Surgical approach in primary total hip arthroplasty: Anatomy, technique and clinical outcomes

©2015 8872147 Canada Inc. Total hip arthroplasty (THA) has revolutionized the treatment of hip arthritis. A number of surgical approaches to the hip joint exist, each with unique advantages and disadvantages. The most commonly used approaches include the direct anterior, direct lateral and posterior approaches. A number of technical intricacies allow safe and efficient femoral and acetabular reconstruction when using each approach. Hip dislocation, abductor insufficiency, fracture and nerve injury are complications of THA, although their relative risk varies by approach. Numerous clinical trials have sought to elicit differences in patient-reported outcomes, complication rates and return to function among the surgical approaches. This review outlines some of the technical pearls of performing a THA through either a direct anterior, direct lateral or posterior approach. A literature review outlines the impact of surgical approach on clinical outcomes and clinically relevant complication rates

The economic impact of periprosthetic infection in total hip arthroplasty

© 2020 Canadian Medical Association. All rights reserved. Background: Periprosthetic joint infection (PJI) is the third leading cause of total hip arthroplasty (THA) failure. Although controversial, 2-stage revision remains the gold standard treatment for PJI in most situations. To date, there have been few studies describing the economic impact of PJI in today\u27s health care environment. The purpose of the current study was to obtain an accurate estimate of the institutional cost associated with the management of PJI in THA and to assess the economic burden of PJI compared with primary uncomplicated THA. Methods: We conducted a review of primary THA cases and 2-stage revision THA for PJI at our institution. Patients were matched for age and body mass index. All costs associated with each procedure were recorded. Descriptive statistics were used to summarize the collected data. Mean costs, length of stay, clinic visits and readmission rates associated with the 2 cohorts were compared. Results: Fifty consecutive cases of revision THA were matched with 50 cases of uncomplicated primary THA between 2006 and 2014. Compared with the primary THA cohort, PJI was associated with a significant increase in mean length of hospital stay (26.5 v. 2.0 d, p \u3c 0.001), mean number of clinic visits (9.2 v. 3.8, p \u3c 0.001), number of readmissions (12 v. 1, p \u3c 0.001) and average overall cost (Can$38 107 v. Can$6764, t = 8.3, p \u3c 0.001). Conclusion: Treatment of PJI is a tremendous economic burden. Our data suggest a 5-fold increase in hospital expenditure in the management of PJI compared with primary uncomplicated THA

Use of the Corail stem for revision total hip arthroplasty: Evaluation of clinical outcomes and cost

© 2019 Joule Inc. or its licensors. Background: With the growing number of total hip arthroplasty (THA) procedures performed, revision surgery is also proportionately increasing, resulting in greater health care expenditures. The purpose of this study was to assess clinical outcomes and cost when using a collared, fully hydroxyapatite-coated primary femoral stem for revision THA compared to commonly used revision femoral stems. Methods: We retrospectively identifed patients who underwent revision THA with a primary stem between 2011 and 2016 and matched them on demographic variables and reason for revision to a similar cohort who underwent revision THA. We extracted operative data and information on in-hospital resource use from the patients\u27 charts to calculate average cost per procedure. Patient-reported outcomes were recorded preoperatively and 1 year postoperatively. Results: We included 20 patients in our analysis, of whom 10 received a primary stem and 10, a typical revision stem. There were no signifcant between-group differences in mean Western Ontario and McMaster Universities Osteoarthritis Index score, Harris Hip Score, 12-Item Short Form Health Survey (SF-12) Mental Composite Scale score or Physical Composite Scale score at 1 year. Operative time was signifcantly shorter and total cost was signifcantly lower (mean difference -3707.64, 95% confdence interval -5532.85 to -1882.43) with a primary stem than with other revision femoral stems. Conclusion: We found similar clinical outcomes and signifcant institutional cost savings with a primary femoral stem in revision THA. This suggests a role for a primary femoral stem such as a collared, fully hydroxyapatite-coated stem for revision THA

