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Background: One route to mitigate the increasing costs of total hip arthroplasty (THA) is outpatient THA, discharging patients on the same day as their surgery. The purpose of this study was to compare the cost of outpatient THA to standard overnight stay in hospital. Methods: This was a preliminary analysis of the first group of patients to complete follow-up in a larger randomized controlled trial among patients who underwent primary THA through a direct anterior approach between June 2015 and November 2017. The study was conducted at a single centre among patients of 1 fellowshiptrained arthroplasty surgeon. We randomly allocated participants to be discharged either as outpatients or on postsurgery day 1 using a modified Zelen consent model. Adverse events were recorded. Participants completed cost questionnaires 2, 6 and 12 weeks after surgery, and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) before and 12 weeks after surgery. We performed cost analyses from health care payer and societal perspectives. Results: A total of 115 participants completed this study, 49 allocated to the outpatient group and 56 to the inpatient group. The adverse event rate was similar for the 2 groups. The WOMAC total score and function subscale score were higher for the outpatient group than the inpatient group at 12 weeks (mean difference 2.1, 95% confidence interval [CI] 0.0 to 4.1, and 6.5, 95% CI 0.4 to 12.5, respectively). From both a health care payer and a societal perspective, inpatient THA was more costly than outpatient THA (mean difference $1006.86, 95% CI -$2158.92 to $145.21, and $1667.40, 95% CI -$3856.64 to $521.84, respectively). Conclusion: Our results suggest that outpatient THA may be a cost-saving procedure compared to inpatient THA from both health care payer and societal perspectives. Further study with larger samples is needed to provide more precision around our estimates. Trial registration: ClinicalTrials.gov, no. NCT03026764. Contexte : Pour limiter l'accroissement des couts de l'arthroplastie totale de la hanche (ATH), on pourrait entre autres effectuer l'intervention en externe, soit donner leur conge aux patients le jour meme de l'intervention. Dans cette etude, le but etait de comparer les couts des ATH pratiquees sur des patients ambulatoires et sur des patients hospitalises selon le traitement standard. Methodes : Nous presentons ici une analyse preliminaire du premier groupe de patients a avoir termine la phase de suivi d'un essai clinique randomise plus vaste mene aupres de patients ayant subi une ATH primaire par voie anterieure directe entre juin 2015 et novembre 2017. L'etude a ete menee dans un seul centre, chez les patients d'un seul chirurgien specialiste en arthroplastie. Les participants ont ete repartis aleatoirement d'apres un schema de Zelen modife, selon qu'ils recevaient leur conge postope ratoire le jour de l'intervention ou le lendemain (jour 1). Les evenements indesi rables ont ete notes. Les participants ont repondu a 2 series de questionnaires : 1 questionnaire sur les couts 2, 6 et 12 semaines apres l'intervention chirurgicale; et l'indice Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) avant l'intervention chirurgicale et 12 semaines apres. Nous avons effectue des analyses de couts du point de vue societal et des regimes d'assurance maladie. Resultats : Au total, 115 participants ont termine l'etude; 49 faisaient partie du groupe des patients ambulatoires et 56, du groupe des patients hospitalises. Les taux d'evenements indesirables etaient semblables dans les 2 groupes. Apres 12 semaines, le score total de l'indice WOMAC et les scores des sous-echelles fonctionnelles etaient plus eleves pour le groupe des patients ambulatoires que pour celui des patients hospitalises (difference moyenne 2,1, intervalle de confance [IC] de 95 % 0,0 a 4,1; et 6,5, IC de 95 % 0,4 a 12,5, respectivement). Du point de vue des regimes d'assurance mala die et du point de vue societal, les couts associes a l'ATH etaient plus eleves chez les patients hospitalises que chez les patients ambulatoires (difference moyenne 1006,86 $, IC de 95 % -2158,92 $ a 145,21 $; et 1667,40 $, IC de 95 % -3856,64 $ a 521,84 $, respectivement). Conclusion : D'apres nos resultats, effectuer les ATH en externe permettrait de reduire les couts, tant du point de vue societal que de celui des regimes d'assurance maladie. Il faudra cependant approfondir la recherche avec de plus grands echantillons pour preciser nos estimations. Numero d'enregistrement de la recherche : ClinicalTrials.gov, no NCT03026764., Total hip arthroplasty (THA) is an effective surgical intervention for the treatment of advanced hip osteoarthritis. The number of these procedures performed in Canada increased by 17.8% between 2012/13 and [...]

