outcomes in the visual analog pain score (VAS), knee range of motion (ROM), straight-leg raise, as well as faster rehabilitation, compared with the standard medial parapatellar (MP) approach. We previously described a new knee replacement technique known as the modified intervastus (MIV) approach. The MIV approach is a muscle- and tendon-sparing approach that is extensile and simple to perform. It may be used in the majority of complex primary cases and revisions. Here we describe the surgical technique for performing the MIV approach and provide functional outcome measures. A total of 127 patients (mean age, 66.75 years) underwent TKA using the MIV approach with 1-year follow-up. Clinical outcomes were assessed by recording both a VAS and knee ROM preoperatively, and again at several postoperative time points when the length of time required to ambulate independently (without assistive devices) was also measured. The VAS decreased significantly from the preoperative period (3.69 ± 2.22) to postoperative day 1 (3.17 ± 1.97) (P < .05). Although knee ROM decreased 1 week after surgery, the ROM increased by 6 weeks after surgery compared with the preoperative ROM, and the trend continued over the 1-year follow-up. One-third (33%) of patients were able to walk independently (without assistive devices) at 2 weeks and 78% at 8 weeks. The MIV approach to the knee is a muscle- and tendon-sparing approach that offers advantages over the SV approach and may be used for complex primary and revision total knee cases.
Continue to: Total knee arthroplasty...
Total knee arthroplasty (TKA) is one of the most common orthopedic surgical procedures, with more than 600,000 TKAs performed annually in the United States, and by 2030 the number is expected to reach 3.48 million per year.1Several approaches have been described for total TKA, and the medial parapatellar (MP) approach to the knee is considered the workhorse of total knee replacements. It is an extensile approach that is easy to perform but may delay active knee extension and straight-leg raise after surgery.2 Alternative approaches such as the subvastus (SV) and midvastus approaches to the knee (Figure 1A) typically allow a more rapid straight-leg raise but may be more challenging to perform and time-consuming in morbidly obese patients, muscular patients, and patients with severe deformities.3
The intervastus approach (Figure 1A) described by Jojima4 and others utilizes the interval between the quadriceps tendon and vastus medialis. Although it is a simple approach to perform that is extensile, it is not considered tendon-sparing since the vastus medialis inserts onto the medial aspect of the quadriceps tendon (Figure 2).5 Therefore, dissecting through this interval, without elevation of the vastus medialis (Figure 3A), damages the quadriceps tendon, and strangulation of the muscle occurs with repair of the arthrotomy site (Figure 3B). This situation is even more likely in patients with a low-lying vastus medialis.6
The modified intervastus (MIV) approach described previously,7 may be used in the majority of patients undergoing TKA. The advantages of this approach include its extensile nature, similarities to an MP approach, and preservation of both the extensor mechanism and the vastus medialis, leading to a more rapid return to active knee extension than is traditionally observed.2,7 The approach is simple to perform, easy to close, and is compatible with more extensile approaches such as a quadriceps snip if required in revision scenarios.7 However, functional outcomes of the MIV approach have not been quantified. It is unknown whether these outcomes will offer any advantages compared with the SV approach. Therefore, the objective of this study was to measure functional outcomes of the MIV approach and to compare the results with those previously published for the SV approach. We hypothesized that using the MIV approach for TKA surgery would lead to early straight-leg raise and increase in knee range of motion (ROM) postoperatively.
SURGICAL TECHNIQUE
The MIV approach preserves the quadriceps tendon and vastus medialis.7 After exposure of the vastus medialis muscle, the interval between the quadriceps tendon and vastus medialis is identified (Figure 4). The fascia overlying the lateral edge of the vastus medialis is incised where it meets the quadriceps tendon (Figure 5). The muscle is then bluntly elevated off the underlying capsule just enough to allow for a capsular repair later (Figure 6). An arthrotomy is then performed from cephalad to caudal (Figure 7). This interval may be extended proximally between the vastus intermedius and vastus medialis to expose the distal femur if needed. The closure is performed by repairing the capsule with absorbable suture (Figure 8A), and the vastus medialis fascia is repaired back to the medial edge of the quadriceps tendon, restoring the anatomy (Figure 8B).
Continue to: PATIENTS AND METHODS...
PATIENTS AND METHODS
A retrospective review of functional outcomes after TKA using the MIV approach was conducted; the study was approved by the University of Illinois Institutional Review Board. A total of 127 patients of mean age 66.75 years (range, 48–86 years) with primary osteoarthritis of the knee who were indicated for a total knee replacement with 1-year follow-up were included. The patient demographics are shown in Table 1. All patients underwent TKA using the MIV approach described above by 2 experienced orthopedic surgeons at the same institution. Patients received spinal anesthesia and a periarticular pain block intraoperatively. A measured resection technique was used by 1 surgeon, and a gap-balancing technique by the other. Surgeon 1 used the Persona PS cemented knee system (Zimmer Biomet, and Surgeon 2 used the Sigma PS cemented knee system (Depuy). Patellar resurfacing was done in all cases. Patellar tracking was checked intraoperatively using the ‘no-touch’ technique, and the need for a lateral release was noted. Drains were removed on postoperative day 1. Oral opioids were given as needed. Intravenous antibiotics were continued for 24 hours. Oral anticoagulants were used for thromboembolism prophylaxis for 3 weeks. Patients were mobilized on the day of surgery with full weight-bearing under the supervision of an experienced physical therapist. Static and dynamic quadriceps exercises were started on the same day of surgery along with active knee ROM exercises. Pain score, extensor lag, ROM, walking ability, and complications were recorded in all patients.
Table 1. Patient Demographics
Total no. of patients | 127 | |
Gender | Male | 44 |
Female | 83 | |
Age (years) | Mean ± Standard deviation | 66.75 ± 9.12 |
Range | 48 – 86 | |
Weight (lb) | Mean ± Standard deviation | 218.38 ± 54.47 |
Range | 125 – 364 | |
BMI (kg/m2) | Mean ± Standard deviation | 34.10 ± 7.22 |
Range | 21.1 – 62.5 | |
The visual analog score (VAS) was obtained preoperatively and recorded on postoperative day 1. Patient walking distance with assistance was measured on the day of surgery, after surgery, and on the day of hospital discharge. Patients were assessed preoperatively and postoperatively at 1 week, 2 weeks, 6 weeks, 3 months, 6 months, and 1 year for knee ROM. A one-way ANOVA was conducted to compare the preoperative and postoperative day 1 VAS with significance set at P < .05 (OriginPro 2015, OriginLab Corporation). Differences in knee ROM between preoperative and postoperative follow-up periods (1 week, 2 weeks, 6 weeks, 3 months, 6 months, and 1 year) were identified using a 1-way ANOVA with a post hoc Tukey test. Significance was set at P < .05.
RESULTS
All patients were able to fully straight-leg raise and demonstrate functional knee ROM by postoperative day 1. The patella tracked centrally in all patients, and none required a lateral retinacular release. The majority of patients were discharged in the first 48 hours after surgery on oral narcotics. None required IV narcotics during their hospital stay or a blood transfusion. Two cases were complicated by severe knee skin blistering postoperatively due to a reaction to an adhesive dressing; one was complicated by skin necrosis leading to a flap reconstruction that became infected, requiring a 2-stage revision. A separate case had an acute postoperative infection that required irrigation and debridement with polyethylene exchange. After a 12-week course of antibiotics, the infection was eradicated. All patients reported a high satisfaction rate during their acute postoperative phase.
Postoperatively, all patients were able to walk on the day of surgery either independently or with some assistance. On the day of surgery, 10% of patients were able to walk >200 feet, and this increased to 65% of patients able to walk >200 feet on the day of discharge (compare Figure 9A and Figure 9B). Within 2 weeks of surgery, 30% of patients could walk independently (without assistive devices), and this number increased to 78% by 8 weeks after surgery (Figure 10).
Pain assessed using the VAS was lower on postoperative day 1 (3.17 ± 1.97) than the preoperative score (3.69 ± 2.22, P< .05). Overall, knee ROM significantly increased during the follow-up after surgery. Initially, the ROM decreased 1 week after surgery (90.82 ± 10.28) compared with preoperative ROM (101.04 ± 19.48, P < .001) (Figure 10). At 2 weeks after surgery, knee ROM returned to the preoperative value (100.70 ± 13.36). By 6 weeks after surgery, knee ROM was 17° greater than the preoperative ROM (118.45 ± 11.89, P < .001). Knee ROM remained stable at 3- and 6-month assessments, and showed further improvement by 1 year (126.62 ± 9.81, P < .001) compared with the preoperative state (Figure 10). The net improvement in knee ROM was 25° of increased knee flexion by 1 year.
Continue to: DISCUSSION...
DISCUSSION
TKA is a successful procedure that restores knee function with pain relief in osteoarthritis patients. The SV approach for TKA has better outcomes in terms of the VAS, ROM, straight-leg raise with faster rehabilitation compared with the standard MP approach;8–12 however, it can be challenging and time-consuming when used in morbidly obese and muscular patients.3 The SV approach can also increase the risk of complications such as patellar tendon avulsion or medial collateral injury because of the difficulty in exposure specifically for knees with limited ROM.13 Here we introduce the MIV approach as an alternative to the SV approach, overcoming most of these difficulties.
With the prevalence of morbid obesity and the market demand for minimally invasive techniques, we believe the MIV approach represents a good approach for surgeons since it is easy to perform, does not require specialized instrumentation, and is a reproducible approach even on the most complex deformities. The minimal time added to ensure blunt elevation of the vastus medialis muscle and an anatomic repair of the underlying knee capsule and vastus medialis fascia to the medial edge of the quadriceps tendon allows restoration of the anatomy and a robust double-layered watertight seal closure with no strangulation of soft tissues. We believe this reproducible muscle- and tendon-sparing approach that allows gentle, soft tissue handling even in the most complex primary total knee cases may lead to less soft tissue swelling, and therefore, less postoperative pain resulting in an accelerated recovery.
The pain level in this group of patients was reduced after the MIV approach as indicated by the VAS. The VAS was significantly decreased on postoperative day 1 compared with the VAS recorded preoperatively (P < .05), indicating patients felt less pain on the day after surgery. The average VAS on postoperative day 1 from other studies for SV approach ranged from 2.1 to 5,9,12,14–19 whereas our MIV approach value was 3.17. Periarticular blocks were available for this study group, and no peripheral nerve blocks were used. Some studies of the SV approach mention the use of peripheral nerve blocks, while others did not describe the method used for treatment or control of postoperative pain. The decreased reported pain levels and the observed increased knee ROM seen in the MIV and SV approach study groups might be attributable to the treatment of postoperative pain.
Patient ambulation also increased from the day of surgery to the day of discharge for the MIV approach. Only 10% of patients were able to walk with assistance >200 feet on the day of surgery; however, this percentage increased to 65% on the discharge day showing an excellent recovery of walking ability within 2 days of surgery. Mehta and colleagues20reported that 95% of patients undergoing subvastus/midvastus approaches could walk >10 blocks at 6 months follow-up. For the MIV approach, 78% of patients were able to walk independently within 8 weeks of surgery.
Continue to: The MIV approach shows improvement...
The MIV approach shows improvement in functional outcomes in terms of knee ROM from preoperative to postoperative. Although knee ROM decreased significantly at postoperative week 1, which is most likely because of a peak in postoperative pain and swelling; the ROM started to increase significantly at postoperative week 6. After 1 year, the knee ROM increased by 25% compared with preoperative ROM for the MIV approach. We found the average knee ROM at postoperative 3 months using the MIV approach to be 120.4°. Knee ROM at postoperative 3 months using the SV approach reported by other studies ranged from 87.1° to 120°.19,21–23 Similarly, after 1 year, the average ROM by MIV approach was 126.62°, whereas average knee ROM from other studies using the SV approach was 114.1°.2,10,19,21 Achieving a knee ROM of 120° allows patients to return to their baseline function and perform activities of daily living without limitation. With the prevalence of knee osteoarthritis in the younger population, the need for increased knee ROM post-TKA becomes more important so patients can return to work and function at their baseline.
In addition to being both a muscle- and tendon-sparing approach, other advantages of the MIV approach are that it is simple to perform and gives similar exposure to the MP approach even in difficult primary cases. It is also as extensile as the medial parapatellar approach, and it can be converted to a quadriceps snip if required. There is also minimal, if any, muscle retraction preventing muscle injury that may be seen with some other muscle-sparing approaches to the knee, especially in more difficult primary total knee cases. Another advantage to this approach, as opposed to the other approaches to the knee described here, is that it allows a double-layered closure, decreasing the possibility of arthrotomy dehiscence. Because of this double-layered closure, there is no muscle strangulation with repair of the arthrotomy site as seen in some other approaches to the knee, and both vascularity and innervation to the vastus medialis are preserved.
One limitation of this study is that it is a retrospective analysis. Future studies of the consequences of using this approach need to include quantitative assessment of muscle function using electromyography or dynamometer measurements, utilization of any number of validated knee score systems to measure functional outcomes, and incorporation of a randomized controlled trial.
In summary, the new MIV approach is easy to perform and is compatible with more extensile approaches such as a quadriceps snip, if required in revision scenarios. The MIV approach preserves the extensor mechanism, vascularity, and innervation to the vastus medialis. Our study documents both safety and good clinical outcomes using the MIV approach in TKA. Therefore, the MIV approach may be used in the majority of patients undergoing TKA.
- Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785. doi:10.2106/JBJS.F.00222.
- Dutka J, Skowronek M, Sosin P, Skowronek P. Subvastus and medial parapatellar approaches in TKA: Comparison of functional results. Orthopedics. 2011;34(6):148-153. doi:10.3928/01477447-20110427-05.
- Hofmann AA, Plaster RL, Murdock LE. Subvastus (Southern) approach for primary total knee arthroplasty. Clin Orthop Relat Res. 1991;(269):70-77.
- Jojima H, Whiteside LA, Ogata K. Anatomic consideration of nerve supply to the vastus medialis in knee surgery. Clin Orthop Relat Res. 2004;423:157-160. doi:10.1097/01.blo.0000128642.61260.b3.
- Chavan SK, Wabale RN. Reviewing morphology of quadriceps femoris muscle. J Morphol Sci. 2016;33(2):112-117. doi:10.4322/jms.053513.
- Holt G, Nunn T, Allen RA, Forrester AW, Gregori A. Variation of the vastus medialis obliquus insertion and its relevance to minimally invasive total knee arthroplasty. J Arthroplasty. 2008;23(4):600-604. doi:10.1016/j.arth.2007.05.053.
- Sartawi M, Kohlman J, Valle C Della. Modified intervastus approach to the knee. J Knee Surg. 2017;31(05):422-424. doi:10.1055/s-0037-1604150.
- Hu X, Wang G, Pei F, et al. A meta-analysis of the sub-vastus approach and medial parapatellar approach in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2013;21(10):2398-2404. doi:10.1007/s00167-012-2080-9.
- Jain S, Wasnik S, Mittal A, Hegde C. Outcome of subvastus approach in elderly nonobese patients undergoing bilateral simultaneous total knee arthroplasty: A randomized controlled study. Indian J Orthop. 2013;47(1):45-49. doi:10.4103/0019-5413.106900.
- Kholeif AM, Radwan YA, Mansour AM, Almoalem HA. Early functional results of the subvastus and medial parapatellar approaches in total knee arthroplasty. Med J Cairo Univ. 2017;85(3):849-854.
- Tzatzairis T, Fiska A, Ververidis A, Tilkeridis K, Kazakos K, Drosos GI. Minimally invasive versus conventional approaches in total knee replacement/arthroplasty: A review of the literature. J Orthop. 2018;15(2):459-466. doi:10.1016/j.jor.2018.03.026.
- Li Z, Cheng W, Sun L, Yao Y, Cao Q, Ye S, et al. Mini-subvastus versus medial parapatellar approach for total knee arthroplasty: a prospective randomized controlled study. Int Orthop. 2018;42(3):543-549. doi:10.1007/s00264-017-3703-z.
- Shah NA, Patil HG, Vaishnav VO, Savale A. Total knee arthroplasty using subvastus approach in stiff knee: a retrospective analysis of 110 cases. Indian J Orthop. 2016;50(2):166-171. doi:10.4103/0019-5413.177582.
- Berstock JR, Murray JR, Whitehouse MR, Blom AW, Beswick AD. Medial subvastus versus the medial parapatellar approach for total knee replacement: A systematic review and meta-analysis of randomized controlled trials. EFORT Open Rev. 2018;3(3):78-84. doi:10.1302/2058-5241.3.170030.
- Pan WM, Li XG, Tang TS, Qian ZL, Zhang Q, Zhang CM. Mini-subvastus versus a standard approach in total knee arthroplasty: A prospective, randomized, controlled study. J Int Med Res. 2010;38(3):890-900. doi:10.1177/147323001003800315.
- Bourke MG, Jull GA, Buttrum PJ, Fitzpatrick PL, Dalton PA, Russell TG. Comparing outcomes of medial parapatellar and subvastus approaches in total knee arthroplasty a randomized controlled trial. J Arthroplasty. 2011;27(3):347-353.e1. doi:10.1016/j.arth.2011.06.005.
- Tomek IM, Kantor SR, Cori LAA, et al. Early patient outcomes after primary total knee arthroplasty with quadriceps-sparing subvastus and medial parapatellar techniques: a randomized, double-blind clinical trial. J Bone Jt Surg Am. 2014;96(11):907-915. doi:10.2106/JBJS.L.01578.
- van Hemert WLW, Senden R, Grimm B, van der Linde MJA, Lataster A, Heyligers IC. Early functional outcome after subvastus or parapatellar approach in knee arthroplasty is comparable. Knee Surg Sports Traumatol Arthrosc. 2011;19(6):943-951. doi:10.1007/s00167-010-1292-0.
- Koh IJ, Kim MW, Kim MS, Jang SW, Park DC, In Y. The patient’s perception does not differ following subvastus and medial parapatellar approaches in total knee arthroplasty: a simultaneous bilateral randomized study. J Arthroplasty. 2016;31(1):112-117. doi:10.1016/j.arth.2015.08.004.
- Mehta N, Bhat MS, Goyal A, Mishra P, Joshi D, Chaudhary D. Quadriceps sparing (subvastus/midvastus) approach versus the conventional medial parapatellar approach in primary knee arthroplasty. J Arthrosc Jt Surg. 2017;4(1):15-20. doi:10.1016/j.jajs.2017.02.004.
- Bridgman SA, Walley G, MacKenzie G, Clement D, Griffiths D, Maffulli N. Sub-vastus approach is more effective than a medial parapatellar approach in primary total knee arthroplasty: A randomized controlled trial. Knee. 2009;16(3):216-222. doi:10.1016/j.knee.2008.11.012.
- Liu HW, Gu WD, Xu NW, Sun JY. Surgical approaches in total knee arthroplasty: A meta-analysis comparing the midvastus and subvastus to the medial peripatellar approach. J Arthroplasty. 2014;29(12):2298-2304. doi:10.1016/j.arth.2013.10.023.
- Varela-Egocheaga JR, Suarez-Suarez MA, Fernandez-Villan M, Gonzalez-Sastre V, Varela-Gomez JR, Rodriguez-Merchan C. Minimally invasive subvastus approach: Improving the results of total knee arthroplasty: a prospective, randomized trial. Clin Orthop Relat Res. 2010;468(5):1200-1208. doi:10.1007/s11999-009-1160-8.
- Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785. doi:10.2106/JBJS.F.00222.
- Dutka J, Skowronek M, Sosin P, Skowronek P. Subvastus and medial parapatellar approaches in TKA: Comparison of functional results. Orthopedics. 2011;34(6):148-153. doi:10.3928/01477447-20110427-05.
- Hofmann AA, Plaster RL, Murdock LE. Subvastus (Southern) approach for primary total knee arthroplasty. Clin Orthop Relat Res. 1991;(269):70-77.
- Jojima H, Whiteside LA, Ogata K. Anatomic consideration of nerve supply to the vastus medialis in knee surgery. Clin Orthop Relat Res. 2004;423:157-160. doi:10.1097/01.blo.0000128642.61260.b3.
- Chavan SK, Wabale RN. Reviewing morphology of quadriceps femoris muscle. J Morphol Sci. 2016;33(2):112-117. doi:10.4322/jms.053513.
- Holt G, Nunn T, Allen RA, Forrester AW, Gregori A. Variation of the vastus medialis obliquus insertion and its relevance to minimally invasive total knee arthroplasty. J Arthroplasty. 2008;23(4):600-604. doi:10.1016/j.arth.2007.05.053.
- Sartawi M, Kohlman J, Valle C Della. Modified intervastus approach to the knee. J Knee Surg. 2017;31(05):422-424. doi:10.1055/s-0037-1604150.
- Hu X, Wang G, Pei F, et al. A meta-analysis of the sub-vastus approach and medial parapatellar approach in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2013;21(10):2398-2404. doi:10.1007/s00167-012-2080-9.
- Jain S, Wasnik S, Mittal A, Hegde C. Outcome of subvastus approach in elderly nonobese patients undergoing bilateral simultaneous total knee arthroplasty: A randomized controlled study. Indian J Orthop. 2013;47(1):45-49. doi:10.4103/0019-5413.106900.
- Kholeif AM, Radwan YA, Mansour AM, Almoalem HA. Early functional results of the subvastus and medial parapatellar approaches in total knee arthroplasty. Med J Cairo Univ. 2017;85(3):849-854.
- Tzatzairis T, Fiska A, Ververidis A, Tilkeridis K, Kazakos K, Drosos GI. Minimally invasive versus conventional approaches in total knee replacement/arthroplasty: A review of the literature. J Orthop. 2018;15(2):459-466. doi:10.1016/j.jor.2018.03.026.
- Li Z, Cheng W, Sun L, Yao Y, Cao Q, Ye S, et al. Mini-subvastus versus medial parapatellar approach for total knee arthroplasty: a prospective randomized controlled study. Int Orthop. 2018;42(3):543-549. doi:10.1007/s00264-017-3703-z.
- Shah NA, Patil HG, Vaishnav VO, Savale A. Total knee arthroplasty using subvastus approach in stiff knee: a retrospective analysis of 110 cases. Indian J Orthop. 2016;50(2):166-171. doi:10.4103/0019-5413.177582.
- Berstock JR, Murray JR, Whitehouse MR, Blom AW, Beswick AD. Medial subvastus versus the medial parapatellar approach for total knee replacement: A systematic review and meta-analysis of randomized controlled trials. EFORT Open Rev. 2018;3(3):78-84. doi:10.1302/2058-5241.3.170030.
- Pan WM, Li XG, Tang TS, Qian ZL, Zhang Q, Zhang CM. Mini-subvastus versus a standard approach in total knee arthroplasty: A prospective, randomized, controlled study. J Int Med Res. 2010;38(3):890-900. doi:10.1177/147323001003800315.
- Bourke MG, Jull GA, Buttrum PJ, Fitzpatrick PL, Dalton PA, Russell TG. Comparing outcomes of medial parapatellar and subvastus approaches in total knee arthroplasty a randomized controlled trial. J Arthroplasty. 2011;27(3):347-353.e1. doi:10.1016/j.arth.2011.06.005.
- Tomek IM, Kantor SR, Cori LAA, et al. Early patient outcomes after primary total knee arthroplasty with quadriceps-sparing subvastus and medial parapatellar techniques: a randomized, double-blind clinical trial. J Bone Jt Surg Am. 2014;96(11):907-915. doi:10.2106/JBJS.L.01578.
- van Hemert WLW, Senden R, Grimm B, van der Linde MJA, Lataster A, Heyligers IC. Early functional outcome after subvastus or parapatellar approach in knee arthroplasty is comparable. Knee Surg Sports Traumatol Arthrosc. 2011;19(6):943-951. doi:10.1007/s00167-010-1292-0.
- Koh IJ, Kim MW, Kim MS, Jang SW, Park DC, In Y. The patient’s perception does not differ following subvastus and medial parapatellar approaches in total knee arthroplasty: a simultaneous bilateral randomized study. J Arthroplasty. 2016;31(1):112-117. doi:10.1016/j.arth.2015.08.004.
- Mehta N, Bhat MS, Goyal A, Mishra P, Joshi D, Chaudhary D. Quadriceps sparing (subvastus/midvastus) approach versus the conventional medial parapatellar approach in primary knee arthroplasty. J Arthrosc Jt Surg. 2017;4(1):15-20. doi:10.1016/j.jajs.2017.02.004.
- Bridgman SA, Walley G, MacKenzie G, Clement D, Griffiths D, Maffulli N. Sub-vastus approach is more effective than a medial parapatellar approach in primary total knee arthroplasty: A randomized controlled trial. Knee. 2009;16(3):216-222. doi:10.1016/j.knee.2008.11.012.
- Liu HW, Gu WD, Xu NW, Sun JY. Surgical approaches in total knee arthroplasty: A meta-analysis comparing the midvastus and subvastus to the medial peripatellar approach. J Arthroplasty. 2014;29(12):2298-2304. doi:10.1016/j.arth.2013.10.023.
- Varela-Egocheaga JR, Suarez-Suarez MA, Fernandez-Villan M, Gonzalez-Sastre V, Varela-Gomez JR, Rodriguez-Merchan C. Minimally invasive subvastus approach: Improving the results of total knee arthroplasty: a prospective, randomized trial. Clin Orthop Relat Res. 2010;468(5):1200-1208. doi:10.1007/s11999-009-1160-8.
TAKE-HOME POINTS
- The modified intervastus approach to the knee spares the quadriceps tendon and the vastus medialis muscle.
- The modified intervastus approach is an extensile approach.
- The modified intersvastus approach is a safe approach to the knee that can be used in total knee arthroplasty and leads to early straight-leg raise and a rapid recovery.
- The modified intervastus approach can be used on the majority of patients requiring a total knee replacement.
- The modified intervastus approach utilizes a unique closure that avoids soft tissue strangulation.
Trends in Utilization of Total Hip Arthroplasty for Femoral Neck Fractures in the United States
ABSTRACT
The ideal mode of fixation for patients with femoral neck fractures is not well defined in the current literature. This study describes the recent trends in surgical management of femoral neck fractures with an analysis on perioperative outcomes.
The National Hospital Discharge Survey was used to identify femoral neck fractures in the United States between 1990 and 2007 (n = 1,155,960) treated with open reduction and internal fixation (ORIF), total hip arthroplasty (THA), or hemiarthroplasty (HA). Trends were examined over the following 3 time periods: 1990 to 1995 (group 1), 1996 to 2001 (group 2), and 2002 to 2007 (group 3). Elixhauser Comorbidity Index and perioperative complications were calculated.
