Early- and Late-Term Dislocation Risk After Primary Hip Arthroplasty in the Medicare Population

doi:10.1016/j.arth.2010.04.014

The Journal of Arthroplasty

Volume 25, Issue 6, Supplement, September 2010, Pages 21-25

https://doi.org/10.1016/j.arth.2010.04.014 Get rights and content

Abstract

From 1998 to 2007 Medicare 5% national sample dataset, 39 271 primary total hip arthroplasty (THA) patients were identified. Dislocations within 2 years (early) and after 2 years (late) of primary THA were identified. Cox regression was used to evaluate patient, hospital, and procedure characteristics for risk of dislocation, and 1540 (3.92%) and 451 (1.15%) patients were diagnosed with early and late dislocations, respectively. Dislocation rate at 6 months' follow-up decreased steadily between 1998 and 2007 from 4.21% to 2.14%. Early and late dislocation risks were lower by 35% (P < .001) and 43% (P = .01), respectively, for patients operated during 2004 and 2007 compared with 1998 and 2003. Higher Charlson index scores (i.e., more comorbid conditions) and surgeon volume were significant risk factors (P ≤ .04). Decrease in dislocation risks after primary THA seems to coincide with increasing use of larger diameter femoral heads. An awareness of risk factors for dislocation can help surgeons identify high-risk patients so as to prescribe appropriate intervention strategies.

Section snippets

Materials and Methods

The Medicare administrative claims that data from the 5% nationwide sample of Medicare beneficiaries between 1998 and 2007 were used to identify patients who underwent primary THA. Primary THA procedures were identified using Current Procedural Terminology (CPT-4) code 27130 from claims submitted by physicians (part B) and International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) code 81.51 from claims submitted by the institutions (inpatient). Patients younger

Results

A total of 39 266 primary THA patients were identified in the Medicare population. A total of 1868 patients (4.76%) from this cohort were diagnosed with postoperative dislocation during the study period. Most dislocations (80.6%) were diagnosed within 2 years of the index procedure. The incidence of dislocation was 3.84% (n = 1506) within 2 years and 0.92% (n = 362) between 2 and 10 years.

The incidence of dislocation has declined steadily since 1998 (Fig. 1). Dislocation incidence at 6 months

Discussion

The decrease in early and late dislocation risks after primary THA seems to coincide with increasing use of large diameter femoral heads. During this study period (1998-2007), the proportion of femoral heads, which were size 32 mm or greater, increased from approximately 12% to 77%. Large femoral head diameters have been shown to improve the head-neck ratio, providing a greater range of motion before component impingement and dislocation. Sultan et al [15] demonstrated that increasing the

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Cited by (111)