Background: Older age (> 40 yr) and osteoarthritis are negative prognostic variables for hip arthroscopy, but their impact has not been quantified from a population standpoint. The purpose of this study was to perform a population-based analysis of hip arthroscopy utilization and associated 2- and 5-year reoperation rates and complications in different age cohorts. Methods: Administrative databases from Ontario, Canada, were retrospectively reviewed to identify patients aged 18-60 years who underwent hip arthroscopy between 2006 and 2016. Patients were stratified into 2 cohorts: 18-39 and 40-60 years of age. Patients were followed for 2 and 5 years to capture the occurrence of subsequent surgery (repeat arthroscopy or total hip arthroplasty) and postoperative complications. Results: A total of 1906 patients underwent hip arthroscopy, 818 (42.9%) of whom were aged 40-60 years. In the entire cohort, revision surgery occurred in 6.5% and 15.1% of cases at 2 and 5 years, respectively. Revision surgery rates were significantly higher among patients aged 40-60 years at 2 (10.8% v. 3.2%, p < 0.001) and 5 years (22.7% v. 8.2%, p < 0.001) than among those aged 18-39 years. Revision rates were higher among patients aged 50-60 years than among those aged 40-49 years at 2 years (14.3% v. 9.1%, p = 0.027). Complication rates did not differ between cohorts. Regression analysis revealed higher 2- and 5-year odds of secondary surgery in patients aged 40-49 years (odds ratio [OR] 2.68, 95% confidence interval [CI] 1.70-4.22; OR 2.82, 95% CI 1.87-4.25; p < 0.001), patients aged 50-60 years (OR 4.39, 95% CI 2.67-7.22; OR 3.44, 95% CI 2.11-5.62; p < 0.001) and those with osteoarthritis (OR 2.41, 95% CI 1.39-4.20; p = 0.002; OR 1.76, 95% CI 1.00-3.09; p = 0.049). Conclusion: Revision surgery rates following hip arthroscopy are significantly higher among older patients and those with concomitant osteoarthritis. Although the data have limitations, they provide useful information to guide surgical decision-making. Contexte : L'age (> 40 ans) et l'arthrose sont des facteurs de pronostic defavorable de l'arthroscopie de la hanche, mais leur impact n'a pas ete quantifie selon un angle populationnel. Le but de l'etude etait d'effectuer une analyse de population du recours a l'arthroscopie de la hanche, et des taux connexes de reintervention et de complications a 2 et 5 ans, dans differentes cohortes d'ages. Methodes : Des bases de donnees administratives de l'Ontario, au Canada, ont ete consul-tees retrospectivement pour identifier des patients ages de 18-60 ans ayant subi une arthroscopie de la hanche entre 2006 et 2016. Les patients ont ete regroupes en 2 cohortes (18-39 ans et 40-60 ans). Ils ont ete suivis pendant 2 et 5 ans pour etablir l'incidence des chirurgies de revision (arthroscopie repetee ou arthroplastie totale de la hanche) et des complications postoperatoires. Resultats : Au total, 1906 patients ont subi une arthroscopie de la hanche, dont 818 (42,9 %) etaient ages de 40-60 ans. Dans l'ensemble de la cohorte, une chirurgie de revision a eu lieu dans 6,5 % et 15,1 % des cas a 2 et 5 ans, respectivement. Les taux de revision chirurgicale etaient significativement plus eleves chez les patients ages de 40-60 ans a 2 ans (10,8 % c. 3,2 %, p < 0,001) et a 5 ans (22,7 % c. 8,2 %, p < 0,001) que chez ceux ages de 18-39 ans. Ils etaient aussi plus eleves chez les patients ages de 50-60 ans que chez ceux ages de 40-49 ans a 2 ans (14,3 % c. 9,1 %, p = 0,027). Les taux de complications ne differaient pas entre les cohortes. L'analyse de regression a revele une probabilite plus elevee de chirurgie secondaire a 2 et 5 ans chez les patients ages de 40-49 ans (rapport des cotes [RC] de 2,68, intervalle de confiance [IC] de 95 % 1,70-4,22; RC de 2,82, IC de 95 % 1,87-4,25; p < 0. 001), les patients ages de 50-60 ans (RC de 4,39, IC de 95 % 2,67-7,22; RC de 3,44, IC de 95 % 2,11-5,62; p < 0,001) et ceux souffrant d'arthrose (RC de 2,41, IC de 95 % 1,39-4,20; p = 0,002; RC de 1,76, IC de 95 % 1,00-3,09; p = 0,049). Conclusion : Les taux de chirurgie de revision a la suite d'une arthroscopie de la hanche sont considerablement plus eleves chez les patients plus ages et ceux atteints d'une arthrose con-comitante. Les donnees presentent des limites, mais elles offrent de l'information utile pour orienter la decision d'operer ou non., Hip arthroscopy utilization continues to increase, as does evidence that it improves patient-reported outcomes; however, a subset of patients require repeat surgical treatment. (1-5) Depending on the population, reoperation rates [...]