Use of HA increased (74.4% to 84.6%), whereas that of THA (7.3% to 4.9%) and ORIF (18.3% to 10.6%) decreased, from group 1 to group 3 in the age group of >80 years. The use of ORIF increased (63.9% to 81.4%), whereas the use of both HA and THA decreased, from group 1 to group 3 in the age group of <50 years. The rate of adverse events increased across all fixation types but was greatest among THA (32.2% to 48.3%).
The femoral neck patient population is now older and has more medical comorbidities. We observed a trend toward performing HA in older patients and ORIF in younger patients. Despite superior functional outcomes reported in THA, this study found a decreased utilization of THA in all age groups along with an increase in adverse events and nonroutine discharges for patients with femoral neck fractures treated with THA.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Continue to: Femoral neck fractures...
Femoral neck fractures are a common occurrence in the United States. A recent study estimated an incidence of >63 per 100,000 population.1-8 Although the incidence appears to have decreased over recent decades, there is a projected exponential increase in the incidence of hip fractures over the next 30 years in the baby boomer population.8,9 Given that these fractures have a significant impact on patient morbidity, mortality, and quality of life, research efforts have been directed toward optimizing the treatment of affected patients and improving the outcomes.4,9-24
The treatment of choice for femoral neck fractures and the use of total hip arthroplasty (THA)11 have been a topic of debate.4,9,10,15-17,22,25 Total hip arthroplasty has been advocated for younger, more active patients, whereas hemiarthroplasty (HA) has been reserved for patients who are older and less active. Although several studies have demonstrated that arthroplasty outperforms open reduction and internal fixation (ORIF) in the elderly population with displaced femoral neck fractures, ORIF is still commonly performed in the United States for nondisplaced fractures and in patients aged <50 years.26-29
In an attempt to quantify the use of THA in the treatment of femoral neck fractures and demonstrate the national trends, Miller and colleagues5 pooled the American Board of Orthopaedic Surgery (ABOS) database and analyzed the treatment trends of surgeons taking part II of the ABOS examination from 1999 to 2011. The authors found an increased utilization of THA by recently graduated orthopedic surgeons. In contrast, Jain and colleagues30 found different national trends when they analyzed data from the National Inpatient Sample containing data between 1990 and 2001 and further found decreased utilization of THA procedures by orthopedic surgeons of all levels of training nationwide. However, neither of these studies reported about the trends in demographics, comorbidities, risk factors, or outcomes in this patient population following surgery.
The purpose of this study was to help clarify the findings of these authors using the largest dataset to date and also report on the perioperative complications associated with each mode of fixation in patients who undergo operative treatment for femoral neck fractures in the United States. Our hypotheses were that the femoral neck fracture patient population has become older and has more medical comorbidities. We also hypothesized that there has been a trend toward performing fewer THA procedures in the United States and that THA is associated with increased perioperative complications compared to those with HA and ORIF.
MATERIALS AND METHODS
We conducted a retrospective epidemiological study using the National Hospital Discharge Survey (NHDS) on surgical trends in the management of femoral neck fractures. The NHDS is a publicly available survey that is conducted annually to provide data of nonfederal, short-stay hospitals to the public. The sample data are weighted to provide nationwide estimates of annual inpatient care. The NHDS includes up to 7 medical diagnoses and 4 procedural codes per case, which are categorized using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, that were collected along with patient demographic information, length of stay (LOS), and discharge disposition. The diagnostic and procedural codes used for this study are presented in the Appendix. The year 2007 was chosen as the endpoint of this study due to the fact that the relative standard error of the NHDS doubled in 2008 as a result of a decrease in its survey size. As this is a publicly available database, our study was exempt from institutional review board approval.
Continue to: All pateints admitted...
All patients admitted with a primary diagnosis of closed transcervical fracture of the femoral neck (ICD-9-CM 820.0x) were selected. This resulted in 1,674,160 fractures. All patients with fractures with a concurrent primary procedural code of ORIF (79.35), HA (81.52), or THA (81.51) were identified, resulting in a total sample size of 1,155,960 surgical fractures. Analysis of the fractures based on additional specificity,ie subcapital versus midcervical versus basicervical, was not carried out because >90% of femoral neck fractures in the database were coded as “unspecified” or “other” (ICD9 CM 820.00 and 820.09, respectively).
Comorbidity burden was quantified using Elixhauser coding algorithms as previously described.31 The Elixhauser comorbidity measure is a model consisting of 31 conditions and has recently been identified as a better predictor of mortality in patients undergoing orthopedic procedures when compared with the Charlson Comorbidity Index.31 Dichotomous variables for each Elixhauser comorbidity were created, and χ2 tests were utilized to assess the association between each comorbidity and mortality. The weighted Elixhauser score for each statistically significant comorbidity was calculated as described by van Walraven and colleagues.32 The Elixhauser comorbidity score was then calculated for each patient by summing the individual weights of all comorbidities. Postoperative adverse events were determined using the complication-screening-package as previously described.33
All adverse events were categorized into 3 categories, including general medical complications, mechanical complications, and surgical complications. All adverse events recorded in the NHDS database are events that occurred during a single hospitalization. Therefore, it does not take into account adverse events that occurred after discharge, and, for example, mortality refers to postoperative mortality that occurs prior to discharge. The study period comprised data captured from 1990 to 2007, and 3 groups were generated from this time period to better characterize patients throughout the large study time frame. Group 1 comprised patients who underwent surgical management of femoral neck fractures from 1990 to 1995, group 2 consisted of patients treated from 1996 to 2001, and group 3 included patients treated from 2002 to 2007.
Categorical data were analyzed using the χ2 test, and continuous data were analyzed by the independent-samples t test and ANOVA. Multivariable binary logistic regression analyses were performed to assess the contributions of individual comorbidities to mortality, adverse events, and nonroutine discharge. Elixhauser comorbidities with a P value of < .10 in the bivariate analysis and presenting in at least 0.2% of the population were included in the logistic regression.31 Odds ratios and confidence intervals were calculated to assess the association between comorbidities and our dichotomous variables. A P value of < .001 defined statistical significance.33 Statistical analysis was conducted using SPSS version 21 (IBM).
RESULTS
Patient Demographics
Our query demonstrated a total of 1,155,960 patients who underwent surgical fixation of femoral neck fractures (Table 1). The most commonly used treatment modality was HA (75%), followed by ORIF (18%) and later by THA (7%). The majority of patients were females in each treatment group. Patients’ age varied according to treatment group, with patients undergoing HA having a mean age of 81.0 ± 9.0 years, patients undergoing ORIF having a mean age of 75.0 ± 17.0 years, and those undergoing THA having a mean age of 79.0 ± 10.0 years (P < .001). The majority of patients were ≥80 years in all treatment groups, but the ORIF group had the greatest proportion of patients <65 years (P < .001). Among patients undergoing HA, 62.4% were ≥80 years, while the ORIF and HA groups consisted of 48.6% and 51.5% of patients in that same age group, respectively.
Continue to: TRENDS ANALYSIS
TRENDS ANALYSIS
There was a significant change in the distributions of the procedures performed according to age group over time. Patients >80 years continued to undergo primarily HA, with an increase from 74.4% during 1990 to 1995 up to 84.6% during the 2002 to 2007 period and a concomitant decrease in ORIF from 18.3% to 10.6% during the same time period in this age group. Surgical trends in patients 65 to 79 years demonstrated a significant decrease in management with ORIF from 19.1% in 1990 to 1995 to 16.8% in the 2002 to 2007 cohort (P < .001 for all, Table 2). There was an increase in the use of HA from 71.9% during the 1990 to 1995 period to 75.5% during the final study period (Table 2, Figure 1). The use of THA for all age groups decreased between 1990 and 2007, except for the 50- to 64-year-old group where THA utilization remained constant.
Management patterns in patients 50 to 64 years varied throughout the analysis and demonstrated the following trend: treatment with HA remained the most common technique used but varied slightly from 59.7% during 1990 to 1995 to 60.3% during 2002 to2007 (P < .001, Table 2). The second most common treatment used was ORIF, which decreased from 32.2% to 31.5% (P < .001, Table 2). The use of THA varied significantly from 8.2% among those managed during 1990 to 1995 to 11.7% during 1996 to 2001 but later declined to the initial 8.2% (P < .001, Table 2).
Analysis of patients ≤49 years demonstrated that ORIF was the preferred technique, which experienced a growth from 63.9% during 1990 to 1995 to 81.4% during the 2002 to 2007 period (P < .001, Table 2). A decreased use in THA was observed from 2.0% in the initial period to 0.6% in the final period (P < .001, Table 2). Use of HA decreased from 34.0% in 1990 to 1995 to 18.0% in 2002 to 2007 (P < .001, Table 2).
LENGTH OF STAY
Mean number of in-hospital days decreased throughout the study period for all treatment techniques. During the 1990 to 1995 study period, patients who underwent ORIF had a mean LOS of 8 ± 7 days, which decreased (P < .001, Table 2) to 6 ± 3 days in 1996 to 2001 and remained constant during 2002 to 2007 (mean 6 ± 4 days). This decrease in LOS was also observed in patients who underwent THA (P < .001, Table 2), who initially had a mean LOS of 11 ± 7 days during 1990 to 1995, which later decreased to 7 ± 5 days for the remainder of the study. The LOS for patients who underwent HA also decreased (P < .001, Table 2), which initially was reported to be 11 ± 11 days during 1990 to 1995, decreasing to 7 ±7 days in 1996–2001 and later to 6 ± 4 days in 2002 to 2007.
COMORBIDITIY ANALYSIS
The Elixhauser Comorbidity Index varied significantly among groups over time (P < .001, Table 2). Overall mean Elixhauser Comorbidity Index score per procedure type is provided in Table 1, with HA patients having the highest score (-0.15 ± 13.09, p<.001).
Continue to: Analysis of the preoperative comorbidities...
Analysis of the preoperative comorbidities demonstrated significant differences among each surgical treatment group (P < .001 for all, Table 3). The most common comorbidities in patients who underwent HA were uncomplicated hypertension (33.2%), fluid/electrolyte disorders (17.4%), chronic pulmonary disease (14.9%), and congestive heart failure (13.7%). The most common comorbidities in the ORIF group were uncomplicated hypertension (30.8%), fluid/electrolyte disorders (14.5%), chronic pulmonary disease (14.0%), and uncomplicated diabetes (10.9%). Patients treated with THA had most commonly uncomplicated hypertension (30.1%), fluid/electrolyte disorders (17.2%), uncomplicated diabetes (15.5%), and chronic pulmonary disease (14.4%). The prevalence of comorbidities is displayed in Table 3.
DISCHARGE STATUS
Mortality varied significantly, being lowest in those who underwent ORIF (0.8%), followed those who underwent THA (1.8%), and HA (2.6%) (P < .001, Table 1).
The majority of patients in each group were discharged to long-term rehabilitation facilities, including 53.0% of those treated with HA, 40.4% of those treated with ORIF, and 44.3% of patients treated with THA. The second most common discharge location was home, which included 14.8% of patients who underwent HA, 32.2% of patients treated with ORIF, and 20.8% of those who underwent THA. Table 3 demonstrates the details of the discharge settings.
Mortality analysis over time demonstrated a significant decrease in each treatment group (P < .001). Mortality in the ORIF group decreased from 1.2% during 1990 to 1995 to 0.8% in 2002 to 2007. Mortality in the THA group also decreased significantly from 0.8% during 1990 to 1995 to 0.5% during the 2002 to 2007 time period. Patients who underwent HA also exhibited a decrease in mortality rate from 3.3% during 1990 to 1995 to 2.2% during 2002 to 2007 (P < .001, Table 4, Figure 2).
GENERAL ADVERSE EVENTS
There was a significant difference (P < .001) in the percentage of adverse events experienced, the maximum being observed in the THA group (41.0%), followed by the HA group (37.9%) and trailed by the ORIF group (20.3%, (P < .001, Table 1). The prevalence of adverse events is detailed in Table 5.
Continue to: Patients who underwent THA...
Patients who underwent THA had the highest rate of any adverse event, LOS, and transfusion rate (Table 1 and Table 5).
The prevalence of postoperative pneumonia was highest in the HA group (3.4%), followed by the ORIF group (2.9%), and the THA group (2.6%) (P < .001, Table 5). There was also a significant difference in rates of intubation, pulmonary insufficiency, acute renal failure, pulmonary embolism, acute myocardial infarction, induced mental disorder, and deep venous thrombosis (P < .001 for all, Table 5).
SURGERY-RELATED ADVERSE EVENTS
Surgery-related outcomes over the entire study period were significantly different according to the type of procedure performed (P < .001, Table 5). Patients who underwent HA had the highest rate of acute postoperative anemia (20.2%), followed by those who underwent THA (19.7%), and ORIF (10.2%). Postoperative bleeding rates also varied significantly, with 1.2% in the HA group, followed by 1.0% in the ORIF group and 0.4% in the THA group (P < .001, Table 5). Acute postoperative infection rates also varied significantly, with the highest rate being observed in the HA group (0.6%) compared to that in the THA and ORIF groups (both 0.3%) (P < .001, Table 5).
