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  • Older patients still fastest-growing demographic for TKA

    Despite total knee arthroplasty becoming more prevalent in patients younger than 65 years of age, the main demographic of growth is still among patients older than 65, according to recent study data.

    Researchers compared 1999 to 2008 U.S. census data for individuals 18 to 44 years old, 45 to 64 years old, and 65 years and older and the number of total knee arthroplasties (TKAs) performed annually in each age group. Per-capita incidence rates were calculated, and the growth rate in all demographics was determined.

    Approximately 305,000 TKAs were performed beyond the number predicted by population growth alone in 2008. Patients older than 65 years of age represented the largest growing cohort, as 151,000 recorded TKA procedures and a per-capita growth rate from 5.2 to 9.1 procedures per 1,000 individuals was observed. Per-capita growth rate also increased from 1.4 to 3.3 procedures per 1,000 individuals among patients 45 to 64 years old.

    TKAs were found to have increased 234% during the span of this study, from 264,000 in 1999 and approximately 616,000 in 2008, with fewer than 48,000 of the additional procedures able to be explained by population increase, according to the researchers.

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  • TKA provides excellent outcomes after lower-extremity amputation

    Although total knee arthroplasty is rare after lower-extremity amputation, it can provide excellent functional and clinical outcomes, according to study results.

    Researchers reviewed 13 primary total knee arthroplasties (TKAs) in 12 patients with prior lower-extremity amputation, among which 12 TKAs were performed on the contralateral side of the amputated limb and one was performed on the ipsilateral side. Using clinical examinations and patient surveys, the researchers calculated preoperative and postoperative Knee Society scores. The study’s primary endpoint was failure, which was defined as revision for any reason. Average clinical follow-up occurred at 6.8 years.

    The researchers observed improvement in Knee Society scores from 30.4 preoperatively to 88.5 following TKA with a prior contralateral amputation.

    At final follow-up, radiographic evidence of aseptic loosening of the tibial components was observed in 23.1% of patients, and the researchers recommended augmentation of tibial fixation with a stem during TKA after contralateral amputation.

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  • Regular physical activity improved patient satisfaction after TKA

    Patients who participated in regular physical activity after undergoing total knee arthroplasty experienced improved satisfaction with their outcomes, according to study results.

    Researchers evaluated physical activity profiles of 369 patients before and after total knee arthroplasty (TKA) using a questionnaire that contained the University of California — Los Angeles activity scale and types of sports activities. Using subgroup comparisons and partial correlation analyses, the researchers assessed the associations of socio-demographic features and postoperative functional outcomes with the physical activity levels, as well as the effects of regular physical activity on patient satisfaction with replaced knees.

    Both before and after TKA, study results showed the three most common sports activities were walking, swimming and bicycling. Although the mean activity level remained similar after TKA, the frequency of moderate activity levels and moderate types of physical activities increased, according to the researchers.

    The researchers also found higher postoperative activity levels reported by patients with higher postoperative function scores. However, socio-demographic factors were not associated with activity level. Overall, greater patient satisfaction was associated with regular physical activity.

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  • Regional anesthesia for hip fracture surgery was not associated with increased 30 day mortality compared to general anesthesia

    A hip fracture can mean surgery and a hospital stay. The type of anesthesia used in that surgery might affect the length of the hospital stay and recovery. Researchers compared the two types of surgical anesthesia in hip fracture patients and found that there was no difference in survival a month after surgery. Patients who had regional anesthesia had a slightly shorter hospital stay.

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  • Prior TKR or revision THR causes increased periprosthetic fractures

    Periprosthetic fractures are especially common in patients with prior total knee replacement or revision total hip replacement a decade after primary total hip replacement, according to study results.