Background: Several commonly used procedures for knee osteoarthritis (OA) are not supported by evidence-based guidelines. The objective of this study was to identify the proportion of patients who underwent knee arthroscopy or magnetic resonance imaging (MRI) and the timing of these procedures before total knee arthroplasty (TKA). Methods: We conducted a retrospective cohort study using administrative data sets from Ontario, Canada. We identified the proportion of patients who underwent knee arthroscopy in the previous 10 years or an MRI in the 3 years before their primary TKA. We also evaluated the rate of arthroscopies by diagnosis. We report the timing of each outcome in relation to the TKA, rates by geographical area, and differences in rates over time. Results: We included 142275 patients, of whom 36379 (25.57%) underwent knee arthroscopy (median time 2.8 [interquartile range (IQR) 1.1-6.0] years); 22% of those were within 1 year of TKA and 52% were within 3 years. The rates of arthroscopies for a diagnosis of osteoarthritis (OA) steadily decreased, while those for meniscal-related diagnoses increased over the study period (p < 0.0001). There was significant variation by region. Of the cohort, 23.2% (n = 32 989) had an MRI before their TKA, with rates significantly increasing over time (p < 0.0001). Conclusion: A substantial proportion of patients with knee OA received diagnostic and therapeutic interventions before TKA that are contrary to clinical practice guidelines. Contexte : Plusieurs interventions diagnostiques ou thérapeutiques d'usage courant pour l'arthrose du genou ne s'appuient sur aucune ligne directrice fondée sur des données probantes. L'objectif de cette étude était d'établir la proportion de patients qui ont subi une arthroscopie ou une épreuve d'imagerie par résonnance magnétique (IRM), et l'intervalle entre ces interventions et l'arthroplastie pour prothèse totale du genou (PTG). Méthodes : Nous avons procédé à une étude de cohorte rétrospective à partir de données administratives de population en Ontario, au Canada. Nous avons établi la proportion de patients soumis à une arthroscopie du genou dans les 10 années ou une IRM dans les 3 années précédant une PTG primaire. Nous avons aussi calculé le taux d'arthroscopies par diagnostic. Nous faisons état du moment de chacune par rapport à la PTG, des taux par région, et les différences de taux avec le temps. Résultats : Nous avons inclus 142 275 patients, dont 36 379 (25,57%) ont subi une arthroscopie du genou (intervalle médian 2,8 ans [intervalle interquartile (IIQ) 1,1-6,0]); 22% d'entre eux ont reçu leur PTG dans l'année suivante et 52% dans les 3 années suivantes. Les taux d'arthroscopies pour un diagnostic d'arthrose ont régulièrement diminué, tandis que les diagnostics liés à des problèmes de ménisque ont augmenté pendant la période de l'étude (p < 0,0001). On a noté une variation significative d'une région à l'autre. Dans cette cohorte, 23,2% des patients (n = 32 989) avaient subi une IRM avant leur PTG, avec des taux significativement croissants avec le temps (p < 0,0001). Conclusion : Dans une proportion substantielle, les patients souffrant d'arthrose du genou ont subi des interventions diagnostiques et thérapeutiques pré-PTG qui sont contraires aux lignes directrices de pratique clinique., Osteoarthritis (OA) of the knee is one of the most common chronic health conditions and is a leading contributor to health care service use. (1-3) The disease typically involves slow [...]

