Advertisement for orthosearch.org.uk
Results 1 - 11 of 11
Results per page:
Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_16 | Pages 25 - 25
19 Aug 2024
MacDonald SJ Lanting B Marsh J Somerville L Zomar B Vasarhelyi E Howard JL McCalden RW Naudie D
Full Access

The increased demand for total hip arthroplasty (THA) is having a significant impact on healthcare resources, resulting in increased interest in outpatient care pathways to reduce resource consumption. This study compared costs between patients who underwent outpatient THA using a Direct Anterior (DA) approach compared to a Direct Lateral (DL) approach to understand the effect of surgical approach on resource use.

We conducted a prospective randomized controlled trial for DA patients undergoing primary THA. We compared patients in the outpatient arm of the trial to a prospective cohort of outpatient DL approach THAs. We recorded all costs including: equipment, length of stay in hospital, and laboratory or other medical tests. Following discharge, participants also completed a self-reported cost diary recording resource utilization such as emergency department visits or subsequent hospitalizations, tests and procedures, consultations or follow-up, healthcare professional services, rehabilitation, use of pain medications, informal care, productivity losses and out of pocket expenditures.

We report costs from both Canadian public health care payer (HCP) and a societal perspective. The HCP perspective includes any direct health costs covered by the publicly funded system. In addition to the health care system costs, the societal perspective also includes additional costs to the patient (e.g. physiotherapy, medication, or assistive devices), as well as any indirect costs such as time off paid employment for patients or caregivers.

We included 127 patients in the DA group (66.6 years old) and 51 patients in the DL group (59.4 years old) (p<0.01).

There were no statistically significant differences in costs between groups from both the healthcare payer (DA= 7910.19, DL= 7847.17, p=0.80) and societal perspectives (DA= 14657.21, DL= 14581.21, p=0.96)

In patients undergoing a successful outpatient hip replacement, surgical approach does not have an effect on cost from in hospital or societal perspectives.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_16 | Pages 56 - 56
19 Aug 2024
McCalden RW Vasarhelyi EM Howard JL Lanting BA Naudie DD MacDonald SJ
Full Access

For over a decade, modular titanium fluted tapered (TFT) stems have demonstrated excellent clinical success for femoral revision total hip arthroplasty (THA) surgery. The aim of this study was to report the short-term outcomes of a novel modern monoblock TFT stem used for revision and complex primary THA with a minimum of 2 years follow-up.

We identified 126 patients who received a single monoblock TFT stem - 26 patients for complex THA (failed fracture fixation) and 100 patients for revision THA. The reasons for revision THA included 40 for previous prosthetic joint infection (PJI), 42 for aseptic loosening, 9 for trunnionosis, 9 for periprosthetic fractures. The Paprosky grading for femoral bone loss at the time of surgery and the measured subsidence of femoral stems at 3 months follow-up were determined. We evaluated the number and indications for re-operations.

The mean time from surgery was 3.9 years (range 2.0 to 6.9 years). A paired t-test analysis showed significant improvement from pre-operative versus post-operative clinical outcome scores (p<0.001) for HHS (38.76 +/- 15.24vs. 83.42 +/- 15.38), WOMAC (45.6 ± 19.0 vs. 69.9 ± 21.3) and SF-12 Physical component (31.7 ± 8.1 vs. 37.8 ± 11.3) and SF-12 Mental component (48.2 ± 12.2 vs. 51.6 ± 12.5). The Paprosky grading for femoral bone loss was Grade 1 (3.9%), Grade 2 (35.7%), Grade 3A (47.6%), Grade 3B (11.1%) and Grade 4 (1.6%) cases. There were 18 re-operations (14.7%) with 13 for PJI (7 treated with implant retention, 6 treated with a two-staged revision), 4 for instability and one for acetabular aseptic loosening. There were no aseptic failures of the stem.

