Effect of Volume on Total Hip Arthroplasty Revision Rates in the United States Medicare Population

Homer Stryker Center for Orthopaedic Education, 325 Corporate Drive, Mahwah, NJ 07430, USA.
The Journal of Bone and Joint Surgery (Impact Factor: 5.28). 12/2008; 90(11):2446-51. DOI: 10.2106/JBJS.G.01300
Source: PubMed


Fewer short-term complications following total hip arthroplasty have been associated with greater hospital and surgeon procedure volume. It remains unclear if procedure volume is associated with longer-term clinical outcomes and revision rates. We examined the association between hospital and surgeon procedure volume and total hip arthroplasty revision rates in the Medicare population at six months to eight years postoperatively.
A subset of the 1997 to 2004 Medicare claims data was used to identify primary and revision total hip arthroplasties. The Kaplan-Meier method and Cox regression analysis were used to determine revision rates and hazard ratios associated with hospital and surgeon procedure volumes at 0.5, two, five, and eight years postoperatively.
About one-third of the primary hip procedures were done at hospitals with the highest annual volumes of total hip arthroplasties (more than 100). Surgeons with an annual volume of more than fifty procedures performed approximately one-sixth of the primary total hip arthroplasties. Patients who had been operated on by these surgeons had a lower revision rate at six months than did patients treated by surgeons with an annual volume of six to ten or eleven to twenty-five procedures (adjusted hazards ratio, 1.67 and 1.63, respectively). There was no effect of surgeon volume at the time of longer-term follow-up.
The majority of the total hip arthroplasties in the Medicare population from 1997 to 2004 were not performed by the highest-volume hospitals or surgeons. Our findings suggest that patients of low-volume surgeons have a greater risk of arthroplasty revision at six months but no greater risk of revision at the time of longer-term follow-up. There appeared to be no significant association between hospital volume and the rate of revisions of total hip arthroplasties.