Table 6, Table 7, and Table 8 detail the results of regression analyses in patients with femoral neck fractures for individual risk factors associated with mortality, any adverse event, and nonroutine discharge to a short- or long-term rehabilitation facility, respectively. Increasing age (50–64 years, OR: 0.238; 65–79 years, OR: 1.762; and ≥80 years, OR: 2.700), THA (OR: 1.743), and HA (OR: 2.574) were found to be independent risk factors for mortality in the perioperative period (P < .001 for each, Table 6). Increasing age (50–64 years, OR: 1.888; 65–79 years, OR: 2.983; and ≥80 years, OR: 3.722), THA (OR: 2.489), and HA (OR: 2.098) were also found to be independent risk factors for any adverse event in the perioperative period (P < .001, Table 7). Age (50–64 years, OR: 1.662; 65–79 years, OR: 4.320; and ≥80 years, OR: 7.102) was the best predictor for nonroutine discharge to a short- or long-term rehabilitation facility (P < .001, Table 8).
DISCUSSION
Femoral neck fractures in the elderly population present a significant financial burden to the healthcare system.1-3,24,25 Consistent with previous epidemiological studies, our results show that the femoral neck fracture population has become older and has more medical comorbidities over the last 3 decades.27,28. Similarly, we also found that the rate of medical, surgical, and mechanical perioperative complications has increased in the same time period. Interestingly, the mortality rate has remained relatively similar.
Continue to: Although patients undergoing HA...
Although patients undergoing HA for femoral neck fractures are older and have more medical comorbidities, we found that the rate of adverse events in the perioperative period for patients undergoing THA was higher than that in the HA group. Consistent with prior studies, patients who underwent THA had higher rates of blood transfusion, pulmonary embolism, and induced mental disorders.34 Multivariable regression analysis demonstrated that after controlling for age, medical comorbidity, and type of surgery performed, THA emerged as an independent risk factor for any adverse event in the perioperative period. Increased anesthesia time, reaming of the acetabulum, and increased complexity of surgery probably account for these changes.
Our study results are consistent with those of Jain and colleagues,30 which showed a decrease in utilization of THA for femoral neck fractures between 1990 and 2001. Since THA is generally indicated for younger, more active patients in relatively good health, this would explain why changes in baseline health in this cohort over the last 20 years would lead to fewer THA procedures being performed. Surgeons in the US may be finding there are fewer patients who are candidates for THA. Miller and colleagues5 reported conflicting results and showed an increase in THA utilization in this patient population. However, their study evaluated treatment trends based on data from the ABOS part II of recently graduated orthopedic surgeons and may not be an accurate representation of national practice trends in the US. The trend toward increased subspecialization may explain their findings. As the authors noted, although they found an increase in the use of THA for femoral neck fractures by new adult reconstruction surgeons, the percentage of new surgeons treating femoral neck fractures has declined.5
Our analysis showed very concrete trends in treatment management at the extremes of the age ranges. There were substantial increases in the use of ORIF for patients <50 years (from 63.9% in 1990–1995 to 81.4% in 2002–2007, P < .001) and in the use of HA for patients >80 years (from 74.4% in 1990–1995 to 84.6% in 2002–2007, P < .001). This trend parallels recent studies that purport better outcomes for young patients undergoing ORIF and elderly patients undergoing HA.30 Our analysis did not demonstrate a large shift in surgeon preference for treatment of patients between 50 and 80 years, although there was a statistically significant decrease in ORIF and THA usage and a reflective increase in HA usage in this population as well. The fact that there has not been as substantial a shift in treatment trends for this large age group is potentially due to the wide variations in comorbid conditions and the functionality that abounds in this age group.1
The limitations of the current study are those inherent with a retrospective database analysis. The reliance on accurate coding brings up a potential for error; however, it is unlikely that comorbidities and outcomes are undercoded as hospitals are incentivized to input values that increase the acuity and thus reimbursement for each hospital stay.35 The database also relies on the ICD-9 procedural and diagnostic codes, which are not as specific as the currently adopted ICD-10 codes; hence, we are unable to distinguish between different forms of internal fixation, for example intramedullary nailing versus dynamic hip screw. This also precludes us from including other critical data such as degree of fracture displacement, cemented versus uncemented implantation, surgical approach for arthroplasty, and functional outcomes of individual patients. Moreover, the database used, although the largest inpatient sample available for analysis, represents only approximately 20% of hospitals nationwide. In addition, as patients cannot be tracked over time within the database, we are limited to outcomes in the perioperative period captured in a single hospital stay and cannot identify readmissions. Finally, our analysis is limited to the years 1990 to 2007 because of an increase in the relative standard error of the database in more recent years. Although this results in data that are not the most current, we believe that this study provides valuable insight regarding the trends in surgical treatment and acute postoperative outcomes of these injuries that have hitherto not been reported. To limit the inherent biases and the limitations within this study, prospective, randomized studies with long-term follow-up comparing outcomes across modes of treatment are needed to definitively determine the optimum form of treatment for this fracture type.
CONCLUSION
This is the largest study to date reporting on national trends in the surgical treatment and outcomes of the femoral neck fracture population. Orthopedic surgeons performing THA should be aware that the femoral neck fracture population is changing and at higher risk for perioperative complications. The advent of bisphosphonate therapy has been suggested as a possible reason for the decrease in fragility fractures and why a larger proportion of the femoral neck fracture population is now >80 years.36,37 With an aging population at a higher risk for perioperative complications, clinicians must take special care in choosing the appropriate surgical intervention that will give their patients the best functional outcome while minimizing the risk of surgical complications. Orthopedic surgeons should weigh the added risk associated with THA in this population.
1. Bishop J, Yang A, Githens M, Sox AH. Evaluation of contemporary trends in femoral neck fracture management reveals discrepancies in treatment. Geriatr Orthop Surg Rehabil. 2016;7(3):135. doi:10.1177/2151458516658328.
2. Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res Off J Am Soc Bone Miner Res. 2007;22(3):465. doi:10.1359/jbmr.061113.
3. Kannus P, Parkkari J, Sievanen H, Heinonen A, Vuori I, Jarvinen M. Epidemiology of hip fractures. Bone. 1996;18(1 Suppl.):57s. doi:10.1016/8756-3282(95)00381-9.
4. Koval KJ, Zuckerman JD. Hip fractures: I. Overview and evaluation and treatment of femoral-neck fractures. J Am Acad Orthop Surg. 1994;2(3):141. doi:10.5435/00124635-199405000-00002.
5. Miller BJ, Callaghan JJ, Cram P, Karam M, Marsh JL, Noiseux NO. Changing trends in the treatment of femoral neck fractures: a review of the American Board of Orthopaedic Surgery database. J Bone Joint Surg. (American) 2014;96(17):e149. doi:10.2106/JBJS.M.01122.
6. Miller BJ, Lu X, Cram P. The trends in treatment of femoral neck fractures in the Medicare population from 1991 to 2008. J Bone Joint Surg. (American) 2013;95(18):e132. doi:10.2106/JBJS.L.01163.
7. Nwachukwu BU, McCormick F, Provencher MT, Roche M, Rubash HE. A comprehensive analysis of Medicare trends in utilization and hospital economics for total knee and hip arthroplasty from 2005 to 2011. J Arthroplast. 2015;30(1):15. doi:10.1016/j.arth.2014.08.025.
8. Su EP, Su SL. Femoral neck fractures: a changing paradigm. Bone Joint J. 2014;96-b(11) Supple A):43. doi:10.1302/0301-620X.96B11.34334.
9. Ahn J, Man LX, Park S, Sodl JF, Esterhai JL. Systematic review of cemented and uncemented hemiarthroplasty outcomes for femoral neck fractures. Clin Orthop Relat Res. 2008;466(10):2513. doi:10.1007/s11999-008-0368-3.
10. Alolabi B, Bajammal S, Shirali J, Karanicolas PJ, Gafni A, Bhandari M. Treatment of displaced femoral neck fractures in the elderly: a cost-benefit analysis. J Orthop Trauma. 2009;23(6):442. doi:10.1097/BOT.0b013e31817614dd.
11. Bentler SE, Liu L, Obrizan M, et al. The aftermath of hip fracture: discharge placement, functional status change, and mortality. Am J Epidemiol. 2009;170(10):1290. doi:10.1093/aje/kwp266.
12. Brox WT, Chan PH, Cafri G, Inacio MC. Similar mortality with general or regional anesthesia in elderly hip fracture patients. Acta Orthop. 2016;87(2):152. doi:10.3109/17453674.2015.1128781.
13. Catal B, Sener M. Treatment and displacement affect the reoperation rate for femoral neck fracture. Clin Orthop Relat Res. 2013;471(12):4096. doi:10.1007/s11999-013-3295-x.
14. Dailiana Z, Papakostidou I, Varitimidis S, Michalitsis S, Veloni A, Malizos K. Surgical treatment of hip fractures: factors influencing mortality. Hippokratia. 2013;17(3):252.
15. Deangelis JP, Ademi A, Staff I, Lewis CG. Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures: a prospective randomized trial with early follow-up. J Orthop Trauma. 2012;26(3):135. doi:10.1097/BOT.0b013e318238b7a5.
16. Hedbeck CJ, Inngul C, Blomfeldt R, Ponzer S, Tornkvist H, Enocson A. Internal fixation versus cemented hemiarthroplasty for displaced femoral neck fractures in patients with severe cognitive dysfunction: a randomized controlled trial. J Orthop Trauma. 2013;27(12):690. doi:10.1097/BOT.0b013e318291f544.
17. Jia Z, Ding F, Wu Y, et al. Unipolar versus bipolar hemiarthroplasty for displaced femoral neck fractures: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res. 2015;10:8. doi:10.1186/s13018-015-0165-0.
18. Lapidus LJ, Charalampidis A, Rundgren J, Enocson A. Internal fixation of garden I and II femoral neck fractures: posterior tilt did not influence the reoperation rate in 382 consecutive hips followed for a minimum of 5 years. J Orthop Trauma. 2013;27(7):386. doi:10.1097/BOT.0b013e318281da6e.
19. Mariconda M, Costa GG, Cerbasi S, et al. Factors predicting mobility and the change in Activities of Daily Living After hip fracture: A 1-year prospective cohort study. J Orthop Trauma. 2016;30(2):71. doi:10.1097/BOT.0000000000000448.
20. Nyholm AM, Gromov K, Palm H, et al. Time to surgery is associated with thirty-day and ninety-day mortality After proximal femoral fracture: A retrospective observational study on prospectively collected data from the Danish Fracture Database Collaborators. J Bone Joint Surg. (American) 2015;97(16):1333. doi:10.2106/JBJS.O.00029.
21. Samuel AM, Russo GS, Lukasiewicz AM, et al. Surgical treatment of femoral neck fractures after 24 hours in patients between the ages of 18 and 49 is associated with poor inpatient outcomes: an analysis of 1361 patients in the National Trauma Data Bank. J Orthop Trauma. 2016;30(2):89. doi:10.1097/BOT.0000000000000456.
22. Yu L, Wang Y, Chen J. Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures: meta-analysis of randomized trials. Clin Orthop Relat Res. 2012;470(8):2235. doi:10.1007/s11999-012-2293-8.
23. Zi-Sheng A, You-Shui G, Zhi-Zhen J, Ting Y, Chang-Qing Z. Hemiarthroplasty vs primary total hip arthroplasty for displaced fractures of the femoral neck in the elderly: a meta-analysis. J Arthroplast. 2012;27(4):583. doi:10.1016/j.arth.2011.07.009.
24. Zielinski SM, Keijsers NL, Praet SF, et al. Functional outcome after successful internal fixation versus salvage arthroplasty of patients with a femoral neck fracture. J Orthop Trauma. 2014;28(12):e273. doi:10.1097/BOT.0000000000000123.
25. Gu Q, Koenig L, Mather RC, 3rd, Tongue J. Surgery for hip fracture yields societal benefits that exceed the direct medical costs. Clin Orthop Relat Res. 2014;472(11):3536. doi:10.1007/s11999-014-3820-6.
26. Forsh DA, Ferguson TA. Contemporary management of femoral neck fractures: the young and the old. Curr Rev Musculoskelet Med. 2012;5(3):214. doi:10.1007/s12178-012-9127-x.
27. Macaulay W, Pagnotto MR, Iorio R, Mont MA, Saleh KJ. Displaced femoral neck fractures in the elderly: hemiarthroplasty versus total hip arthroplasty. J Am Acad Orthop Surg. 2006;14(5):287. doi:10.5435/00124635-200605000-00004.
28. Miyamoto RG, Kaplan KM, Levine BR, Egol KA, Zuckerman JD. Surgical management of hip fractures: an evidence-based review of the literature. I: Femoral neck fractures. J Am Acad Orthop Surg. 2008;16(10):596. doi:10.5435/00124635-200810000-00005.
29. Probe R, Ward R. Internal fixation of femoral neck fractures. J Am Acad Orthop Surg. 2006;14(9):565. doi:10.5435/00124635-200609000-00006.
30. Jain NB, Losina E, Ward DM, Harris MB, Katz JN. Trends in surgical management of femoral neck fractures in the United States. Clin Orthop Relat Res. 2008;466(12):3116. doi:10.1007/s11999-008-0392-3.
31. Menendez ME, Neuhaus V, van Dijk CN, Ring D. The Elixhauser comorbidity method outperforms the Charlson index in predicting inpatient death after orthopaedic surgery. Clin Orthop Relat Res. 2014;472(9):2878. doi:10.1007/s11999-014-3686-7.