This novel modern monoblock TFT stem provided reliable femoral fixation and has increasingly supplanted the use of modular TFT stems for complex primary and revision surgery in our institution.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_12 | Pages 81 - 81
23 Jun 2023
MacDonald SJ Alatassi R Somerville L Howard JL
Full Access

The Canadian Cardiovascular Society (CCS) recommends performing daily troponin testing on postoperative days 0 through 3 for noncardiac surgical patients to decrease the mortality rate due to myocardial injury. Indications for testing include:

->65 yo

-45-64 yo with significant cardiovascular disease

-a Revised Cardiac Risk Index score (RCRI) > 1

Troponin elevation > 30 ng/L is termed “myocardial injury after noncardiac surgery” (MINS).

The study objective was to determine the prognostic relevance of applying CCS recommendations.

669 patients undergoing THA were included in the study. Based on the CCS recommendation there were 4 patient Groups depending on whether or not they met the MINS screening protocol criteria and whether or not it was applied:

-A - met & applied (n=181)

-B - met & not applied (n=248)

-C – not met & applied (n=10)

-D – not met & not applied (n=230)

307 (45.8%) males and 363 (54.2%) females with an average age of 67.8 years were included. Group A- 24% incidence (43 patients) of troponin rise & 5% incidence (9 patients) of cardiac complications. Group B- 0.4% incidence (1 patient) of cardiac complications.

Groups A + B – representing all patients who should have had the MINS screening protocol applied according to the CCS recommendations − 10 (2.3%) patients developed cardiac complication and one (0.2%) patient death

MINS screening protocol group (A & C) LOS was 4.0 days compared to 1.4 days for those not screened (p-value: <0.001).

Applying the CCS MINS screening protocol to elective THA patients added no benefit in predicting/preventing postoperative cardiac events but was associated with a significant increase in LOS. Following current CCS recommendations without more specifications and clinical evidence is unwarranted.


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_12 | Pages 71 - 71
1 Oct 2019
Howard JL Zomar B Marsh JD Bryant D Lanting BA
Full Access

Introduction

Total hip arthroplasty (THA) is an effective surgery for the treatment of advanced osteoarthritis but increasing numbers of these procedures are having a significant impact on healthcare budgets. One route to mitigate the increasing costs is outpatient THA, discharging patients on the same day as their surgery. The purpose of this study was to determine the cost of outpatient THA compared to standard overnight stay in hospital.

Methods

This was a prospective-randomized controlled trial for patients undergoing primary THA through a direct anterior approach. Participants were randomized to be discharged on the same day as surgery, as outpatients, or on day one post-surgery, as inpatients, using a Zelen consent model. Adverse events were assessed, and participants completed self-reported cost questionnaires at two-, six- and 12-weeks post-surgery, and the WOMAC preoperatively and at 12-weeks post-surgery. We performed a cost analysis from health care payer (HCP) and societal perspectives.


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_12 | Pages 9 - 9
1 Oct 2019
Wood T Ndoja S Howard JL McCalden RW Lanting BA Naudie DDR
Full Access

Introduction

Trunnion wear has been reported as a cause for failure of modern total hip replacement implants. While there are several reports on the prevalence of trunnion corrosion with specific stem designs, little is known about the prevalence of this problem across other femoral stem designs. The purpose of this study is to review three commonly used uncemented femoral stems and to correlate any established risk factors with rates of revision.

Methods

We reviewed all patients followed prospectively over a 15-year period (March 2000 to September 2015) who underwent total hip arthroplasty with one of three modern uncemented femoral stem designs. All of the stems were made of titanium (Ti6Al4V alloy) with a 12/14 taper design. We included only metal (cobalt chromium) on highly cross-linked polyethylene articulations. We evaluated age, gender, body mass index (BMI), femoral head size, head length, neck angle and offset as potential risk factors for all cause revision and revision excluding infection by univariate analysis. We performed a logistic regression analysis with odds ratios (OR) for each parameter for both all cause revision as well as with infection excluded. We used a p value of <0.05 as a level of significance.