ObjectiveTo determine the cost-effectiveness of arthroscopic surgery in addition to non-operative treatments compared with non-operative treatments alone in patients with knee osteoarthritis (OA).Design, setting and participantsWe conducted an economic evaluation alongside a single-centre, randomised trial among patients with symptomatic, radiographic knee OA (KL grade ≥ 2).InterventionsPatients received arthroscopic debridement and partial resection of degenerative knee tissues in addition to optimised non-operative therapy, or optimised non-operative therapy only.Main outcome measuresDirect and indirect costs were collected prospectively over the 2-year study period. The effectiveness outcomes were the Western Ontario McMaster Osteoarthritis Index (WOMAC) and quality-adjusted life years (QALYs). Cost-effectiveness was estimated using the net benefit regression framework considering a range of willingness-to-pay values from the Canadian public payer and societal perspectives. We calculated incremental cost-effectiveness ratios and conducted sensitivity analyses using the extremes of the 95% CIs surrounding mean differences in effect between groups.Results168 patients were included. Patients allocated to arthroscopy received partial resection and debridement of degenerative meniscal tears (81%) and/or articular cartilage (97%). There were no significant differences between groups in use of non-operative treatments. The incremental net benefit was negative for all willingness-to-pay values. Uncertainty estimates suggest that even if willing to pay $400,000 to achieve a clinically important improvement in WOMAC score, or ≥$50,000 for an additional QALY, there is

Background: Periprosthetic joint infection (PJI) is the third leading cause of total hip arthroplasty (THA) failure. Although controversial, 2-stage revision remains the gold standard treatment for PJI in most situations. To date, there have been few studies describing the economic impact of PJI in today's health care environment. The purpose of the current study was to obtain an accurate estimate of the institutional cost associated with the management of PJI in THA and to assess the economic burden of PJI compared with primary uncomplicated THA. Methods: We conducted a review of primary THA cases and 2-stage revision THA for PJI at our institution. Patients were matched for age and body mass index. All costs associated with each procedure were recorded. Descriptive statistics were used to summarize the collected data. Mean costs, length of stay, clinic visits and readmission rates associated with the 2 cohorts were compared. Results: Fifty consecutive cases of revision THA were matched with 50 cases of uncomplicated primary THA between 2006 and 2014. Compared with the primary THA cohort, PJI was associated with a significant increase in mean length of hospital stay (26.5 v. 2.0 d, p < 0.001), mean number of clinic visits (9.2 v. 3.8, p < 0.001), number of readmissions (12 v. 1, p < 0.001) and average overall cost (Can$38 107 v. Can$6764, t = 8.3, p < 0.001). Conclusion: Treatment of PJI is a tremendous economic burden. Our data suggest a 5-fold increase in hospital expenditure in the management of PJI compared with primary uncomplicated THA. Contexte : L'infection articulaire periprothetique (IAP) arrive au troisieme rang des principales causes d'echec de l'arthroplastie (ou prothese) totale de la hanche (PTH). Meme si elle est controversee, la revision en 2 etapes demeure le traitement standard pour l'IAP dans la plupart des cas. A ce jour, peu d'etudes ont decrit l'impact economique de l'IAP dans l'environnement actuel des soins de sante. Le but de la presente etude etait d'obtenir une estimation precise des couts institutionnels associes a la prise en charge de l'IAP dans la PTH et d'evaluer le fardeau economique de l'IAP comparativement a une PTH primaire non compliquee. Methodes : Nous avons passe en revue les cas de PTH primaire et de revision de PTH en 2 etapes pour cause d'IAP dans notre etablissement. Les patients ont ete assortis selon l'age et l'indice de masse corporelle. Tous les couts associes a chaque intervention ont ete consignes. Des statistiques descriptives ont servi a resumer les donnees recueillies. Nous avons compare les couts moyens, la duree des sejours, les visites a la clinique et les taux de readmission associes aux 2 cohortes. Resultats : Cinquante cas consecutifs de revision de PTH ont ete assortis a 50 cas de PTH primaire non compliquee entre 2006 et 2014. Comparativement a la cohorte de PTH primaire, les cas d'IAP ont ete associes a une augmentation significative de la duree moyenne du sejour hospitalier (26,5 j c. 2,0 j, p < 0,001), du nombre moyen de visites a la clinique (9,2 c. 3,8, p < 0,001), du nombre des readmissions (12 c. 1, p < 0,001) et du cout global moyen (38 107 $ CA c. 6764 $ CA, t = 8,3, p < 0,001). Conclusion : Le traitement de l'IAP represente un enorme fardeau economique. Selon nos donnees, les depenses hospitalieres associees a sa prise en charge sont 5 fois plus grandes que pour la PTH primaire non compliquee., Deep infection is a devastating complication in total hip arthroplasty (THA) resulting in significant patient and institutional burden. Current literature suggests that the incidence of periprosthetic joint infection (PJI) is [...]