32. Van Walraven C, Austin PC, Jennings A, Quan H, Forster AJ. A modification of the Elixhauser Comorbidity measures into a point system for hospital death using administrative data. Med Care. 2009;47(6):626-633.
33. Best MJ, Buller LT, Falakassa J, Vecchione D. Risk factors for nonroutine discharge in patients undergoing spinal fusion for intervertebral disc disorders. Iowa Orthop J. 2015;35:147.
34. Schairer WW, Lane JM, Halsey DA, Iorio R, Padgett DE, McLawhorn AS. The Frank Stinchfield award: total hip arthroplasty for femoral neck fracture is not a typical DRG 470: A propensity-matched cohort study. Clin Orthop Relat Res. 2017;475(2):353-360. doi:10.1007/s11999-016-4868-2.
35. Nikkel LE, Fox EJ, Black KP, Davis C, Andersen L, Hollenbeak CS. Impact of comorbidities on hospitalization costs following hip fracture. J Bone Joint Surg Am. 2012;94(1):9. doi:10.2106/JBJS.J.01077.
36. Bilezikian JP. Efficacy of bisphosphonates in reducing fracture risk in postmenopausal osteoporosis. Am J Med. 2009;122(2 Suppl.):S14. doi:10.1016/j.amjmed.2008.12.003.
37. Siris ES, Pasquale MK, Wang Y, Watts NB. Estimating bisphosphonate use and fracture reduction among US women aged 45 years and older, 2001-2008. J Bone Miner Res Off J Am Soc Bone Miner Res. 2011;26(1):3. doi:10.1002/jbmr.189.
ABSTRACT
The ideal mode of fixation for patients with femoral neck fractures is not well defined in the current literature. This study describes the recent trends in surgical management of femoral neck fractures with an analysis on perioperative outcomes.
The National Hospital Discharge Survey was used to identify femoral neck fractures in the United States between 1990 and 2007 (n = 1,155,960) treated with open reduction and internal fixation (ORIF), total hip arthroplasty (THA), or hemiarthroplasty (HA). Trends were examined over the following 3 time periods: 1990 to 1995 (group 1), 1996 to 2001 (group 2), and 2002 to 2007 (group 3). Elixhauser Comorbidity Index and perioperative complications were calculated.
Use of HA increased (74.4% to 84.6%), whereas that of THA (7.3% to 4.9%) and ORIF (18.3% to 10.6%) decreased, from group 1 to group 3 in the age group of >80 years. The use of ORIF increased (63.9% to 81.4%), whereas the use of both HA and THA decreased, from group 1 to group 3 in the age group of <50 years. The rate of adverse events increased across all fixation types but was greatest among THA (32.2% to 48.3%).
The femoral neck patient population is now older and has more medical comorbidities. We observed a trend toward performing HA in older patients and ORIF in younger patients. Despite superior functional outcomes reported in THA, this study found a decreased utilization of THA in all age groups along with an increase in adverse events and nonroutine discharges for patients with femoral neck fractures treated with THA.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Continue to: Femoral neck fractures...
Femoral neck fractures are a common occurrence in the United States. A recent study estimated an incidence of >63 per 100,000 population.1-8 Although the incidence appears to have decreased over recent decades, there is a projected exponential increase in the incidence of hip fractures over the next 30 years in the baby boomer population.8,9 Given that these fractures have a significant impact on patient morbidity, mortality, and quality of life, research efforts have been directed toward optimizing the treatment of affected patients and improving the outcomes.4,9-24
The treatment of choice for femoral neck fractures and the use of total hip arthroplasty (THA)11 have been a topic of debate.4,9,10,15-17,22,25 Total hip arthroplasty has been advocated for younger, more active patients, whereas hemiarthroplasty (HA) has been reserved for patients who are older and less active. Although several studies have demonstrated that arthroplasty outperforms open reduction and internal fixation (ORIF) in the elderly population with displaced femoral neck fractures, ORIF is still commonly performed in the United States for nondisplaced fractures and in patients aged <50 years.26-29
In an attempt to quantify the use of THA in the treatment of femoral neck fractures and demonstrate the national trends, Miller and colleagues5 pooled the American Board of Orthopaedic Surgery (ABOS) database and analyzed the treatment trends of surgeons taking part II of the ABOS examination from 1999 to 2011. The authors found an increased utilization of THA by recently graduated orthopedic surgeons. In contrast, Jain and colleagues30 found different national trends when they analyzed data from the National Inpatient Sample containing data between 1990 and 2001 and further found decreased utilization of THA procedures by orthopedic surgeons of all levels of training nationwide. However, neither of these studies reported about the trends in demographics, comorbidities, risk factors, or outcomes in this patient population following surgery.
The purpose of this study was to help clarify the findings of these authors using the largest dataset to date and also report on the perioperative complications associated with each mode of fixation in patients who undergo operative treatment for femoral neck fractures in the United States. Our hypotheses were that the femoral neck fracture patient population has become older and has more medical comorbidities. We also hypothesized that there has been a trend toward performing fewer THA procedures in the United States and that THA is associated with increased perioperative complications compared to those with HA and ORIF.
MATERIALS AND METHODS
We conducted a retrospective epidemiological study using the National Hospital Discharge Survey (NHDS) on surgical trends in the management of femoral neck fractures. The NHDS is a publicly available survey that is conducted annually to provide data of nonfederal, short-stay hospitals to the public. The sample data are weighted to provide nationwide estimates of annual inpatient care. The NHDS includes up to 7 medical diagnoses and 4 procedural codes per case, which are categorized using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, that were collected along with patient demographic information, length of stay (LOS), and discharge disposition. The diagnostic and procedural codes used for this study are presented in the Appendix. The year 2007 was chosen as the endpoint of this study due to the fact that the relative standard error of the NHDS doubled in 2008 as a result of a decrease in its survey size. As this is a publicly available database, our study was exempt from institutional review board approval.
Continue to: All pateints admitted...
All patients admitted with a primary diagnosis of closed transcervical fracture of the femoral neck (ICD-9-CM 820.0x) were selected. This resulted in 1,674,160 fractures. All patients with fractures with a concurrent primary procedural code of ORIF (79.35), HA (81.52), or THA (81.51) were identified, resulting in a total sample size of 1,155,960 surgical fractures. Analysis of the fractures based on additional specificity,ie subcapital versus midcervical versus basicervical, was not carried out because >90% of femoral neck fractures in the database were coded as “unspecified” or “other” (ICD9 CM 820.00 and 820.09, respectively).
Comorbidity burden was quantified using Elixhauser coding algorithms as previously described.31 The Elixhauser comorbidity measure is a model consisting of 31 conditions and has recently been identified as a better predictor of mortality in patients undergoing orthopedic procedures when compared with the Charlson Comorbidity Index.31 Dichotomous variables for each Elixhauser comorbidity were created, and χ2 tests were utilized to assess the association between each comorbidity and mortality. The weighted Elixhauser score for each statistically significant comorbidity was calculated as described by van Walraven and colleagues.32 The Elixhauser comorbidity score was then calculated for each patient by summing the individual weights of all comorbidities. Postoperative adverse events were determined using the complication-screening-package as previously described.33
All adverse events were categorized into 3 categories, including general medical complications, mechanical complications, and surgical complications. All adverse events recorded in the NHDS database are events that occurred during a single hospitalization. Therefore, it does not take into account adverse events that occurred after discharge, and, for example, mortality refers to postoperative mortality that occurs prior to discharge. The study period comprised data captured from 1990 to 2007, and 3 groups were generated from this time period to better characterize patients throughout the large study time frame. Group 1 comprised patients who underwent surgical management of femoral neck fractures from 1990 to 1995, group 2 consisted of patients treated from 1996 to 2001, and group 3 included patients treated from 2002 to 2007.
Categorical data were analyzed using the χ2 test, and continuous data were analyzed by the independent-samples t test and ANOVA. Multivariable binary logistic regression analyses were performed to assess the contributions of individual comorbidities to mortality, adverse events, and nonroutine discharge. Elixhauser comorbidities with a P value of < .10 in the bivariate analysis and presenting in at least 0.2% of the population were included in the logistic regression.31 Odds ratios and confidence intervals were calculated to assess the association between comorbidities and our dichotomous variables. A P value of < .001 defined statistical significance.33 Statistical analysis was conducted using SPSS version 21 (IBM).
RESULTS
Patient Demographics
Our query demonstrated a total of 1,155,960 patients who underwent surgical fixation of femoral neck fractures (Table 1). The most commonly used treatment modality was HA (75%), followed by ORIF (18%) and later by THA (7%). The majority of patients were females in each treatment group. Patients’ age varied according to treatment group, with patients undergoing HA having a mean age of 81.0 ± 9.0 years, patients undergoing ORIF having a mean age of 75.0 ± 17.0 years, and those undergoing THA having a mean age of 79.0 ± 10.0 years (P < .001). The majority of patients were ≥80 years in all treatment groups, but the ORIF group had the greatest proportion of patients <65 years (P < .001). Among patients undergoing HA, 62.4% were ≥80 years, while the ORIF and HA groups consisted of 48.6% and 51.5% of patients in that same age group, respectively.
Continue to: TRENDS ANALYSIS
TRENDS ANALYSIS
There was a significant change in the distributions of the procedures performed according to age group over time. Patients >80 years continued to undergo primarily HA, with an increase from 74.4% during 1990 to 1995 up to 84.6% during the 2002 to 2007 period and a concomitant decrease in ORIF from 18.3% to 10.6% during the same time period in this age group. Surgical trends in patients 65 to 79 years demonstrated a significant decrease in management with ORIF from 19.1% in 1990 to 1995 to 16.8% in the 2002 to 2007 cohort (P < .001 for all, Table 2). There was an increase in the use of HA from 71.9% during the 1990 to 1995 period to 75.5% during the final study period (Table 2, Figure 1). The use of THA for all age groups decreased between 1990 and 2007, except for the 50- to 64-year-old group where THA utilization remained constant.
Management patterns in patients 50 to 64 years varied throughout the analysis and demonstrated the following trend: treatment with HA remained the most common technique used but varied slightly from 59.7% during 1990 to 1995 to 60.3% during 2002 to2007 (P < .001, Table 2). The second most common treatment used was ORIF, which decreased from 32.2% to 31.5% (P < .001, Table 2). The use of THA varied significantly from 8.2% among those managed during 1990 to 1995 to 11.7% during 1996 to 2001 but later declined to the initial 8.2% (P < .001, Table 2).
Analysis of patients ≤49 years demonstrated that ORIF was the preferred technique, which experienced a growth from 63.9% during 1990 to 1995 to 81.4% during the 2002 to 2007 period (P < .001, Table 2). A decreased use in THA was observed from 2.0% in the initial period to 0.6% in the final period (P < .001, Table 2). Use of HA decreased from 34.0% in 1990 to 1995 to 18.0% in 2002 to 2007 (P < .001, Table 2).
LENGTH OF STAY
Mean number of in-hospital days decreased throughout the study period for all treatment techniques. During the 1990 to 1995 study period, patients who underwent ORIF had a mean LOS of 8 ± 7 days, which decreased (P < .001, Table 2) to 6 ± 3 days in 1996 to 2001 and remained constant during 2002 to 2007 (mean 6 ± 4 days). This decrease in LOS was also observed in patients who underwent THA (P < .001, Table 2), who initially had a mean LOS of 11 ± 7 days during 1990 to 1995, which later decreased to 7 ± 5 days for the remainder of the study. The LOS for patients who underwent HA also decreased (P < .001, Table 2), which initially was reported to be 11 ± 11 days during 1990 to 1995, decreasing to 7 ±7 days in 1996–2001 and later to 6 ± 4 days in 2002 to 2007.
COMORBIDITIY ANALYSIS
The Elixhauser Comorbidity Index varied significantly among groups over time (P < .001, Table 2). Overall mean Elixhauser Comorbidity Index score per procedure type is provided in Table 1, with HA patients having the highest score (-0.15 ± 13.09, p<.001).
Continue to: Analysis of the preoperative comorbidities...
Analysis of the preoperative comorbidities demonstrated significant differences among each surgical treatment group (P < .001 for all, Table 3). The most common comorbidities in patients who underwent HA were uncomplicated hypertension (33.2%), fluid/electrolyte disorders (17.4%), chronic pulmonary disease (14.9%), and congestive heart failure (13.7%). The most common comorbidities in the ORIF group were uncomplicated hypertension (30.8%), fluid/electrolyte disorders (14.5%), chronic pulmonary disease (14.0%), and uncomplicated diabetes (10.9%). Patients treated with THA had most commonly uncomplicated hypertension (30.1%), fluid/electrolyte disorders (17.2%), uncomplicated diabetes (15.5%), and chronic pulmonary disease (14.4%). The prevalence of comorbidities is displayed in Table 3.
DISCHARGE STATUS
Mortality varied significantly, being lowest in those who underwent ORIF (0.8%), followed those who underwent THA (1.8%), and HA (2.6%) (P < .001, Table 1).
The majority of patients in each group were discharged to long-term rehabilitation facilities, including 53.0% of those treated with HA, 40.4% of those treated with ORIF, and 44.3% of patients treated with THA. The second most common discharge location was home, which included 14.8% of patients who underwent HA, 32.2% of patients treated with ORIF, and 20.8% of those who underwent THA. Table 3 demonstrates the details of the discharge settings.