Effect of the extent of release for knee balancing on post-operative limb coronal alignment after primary total knee arthroplasty

© 2020 Alzahrani et al. Introduction: Outcomes and longevity of total knee arthroplasty (TKA) depend mainly on restoring knee function, through precise bony resection and appropriate soft tissue balancing. The current literature lacks evidence regarding the degree of radiographic change after intra-operative knee balancing. The purpose of our study was to assess the degree of change in coronal lower extremity alignment by comparing pre-operative to post-operative full-length radiographs (FLR) after quantifying the degree of intra-operative knee balancing and corre-late patient-reported outcomes to the extent of balancing required. Patients and Methods: One hundred and fifty-four patients undergoing primary TKA for varus knee osteoarthritis were included in the study. The performed soft tissue releases and bony adjustments to obtain a balanced TKA intra-operatively were prospectively documen-ted and were grouped into minimal, moderate and extensive release groups. Hip-knee-ankle angle (HKA), anatomical femoral-tibial angle (FTA), condylar hip angle (CH), medial proximal tibial angle (MPTA) and condylar plateau angle (CPA) were measured on full-length radiographs both pre-operatively and post-operatively. Frequencies of the soft tissue releases and bony resections in addition to descriptive statistics of the measured angles on the radiographs were recorded. In addition, patient-reported outcome scores (PROMs) were compared between the grouped patients. Results: Of those that were included in the study, 66 knees (42.9%) required minimal release to adequately balance the knee, while 70 (45.5%) required moderate release and 18 (11.7%) required extensive release. No statistically significant differences were found in change of alignment between the groups for all the measured angles. In addition, no difference in PROMs was seen between the groups both pre-and post-operatively. Conclusion: Although we found no association between post-operative coronal alignment of a TKA and the degree of soft tissue release and bony resection, this likely represents the fact that a balanced TKA is dynamic and not dependent on change of single radiographic parameters. Patient-reported outcomes were not impacted by the extent of releases

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Gait analysis following release of the short external rotators during an anterior approach for total hip arthroplasty

© The Author(s) 2018. Background: Cadaveric and clinical studies suggest surgical release of the short external rotators is sometimes necessary to improve exposure during total hip arthroplasty (THA) using an anterior approach. The purpose of this study was to determine the impact of those surgical releases on gait following THA. Methods: 15 patients undergoing THA using an anterior approach, anterior approach with surgical releases, or posterior approach underwent 3-D gait analysis preoperatively, and at 6 and 12 weeks postoperatively. At each time point, temporal parameters, kinematics, and kinetics were compared. The anterior approach was compared to the anterior approach cohort with surgical releases, and the surgical release cohort was compared to a posterior approach cohort. The mean change score between preoperative and 6 weeks, and 6-week to 12-week analyses were analysed. Results: There were no demographic differences between the groups. There were no significant differences between the groups for the temporal parameters and kinematic analyses at either time point comparison. The surgical release cohort had a lower hip internal rotation moment compared to the anterior approach cohort for the 6- to 12-week comparison (p = 0.05), and compared to the posterior approach cohort for the preoperative to 6-week (p = 0.03) and 6- to 12-week comparison (p = 0.02). Conclusion: Releasing the short external rotators during an anterior approach did not cause significant temporal and kinematic changes after THA. However, small changes in hip internal rotation moments can be expected. These findings should be correlated with patient-reported outcome measures to determine if these gait anomalies predict poor outcome following THA

In-Hospital Cost Analysis of Total Hip Arthroplasty: Does Surgical Approach Matter?