    Researchers identified 58,521 Medicare beneficiaries who had elective primary total hip replacement (THR) for non-fracture diagnoses between July 1995 and June 1996 and followed them using Medicare Part A claims data through 2008. Using ICD-9 codes, researchers identified periprosthetic femoral fractures occurring from 2006 to 2008. The incidence density method was used to calculate the annual incidence of periprosthetic femoral fractures, and Cox proportional hazards models were used to identify risk factors for periprosthetic fracture. The risk of hospitalization during the subsequent year was also calculated.

    Overall, 55% of patients who had elective primary THR between July 1995 and June 1996 survived until January 2006, with 0.7% of these patients developing a periprosthetic femoral fracture between 2006 and 2008. The researchers found an annual incidence of periprosthetic fractures of 26 per 10,000 person-years among these individuals.

    According to Cox proportional hazards models, patients had a greater risk of periprosthetic fracture after having a total knee replacement or a revision total hip replacement between the primary THR and 2006. The researchers found a three-fold higher risk of hospitalization in the subsequent year among THR patients who sustained periprosthetic femoral fracture compared with patients without fractures.

    “These data will help clinicians as they portray to patients and their families the long-term concerns associated with living with a hip implant,” the researchers wrote. “The message is that periprosthetic fractures are relatively rare, though more frequent in patients with multiple implants. Further, these fractures are typically associated with the need for considerable subsequent medical care, as they are accompanied by a much greater risk hospitalization in the subsequent year than experienced by THR recipients who did not have hip fracture.”

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  • Comparable readmission rates found for inpatient and outpatient TJA

    Patients undergoing outpatient total joint arthroplasty had readmission rates, number of emergency room visits and patient satisfaction outcomes comparable patients who underwent inpatient procedures, according to a presenter at the American Academy of Orthopaedic Surgeons Annual Meeting.

    “There has been a recent demand in outpatient total joint arthroplasty [TJA] stemming from better protocols, pain management and physical therapy,” Walter B. Beaver Jr., MD, medical director at OrthoCarolina in Charlotte, N.C., said. “The big question is, are there safety concerns with outpatient TJA? And more recently, there are concerns about penalties for readmission.”

    According to Beaver and his colleagues, under the Patient Care and Affordability Act, Medicare is focusing on 30-day readmission rates for certain diagnoses and is penalizing hospitals financially for readmissions in this timeframe. “In 2015, [CMS is] probably going to include total hip and total knee arthroplasty in the penalties for readmission, and the penalties may be a maximum of 3%,” Beaver said.

    Study inclusion criteria

    Beaver and his colleagues sought to determine whether outpatient or inpatient TJA influenced hospital readmission rates during the 30-day postoperative period. They completed telephone surveys with 235 patients, including 137 outpatients and 98 inpatients who underwent TJA at the same institution between September 2010 and May 2011. One surgeon performed all of the outpatient TJAs, and two surgeons who performed the inpatient TJAs, which included hospital stays with a minimum of 2 days.

    Criteria for outpatient TJA included a body mass index of less than 40 kg/m2 and no active cardiopulmonary issues, sleep apnea, or history of deep venous thrombosis or pulmonary embolus. Patients also had to live less than 1 hour from the hospital and have good family support.

    Readmission rates were 5.7% for inpatient TJA vs. 10.1% for outpatient TJA. “At our cohort size, there was no statistical significance seen,” Beaver said.

    When researchers included emergency room visits with readmissions, 6.7% of inpatients and 12.4% of outpatients required unplanned medical care after hospital discharge; again, according to Beaver, this difference was not statistically significant.

    Readmission rates

    Researchers observed no statistically significant differences between the two groups for readmission during the first 4 postoperative days or when stratified by joint: In the inpatient group, seven total knee arthroplasty (TKA) patients and no total hip arthroplasty (THA) patients were readmitted during the 30-day postoperative period, and in the outpatient group, 16 TKA patients and one THA patient were readmitted.

    Both patient groups reported high patient satisfaction, with no statistically significant difference between the two groups.