Background: With the growing number of total hip arthroplasty (THA) procedures performed, revision surgery is also proportionately increasing, resulting in greater health care expenditures. The purpose of this study was to assess clinical outcomes and cost when using a collared, fully hydroxyapatite-coated primary femoral stem for revision THA compared to commonly used revision femoral stems. Methods: We retrospectively identified patients who underwent revision THA with a primary stem between 2011 and 2016 and matched them on demographic variables and reason for revision to a similar cohort who underwent revision THA. We extracted operative data and information on in-hospital resource use from the patients' charts to calculate average cost per procedure. Patient-reported outcomes were recorded preoperatively and 1 year postoperatively. Results: We included 20 patients in our analysis, of whom 10 received a primary stem and 10, a typical revision stem. There were no significant between-group differences in mean Western Ontario and McMaster Universities Osteoarthritis Index score, Harris Hip Score, 12-Item Short Form Health Survey (SF-12) Mental Composite Scale score or Physical Composite Scale score at 1 year. Operative time was significantly shorter and total cost was significantly lower (mean difference -3707.64, 95% confidence interval -5532.85 to -1882.43) with a primary stem than with other revision femoral stems. Conclusion: We found similar clinical outcomes and significant institutional cost savings with a primary femoral stem in revision THA. This suggests a role for a primary femoral stem such as a collared, fully hydroxyapatite-coated stem for revision THA. Contexte: Avec le nombre croissant d'interventions pour prothese de hanche (PTH) effectuees, la chirurgie de revision est aussi proportionnellement en hausse, ce qui entraine des couts superieurs pour le systeme de sante. Le but de cette etude etait d'evaluer les resultats cliniques et le cout associes a l'emploi d'une prothese femorale primaire a collerette entierement recouverte d'hydroxyapatite pour la revision de PTH, comparativement a d'autres protheses d'usage courant utilisees pour les revisions. Methodes: Nous avons identifie retrospectivement les patients ayant subi une revision de PTH avec une prothese primaire entre 2011 et 2016 et nous les avons assortis selon les caracteristiques demographiques et le motif de la revision a une cohorte simil aire soumise a une revision de PTH. Nous avons extrait les donnees sur l'operation et sur l'utilisation des ressources hospitalieres a partir des dossiers des patients pour calculer le cout par intervention. Les resultats declares par les patients ont ete notes avant l'intervention et 1 an apres. Resultats: Nous avons inclus 20 patients dans notre analyse, dont 10 ont recu une prothese primaire et 10, une revision de prothese typique. On n'a note aucune difference significative entre les groupes pour ce qui est du score WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) moyen pour l'arthrose, du score de Harris pour la hanche, ou des sous-echelles sante mentale ou sante physique a 1 an du questionnaire SF-12 (12-Item Short Form Health Survey). L'intervention a dure significativement moins longtemps et le cout a ete significativement moindre (difference moyenne -3707,64, intervalle de confiance de 95% -5532,85 a -1882,43) avec une prothese primaire qu'avec les autres protheses de revision. Conclusion: Nous avons observe des resultats cliniques similaires et des economies significatives pour l'etablissement avec la prothese primaire utilisee pour la revision de PTH. Cela donne a penser que la prothese femorale primaire, par exemple, a collerette et entierement recouverte d'hydroxyapatite, aurait un role a jouer pour la revision de PTH., Although total hip arthroplasty (THA) is considered a widely successful operation, the increasing number of procedures has resulted in a growing number of revision operations. (1)' (2) The most common [...]