© 2016 Elsevier Inc. The purposes of this study were to determine the impact of surgical approach on costs of total hip arthroplasty (THA) from a hospital perspective and to provide an updated cost estimation of THA. A prospective, microcosting analysis was performed on 118 patients undergoing a THA through an anterior, lateral, or posterior approach. We determined that overall costs (intraoperative costs and hospital stay) were significantly less for the anterior ($7300.22; 95$7853.10; 95% CI, 7577.29-8128.91; P = .031) and anterior vs posterior approach ($8287.46; 95% CI, 7906.42-8668.51; P \u3c .001). A reduction in hospital length of stay when THA was performed through an anterior approach contributed significantly to an overall reduction in costs from a hospital perspective

Perioperative Predictors of Length of Stay After Total Hip Arthroplasty

© 2016 Elsevier Inc. Background: Few studies had examined whether specific patient variables or performance on functional testing can predict length of stay (LOS) after total hip arthroplasty (THA). Such tools would enable providers to minimize prolonged LOS by planning appropriate discharge dispositions preoperatively. Methods: We prospectively recruited 120 patients undergoing a THA through an anterior (n = 40), posterior (n = 40), or lateral (n = 40) approach. Patients performed a timed up-and-go (TUG) test preoperatively to determine if it was predictive of hospital LOS after THA. Other variables of interest included patient age, body mass index, age-adjusted Charlson Comorbidity Index, mean procedure time, and time spent in the postanesthetic care unit. A logistic regression analysis was performed to determine which variables predicted LOS greater than 48 hours, which is our institution\u27s target time to discharge. Results: The TUG test was predictive of LOS beyond 48 hours. For every 5-second interval increase in TUG time, patients were twice as likely to stay in hospital beyond 48 hours (odds ratio [OR] = 2.02, 95% confidence interval [CI] = 1.02-4.01, P = .043). Patient age (OR = 0.97, 95% CI = 0.90-1.05, P = .46), body mass index (OR = 1.01, 95% CI = 0.86-1.18, P = .90), Charlson Comorbidity Index (OR = 1.29, 95% CI = 0.68-2.44, P = .44), mean procedure time (OR = 1.05, 95% CI = 0.97-1.14, P = .27), and mean time in the postanesthetic care unit (OR = 1.00, 95% CI = 0.99-1.00, P = .94) were not predictive of increased LOS. Conclusion: The TUG test was predictive of hospital LOS after THA. It is a simple functional test that can be used to assist with discharge planning preoperatively to minimize extended hospital stays

A cost analysis of single-stage bilateral versus two-stage direct anterior total hip arthroplasty

© 2016 Wichtig Publishing. Purpose: The potential cost savings of single-stage bilateral total hip arthroplasty (THA) are unclear, and the risks associated with it are not well defined. We sought to compare the costs and perioperative complications of single-stage bilateral THA via the direct anterior approach (DAA) to a two-stage bilateral protocol. Methods: We retrospectively reviewed patients who underwent a single- stage bilateral DAA THA and compared them to a two-stage THA group. We conducted a cost analysis from both the hospital perspective and the Ministry of Health (MOH) perspective. Results: 24 patients were included in this study. The 2 groups were similar in age (58.9 vs 63.9 yrs), height (169.2 vs 170.9 cm), weight (80.2 vs 78.6 kg), BMI (27.9 vs 26.3 kg/m2), ASA score (2.2 vs 2.2), and CCI score (2.3 vs 2.9). The mean cost per patient from the hospital perspective for the single-stage group was $10,728.13 (SD = 621.46) compared to$12,670.63 (SD = 519.72) for the two-stage group (Mean Difference = $1,942.50, 95$1,457.49 to $2,427.51, p\u3c0.001). Similarly, from the MOH perspective, the cost for the single-stage group was$12,552.34 (SD = 644.93) compared to $14,740.58 (SD = 598.07) for the two-stage group (Mean Difference =$2,188.24, 95% CI = $1,661.67 to$2,714.81, p\u3c0.001). There were no significant differences in complication rate between groups. The largest percent of total cost savings from a hospital perspective was attributed to cost of operating room staff and OR set-up (55%). Conclusions: Our results suggest that single-stage bilateral DAA THA results in significant cost savings compared to two-stage DAA THA