Demographic, Comorbidity, and Episode of Care Trends in Primary Hip Arthroplasty: 2008 to 2018

Background While previous studies have provided insight into time-trends in age and comorbidities of total hip arthroplasty (THA) patients, there is limited recent literature from within the past decade. The implication of these findings is relevant due to the projected THA volume increase and continued emphasis on healthcare system cost-containment policies. Therefore, the purpose of this study was to identify trends in THA patient demographics, comorbidities, and episode of care from 2008 to 2018. Methods The National Surgical Quality Improvement Program (NSQIP) was queried to identify patient demographics, comorbidities, and episodes of care outcomes in patients undergoing primary THA from 2008 to 2018 (n = 216,524). Trends were analyzed using analysis of variances for continuous variables, while categorical variables were analyzed using chi-squared or Monte Carlo tests, where applicable. Results From 2008 to 2018, there were no clinically significant differences in age and body mass index (BMI) in patients with BMI over 40 kg/m2. However, modifiable comorbidities including patients with hypertension (60.2% in 2008, 54.3 in 2018%, p < 0.001) and anemia (19% in 2008, 11.2%, in 2016, p < 0.001) improved. Functional status and the overall morbidity probability have improved with a decrease in hospital lengths of stay (4.0 ± 2.8 days in 2008, 2.1 ± 2.2 days in 2018, p < 0.001), 30-day readmissions (4.2% in 2009, 3.3% in 2018, p < 0.001), and significant increase in home-discharges (70.1% in 2008, 87.3% in 2018, p < 0.001). Conclusion Patient overall health status improved from 2008 to 2018. While conjectural, our findings may be a reflection of a global shift toward value-based comprehensive care centering on patient optimization prior to arthroplasty, quality-of-care, and curtailing costs by mitigating perioperative adverse events.This study's level of evidence is III.

Hip Profile in World Elite Junior Badminton Players: Impingement and Range of Motion Data from the World Junior Badminton Championship 2018

Badminton is played with repetitive high loading to the hip with lunging and jumps. In sports like soccer there is a high prevalence of femoroacetabular impingement syndrome in youth populations which may predispose them to osteoarthritis (OA). Internal rotation deficit in the hip of football players is a predictor of hip and groin pain and differences in the range of motion (ROM) of the hip between sex and different ethnicities exist. Early hip replacements in former elite badminton players due to OA seem to be a problem. There are no published values for ROM and impingement of the hip in badminton. The purpose is to report ROM and impingement of the hip in elite junior badminton players and to report any differences between sex and ethnicities. Players at the World Junior Championship 2018 were examined for hip flexion, rotation, and impingement test. Injury history was obtained from a questionnaire. Two hundred and eighty-four players of 433 aged 16 to 18 years were examined. One hundred and forty-three players answered the questionnaire. Females demonstrated greater hip ROM than males. In the dominant side hip flexion was (137.7 degrees [ ± 9.1] vs. 132.2 degrees [ ± 11.1], p < 0.001), internal rotation range of motion or IROM (60.0 degrees [ ± 10.9] vs. 49 degrees [ ± 11.1], p < 0.001) and external rotation range of motion or EROM (57.9 degrees [ ± 9.9] vs. 54.7 degrees [ ± 8.9], 0.004). Hip flexion was higher in Asian players compared with non-Asian players (139.1 degrees [ ± 8.4] vs. 130.3 degrees [ ± 10.7], p < 0.001). One hundred (35%) players had at least one positive impingement test. A possible relationship between a positive FADIR and a decrease in hip flexion was found in the dominant hip, OR 1.06 (1.02–1.11) p = 0.005. A total of 104 previous injuries lasting over 30 days were reported with five hip-related injuries. No correlation between injury and examinations was found. Females and Asians demonstrated higher ROM in the hip than males and non-Asians. Impingement of the hip is frequent and may be related to low hip flexion.