Mortality analysis over time demonstrated a significant decrease in each treatment group (P < .001). Mortality in the ORIF group decreased from 1.2% during 1990 to 1995 to 0.8% in 2002 to 2007. Mortality in the THA group also decreased significantly from 0.8% during 1990 to 1995 to 0.5% during the 2002 to 2007 time period. Patients who underwent HA also exhibited a decrease in mortality rate from 3.3% during 1990 to 1995 to 2.2% during 2002 to 2007 (P < .001, Table 4, Figure 2).
GENERAL ADVERSE EVENTS
There was a significant difference (P < .001) in the percentage of adverse events experienced, the maximum being observed in the THA group (41.0%), followed by the HA group (37.9%) and trailed by the ORIF group (20.3%, (P < .001, Table 1). The prevalence of adverse events is detailed in Table 5.
Continue to: Patients who underwent THA...
Patients who underwent THA had the highest rate of any adverse event, LOS, and transfusion rate (Table 1 and Table 5).
The prevalence of postoperative pneumonia was highest in the HA group (3.4%), followed by the ORIF group (2.9%), and the THA group (2.6%) (P < .001, Table 5). There was also a significant difference in rates of intubation, pulmonary insufficiency, acute renal failure, pulmonary embolism, acute myocardial infarction, induced mental disorder, and deep venous thrombosis (P < .001 for all, Table 5).
SURGERY-RELATED ADVERSE EVENTS
Surgery-related outcomes over the entire study period were significantly different according to the type of procedure performed (P < .001, Table 5). Patients who underwent HA had the highest rate of acute postoperative anemia (20.2%), followed by those who underwent THA (19.7%), and ORIF (10.2%). Postoperative bleeding rates also varied significantly, with 1.2% in the HA group, followed by 1.0% in the ORIF group and 0.4% in the THA group (P < .001, Table 5). Acute postoperative infection rates also varied significantly, with the highest rate being observed in the HA group (0.6%) compared to that in the THA and ORIF groups (both 0.3%) (P < .001, Table 5).
Table 6, Table 7, and Table 8 detail the results of regression analyses in patients with femoral neck fractures for individual risk factors associated with mortality, any adverse event, and nonroutine discharge to a short- or long-term rehabilitation facility, respectively. Increasing age (50–64 years, OR: 0.238; 65–79 years, OR: 1.762; and ≥80 years, OR: 2.700), THA (OR: 1.743), and HA (OR: 2.574) were found to be independent risk factors for mortality in the perioperative period (P < .001 for each, Table 6). Increasing age (50–64 years, OR: 1.888; 65–79 years, OR: 2.983; and ≥80 years, OR: 3.722), THA (OR: 2.489), and HA (OR: 2.098) were also found to be independent risk factors for any adverse event in the perioperative period (P < .001, Table 7). Age (50–64 years, OR: 1.662; 65–79 years, OR: 4.320; and ≥80 years, OR: 7.102) was the best predictor for nonroutine discharge to a short- or long-term rehabilitation facility (P < .001, Table 8).
DISCUSSION
Femoral neck fractures in the elderly population present a significant financial burden to the healthcare system.1-3,24,25 Consistent with previous epidemiological studies, our results show that the femoral neck fracture population has become older and has more medical comorbidities over the last 3 decades.27,28. Similarly, we also found that the rate of medical, surgical, and mechanical perioperative complications has increased in the same time period. Interestingly, the mortality rate has remained relatively similar.
Continue to: Although patients undergoing HA...
Although patients undergoing HA for femoral neck fractures are older and have more medical comorbidities, we found that the rate of adverse events in the perioperative period for patients undergoing THA was higher than that in the HA group. Consistent with prior studies, patients who underwent THA had higher rates of blood transfusion, pulmonary embolism, and induced mental disorders.34 Multivariable regression analysis demonstrated that after controlling for age, medical comorbidity, and type of surgery performed, THA emerged as an independent risk factor for any adverse event in the perioperative period. Increased anesthesia time, reaming of the acetabulum, and increased complexity of surgery probably account for these changes.
Our study results are consistent with those of Jain and colleagues,30 which showed a decrease in utilization of THA for femoral neck fractures between 1990 and 2001. Since THA is generally indicated for younger, more active patients in relatively good health, this would explain why changes in baseline health in this cohort over the last 20 years would lead to fewer THA procedures being performed. Surgeons in the US may be finding there are fewer patients who are candidates for THA. Miller and colleagues5 reported conflicting results and showed an increase in THA utilization in this patient population. However, their study evaluated treatment trends based on data from the ABOS part II of recently graduated orthopedic surgeons and may not be an accurate representation of national practice trends in the US. The trend toward increased subspecialization may explain their findings. As the authors noted, although they found an increase in the use of THA for femoral neck fractures by new adult reconstruction surgeons, the percentage of new surgeons treating femoral neck fractures has declined.5
Our analysis showed very concrete trends in treatment management at the extremes of the age ranges. There were substantial increases in the use of ORIF for patients <50 years (from 63.9% in 1990–1995 to 81.4% in 2002–2007, P < .001) and in the use of HA for patients >80 years (from 74.4% in 1990–1995 to 84.6% in 2002–2007, P < .001). This trend parallels recent studies that purport better outcomes for young patients undergoing ORIF and elderly patients undergoing HA.30 Our analysis did not demonstrate a large shift in surgeon preference for treatment of patients between 50 and 80 years, although there was a statistically significant decrease in ORIF and THA usage and a reflective increase in HA usage in this population as well. The fact that there has not been as substantial a shift in treatment trends for this large age group is potentially due to the wide variations in comorbid conditions and the functionality that abounds in this age group.1
The limitations of the current study are those inherent with a retrospective database analysis. The reliance on accurate coding brings up a potential for error; however, it is unlikely that comorbidities and outcomes are undercoded as hospitals are incentivized to input values that increase the acuity and thus reimbursement for each hospital stay.35 The database also relies on the ICD-9 procedural and diagnostic codes, which are not as specific as the currently adopted ICD-10 codes; hence, we are unable to distinguish between different forms of internal fixation, for example intramedullary nailing versus dynamic hip screw. This also precludes us from including other critical data such as degree of fracture displacement, cemented versus uncemented implantation, surgical approach for arthroplasty, and functional outcomes of individual patients. Moreover, the database used, although the largest inpatient sample available for analysis, represents only approximately 20% of hospitals nationwide. In addition, as patients cannot be tracked over time within the database, we are limited to outcomes in the perioperative period captured in a single hospital stay and cannot identify readmissions. Finally, our analysis is limited to the years 1990 to 2007 because of an increase in the relative standard error of the database in more recent years. Although this results in data that are not the most current, we believe that this study provides valuable insight regarding the trends in surgical treatment and acute postoperative outcomes of these injuries that have hitherto not been reported. To limit the inherent biases and the limitations within this study, prospective, randomized studies with long-term follow-up comparing outcomes across modes of treatment are needed to definitively determine the optimum form of treatment for this fracture type.
CONCLUSION
This is the largest study to date reporting on national trends in the surgical treatment and outcomes of the femoral neck fracture population. Orthopedic surgeons performing THA should be aware that the femoral neck fracture population is changing and at higher risk for perioperative complications. The advent of bisphosphonate therapy has been suggested as a possible reason for the decrease in fragility fractures and why a larger proportion of the femoral neck fracture population is now >80 years.36,37 With an aging population at a higher risk for perioperative complications, clinicians must take special care in choosing the appropriate surgical intervention that will give their patients the best functional outcome while minimizing the risk of surgical complications. Orthopedic surgeons should weigh the added risk associated with THA in this population.
ABSTRACT
The ideal mode of fixation for patients with femoral neck fractures is not well defined in the current literature. This study describes the recent trends in surgical management of femoral neck fractures with an analysis on perioperative outcomes.
The National Hospital Discharge Survey was used to identify femoral neck fractures in the United States between 1990 and 2007 (n = 1,155,960) treated with open reduction and internal fixation (ORIF), total hip arthroplasty (THA), or hemiarthroplasty (HA). Trends were examined over the following 3 time periods: 1990 to 1995 (group 1), 1996 to 2001 (group 2), and 2002 to 2007 (group 3). Elixhauser Comorbidity Index and perioperative complications were calculated.
Use of HA increased (74.4% to 84.6%), whereas that of THA (7.3% to 4.9%) and ORIF (18.3% to 10.6%) decreased, from group 1 to group 3 in the age group of >80 years. The use of ORIF increased (63.9% to 81.4%), whereas the use of both HA and THA decreased, from group 1 to group 3 in the age group of <50 years. The rate of adverse events increased across all fixation types but was greatest among THA (32.2% to 48.3%).
The femoral neck patient population is now older and has more medical comorbidities. We observed a trend toward performing HA in older patients and ORIF in younger patients. Despite superior functional outcomes reported in THA, this study found a decreased utilization of THA in all age groups along with an increase in adverse events and nonroutine discharges for patients with femoral neck fractures treated with THA.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Continue to: Femoral neck fractures...
Femoral neck fractures are a common occurrence in the United States. A recent study estimated an incidence of >63 per 100,000 population.1-8 Although the incidence appears to have decreased over recent decades, there is a projected exponential increase in the incidence of hip fractures over the next 30 years in the baby boomer population.8,9 Given that these fractures have a significant impact on patient morbidity, mortality, and quality of life, research efforts have been directed toward optimizing the treatment of affected patients and improving the outcomes.4,9-24
The treatment of choice for femoral neck fractures and the use of total hip arthroplasty (THA)11 have been a topic of debate.4,9,10,15-17,22,25 Total hip arthroplasty has been advocated for younger, more active patients, whereas hemiarthroplasty (HA) has been reserved for patients who are older and less active. Although several studies have demonstrated that arthroplasty outperforms open reduction and internal fixation (ORIF) in the elderly population with displaced femoral neck fractures, ORIF is still commonly performed in the United States for nondisplaced fractures and in patients aged <50 years.26-29
In an attempt to quantify the use of THA in the treatment of femoral neck fractures and demonstrate the national trends, Miller and colleagues5 pooled the American Board of Orthopaedic Surgery (ABOS) database and analyzed the treatment trends of surgeons taking part II of the ABOS examination from 1999 to 2011. The authors found an increased utilization of THA by recently graduated orthopedic surgeons. In contrast, Jain and colleagues30 found different national trends when they analyzed data from the National Inpatient Sample containing data between 1990 and 2001 and further found decreased utilization of THA procedures by orthopedic surgeons of all levels of training nationwide. However, neither of these studies reported about the trends in demographics, comorbidities, risk factors, or outcomes in this patient population following surgery.
The purpose of this study was to help clarify the findings of these authors using the largest dataset to date and also report on the perioperative complications associated with each mode of fixation in patients who undergo operative treatment for femoral neck fractures in the United States. Our hypotheses were that the femoral neck fracture patient population has become older and has more medical comorbidities. We also hypothesized that there has been a trend toward performing fewer THA procedures in the United States and that THA is associated with increased perioperative complications compared to those with HA and ORIF.
MATERIALS AND METHODS
We conducted a retrospective epidemiological study using the National Hospital Discharge Survey (NHDS) on surgical trends in the management of femoral neck fractures. The NHDS is a publicly available survey that is conducted annually to provide data of nonfederal, short-stay hospitals to the public. The sample data are weighted to provide nationwide estimates of annual inpatient care. The NHDS includes up to 7 medical diagnoses and 4 procedural codes per case, which are categorized using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, that were collected along with patient demographic information, length of stay (LOS), and discharge disposition. The diagnostic and procedural codes used for this study are presented in the Appendix. The year 2007 was chosen as the endpoint of this study due to the fact that the relative standard error of the NHDS doubled in 2008 as a result of a decrease in its survey size. As this is a publicly available database, our study was exempt from institutional review board approval.
Continue to: All pateints admitted...
All patients admitted with a primary diagnosis of closed transcervical fracture of the femoral neck (ICD-9-CM 820.0x) were selected. This resulted in 1,674,160 fractures. All patients with fractures with a concurrent primary procedural code of ORIF (79.35), HA (81.52), or THA (81.51) were identified, resulting in a total sample size of 1,155,960 surgical fractures. Analysis of the fractures based on additional specificity,ie subcapital versus midcervical versus basicervical, was not carried out because >90% of femoral neck fractures in the database were coded as “unspecified” or “other” (ICD9 CM 820.00 and 820.09, respectively).
Comorbidity burden was quantified using Elixhauser coding algorithms as previously described.31 The Elixhauser comorbidity measure is a model consisting of 31 conditions and has recently been identified as a better predictor of mortality in patients undergoing orthopedic procedures when compared with the Charlson Comorbidity Index.31 Dichotomous variables for each Elixhauser comorbidity were created, and χ2 tests were utilized to assess the association between each comorbidity and mortality. The weighted Elixhauser score for each statistically significant comorbidity was calculated as described by van Walraven and colleagues.32 The Elixhauser comorbidity score was then calculated for each patient by summing the individual weights of all comorbidities. Postoperative adverse events were determined using the complication-screening-package as previously described.33
All adverse events were categorized into 3 categories, including general medical complications, mechanical complications, and surgical complications. All adverse events recorded in the NHDS database are events that occurred during a single hospitalization. Therefore, it does not take into account adverse events that occurred after discharge, and, for example, mortality refers to postoperative mortality that occurs prior to discharge. The study period comprised data captured from 1990 to 2007, and 3 groups were generated from this time period to better characterize patients throughout the large study time frame. Group 1 comprised patients who underwent surgical management of femoral neck fractures from 1990 to 1995, group 2 consisted of patients treated from 1996 to 2001, and group 3 included patients treated from 2002 to 2007.
