Study: No Clinical Difference Between BHR and THA, But…
While it is true that new research has found no clinical difference between Birmingham hip resurfacing (BHR) and total hip arthroplasty (THA), the authors recommend considering other issues when deciding on which procedure to perform.
The research, “Birmingham Hip Resurfacing vs Total Hip Arthroplasty: A Matched-Pair Comparison of Clinical Outcomes,” appears in the December 2017 edition of The Journal of Arthroplasty.
Benjamin Domb, M.D., founder and medical director of The American Hip Institute in Hinsdale, Illinois, co-author on the study, commented to OTW, “BHR has been put forth as a surgery that may allow superior function when compared to THR [total hip replacement] for certain patient populations. Ceiling effects of legacy outcomes measurement tools have made it difficult to assess whether there is a real difference.”
“The advent of the Forgotten Joint Score (FJS) has addressed the problem of ceiling effects. Based on the results, we believe that while functional outcomes may not be different from THR, BHR retains its place as an excellent surgery for a subset of patients.”
“The matched-pair cohort study is one of the best study designs at our disposal, short of a randomized controlled trial. Since patients will rarely agree to be randomized to surgical treatment arms of this sort, this study design enables us to compare the two surgeries while controlling for as many other variables as possible.”
“The greatest significance of this study is that it is one of the first studies to look at either BHR or THR outcomes using the FJS.”
“In both cohorts, patients reported that they had nearly forgotten about their arthroplasty, and rarely remembered they had an implant in their hip. While most previous outcomes studies on arthroplasty have focused on revision rates and radiographic outcomes, in the 21st century the bar for success of joint arthroplasty is higher.”
“By elevating our standards using outcomes measurement tools that are not plagued by ceiling effects, we can more finely discriminate between ‘good’ and ‘great.’”
“In considering BHR vs. THR, patients may be counseled that if there is any functional difference in outcomes, it was too fine a difference to detect in this study. However, the outcomes of BHR match up well against THR from a functional standpoint, which may justify its use in a select subset of patients.”
“We believe that both BHR and minimally invasive THR can have excellent functional outcomes. As we perform arthroplasty in younger and more active patients, discerning between ‘good’ and ‘great’ functional outcomes become vitally important.”
“One of the potential advantages of the BHR, from a functional standpoint, is that it generally reproduces the patient’s own native femoral version, length, and offset.”
“THR, on the other hand, can significantly change each of these variables. To achieve better functional outcomes with THR in high demand patients, we believe that 3D patient-specific planning, with robotics or other tools, will improve our ability to accurately recreate native femoral version, length, and offset.”
Rush Research: Outpatient Arthroplasty Safe as Inpatient
In a recent study from Rush University Medical Center in Chicago, orthopedic researchers found that outpatient arthroplasty is indeed safe. The researchers, who included Craig Della Valle, M.D., chief of adult reconstructive surgery at Rush, examined morbidity in same-day and inpatient surgical procedures, looking at complications and readmission rates.
Their work, “Same-Day Discharge Compared with Inpatient Hospitalization Following Hip and Knee Arthroplasty,” was published in the December 6, 2017 edition of The Journal of Bone and Joint Surgery.
The authors wrote, “Patients who underwent primary elective total hip arthroplasty, total knee arthroplasty, or unicompartmental knee arthroplasty from 2005 to 2014 were identified from the National Surgical Quality Improvement Program registry.”
“Of 177,818 patients identified, 1,236 underwent a same-day surgical procedure. After matching, there were no differences in overall adverse events or readmission between same-day and inpatient groups, although inpatients had increased thromboembolic events and same-day patients had an increased rate of return to the operating room.”
“When procedures were assessed individually, the only difference identified was that the same-day total knee arthroplasty cohort had an increased return to the operating room compared with the inpatient total knee arthroplasty cohort.”
“Body mass index of ≥35 kg/m, insulin-dependent diabetes, non-insulin-dependent diabetes, and age of ≥85 years were associated with 30-day readmission following same-day surgical procedures. Infection was the most common reason for reoperation and readmission following same-day procedures.”
Dr. Della Valle told OTW, “I think that many surgeons and patients are interested in the concept of outpatient arthroplasty however the big concern is always, ‘Is it just as safe as staying in the hospital?’ I think the results of this study and others suggest that answer is ‘yes.’”
“This concept still needs to be followed carefully, especially with the removal of total knee arthroplasty from the inpatient only list to ensure it is safe. My sense is in the right centers, if the right patients are chosen it appears to be just as safe.”
Operating on the Muscular Sclerotic Patient
Researchers from Cleveland Clinic, SUNY Downstate Medical Center, and Case Western Reserve University have found evidence that total hip arthroplasty (THA) is especially risky and complex for patients with multiple sclerosis (MS).
The novel study, “Does Multiple Sclerosis Affect the Inpatient Perioperative Outcomes After Total Hip Arthroplasty?,” appears in the December 2017 edition of The Journal of Arthroplasty.
Carlos A. Higuera, M.D. orthopedic surgeon at Cleveland Clinic in Ohio and co-author on the study, told OTW, “We have a significant amount of patients with MS that need THA. We noted that some of these patients had a larger number of complications and length of stay (LOS). So, we wanted to check if this was an issue in a larger dataset.”
“This study used the National Inpatient Sample (NIS) database, which is the United States’ largest all-payer database of inpatient admissions, and includes millions of patients for each year.”
“Additionally, patients who had a diagnosis of MS at the time of THA and patients without MS at the time of THA were matched in a 1:3 ratio using propensity score matching based on age, gender, race, Elixhauser score, and year of surgery, to control for potential confounders when comparing the perioperative outcomes, LOS, and discharge disposition. Also, osteonecrosis was included as a confounder in the analysis.”
“That MS was associated with a much higher risk for perioperative complications including postoperative anemia, fever, genitourinary, and transfusion, as well as increased LOS, and [patients] had a greater chance of going to a care facility after hospital discharge.”
“We suggest a multi-disciplinary approach, with the involvement of orthopedic surgeons with other practitioners such as neurologists and anesthesiologists, which may help optimize preoperative planning and counseling, to enhance the care of potential THA candidates.”
“This study may be used when risk stratification is developed for evaluation of outcomes after THA. Such outcomes measures are often used for reimbursement and quality assessments done by payors and state and federal agencies including CMS [Centers for Medicare and Medicaid Services].”
“We think that orthopedic surgeons should be aware of the fact that MS patients who undergo THA have a potentially increased risk for perioperative complications, longer LOS, and discharge to care facilities rather than home. Also, working with neurologists may help with optimizing preoperative planning and counseling to enhance the care of such patients.”