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_13 | Pages 26 - 26
1 Oct 2018
McCalden RW Ponnusamy K Vasarhelyi EM Somerville LE Howard JL MacDonald SJ Naudie DD Marsh JD
Full Access

Introduction

The purpose of this study is to estimate the cost-effectiveness of performing total hip arthroplasty (THA) versus nonoperative management (NM) in non-obese (BMI 18.5–24.9), overweight (25–29.9), obese (30–34.9), severely-obese (35–39.9), morbidly-obese (40–49.9), and super-obese (50+) patients.

Methods

We constructed a state-transition Markov model to compare the cost-utility of THA and NM in the six above-mentioned BMI groups over a 15-year time period. Model parameters for transition probability (i.e. risk of revision, re-revision, death), utility, and costs (inflation adjusted to 2017 US dollars) were estimated from the literature. Direct medical costs of managing hip arthritis were accounted in the model. Indirect societal costs were not included. A 3% annual discount rate was used for costs and utilities. The primary outcome was the incremental cost-effectiveness ratio (ICER) of THA versus NM. One-way and Monte Carlo probabilistic sensitivity analysis of the model parameters were performed to determine the robustness of the model.


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_13 | Pages 10 - 10
1 Oct 2018
Howard JL Aljurayyan A Somerville L Teeter MG Vasarhelyi E Lanting B
Full Access

Introduction

Early functional recovery following total hip arthroplasty (THA) has the potential to increase patient satisfaction and reduce resource utilization. The direct anterior approach (DA) has been shown to provide earlier recovery compared to the direct lateral (DL) approach based on functional tests and outcome scores. There are limited studies that objectively evaluate functional recovery comparing the two approaches in the early post-operative period. Activity trackers have emerged as a valid tool to objectively quantify physical activity levels and potentially better assess functional status compared to commonly reported functional questionnaires. The purpose of this study is to measure physical activity levels in patients undergoing THA with the DA approach and compare these to THA with the direct lateral approach in the immediate postoperative period.

Methods

In a tertiary academic center we prospectively enrolled patients with primary OA that were eligible for a primary THA undergoing either the DA or the DL approach using the same prosthesis. Patients with comorbidities precluding them from ambulation, diagnoses of AVN or RA or undergoing bilateral THA were excluded. The number of steps walked per day were measured using wristband activity tracking technology for one week preoperatively, the first 2 weeks postoperatively and for 1 week leading up to their 6-week follow-up appointment. The University of California, Los Angeles (UCLA) activity score was also collected at the same two time points. Demographics were analyzed with descriptive statistics. A non-parametric Mann Whitney U test was used to determine whether a difference in physical activity levels exist between the DA and DL approach groups in the first 2 weeks and 6 weeks postoperatively.


The Bone & Joint Journal
Vol. 100-B, Issue 7 | Pages 891 - 897
1 Jul 2018
Teeter MG Lanting BA Naudie DD McCalden RW Howard JL MacDonald SJ

Aims

The aim of this study was to determine whether there is a difference in the rate of wear between acetabular components positioned within and outside the ‘safe zones’ of anteversion and inclination angle.

Patients and Methods

We reviewed 100 hips in 94 patients who had undergone primary total hip arthroplasty (THA) at least ten years previously. Patients all had the same type of acetabular component with a bearing couple which consisted of a 28 mm cobalt-chromium head on a highly crosslinked polyethylene (HXLPE) liner. A supine radiostereometric analysis (RSA) examination was carried out which acquired anteroposterior (AP) and lateral paired images. Acetabular component anteversion and inclination angles were measured as well as total femoral head penetration, which was divided by the length of implantation to determine the rate of polyethylene wear.


The Bone & Joint Journal
Vol. 97-B, Issue 7 | Pages 911 - 916
1 Jul 2015
Del Balso C Teeter MG Tan SC Lanting BA Howard JL

Tribocorrosion at the head–neck taper interface – so-called ‘taperosis’ – may be a source of metal ions and particulate debris in metal-on-polyethylene total hip arthroplasty (THA).

We examined the effect of femoral head length on fretting and corrosion in retrieved head–neck tapers in vivo for a minimum of two years (mean 8.7 years; 2.6 to 15.9). A total of 56 femoral heads ranging from 28 mm to 3 mm to 28 mm + 8 mm, and 17 femoral stems featuring a single taper design were included in the study. Fretting and corrosion were scored in three horizontally oriented concentric zones of each taper by stereomicroscopy.