    “There was no statistical difference when looking at 30-day hospital readmission rate and patient satisfaction,” Beaver said. “However, there was a higher readmission rate for the outpatient surgery group, which was clinically meaningful. This may have financial implications due to higher readmission rates for the outpatient group. Implications could affect bundled payments in the future, and this is especially true for total knee arthroplasty.”

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  • Hepatitis C infection did not affect outcomes after total hip arthroplasty

    Clinical and patient-reported outcomes following total hip arthroplasty in patients with chronic hepatitis C were comparable to outcomes of patients without the infection at a mean 6-year follow-up, according to a presenter at the American Academy of Orthopaedic Surgeons Annual Meeting.

    “Hepatitis C can affect approximately 3% of orthopedic patients, many of whom undergo total joint arthroplasty,” said Samik Banerjee, MBBS, MS, MRCS (Glasg), of the Department of Orthopaedic Surgery and Center for Joint Preservation and Replacement at the Rubin Institute for Advanced Orthopedics and Sinai Hospital of Baltimore. “However, there has been a paucity of reports on the outcomes of primary total hip arthroplasty in patients with hepatitis C.”

    Similar implant survivorship

    Banerjee and his colleagues compared the clinical and patient-reported outcomes of 49 patients (54 hips) who underwent primary total hip arthroplasty (THA) to a matched cohort of 148 THAs in patients without hepatitis C. All patients underwent THA during 2002 to 2011. Patients with hepatitis C included 10 women and 39 men who had a mean age of 57 years. Mean follow-up was 6 years, and the underlying cause of hip disease was end-stage osteoarthritis in 49 hips and avascular necrosis in five. Patients were matched according to age, gender, body mass index, cause of hip disease and mean follow-up duration.

    Overall implant survivorship was statistically similar between the groups: 98% in the patients with hepatitis C and 98.5% in the matched control group. “The hepatitis C group had one aseptic revision, while the matched cohort had two revisions during this period,” Banerjee said during his presentation.

    Researchers also found no difference between the groups in the postoperative Harris hip score, with an improvement to a mean of 89 points in the patients with hepatitis C and an improvement to a mean of 90 points in the comparison group.

    Superficial infection, hematoma

    Banerjee and colleagues also reported no significant differences in the complication rate between the groups, but in the hepatitis C group, he and his colleagues found a superficial infection and two wound hematoma cases. Furthermore, they found no differences in the SF-36 physical and mental component scores or UCLA activity scores. Postoperative radiographic evaluation revealed no component malalignment, symptomatic progressive radiolucencies, change in component position or implant subsidence.

    “From our study, we can agree [with previously published data] that there is no difference in aseptic implant survivorship, activity levels or functional outcomes after THA,” Banerjee said. “We believe that a prior history of chronic hepatitis C alone may not predict inferior clinical outcomes, and we also believe more prospective studies are necessary to better evaluate these outcomes.”

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  • Blood Metal Ions Tied to Failed Hip Replacement, Resurfacing

    Raised levels of blood metal ions are associated with failed metal-on-metal hip resurfacings and total hip arthroplasties, according to a study published in the July 2 issue of The Journal of Bone & Joint Surgery.

    The researchers found that patients with failed arthroplasty had significantly higher blood cobalt and chromium ion levels than patients with non-failed arthroplasty (P < 0.01).

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  • Partial knee replacement safer than total knee replacement

    Partial knee replacement surgery is safer than total knee replacement according to a new study published in The Lancet.

    Patients who had a partial knee replacement are 40 per cent more likely to have a re-operation, known as revision surgery, during the first eight years after the replacement, than those that had a total knee replacement.

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  • Obesity may be driving increasing need for knee and hip replacements in steadily younger patients

    The impact of being overweight has far reaching health implications — implications that may be taking a toll at an earlier age.

    In a new study, researchers found that packing on the pounds may be setting the stage for total knee or hip replacement at increasingly younger ages.

    Further, the scientists found that being overweight or obese had a greater impact on the knee than the hip.

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