Postoperative Doxycycline Did Not Improve Early Postoperative Outcomes in Hip Arthroscopy Patients: A Retrospective Cohort Study

Doxycycline has been shown to reduce fibroblast activity in the treatment of multiple pathologies, and was utilized as part of the postoperative medication protocol to help prevent adhesions from developing after hip arthroscopy. The purpose of this study was to compare early postoperative pain outcomes between consecutive case series of femoroacetabular impingement syndrome (FAIS) patients treated with or without a 7-day postoperative course of doxycycline following hip arthroscopy. We hypothesized that the doxycycline-treated group would have superior patient-reported outcomes at 6 weeks, and the effect would be more pronounced for patients with low preoperative mental health scores.Our institutional review board–approved prospective outcomes registry was queried for patients who had undergone arthroscopic femoral osteochondroplasty and/or labral repair or reconstruction secondary to FAIS performed by a single, fellowship-trained surgeon. A 7-day postoperative course of doxycycline was initiated in 2018. Six-week postoperative Hip Disability and Osteoarthritis Outcome Score (HOOS) global (HOOSglobal) and International Hip Outcome Tool (iHOT) scores were compared between the consecutive series treated with versus without doxycycline. Additional subgroup analysis was performed on patients with low preoperative Veterans RAND 12-Item Health Survey (VR-12) mental component scores to determine possible additional benefit of postoperative doxycycline in this group.A total of 134 patients (98 female, 36 male, age = 36.2 ± 13.4 years, body mass index [BMI] = 27.2 ± 5 kg/m2) were identified between 2013 and 2020. There were no differences between the control (n = 84) and doxycycline group (n = 50) in age, sex, or BMI. Postoperative HOOSglobal scores (control = 58.5 ± 13.1, doxycycline = 58.7 ± 14.7, p = 0.96) and iHOT scores (control = 54.4 ± 22.2, doxycycline = 52.3 ± 24.8, p = 0.61) did not differ between groups. The subset of 83 patients with low preoperative mental scores showed no differences in HOOSglobal (control = 51.6 ± 13.3, doxycycline = 57.3 ± 7.4, p = 0.12) or iHOT scores (control = 45.5 ± 20.3, doxycycline = 53.6 ± 23.1, p = 0.250).Our results do not support the hypothesis that postoperative doxycycline leads to significant improvement in early postoperative pain scores or functional outcomes in patients undergoing hip arthroscopy for FAIS.

The Effect of Femoral Malrotation in Offset Templating for Total Hip Arthroplasty: A Cadaveric Study and Curvilinear Analysis

Techniques allow assessment of preoperative offset in hip arthroplasty. This study assessed femoral rotation in preoperative offset templating using a cadaveric model. Ten femurs were imaged at degrees of rotation. Offset was measured. A generalizable equation predicting change in offset was derived with a curvilinear model. Statistically significant differences at rotational positions were found. For 30 degrees of internal rotation, 2.1 mm change in adjusted mean offset existed; for 30 degrees of external rotation, 8.4 mm change existed. Improved awareness of malrotation of the proximal femur and templating adjustments may improve total hip arthroplasty outcomes. This study reflects level of evidence III.

The Surgeon Mentor Program: Outcomes of Total Hip Arthroplasty via the Direct Anterior Approach

The direct anterior approach (DAA) for total hip arthroplasty has been increasing in popularity due to potential benefits including less pain, faster recovery, decreased risk of dislocation, and a reduced length of stay. The DAA has been described by many to have a steep learning curve owing to its greater risk of complications when first using the approach. The primary aim of this study was to design and implement a specific surgeon mentor program in an attempt to reduce the learning curve of the DAA. Surgeons completed the surgical education and mentoring program designed to reduce the initial increase in complication rate when first learning the DAA in a public hospital setting. A retrospective review of clinical and radiological outcomes on the first 67 cases was then conducted. Of these, 43 cases were eligible for inclusion. The 43 patients in this study had a mean age of 66.7, BMI of 26.7, and 57% of them were female. Follow-up was between 39 and 49 months, with a mean of 46 months. There were no fractures, dislocations, or blood transfusions. One patient required revision for deep infection. The mean length of stay was 2.81 days. At 6 weeks postoperative, 86% were independently mobile, 9.3% were using a cane, and 4.7% were being weaned off a walker. The radiological assessments found a mean cup abduction of 39.9 ± 5.1 degrees, mean femoral offset of 1.6 ± 5.5 mm, and a total hip offset of 1.3 ± 7 mm greater than the contralateral hip. Patients had a mean leg length discrepancy of −0.9 ± 5.9 mm. In conclusion, a surgeon mentoring program was designed and implemented to reduce the learning curve of the DAA in our center, with satisfactory 3-year clinical and radiological outcomes achieved. This study provides preliminary support for the potential utility of the mentoring program in facilitating other centers in safely introducing the DAA into their practice without an initial increase in complication rate.