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Available from: Michael T Manley
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    • "A few studies have evaluated the role of micromotion and backside wear in the eventual development of osteolysis, and these have indicated that it increases the risk of revision (Wasielewski et al. 1997, Parks et al. 1998). Clinically, the use of metal-backed TKAs has a high success rate at long-term follow-up (Manley et al. 2008, Bae et al. 2012, Nouta et al. 2012b), but backside wear continues to be an issue that limits implant longevity. In contrast, as demonstrated by radiostereometric analysis (RSA) techniques, the monoblock all-polyethylene tibial component has less component migration and better tibial fixation than fixed, metal-backed designs (Norgren et al. 2004, Hyldahl et al. 2005, Nouta et al. 2012b). "
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    ABSTRACT: Background and purpose With younger patients seeking reconstructions and the activity-based demands placed on the arthroplasty construct, consideration of the role that implant characteristics play in arthroplasty longevity is warranted. We therefore evaluated the risk of early revision for a monoblock all-polyethylene tibial component compared to a metal-backed modular tibial construct with the same articular geometry in a sample of total knee arthroplasties (TKAs). We evaluated risk of revision in younger patients (< 65 years old) and in older patients (≥ 65 years old). Method Fixed primary TKAs with implants from a single manufacturer, performed between April 2001 and December 2010, were analyzed retrospectively. Patient characteristics, surgeon, hospital, procedure, and implant characteristics were compared according to tibial component type (monoblock all-polyethylene vs. metal-backed modular). All-cause revisions and aseptic revisions were evaluated. We used descriptive statistics and Cox regression models. Results 27,657 TKAs were identified, 2,306 (8%) with monoblock and 25,351 (92%) with modular components. In adjusted models, the risk of early all-cause revision (hazard ratio (HR) = 0.5, 95% confidence interval (CI): 0.3–0.8) and aseptic revision (HR = 0.6, CI: 0.3–1.2) was lower for the monoblock cohort than for the modular cohort. In older patients, the early risk of all-cause revision was 0.6 (CI: 0.4–1.0) for the monoblock cohort compared to the modular cohort. In younger patients, the adjusted risk of all-cause revision (HR = 0.3, CI: 0.1–0.7) and of aseptic revision (HR = 0.3, CI: 0.1–0.7) were lower for the monoblock cohort than for the modular cohort. Interpretation Overall, monoblock tibial constructs had a 49% lower early risk of all-cause revision and a 41% lower risk of aseptic revision than modular constructs. In younger patients with monoblock components, the early risk of revision for any cause was even lower.
    Full-text · Article · Nov 2013 · Acta Orthopaedica
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    • "In addition, some patient characteristics such as body mass index and physical activity were not available in the register. Hospital arthroplasty volume, surgical expertise, and a surgeon's annual case load may reduce the revision risk, although the current evidence is inconclusive (Losina et al. 2004, Judge et al. 2006, Shervin et al. 2007, Manley et al. 2008 "
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    ABSTRACT: Background and purpose Little is known about the effect of the learning curve for different types of total hip arthroplasties (THAs). We investigated the prostheses survival of THAs just after the implementation of a model new to the hospital, and compared these results with the results of THAs done when more than 100 implantations had been undertaken. In addition, we investigated whether differences exist between different types of femoral stems and acetabular cups at the early implementation phase. Patients and methods We used comprehensive registry data from all units (n = 76) that performed THAs for primary osteoarthritis in Finland between 1998 and 2007. Complete data including follow-up data to December 31, 2010 or until death were available for 33,819 patients (39,125 THAs). The stems and cups used were given order numbers in each hospital and classified into 5 groups: operations with order number (a) 1–15, (b) 16–30, (c) 31–50, (d) 51–100, and (e) > 100. We used Cox’s proportional hazards modeling for calculation of the adjusted hazard ratios for the risk of revision during the 3 years following the implementation of a new THA endoprosthesis type in the groups. Results Introduction of new endoprosthesis types was common, as more than 1 in 7 patients received a type that had been previously used in 15 or less operations. For the first 15 operations after a stem or cup type was introduced, there was an elevated risk of revision (hazard ratio (HR) = 1.3, 95% CI: 1.1–1.5). There were differences in the risk of early revision between stem and cup types at implementation. Interpretation The first 15 operations with a new stem or cup model had an increased risk of early revision surgery. Stems and cups differed in their early revision risk, particularly at the implementation phase. Thus, the risk of early revision at the implementation phase should be considered when a new type of THA is brought into use.
    Full-text · Article · Jan 2013 · Acta Orthopaedica
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    • "Six papers [20,21,35,37,91,92] reported on the association of hospital volume with revision. One study found a statistically significant increased risk for low-volume hospitals. "
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    ABSTRACT: Background Numerous papers have been published examining risk factors for revision of primary total hip arthroplasty (THA), but there have been no comprehensive systematic literature reviews that summarize the most recent findings across a broad range of potential predictors. Methods We performed a PubMed search for papers published between January, 2000 and November, 2010 that provided data on risk factors for revision of primary THA. We collected data on revision for any reason, as well as on revision for aseptic loosening, infection, or dislocation. For each risk factor that was examined in at least three papers, we summarize the number and direction of statistically significant associations reported. Results Eighty-six papers were included in our review. Factors found to be associated with revision included younger age, greater comorbidity, a diagnosis of avascular necrosis (AVN) as compared to osteoarthritis (OA), low surgeon volume, and larger femoral head size. Male sex was associated with revision due to aseptic loosening and infection. Longer operating time was associated with revision due to infection. Smaller femoral head size was associated with revision due to dislocation. Conclusions This systematic review of literature published between 2000 and 2010 identified a range of demographic, clinical, surgical, implant, and provider variables associated with the risk of revision following primary THA. These findings can inform discussions between surgeons and patients relating to the risks and benefits of undergoing total hip arthroplasty.
    Full-text · Article · Dec 2012 · BMC Musculoskeletal Disorders
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