Is Timing of Total Hip Arthroplasty and Lumbar Spine Fusion Associated With Risk of Hip Dislocation?
2023, Arthroplasty Today
In patients with concomitant hip and lumbar spine disease, the question of which surgery—total hip arthroplasty (THA) or lumbar spine fusion (LSF)—to address first has not been adequately answered. We aimed to evaluate the risk of dislocation after THA in patients with LSF first or after THA.
Retrospective review utilizing the PearlDiver database querying Current Procedural Terminology codes for LSF in the year prior (LSF first) or in the year after primary or revision THA (THA first). International Classification of Disease codes identified postoperative hip dislocation as our primary outcome variable. Demographic data collected included age, sex, and obesity. Dislocation rates were described as a proportion of the cohort and compared with chi-square tests.
We identified 280,857 primary THA and 42,314 revision THA cases from 2012-2019. Of these, 2090 underwent primary THA and LSF, and 283 underwent revision THA and LSF within a year of each procedure. No differences in age, sex, or obesity between groups were noted. No difference in rate of all-time dislocation for primary THA was noted for the LSF first 51/1429 (3.6%) compared to the THA first 30/661 (4.0%) groups (P = .34), or for revision THA with LSF first 48/204 (23.5%) compared to THA first 27/117 (23.1%) groups (P = 1.0).
There was no difference in the risk of dislocation after primary or revision THA if LSF occurred prior to or after the THA. These findings can help surgeons as they counsel patients with concomitant lumbar spine and hip degeneration.
Fibromyalgia Increases Post-operative Healthcare Utilization Following total Hip Arthroplasty
2023, Journal of Arthroplasty
Preoperative factors can complicate the postoperative course and increase health care utilization following total hip arthroplasty (THA). Fibromyalgia is not generally recognized as a modifiable risk factor prior to THA. The aim of this investigation was to assess the effect of fibromyalgia on postoperative health care utilization following THA.
Patients who underwent primary THA from 2018 to 2019 were identified from a large national database using Current Procedural Terminology and International Classification of Diseases, tenth revision (International Classification of Diseases-10) codes. Patient demographics, age, sex, and preoperative opioid use were collected. Analysis compared patients who did and did not have fibromyalgia for postoperative health care utilization metrics; lengths of stay (LOS), 90-day postoperative opioid usages, dislocations, and emergency room visits. Independent t-tests were used to compare LOS and rates of ongoing opioid use. Logistic regression analyses with adjusted odds ratios evaluated the risk of dislocation and emergency room visit after adjusting for demographic characteristics and comorbidities.
Compared to those who did not have fibromyalgia, patients who had fibromyalgia experienced longer LOS (P < .0001), increased odds of opioid use 90 days postoperatively (P < .0001) as well as increased odds of hip dislocation (P < .0001) and presentation to the emergency room (P < .0001). Patients who had fibromyalgia were also more likely to be “frequent flyers” with ≥5 emergency room visits after THA (P < .0001).
Fibromyalgia can complicate postoperative care following THA with increased LOS, higher rates of opioid use, and increased odds of dislocation and emergency room visits. As focus shifts to preoperative optimization and risk stratification, more attention should be placed on fibromyalgia prior to THA.
Incidence of Instability Following Primary Total Hip Arthroplasty Continues to Decline in the Medicare Population
2023, Journal of Arthroplasty
Instability has been the primary cause of failure following primary total hip arthroplasty (THA) leading to revision hip surgery. The purpose of this study was to determine if instability rates have further declined following advances in primary THA, including dual mobility articulations, direct anterior approaches, advanced technologies, and improved knowledge of the hip-spine relationships.
Using the 5% Medicare Part B claims data from 1999 to 2019, we identified 81,573 patients who underwent primary THA for osteoarthritis. Patients who experienced instability at 3 months, 6 months, 1 year, and 2 years were identified. Multivariate cox regression analyses evaluated the effect of patient and procedure characteristics on the risk of instability.
Instability at 1 year following primary THA declined from approximately 4% in 2000 to 2.3% in 2010 and 1.6% in 2018. The leading cause of revision surgery was infection (18.6%), followed by periprosthetic fracture (14%), mechanical loosening (11.5%), and instability (9.4%). High-risk groups for instability continue to include increased age, higher Charlson index, obesity, lumbar spine pathology, and neurocognitive disorders.
Instability is no longer the leading etiology of failure following primary THA with a decline of approximately 40% over the past decade. Infection, periprosthetic fracture, mechanical loosening, and then instability are now the leading causes of failure. Multiple factors may play a role in the decline of instability, including increased use of dual mobility articulations, direct anterior approaches, improved knowledge of the hip-spine relationships, and use of advanced technologies.
It is the Opioids Not the Spine Surgeon; Dislocation After Total Hip Arthroplasty is Associated With Opioid Use in Patients Who Have Prior Lumbar Spine Fusion
2023, Journal of Arthroplasty
Patients who have prior lumbar spine fusion (LSF) have an increased risk for dislocation after total hip arthroplasty (THA). These patients also have elevated rates of opioid use. We aimed to evaluate the associated risk of dislocation after THA in patients who have prior LSF comparing those who have opioid use to those who do not.
This was a retrospective review using a large national database of 246,617 primary and 34,083 revision THA cases from 2012 to 2019. There were 1,903 primary THA and 288 revision THA cases identified with LSF prior to THA. Postoperative hip dislocation was our primary outcome variable and patients were stratified to use or nonuse of opioid at THA. Demographic data including age, sex, and obesity were collected. Multivariate analyses evaluated association of opioid use and dislocation after adjusting for demographics.
There was increased odds of dislocation for opioid use at THA for both primary (adjusted Odds Ratio [aOR] = 2.29, 95% Confidence Interval [CI] 1.46 to 3.57, P < .0003) and revision THA (aOR = 1.92, 95% CI 1.62 to 3.08, P < .0003), in patients who have prior LSF. Prior LSF without opioid use was associated with increased odds of dislocation (aOR = 1.38, 95% CI 1.01 to 1.88, P = .04), but this was lower than the associated risk of opioid use without LSF (aOR 1.72, 95% CI 1.63 to 1.81, P < .001).
Increased odds of dislocation were noted with opioid use at time of THA in patients who have prior LSF. Associated risk of dislocation was higher for opioid use than prior LSF. This suggests that dislocation risk is multifactorial and we should look to strategies to reduce opioid use prior to THA.
An Analysis of a National Administrative Dataset Demonstrating No Evidence of Increase in Elective Primary Total Hip Arthroplasty Dislocation Rates When Postoperative Hip Precautions are Not Used
2022, Journal of Arthroplasty
The purpose of this study is to determine whether there is a higher dislocation rate when postoperative hip precautions are not used for primary total hip arthroplasty (THA).
A survey was conducted of the hip precautions used by orthopaedic departments in England performing elective primary THA. From the responses to the survey an interrupted time series analysis was performed using the hospital admissions data from the Hospital Episode Statistics (HES) database during the period April 1, 2011 to December 31, 2019 and subsequent dislocations of these prostheses up to June 30, 2020. These were used to determine dislocations within 180 days of primary surgery and emergency readmissions within 30 days of discharge.
Records were reviewed from 229,057 patients receiving primary, elective THA across 114 hospitals. In total, 1,807 (0.8%) dislocations were recorded within 180 days of surgery. There were 12,416 (5.4%) emergency readmissions within 30 days of surgery. Within hospitals where hip precautions were stopped, the proportion of patients having a dislocation was 0.8% both before and after stopping precautions, with a significant postintervention trend towards fewer dislocations (P < .001). There was also a significant immediate change in median length of stay from 4 to 3 days (P < .001) but no significant trend in the proportion of emergency readmissions within 30 days.
There is no evidence of an increase in early dislocation or 30-day readmission rates after stopping traditional postoperative hip precautions in primary THA. Potential reductions in length of stay will reduce the risks associated with an extended hospital admission, improve service efficiency, and reduce costs.
Development of bony range of motion (B-ROM) boundary for total hip replacement planning
2022, Computer Methods and Programs in Biomedicine
Pre-operative surgical planning using computer simulation is increasingly standard practice before Total Hip Arthroplasty (THA), in order to determine the optimal implant positions, and thereby minimise post-operative complications such as dislocation, wear and leg length discrepancy. One of the limitations of current methods, however, is the lack of information on the subject-specific reference range of motion (ROM) that could be used as targets for surgical planning. Only a limited number of hip motions are considered, which are neither subject-specific, nor representative of all the hip motions associated with all the activities of daily livings (ADLs). In this paper, therefore, a method was developed to calculate subject-specific representative bony range of motion (B-ROM) that would cover all the possible joint motions and presented in terms of pure joint motions.
Only 3D bone geometries of femur and pelvis, constructed from personalised CT scan, were used as inputs for healthy hip joint whereas implant geometries and their positions on native bone geometries were required for planned treatment side or replaced side. Hip joint motion simulation was carried out using six different Tait-Bryan intrinsic rotation sequences of three pure joint motions - flexion-extension, abduction-adduction and internal-external rotation, and B-ROM was then identified for any of these six different sequences which caused earliest feasible impingement. The B-ROM could be used as a list of ROM data points or visualised as multiple 2D surface plots or a 3D envelop. Using the developed method, the B-ROM of a contralateral healthy hip joint of a patient can be used to define the subject-specific target ROM values to inform the surgical planning of the arthritic hip side so that the patient's natural ROM could be restored as closely as possible by the planned implant placements. This was demonstrated with a clinical verification study using ‘non-dislocating’ and ‘dislocating’ THA patients.
The results supported the study hypothesis that the percentage of intersected volume of the healthy and replaced side B-ROM was higher for the ‘Non-Dislocator’ patient (95%) compared to ‘Dislocator’ (78%). Also, the results showed that the only one sequence (first flexion-extension, then abduction-adduction and finally internal-external rotation) was not adequate to identify all the possible limiting B-ROM, and therefore, all the six rotation sequences should be considered.
The method encompasses every potential ADL, and as a result, more comprehensive surgical planning is possible, as the implant positions can be optimised in order to maximise impingement-free ROM, and consequently minimise clinical complications.