Categorical data were analyzed using the χ2 test, and continuous data were analyzed by the independent-samples t test and ANOVA. Multivariable binary logistic regression analyses were performed to assess the contributions of individual comorbidities to mortality, adverse events, and nonroutine discharge. Elixhauser comorbidities with a P value of < .10 in the bivariate analysis and presenting in at least 0.2% of the population were included in the logistic regression.31 Odds ratios and confidence intervals were calculated to assess the association between comorbidities and our dichotomous variables. A P value of < .001 defined statistical significance.33 Statistical analysis was conducted using SPSS version 21 (IBM).
RESULTS
Patient Demographics
Our query demonstrated a total of 1,155,960 patients who underwent surgical fixation of femoral neck fractures (Table 1). The most commonly used treatment modality was HA (75%), followed by ORIF (18%) and later by THA (7%). The majority of patients were females in each treatment group. Patients’ age varied according to treatment group, with patients undergoing HA having a mean age of 81.0 ± 9.0 years, patients undergoing ORIF having a mean age of 75.0 ± 17.0 years, and those undergoing THA having a mean age of 79.0 ± 10.0 years (P < .001). The majority of patients were ≥80 years in all treatment groups, but the ORIF group had the greatest proportion of patients <65 years (P < .001). Among patients undergoing HA, 62.4% were ≥80 years, while the ORIF and HA groups consisted of 48.6% and 51.5% of patients in that same age group, respectively.
Continue to: TRENDS ANALYSIS
TRENDS ANALYSIS
There was a significant change in the distributions of the procedures performed according to age group over time. Patients >80 years continued to undergo primarily HA, with an increase from 74.4% during 1990 to 1995 up to 84.6% during the 2002 to 2007 period and a concomitant decrease in ORIF from 18.3% to 10.6% during the same time period in this age group. Surgical trends in patients 65 to 79 years demonstrated a significant decrease in management with ORIF from 19.1% in 1990 to 1995 to 16.8% in the 2002 to 2007 cohort (P < .001 for all, Table 2). There was an increase in the use of HA from 71.9% during the 1990 to 1995 period to 75.5% during the final study period (Table 2, Figure 1). The use of THA for all age groups decreased between 1990 and 2007, except for the 50- to 64-year-old group where THA utilization remained constant.
Management patterns in patients 50 to 64 years varied throughout the analysis and demonstrated the following trend: treatment with HA remained the most common technique used but varied slightly from 59.7% during 1990 to 1995 to 60.3% during 2002 to2007 (P < .001, Table 2). The second most common treatment used was ORIF, which decreased from 32.2% to 31.5% (P < .001, Table 2). The use of THA varied significantly from 8.2% among those managed during 1990 to 1995 to 11.7% during 1996 to 2001 but later declined to the initial 8.2% (P < .001, Table 2).
Analysis of patients ≤49 years demonstrated that ORIF was the preferred technique, which experienced a growth from 63.9% during 1990 to 1995 to 81.4% during the 2002 to 2007 period (P < .001, Table 2). A decreased use in THA was observed from 2.0% in the initial period to 0.6% in the final period (P < .001, Table 2). Use of HA decreased from 34.0% in 1990 to 1995 to 18.0% in 2002 to 2007 (P < .001, Table 2).
LENGTH OF STAY
Mean number of in-hospital days decreased throughout the study period for all treatment techniques. During the 1990 to 1995 study period, patients who underwent ORIF had a mean LOS of 8 ± 7 days, which decreased (P < .001, Table 2) to 6 ± 3 days in 1996 to 2001 and remained constant during 2002 to 2007 (mean 6 ± 4 days). This decrease in LOS was also observed in patients who underwent THA (P < .001, Table 2), who initially had a mean LOS of 11 ± 7 days during 1990 to 1995, which later decreased to 7 ± 5 days for the remainder of the study. The LOS for patients who underwent HA also decreased (P < .001, Table 2), which initially was reported to be 11 ± 11 days during 1990 to 1995, decreasing to 7 ±7 days in 1996–2001 and later to 6 ± 4 days in 2002 to 2007.
COMORBIDITIY ANALYSIS
The Elixhauser Comorbidity Index varied significantly among groups over time (P < .001, Table 2). Overall mean Elixhauser Comorbidity Index score per procedure type is provided in Table 1, with HA patients having the highest score (-0.15 ± 13.09, p<.001).
Continue to: Analysis of the preoperative comorbidities...
Analysis of the preoperative comorbidities demonstrated significant differences among each surgical treatment group (P < .001 for all, Table 3). The most common comorbidities in patients who underwent HA were uncomplicated hypertension (33.2%), fluid/electrolyte disorders (17.4%), chronic pulmonary disease (14.9%), and congestive heart failure (13.7%). The most common comorbidities in the ORIF group were uncomplicated hypertension (30.8%), fluid/electrolyte disorders (14.5%), chronic pulmonary disease (14.0%), and uncomplicated diabetes (10.9%). Patients treated with THA had most commonly uncomplicated hypertension (30.1%), fluid/electrolyte disorders (17.2%), uncomplicated diabetes (15.5%), and chronic pulmonary disease (14.4%). The prevalence of comorbidities is displayed in Table 3.
DISCHARGE STATUS
Mortality varied significantly, being lowest in those who underwent ORIF (0.8%), followed those who underwent THA (1.8%), and HA (2.6%) (P < .001, Table 1).
The majority of patients in each group were discharged to long-term rehabilitation facilities, including 53.0% of those treated with HA, 40.4% of those treated with ORIF, and 44.3% of patients treated with THA. The second most common discharge location was home, which included 14.8% of patients who underwent HA, 32.2% of patients treated with ORIF, and 20.8% of those who underwent THA. Table 3 demonstrates the details of the discharge settings.
Mortality analysis over time demonstrated a significant decrease in each treatment group (P < .001). Mortality in the ORIF group decreased from 1.2% during 1990 to 1995 to 0.8% in 2002 to 2007. Mortality in the THA group also decreased significantly from 0.8% during 1990 to 1995 to 0.5% during the 2002 to 2007 time period. Patients who underwent HA also exhibited a decrease in mortality rate from 3.3% during 1990 to 1995 to 2.2% during 2002 to 2007 (P < .001, Table 4, Figure 2).
GENERAL ADVERSE EVENTS
There was a significant difference (P < .001) in the percentage of adverse events experienced, the maximum being observed in the THA group (41.0%), followed by the HA group (37.9%) and trailed by the ORIF group (20.3%, (P < .001, Table 1). The prevalence of adverse events is detailed in Table 5.
Continue to: Patients who underwent THA...
Patients who underwent THA had the highest rate of any adverse event, LOS, and transfusion rate (Table 1 and Table 5).
The prevalence of postoperative pneumonia was highest in the HA group (3.4%), followed by the ORIF group (2.9%), and the THA group (2.6%) (P < .001, Table 5). There was also a significant difference in rates of intubation, pulmonary insufficiency, acute renal failure, pulmonary embolism, acute myocardial infarction, induced mental disorder, and deep venous thrombosis (P < .001 for all, Table 5).
SURGERY-RELATED ADVERSE EVENTS
Surgery-related outcomes over the entire study period were significantly different according to the type of procedure performed (P < .001, Table 5). Patients who underwent HA had the highest rate of acute postoperative anemia (20.2%), followed by those who underwent THA (19.7%), and ORIF (10.2%). Postoperative bleeding rates also varied significantly, with 1.2% in the HA group, followed by 1.0% in the ORIF group and 0.4% in the THA group (P < .001, Table 5). Acute postoperative infection rates also varied significantly, with the highest rate being observed in the HA group (0.6%) compared to that in the THA and ORIF groups (both 0.3%) (P < .001, Table 5).
Table 6, Table 7, and Table 8 detail the results of regression analyses in patients with femoral neck fractures for individual risk factors associated with mortality, any adverse event, and nonroutine discharge to a short- or long-term rehabilitation facility, respectively. Increasing age (50–64 years, OR: 0.238; 65–79 years, OR: 1.762; and ≥80 years, OR: 2.700), THA (OR: 1.743), and HA (OR: 2.574) were found to be independent risk factors for mortality in the perioperative period (P < .001 for each, Table 6). Increasing age (50–64 years, OR: 1.888; 65–79 years, OR: 2.983; and ≥80 years, OR: 3.722), THA (OR: 2.489), and HA (OR: 2.098) were also found to be independent risk factors for any adverse event in the perioperative period (P < .001, Table 7). Age (50–64 years, OR: 1.662; 65–79 years, OR: 4.320; and ≥80 years, OR: 7.102) was the best predictor for nonroutine discharge to a short- or long-term rehabilitation facility (P < .001, Table 8).
DISCUSSION
Femoral neck fractures in the elderly population present a significant financial burden to the healthcare system.1-3,24,25 Consistent with previous epidemiological studies, our results show that the femoral neck fracture population has become older and has more medical comorbidities over the last 3 decades.27,28. Similarly, we also found that the rate of medical, surgical, and mechanical perioperative complications has increased in the same time period. Interestingly, the mortality rate has remained relatively similar.
Continue to: Although patients undergoing HA...
Although patients undergoing HA for femoral neck fractures are older and have more medical comorbidities, we found that the rate of adverse events in the perioperative period for patients undergoing THA was higher than that in the HA group. Consistent with prior studies, patients who underwent THA had higher rates of blood transfusion, pulmonary embolism, and induced mental disorders.34 Multivariable regression analysis demonstrated that after controlling for age, medical comorbidity, and type of surgery performed, THA emerged as an independent risk factor for any adverse event in the perioperative period. Increased anesthesia time, reaming of the acetabulum, and increased complexity of surgery probably account for these changes.
Our study results are consistent with those of Jain and colleagues,30 which showed a decrease in utilization of THA for femoral neck fractures between 1990 and 2001. Since THA is generally indicated for younger, more active patients in relatively good health, this would explain why changes in baseline health in this cohort over the last 20 years would lead to fewer THA procedures being performed. Surgeons in the US may be finding there are fewer patients who are candidates for THA. Miller and colleagues5 reported conflicting results and showed an increase in THA utilization in this patient population. However, their study evaluated treatment trends based on data from the ABOS part II of recently graduated orthopedic surgeons and may not be an accurate representation of national practice trends in the US. The trend toward increased subspecialization may explain their findings. As the authors noted, although they found an increase in the use of THA for femoral neck fractures by new adult reconstruction surgeons, the percentage of new surgeons treating femoral neck fractures has declined.5
Our analysis showed very concrete trends in treatment management at the extremes of the age ranges. There were substantial increases in the use of ORIF for patients <50 years (from 63.9% in 1990–1995 to 81.4% in 2002–2007, P < .001) and in the use of HA for patients >80 years (from 74.4% in 1990–1995 to 84.6% in 2002–2007, P < .001). This trend parallels recent studies that purport better outcomes for young patients undergoing ORIF and elderly patients undergoing HA.30 Our analysis did not demonstrate a large shift in surgeon preference for treatment of patients between 50 and 80 years, although there was a statistically significant decrease in ORIF and THA usage and a reflective increase in HA usage in this population as well. The fact that there has not been as substantial a shift in treatment trends for this large age group is potentially due to the wide variations in comorbid conditions and the functionality that abounds in this age group.1
The limitations of the current study are those inherent with a retrospective database analysis. The reliance on accurate coding brings up a potential for error; however, it is unlikely that comorbidities and outcomes are undercoded as hospitals are incentivized to input values that increase the acuity and thus reimbursement for each hospital stay.35 The database also relies on the ICD-9 procedural and diagnostic codes, which are not as specific as the currently adopted ICD-10 codes; hence, we are unable to distinguish between different forms of internal fixation, for example intramedullary nailing versus dynamic hip screw. This also precludes us from including other critical data such as degree of fracture displacement, cemented versus uncemented implantation, surgical approach for arthroplasty, and functional outcomes of individual patients. Moreover, the database used, although the largest inpatient sample available for analysis, represents only approximately 20% of hospitals nationwide. In addition, as patients cannot be tracked over time within the database, we are limited to outcomes in the perioperative period captured in a single hospital stay and cannot identify readmissions. Finally, our analysis is limited to the years 1990 to 2007 because of an increase in the relative standard error of the database in more recent years. Although this results in data that are not the most current, we believe that this study provides valuable insight regarding the trends in surgical treatment and acute postoperative outcomes of these injuries that have hitherto not been reported. To limit the inherent biases and the limitations within this study, prospective, randomized studies with long-term follow-up comparing outcomes across modes of treatment are needed to definitively determine the optimum form of treatment for this fracture type.
CONCLUSION
This is the largest study to date reporting on national trends in the surgical treatment and outcomes of the femoral neck fracture population. Orthopedic surgeons performing THA should be aware that the femoral neck fracture population is changing and at higher risk for perioperative complications. The advent of bisphosphonate therapy has been suggested as a possible reason for the decrease in fragility fractures and why a larger proportion of the femoral neck fracture population is now >80 years.36,37 With an aging population at a higher risk for perioperative complications, clinicians must take special care in choosing the appropriate surgical intervention that will give their patients the best functional outcome while minimizing the risk of surgical complications. Orthopedic surgeons should weigh the added risk associated with THA in this population.