High tibial osteotomy (HTO) fixation can be achieved using various plate designs. Compared with nonlocking plates, the stability of locking plates allows patients to return to weight-bearing and work sooner and may also decrease postoperative complications, introducing the potential for overall cost savings. However, material costs for locking plates are higher, and the plate bulkiness may lead to additional surgery to remove the plate. We conducted a retrospective study to evaluate the cost-effectiveness of a locking versus a nonlocking plate in HTO from both the health care payer and societal perspectives up to 12 months postoperative. We observed that from a health care payer perspective, the locking plate was not cost-effective. However, the locking plate was cost-effective from the societal perspective (addition of indirect costs, such as time off work). These findings highlight the importance of considering costing perspective in economic evaluations for chronic conditions, particularly in publicly funded health care systems., The global burden of musculoskeletal (MSK) diseases is substantial and continues to grow as the population ages, posing a heavy economic burden on the Canadian health care system. In osteoarthritis [...]

Background: In previous studies, 50%-70% of patients referred to orthopedic surgeons for total knee replacement (TKR) were not surgical candidates at the time of initial assessment. The purpose of our [...]

Purpose: To evaluate the longitudinal trends in knee arthroscopy utilization in relation to published negative randomized controlled trials, focusing on annual rates, patient demographics and associated 30-day post-operative complications.Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology billing codes to identify arthroscopy cases between 2006 and 2016. 30-day post-operative complications were identified, and potential risk factors analysed using univariate and multivariate analyses.Results: 68,346 patients underwent knee arthroscopy, of which 47,446 (69.5%) represented partial meniscectomies. The annual procedural rate, as a proportion of all reported cases, increased significantly from 2006 (0.3%) to 2016 (1.6%; p < 0.001), along with a significant increase in average patient age (44.3 ± 15.5 to 48.4 ± 14.5; p < 0.001). Specifically focusing on the meniscectomy cohort, average patient age significantly increased from 47.9 ± 15.1 to 50.7 ± 13.5 (p = 0.001). The overall incidence of complications was 2.0% (n = 1333), with major complications in 0.9% (n = 639) and minor complications in 1.0% (n = 701). Common complications included a return to the operating room (0.5%), deep vein thrombosis/thrombophlebitis (0.4%), and superficial infection (0.2%). Operating time > 90 min, diabetes, steroid use, ASA class 2+, and dialysis-dependency were the predictors of overall complication rates.Conclusion: Despite the publication of negative trials and new clinical practice guidelines, knee arthroscopy utilization and average patient age continue to increase. Given the high utilization, even low adverse event rates equate to substantial numbers of patients with minor and major complications. The NSQIP data show a gap in knowledge translation to clinical practice and highlight the need for improved clinical guidelines.Level Of Evidence: Cohort study; Level III. [ABSTRACT FROM AUTHOR]