Head length was observed to affect fretting (p = 0.03), with 28 mm + 8 mm femoral heads showing greater total fretting scores than all other head lengths. The central zone of the femoral head bore taper was subject to increased fretting damage (p = 0.01), regardless of head length or stem offset. High-offset femoral stems were associated with greater total fretting of the bore taper (p = 0.04).

Increased fretting damage is seen with longer head lengths and high-offset femoral stems, and occurs within a central concentric zone of the femoral head bore taper. Further investigation is required to determine the effect of increased head size, and variations in head–neck taper design.

Cite this article: Bone Joint J 2015; 97-B:911–16.


The Bone & Joint Journal
Vol. 97-B, Issue 3 | Pages 312 - 317
1 Mar 2015
Amanatullah DF Howard JL Siman H Trousdale RT Mabry TM Berry DJ

Revision total hip arthroplasty (THA) is challenging when there is severe loss of bone in the proximal femur. The purpose of this study was to evaluate the clinical and radiographic outcomes of revision THA in patients with severe proximal femoral bone loss treated with a fluted, tapered, modular femoral component. Between January 1998 and December 2004, 92 revision THAs were performed in 92 patients using a single fluted, tapered, modular femoral stem design. Pre-operative diagnoses included aseptic loosening, infection and peri-prosthetic fracture. Bone loss was categorised pre-operatively as Paprosky types III-IV, or Vancouver B3 in patients with a peri-prosthetic fracture. The mean clinical follow-up was 6.4 years (2 to 12). A total of 47 patients had peri-operative complications, 27 of whom required further surgery. However, most of these further operations involved retention of a well-fixed femoral stem, and 88/92 femoral components (97%) remained in situ. Of the four components requiring revision, three were revised for infection and were well fixed at the time of revision; only one (1%) was revised for aseptic loosening. The most common complications were post-operative instability (17 hips, 19%) and intra-operative femoral fracture during insertion of the stem (11 hips, 12%). Diaphyseal stress shielding was noted in 20 hips (22%). There were no fractures of the femoral component. At the final follow-up 78% of patients had minimal or no pain.

Revision THA in patients with extensive proximal femoral bone loss using the Link MP fluted, tapered, modular stem led to a high rate of osseointegration of the stem at mid-term follow-up.

Cite this article: Bone Joint J 2015; 97-B:312–17.


The Bone & Joint Journal
Vol. 95-B, Issue 6 | Pages 758 - 763
1 Jun 2013
Rajgopal R Martin R Howard JL Somerville L MacDonald SJ Bourne R

The purpose of this study was to examine the complications and outcomes of total hip replacement (THR) in super-obese patients (body mass index (BMI) > 50 kg/m2) compared with class I obese (BMI 30 to 34.9 kg/m2) and normal-weight patients (BMI 18.5 to 24.9 kg/m2), as defined by the World Health Organization.

A total of 39 THRs were performed in 30 super-obese patients with a mean age of 53 years (31 to 72), who were followed for a mean of 4.2 years (2.0 to 11.7). This group was matched with two cohorts of normal-weight and class I obese patients, each comprising 39 THRs in 39 patients. Statistical analysis was performed to determine differences among these groups with respect to complications and satisfaction based on the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index, the Harris hip score (HHS) and the Short-Form (SF)-12 questionnaire.

Super-obese patients experienced significantly longer hospital stays and higher rates of major complications and readmissions than normal-weight and class I obese patients. Although super-obese patients demonstrated reduced pre-operative and post-operative satisfaction scores, there was no significant difference in improvement, or change in the score, with respect to HHS or the WOMAC osteoarthritis index.

Super-obese patients obtain similar satisfaction outcomes as class I obese and normal-weight patients with respect to improvement in their scores. However, they experience a significant increase in length of hospital stay and major complication and readmission rates.

Cite this article: Bone Joint J 2013;95-B:758–63.