Complications and Unsuccessful Same-Day Discharge Following Outpatient Total Hip Arthroplasty (THA) in the Medicare Population: Incidence, Risk Factors, and Clinical Impact

In 2020, total hip arthroplasty (THA) was removed from the inpatient-only list by the Centers for Medicare and Medicaid Services. The objective was to analyze outpatient THA in the Medicare population to understand incidence of failed same-day discharge (SDD) and risk factors for complications and extended length of stay (LOS). The 2015–2019 American College of Surgeons—National Surgical Quality Improvement Program database was queried for Medicare patients (≥ 65 years) undergoing outpatient THA. Short-term complications, LOS, and discharge destination were evaluated. Multivariate logistic regression was used to evaluate risk factors for complications, failed SDD, reoperation, readmission, and non-home discharge disposition. Overall, 2,063 THAs were included. Complication rate was 7.4%. The number of patients staying in the hospital ≥ 1 day was 1,080 (52%). A total of 151 patients (7.3%) experienced a non-home discharge. Predictors for having any complication was an extended LOS ≥ 1 day (odds ratio [OR] 2.86), p < 0.001. Significant predictors for failed SDD were smoking history (OR 2.25), operative time ≥ 82 minutes (OR 1.98), American Society of Anesthesiologists Class > II (OR 1.67), and age ≥ 71 (OR 1.31) (all p ≤ 0.004). Significant predictors for a non-home discharge were LOS ≥ 1 day (OR 13.71), American Society of Anesthesiologists Class > II (OR 2.36), age ≥ 71 (OR 2.07), operative time ≥ 82 minutes (OR 1.88), and female gender (OR 1.81), all p ≤ 0.003. The current study identifies the incidence, risk factors, and clinical impact of postoperative complications and prolonged LOS in Medicare-aged patients undergoing outpatient THA. Providers should consider preoperatively risk stratifying patients to reduce the costs associated with extended LOS, complication, and unplanned discharge destination.

Use of 3D Printed Models to Determine Accurate Bone Cuts during a Periacetabular Osteotomy for Developmental Hip Dysplasia

The periacetabular osteotomy (PAO) is a powerful tool to delay the progression of hip arthritis by reorienting the acetabulum. This study aimed to use three-dimensional (3D)-printed models of the pelvis, reconstructed from the computed tomography (CT) scans of patients, to model how the level of dysplasia and its location ilium osteotomy affect radiographic outcomes following PAO. This pilot study aims to determine if preoperative 3D printing/planning can assist in predicting radiographic outcomes. We performed a retrospective review of five patients with differing levels of hip dysplasia for whom we had obtained CT scans before PAO surgery. For each patient, we printed two pelvis models that would undergo standardized cuts of the PAO procedure, with variations only in the distance of the ilium start point (one-third of the distance between the anterior superior iliac spine and anterior inferior iliac spine [AIIS] vs. two-thirds of the distance). We then mobilized the acetabular fragment into eight reproducible positions in space by moving the ilium cut a combination of 0, 1, or 2 cm anterior/lateral. Each position of the newly realigned acetabula was examined under fluoroscopy to obtain a standardized anteroposterior view, and to obtain standardized radiographic measurements in the form of lateral center edge angle (CEA), acetabular depth, Tonnis angle, and acetabular inclination. We performed 80 simulations of the PAO with varying degrees of acetabular mobilization. On average, in the models where the supra-acetabular cut was closer to the AIIS, we found more significant degrees of radiographic correction, regarding Tonnis angles (12.91 vs. 7.95, p = 0.0175), acetabular inclination (20.25 vs. 9.875, p = 0.027), and lateral CEA (11.75 vs. 2.5, p = 0.061). Patients who had greater dysplasia also had more significant degrees of radiographic Tonnis angle correction with the same mobilization movements of the acetabula (p = 0.005). When utilizing 3D printing to model PAO in dysplasia pelvises, we found that both a higher level of preoperative dysplasia and starting the supra-acetabular osteotomy closer to the AIIS were associated with more powerful corrections following smaller manipulations.

