Volume-Outcome Relationships in Reverse TSA
In an OrthoBuzz post from early 2016, JBJS Editor-in-Chief Marc Swiontkowski, MD observed the following about volume-outcome relationships in total hip and total knee arthroplasty: “the higher the surgeon volume, the better the patient outcomes.”
Now, in a national database analysis of >38,200 patients who underwent a reverse total shoulder arthroplasty (RSA), Farley et al. find a similar inverse relationship between hospital volumes of this increasingly popular surgery and clinical outcomes. Reporting in the March 4, 2020 issue of JBJS, they found a similarly inverse relationship between hospital volume and resource utilization.
This study distinguishes itself with its large dataset and by crunching the data into specific hospital-volume strata for each category of clinical outcome (90-day complications, 90-day revisions, and 90-day readmissions) and resource-utilization outcome (cost of care, length of stay, and discharge disposition).
Specifically, on the clinical side, Farley et al. found the following:
- A 1.42 times increased odds of any medical complication in the lowest-volume category (1 to 9 RSAs/yr) compared with the highest-volume category (≥69 RSAs/yr)
- A 1.38 times increased odds of any readmission in the lowest-volume category (1 to 16 RSAs/yr) compared with the highest-volume category (≥70 RSAs/yr)
- A 1.88 times increased odds of any 90-day revision in the lowest-volume category (1 to 16 RSAs/yr) compared with the highest-volume category (≥54 RSAs/yr)
Here are the findings from the resource-utilization side:
- A 4.03 times increased odds of increased cost of care in the lowest-volume category (1 to 5 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)
- A 2.26 times increased odds of >2-day length of stay in the lowest-volume category (1 to 10 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)
- A 1.68 times increased odds of non-home discharge in the lowest-volume category (1 to 31 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)
Farley et al. say hospital volume should be interpreted as a “composite marker” that is probably related to surgical experience, ancillary staff familiarity, and protocolized pathways. They “recommend a target volume of >9 RSAs/yr to avoid the highest risk of detrimental 90-day outcomes,” and they suggest that the outcome disparities could be addressed by “consolidation of care for RSA patients at high-performing institutions.”
Preventing Acetabular Component Migration in Revision THA
Revision total hip arthroplasty (THA) is a challenging procedure for many reasons, not the least of which is the risk of aseptic loosening leading to re-revision, especially in patients with severe acetabular defects. Acetabular components made of porous tantalum have a developed a good reputation for lower rates of re-revision, relative to components made of other materials. In the November 21, 2018 issue of The Journal of Bone & Joint Surgery, Solomon et al. bolster the evidence base regarding the success of porous tantalum acetabular components in revision THA.
The authors conducted a single-center prospective cohort study that used radiostereometric analysis (RSA) to accurately measure acetabular component migration in 55 revision THAs that involved a porous tantalum acetabular component. Over a mean follow-up of 4 years, 48 of the 55 components migrated <1 mm, the threshold that, based on previous findings in the literature, the authors defined as predicting later loosening. Five of the 7 components that exceeded the threshold were re-revised for loosening related to patient symptoms.
The RSA data for the 5 components that required re-revision revealed large proximal translations and sagittal rotations that increased over time until re-revision, although the RSA readings revealed that the majority of the migration occurred in the first 6 weeks. Among the components that did not exceed the 1 mm threshold for migration at 2 years, none have been subsequently re-revised for loosening.
The authors also analyzed fixation methods in this cohort. They found that, at 2 years, the median proximal translation of components that used inferior screw fixation was significantly lower than that of components without inferior screw fixation. The take-home messages from this study seem to be as follows:
- Porous tantalum acetabular components really do perform well in revision THA.
- When indicated, inferior screw fixation lowers the risk of component migration.
- Early component migration is a good predictor of long-term component survivorship.
For Rotator Cuff Deficiency, RSA Delivers Good Long-term Results
In a recent OrthoBuzz post about minimal-incision total hip arthroplasty, we observed that “it is the long-term results [of orthopaedic procedures] that really matter.” Along those lines, in the November 15, 2017 issue of The Journal of Bone & Joint Surgery, Cuff et al. provide 10-year follow-up results of reverse shoulder arthroplasty (RSA) in patients with end-stage rotator cuff deficiency. The 5-year follow-up results were published in a 2012 JBJS article.
Forty-two of the original 96 shoulders were available for clinical follow-up at a minimum of 10 years. Here’s what the authors found:
- Patients retained their gains in total average preop-vs-postop ASES and SST scores.
- Survivorship (percentage of shoulders not requiring revision) was 90.7%.
- There was decreased range of shoulder motion in all planes between 5 and 10 years of follow-up, but there was no consistent trend of an increase in shoulder pain.
Cuff et al. attribute these positive and durable outcomes in part to the use of 5.0-mm peripheral locking screws for baseplate fixation, which they say “provided improved early fixation and allowed for osseous ingrowth into the baseplate.”
“New” but Not Necessarily “Improved”
A review of five hip- and knee-implant innovations, initiated by the FDA in reaction to serious problems with metal-on-metal hip bearings, found that none offered meaningful functional or patient-outcome benefits over older designs. The systematic review of 118 studies and more than 13,000 patients, published in the BMJ, also found that three of the new designs—ceramic-on-ceramic hip bearings, modular femoral necks, and high-flexion knee implants—were associated with higher revision rates relative to established designs. The other two innovations—uncemented monoblock acetabular cups and sex-specific knee implants—provided no benefit over older designs but had comparable revision rates.
The BMJ authors claim that the purpose of the review was not to “criticise the surgical community or orthopaedic industry,” but rather to “highlight that the status quo regarding the introduction of new device technologies is not acceptable.”
The BMJ authors cite stepwise introduction of new implant technologies as one way to avoid exposing large numbers of patients to innovations whose safety and efficacy are unproven. In a 2011 JBJS supplement, authors (two of whom also co-authored the BMJ study) proposed using roentgen stereophotogrammetric analysis (RSA) and national joint registry data to facilitate phased clinical introduction of new implants.
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