1. Bishop J, Yang A, Githens M, Sox AH. Evaluation of contemporary trends in femoral neck fracture management reveals discrepancies in treatment. Geriatr Orthop Surg Rehabil. 2016;7(3):135. doi:10.1177/2151458516658328.
2. Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res Off J Am Soc Bone Miner Res. 2007;22(3):465. doi:10.1359/jbmr.061113.
3. Kannus P, Parkkari J, Sievanen H, Heinonen A, Vuori I, Jarvinen M. Epidemiology of hip fractures. Bone. 1996;18(1 Suppl.):57s. doi:10.1016/8756-3282(95)00381-9.
4. Koval KJ, Zuckerman JD. Hip fractures: I. Overview and evaluation and treatment of femoral-neck fractures. J Am Acad Orthop Surg. 1994;2(3):141. doi:10.5435/00124635-199405000-00002.
5. Miller BJ, Callaghan JJ, Cram P, Karam M, Marsh JL, Noiseux NO. Changing trends in the treatment of femoral neck fractures: a review of the American Board of Orthopaedic Surgery database. J Bone Joint Surg. (American) 2014;96(17):e149. doi:10.2106/JBJS.M.01122.
6. Miller BJ, Lu X, Cram P. The trends in treatment of femoral neck fractures in the Medicare population from 1991 to 2008. J Bone Joint Surg. (American) 2013;95(18):e132. doi:10.2106/JBJS.L.01163.
7. Nwachukwu BU, McCormick F, Provencher MT, Roche M, Rubash HE. A comprehensive analysis of Medicare trends in utilization and hospital economics for total knee and hip arthroplasty from 2005 to 2011. J Arthroplast. 2015;30(1):15. doi:10.1016/j.arth.2014.08.025.
8. Su EP, Su SL. Femoral neck fractures: a changing paradigm. Bone Joint J. 2014;96-b(11) Supple A):43. doi:10.1302/0301-620X.96B11.34334.
9. Ahn J, Man LX, Park S, Sodl JF, Esterhai JL. Systematic review of cemented and uncemented hemiarthroplasty outcomes for femoral neck fractures. Clin Orthop Relat Res. 2008;466(10):2513. doi:10.1007/s11999-008-0368-3.
10. Alolabi B, Bajammal S, Shirali J, Karanicolas PJ, Gafni A, Bhandari M. Treatment of displaced femoral neck fractures in the elderly: a cost-benefit analysis. J Orthop Trauma. 2009;23(6):442. doi:10.1097/BOT.0b013e31817614dd.
11. Bentler SE, Liu L, Obrizan M, et al. The aftermath of hip fracture: discharge placement, functional status change, and mortality. Am J Epidemiol. 2009;170(10):1290. doi:10.1093/aje/kwp266.
12. Brox WT, Chan PH, Cafri G, Inacio MC. Similar mortality with general or regional anesthesia in elderly hip fracture patients. Acta Orthop. 2016;87(2):152. doi:10.3109/17453674.2015.1128781.
13. Catal B, Sener M. Treatment and displacement affect the reoperation rate for femoral neck fracture. Clin Orthop Relat Res. 2013;471(12):4096. doi:10.1007/s11999-013-3295-x.
14. Dailiana Z, Papakostidou I, Varitimidis S, Michalitsis S, Veloni A, Malizos K. Surgical treatment of hip fractures: factors influencing mortality. Hippokratia. 2013;17(3):252.
15. Deangelis JP, Ademi A, Staff I, Lewis CG. Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures: a prospective randomized trial with early follow-up. J Orthop Trauma. 2012;26(3):135. doi:10.1097/BOT.0b013e318238b7a5.
16. Hedbeck CJ, Inngul C, Blomfeldt R, Ponzer S, Tornkvist H, Enocson A. Internal fixation versus cemented hemiarthroplasty for displaced femoral neck fractures in patients with severe cognitive dysfunction: a randomized controlled trial. J Orthop Trauma. 2013;27(12):690. doi:10.1097/BOT.0b013e318291f544.
17. Jia Z, Ding F, Wu Y, et al. Unipolar versus bipolar hemiarthroplasty for displaced femoral neck fractures: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res. 2015;10:8. doi:10.1186/s13018-015-0165-0.
18. Lapidus LJ, Charalampidis A, Rundgren J, Enocson A. Internal fixation of garden I and II femoral neck fractures: posterior tilt did not influence the reoperation rate in 382 consecutive hips followed for a minimum of 5 years. J Orthop Trauma. 2013;27(7):386. doi:10.1097/BOT.0b013e318281da6e.
19. Mariconda M, Costa GG, Cerbasi S, et al. Factors predicting mobility and the change in Activities of Daily Living After hip fracture: A 1-year prospective cohort study. J Orthop Trauma. 2016;30(2):71. doi:10.1097/BOT.0000000000000448.
20. Nyholm AM, Gromov K, Palm H, et al. Time to surgery is associated with thirty-day and ninety-day mortality After proximal femoral fracture: A retrospective observational study on prospectively collected data from the Danish Fracture Database Collaborators. J Bone Joint Surg. (American) 2015;97(16):1333. doi:10.2106/JBJS.O.00029.
21. Samuel AM, Russo GS, Lukasiewicz AM, et al. Surgical treatment of femoral neck fractures after 24 hours in patients between the ages of 18 and 49 is associated with poor inpatient outcomes: an analysis of 1361 patients in the National Trauma Data Bank. J Orthop Trauma. 2016;30(2):89. doi:10.1097/BOT.0000000000000456.
22. Yu L, Wang Y, Chen J. Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures: meta-analysis of randomized trials. Clin Orthop Relat Res. 2012;470(8):2235. doi:10.1007/s11999-012-2293-8.
23. Zi-Sheng A, You-Shui G, Zhi-Zhen J, Ting Y, Chang-Qing Z. Hemiarthroplasty vs primary total hip arthroplasty for displaced fractures of the femoral neck in the elderly: a meta-analysis. J Arthroplast. 2012;27(4):583. doi:10.1016/j.arth.2011.07.009.
24. Zielinski SM, Keijsers NL, Praet SF, et al. Functional outcome after successful internal fixation versus salvage arthroplasty of patients with a femoral neck fracture. J Orthop Trauma. 2014;28(12):e273. doi:10.1097/BOT.0000000000000123.
25. Gu Q, Koenig L, Mather RC, 3rd, Tongue J. Surgery for hip fracture yields societal benefits that exceed the direct medical costs. Clin Orthop Relat Res. 2014;472(11):3536. doi:10.1007/s11999-014-3820-6.
26. Forsh DA, Ferguson TA. Contemporary management of femoral neck fractures: the young and the old. Curr Rev Musculoskelet Med. 2012;5(3):214. doi:10.1007/s12178-012-9127-x.
27. Macaulay W, Pagnotto MR, Iorio R, Mont MA, Saleh KJ. Displaced femoral neck fractures in the elderly: hemiarthroplasty versus total hip arthroplasty. J Am Acad Orthop Surg. 2006;14(5):287. doi:10.5435/00124635-200605000-00004.
28. Miyamoto RG, Kaplan KM, Levine BR, Egol KA, Zuckerman JD. Surgical management of hip fractures: an evidence-based review of the literature. I: Femoral neck fractures. J Am Acad Orthop Surg. 2008;16(10):596. doi:10.5435/00124635-200810000-00005.
29. Probe R, Ward R. Internal fixation of femoral neck fractures. J Am Acad Orthop Surg. 2006;14(9):565. doi:10.5435/00124635-200609000-00006.
30. Jain NB, Losina E, Ward DM, Harris MB, Katz JN. Trends in surgical management of femoral neck fractures in the United States. Clin Orthop Relat Res. 2008;466(12):3116. doi:10.1007/s11999-008-0392-3.
31. Menendez ME, Neuhaus V, van Dijk CN, Ring D. The Elixhauser comorbidity method outperforms the Charlson index in predicting inpatient death after orthopaedic surgery. Clin Orthop Relat Res. 2014;472(9):2878. doi:10.1007/s11999-014-3686-7.
32. Van Walraven C, Austin PC, Jennings A, Quan H, Forster AJ. A modification of the Elixhauser Comorbidity measures into a point system for hospital death using administrative data. Med Care. 2009;47(6):626-633.
33. Best MJ, Buller LT, Falakassa J, Vecchione D. Risk factors for nonroutine discharge in patients undergoing spinal fusion for intervertebral disc disorders. Iowa Orthop J. 2015;35:147.
34. Schairer WW, Lane JM, Halsey DA, Iorio R, Padgett DE, McLawhorn AS. The Frank Stinchfield award: total hip arthroplasty for femoral neck fracture is not a typical DRG 470: A propensity-matched cohort study. Clin Orthop Relat Res. 2017;475(2):353-360. doi:10.1007/s11999-016-4868-2.
35. Nikkel LE, Fox EJ, Black KP, Davis C, Andersen L, Hollenbeak CS. Impact of comorbidities on hospitalization costs following hip fracture. J Bone Joint Surg Am. 2012;94(1):9. doi:10.2106/JBJS.J.01077.
36. Bilezikian JP. Efficacy of bisphosphonates in reducing fracture risk in postmenopausal osteoporosis. Am J Med. 2009;122(2 Suppl.):S14. doi:10.1016/j.amjmed.2008.12.003.
37. Siris ES, Pasquale MK, Wang Y, Watts NB. Estimating bisphosphonate use and fracture reduction among US women aged 45 years and older, 2001-2008. J Bone Miner Res Off J Am Soc Bone Miner Res. 2011;26(1):3. doi:10.1002/jbmr.189.
1. Bishop J, Yang A, Githens M, Sox AH. Evaluation of contemporary trends in femoral neck fracture management reveals discrepancies in treatment. Geriatr Orthop Surg Rehabil. 2016;7(3):135. doi:10.1177/2151458516658328.
2. Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res Off J Am Soc Bone Miner Res. 2007;22(3):465. doi:10.1359/jbmr.061113.
3. Kannus P, Parkkari J, Sievanen H, Heinonen A, Vuori I, Jarvinen M. Epidemiology of hip fractures. Bone. 1996;18(1 Suppl.):57s. doi:10.1016/8756-3282(95)00381-9.
4. Koval KJ, Zuckerman JD. Hip fractures: I. Overview and evaluation and treatment of femoral-neck fractures. J Am Acad Orthop Surg. 1994;2(3):141. doi:10.5435/00124635-199405000-00002.
5. Miller BJ, Callaghan JJ, Cram P, Karam M, Marsh JL, Noiseux NO. Changing trends in the treatment of femoral neck fractures: a review of the American Board of Orthopaedic Surgery database. J Bone Joint Surg. (American) 2014;96(17):e149. doi:10.2106/JBJS.M.01122.
6. Miller BJ, Lu X, Cram P. The trends in treatment of femoral neck fractures in the Medicare population from 1991 to 2008. J Bone Joint Surg. (American) 2013;95(18):e132. doi:10.2106/JBJS.L.01163.
7. Nwachukwu BU, McCormick F, Provencher MT, Roche M, Rubash HE. A comprehensive analysis of Medicare trends in utilization and hospital economics for total knee and hip arthroplasty from 2005 to 2011. J Arthroplast. 2015;30(1):15. doi:10.1016/j.arth.2014.08.025.
8. Su EP, Su SL. Femoral neck fractures: a changing paradigm. Bone Joint J. 2014;96-b(11) Supple A):43. doi:10.1302/0301-620X.96B11.34334.
9. Ahn J, Man LX, Park S, Sodl JF, Esterhai JL. Systematic review of cemented and uncemented hemiarthroplasty outcomes for femoral neck fractures. Clin Orthop Relat Res. 2008;466(10):2513. doi:10.1007/s11999-008-0368-3.
10. Alolabi B, Bajammal S, Shirali J, Karanicolas PJ, Gafni A, Bhandari M. Treatment of displaced femoral neck fractures in the elderly: a cost-benefit analysis. J Orthop Trauma. 2009;23(6):442. doi:10.1097/BOT.0b013e31817614dd.
11. Bentler SE, Liu L, Obrizan M, et al. The aftermath of hip fracture: discharge placement, functional status change, and mortality. Am J Epidemiol. 2009;170(10):1290. doi:10.1093/aje/kwp266.
12. Brox WT, Chan PH, Cafri G, Inacio MC. Similar mortality with general or regional anesthesia in elderly hip fracture patients. Acta Orthop. 2016;87(2):152. doi:10.3109/17453674.2015.1128781.
13. Catal B, Sener M. Treatment and displacement affect the reoperation rate for femoral neck fracture. Clin Orthop Relat Res. 2013;471(12):4096. doi:10.1007/s11999-013-3295-x.
14. Dailiana Z, Papakostidou I, Varitimidis S, Michalitsis S, Veloni A, Malizos K. Surgical treatment of hip fractures: factors influencing mortality. Hippokratia. 2013;17(3):252.
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TAKE-HOME POINTS
- The femoral neck patient population is older and has more medical comorbidities.
- Hemiarthroplasty (HA) is being performed more commonly in patients > 50 years old for femoral neck fractures.
- Open reduction and internal fixation is being performed more commonly in patients > 80 years old for femoral neck fractures.
- The rate of adverse events following femoral neck fracture is higher in the total hip arthroplasty (THA) group than in the HA group.
- THA is an independent risk factor for adverse events following femoral neck fracture.