Hip Instability Leading to Metallosis, Polyethylene Wear, and Failure of an Oxinium Femoral Head: A Case Report and Review of Literature

Oxinium is a zirconium metal alloy with an oxidized (ceramicized) surface that aims to mimic the superior wear properties of a ceramic femoral head while maintaining the high strength of metal-bearing surfaces. There are several reports that illustrate the wear and/or failure of Oxinium femoral heads following abnormal head contact with metal cup, with only a few studies reporting on the occurrence of metallosis. We present a case of metallosis and failure of Oxinium femoral head following two incidents of hip instability and one closed reduction. Successful revision was performed with cemented cup and metal femoral head, with 68 months of follow-up. We aimed to highlight the importance of achieving stable and well-oriented hip components when using Oxinium-bearing surfaces and to present a short literature review regarding the wear of oxidized zirconium-bearing surfaces in hip arthroplasty.

A High-Volume, Academic Orthopedic Specialty Hospital Provides the Shortest Operative Times in Total Hip Arthroplasty

Operative time is a potential modifiable target for reducing cost and optimizing efficiency in total hip arthroplasty (THA). Shorter operative times are associated with decreased costs and complications. One proposed solution for reducing operating room (OR) times is to preferentially perform THAs at a higher volume center. The purpose of this study is to investigate the impact of different hospital settings on mean operative time in THA. A retrospective analysis of 7,694 consecutive primary and revision THA cases across four different hospitals was conducted. The hospitals reviewed in this study include a high-volume academic (HVA) orthopedic hospital, a large tertiary, low-volume academic (LVA) center, a high-volume community (HVC) hospital, and a low-volume community (LVC) hospital. Operative times, patient baseline demographics, and procedure classification (inpatient vs. outpatient) were collected. For primary THA, the HVA hospital maintained the statistically lowest total OR times followed by the HVC hospital (155.96 vs. 167.27 minutes, p < 0.0001). The LVC and HVC centers had similar total OR times (175.48 vs. 167.27 minutes, p = 0.578). For revision THA, the LVC center had the shortest total OR time followed by the HVA, LVA, and HVC sites (194.85 vs. 224.69 vs. 244.07 vs. 279.54 minutes). However, there were a larger amount of revision cases performed at our HVA sites than our community hospitals (523 vs. 123 cases). Our HVA hospital specialized in orthopedic care experiences shorter primary THA OR times than community hospitals. These findings suggest that in addition to hospital volume, factors such as specialized staffing, standardized OR protocols, and additional resources affect operative times, making HVA centers better equipped to handle primary THA.

Anatomy of the Sciatic Nerve in Relation to the Bernese Periacetabular Osteotomy: A Cadaveric Study

Prior studies have examined the role of hip and knee positioning, specifically hip extension and knee flexion, to reduce the risk of sciatic nerve palsy during the Bernese periacetabular osteotomy. They have qualitatively noted that the sciatic nerve moves farther from the connection between the ischial and posterior column osteotomies in hip extension than flexion but has not precisely measured this change in position. This cadaveric study aimed to quantitatively evaluate how hip positioning affects the location of the sciatic nerve relative to the connection between the ischial and posterior column osteotomies. We dissected four cadaveric specimens (three females and one male) with a mean age of 83.0 ± 7.8. An anterior Smith–Peterson approach was performed to allow the cuts for the periacetabular osteotomy (PAO). A posterolateral approach was taken to identify the sciatic nerve and its emergence from the pelvis. Measurements were performed on the width of the posterior column and, in both hip flexion and extension, the distance from the emergence of the sciatic nerve from the pelvis to the connection point between the ischial and posterior column osteotomies. Each measurement was performed independently by two observers. All data are reported as a mean ± standard deviation (range). The width of the posterior column was 4.84 ± 0.48 cm (range: 4.20–5.35 cm). The distances from the sciatic nerve's emergence to the osteotomy connection point in extension and flexion were 4.73 ± 0.79 and 2.93 ± 0.85 cm, respectively. The distance from the sciatic nerve's emergence to the osteotomy connection point was significantly greater in hip extension than hip flexion (p = 0.021). When the hip is flexed, the distance from the sciatic nerve to the posterior column osteotomy connection point is significantly less than when it is in extension. This anatomic finding is essential for surgical safety, as it provides further evidence on the importance of positioning for reducing the risk of sciatic nerve injury during a PAO.