The Problem With a Failed Total Hip Replacement

It doesn't take a crystal ball to see that there's trouble ahead for America's seniors. More and more older adults are in need of a total hip revision surgery. Nearly 18 per cent of all total hip replacements done in the United States have to be revised at some point. Current estimates are that in the next 20 years, the need for total hip revisions will increase dramatically.

There are other factors to consider with this problem. First, the cost. Can we really bear the financial burden of these surgeries? Second, there is already a shortage of surgeons who perform this operation. Joint replacement revision is a subspecialty all of its own.

The procedure is difficult and complex. Surgeons aren't being reimbursed adequately by Medicare. So while the number of older adults needing this operation is on the rise, the number of surgeons available to perform the procedure is on the decline. That presents an interesting dilemma for all concerned.

As with most problems, there is more beneath the surface than meets the eye. Revision of primary (first-time) hip replacements often comes with its own problems. More bone grafts are needed requiring longer hospital stays. Patients are less likely to be discharged home and more likely to be transferred to an extended care facility.

Longer operative times and longer hospital stays translate into higher total costs. And long-term studies show that these patients are more likely to be rehospitalized within the first 90-days of the revision operation. That adds to the total cost as well.

So how come there's such an increase in the number of revision operations required? And what can be done to prevent this from happening? Studies show that the relative number of revision operations hasn't really increased. It's more the fact that more adults are having their first hip replacement and more of those are being done at a younger age. If patients outlive the life of their implant, then revision surgery is needed. Or if there are complications from the first surgery, a revision replacement might be needed.

Two preoperative factors stand out as possible predictors of a poor outcome after revision surgery. One is preoperative pain. The other is medical co-morbidities. Research shows that older adults with higher levels of pain and lower levels of function because of other health problems were more likely to have a poor outcome from the revision surgery.

If revision surgery is going to be a fact in the near future, then what can be done now to head it off at the pass? Some suggest building more high-volume orthopedic specialty hospitals. Studies show that there are fewer complications when a surgeon performs the same operation on a larger number of patients.

Specialty centers of this type would draw more patients and attract more physicians with a subspecialty practice in revision hip replacements. With fewer complications, costs can be contained. Preventing infection, dislocation, or fractures of the bone around the primary implant could go a long way in protecting the implant and reducing the need for revision surgery.

But the total cost of revision operations aren't just caused by the surgery itself. Data collected over time also shows that the charge for the implants has gone up. And the total cost for rehabilitation services has also escalated over time. Of course, patients who have to go to an extended care facility instead of home require more services and the cost of those services adds up.

It's clear that there's going to be a shortage of qualified surgeons to perform these revision operations. What else can be done about the possible imbalance between supply and demand of specialty surgeons? One natural solution to the problem has already been provided. More non-U.S. trained surgeons are filling surgical positions.

Some suggest putting an end to fee reductions proposed by Medicare. Instead, Medicare reimbursement for primary and revision surgeries must be increased. Otherwise, surgeons will turn to other types of surgeries that pay better just in order to stay in business.

Surgeons have also cited high legal costs of malpractice claims as a deterrent to performing these procedures. Surgeons who perform more than 100 hip and knee replacement operations each year have a much higher risk of being sued for complications such as nerve injury, leg length difference, infection, damage to blood vessels, and implant/joint dislocation. What can be done to reduce complications and the risk of litigation?

The authors suggest developing and using evidence-based guidelines for standard of care, patient safety, reducing complications, and managing patient expectations at the time of the surgery. Added together, these steps represent best-practice procedures for both hospitals and specialty centers. The final result might be total decreased costs as a result of reduced hospital length-of-stay, fewer complications, and fewer revision operations.

Studies like this that review current statistics show a need to try and change what might become a huge medical and economic burden on the current health care system. Addressing the potential inadequate surgeon workforce is just one of the many factors under consideration.

Reference: 

Christopher Espinoza-Ervin, et al. Hip Reconstruction. Can We Afford Revision Total Hip Replacement? In Current Orthopaedic Practice. January/February 2009. Vol. 20. No. 1. Pp. 29-33.

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