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: Benefits or funds were received in partial or total support of the research material described in this article. These benefits and/or support were received from the following source: Stryker.

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Winner of the Dorr AwardEarly- and Late-Term Dislocation Risk After Primary Hip Arthroplasty in the Medicare Population

Abstract

Section snippets

Materials and Methods

Results

Discussion

The epidemiology of revision total hip arthroplasty in the United States

J Bone Joint Surg Am

Dislocation in total hip arthroplasties

Clin Orthop Rel Res

Prevalence of dislocation after total hip arthroplasty through a posterolateral approach with partial capsulectomy and capsulorrhaphy

J Bone Joint Surg

Modular revision for recurrent dislocation of primary or revision total hip arthroplasty

J Arthroplasty

Modular component exchange for treatment of recurrent dislocation of a total hip replacement in selected patients

J Bone Joint Surg

Effect of femoral head diameter and operative approach on risk of dislocation after primary total hip arthroplasty

J Bone Joint Surg

Range of motion and stability in total hip arthroplasty with 28-, 32-, 39-, and 44-mm femoral head sizes

J Arthroplasty

Biomechanics of large femoral heads: what they do and don't do

Clin Orthop Rel Res

Orthopedic Network News

Winner of the Dorr Award
Early- and Late-Term Dislocation Risk After Primary Hip Arthroplasty in the Medicare Population