att tjr oct04

Modes of Failure in Revision Hip and Knee ReplacementKevin J. Bozic, MD, MBAHarry E. Rubash, MD

J. Berry, MDKhaled J. Saleh, MD, MPHSridhar M. Durbhakula, MD

Its like dj vu all over again!

BackgroundTotal joint replacement is one of the most commonly performed and successful operations in orthopaedics as defined by clinical outcomes and implant survivorship*

*

BackgroundTotal joint replacement (TJR) is one of the most cost-effective procedures in all of medicine.

TJA Volume Estimates

Chart1

37500086250

485000121250

620800173824

807040242112

1073363.2354209.856

1449040.32507164.112

1956204.432684671.5512

Projections*

Primary TJA

Revision TJA

Year

Number of Procedures

Primary and Revision TJA Procedures Performed in the US

THA Volume in US

Estimates of Primary and Revision THA Procedures in the US

Projections

Year1991199219931994199519961997199819992000200520102015202020252030

Primary TJA117000127000125000124000134000138000144000160000168000375000485000620800807040107336314490401956204

Revision TJA25000230002600028000290003000030000330003700086250121250173824242112354210507164684672

Total142000150000151000152000163000168000174000193000205000461250

% Revisions18%15%17%18%18%18%17%17%18%19%20%22%23%25%26%26%

21%18%21%23%22%22%21%21%22%23%25%28%30%33%35%35%

0.8227638127

Year1905190519051905190519051905

Primary THA172000175000184200203500226000251300273800

Revision THA39560437505157661050745808795595830

THA Volume in US

00

00

00

00

00

00

00

Projections*

Primary TJA

Revision TJA

Year


Primary and Revision THA Procedures Performed in the US

Case Mix

Ratio of Primary:Revision THARatio of Primary:Revision TKA

200220012000200220012000

National {Statistics, 2002 #22}94:06:0094:06:0093:07:0096:04:0096:04:0096:04:00

UCSF70:30:0064:36:0063:37:0077:23:0077:23:0079:21:00

Primary TJA ProceduresRevision TJA Procedures

National94%6%

UCSF71%29%


National95%5%

UCSF70%30%

Primary THA ProceduresRevision TJA Procedures

National95%5%

UCSF73%27%


UCSF71%29%


UCSF70%30%


UCSF73%27%

Primary THA ProceduresRevision THA Procedures

US Averages82%18%

Academic Medical Centers66%34%


UCSF72%28%

19981999200020012002

27130 (Primary Total Hip Replacement)6441103127142

27134 (Revision Total Hip Replacement)3019607062

27447 (Primary Total Knee Replacement)6245126134147

27487 (Revision Total Knee Replacement)187344045

Total Number of Arthroplasty Procedures174112323371396

66%

Primary THA ProceduresRevision THA Procedures

Academic Medical Centers66%34%

Case Mix

0

0

UCSF

Sheet2

00

00

US Averages

Academic Medical Centers

Sheet3

0

0

Academic Medical Centers

Year19951996199719981999

Operating Margin6%5%4%3%2%

Year19951999

Operating Margin6%2%

Operating MarginYear

6%1995

2%1999

Year200520102015202020252030

Primary THA175000184200203500226000251300273800

Revision THA437505157661050745808795595830

Total

11700025000

12700023000

12500026000

12400028000

13400029000

13800030000

14400030000

16000033000

16800037000

17200039560

17500043750

18420051576

20350061050

22600074580

25130087955

27380095830

Projections*

Primary THA

Revision THA

Year


Primary and Revision THA Procedures Performed in the US

Source: AHRQ, HCUPnet, 2002 Nationwide Inpatient Sample, http://hcup.ahrq.gov/HCUPnet.asp, site accessed on July 26, 2004. Total Hip Replacement is sum of ICD9-CM Procedure Codes 81.51 and 81.53. 81.51 Total Hip Replacement, 81.53 Revise Hip Replacement. NIS data is collected for calendar years (January December). Routine discharge is discharge to home only. Discharge to another institution includes discharge to SNF and IRF.U.S. TJR Payer Mix

DRG 209/471: 1998-2002% of Medicare Discharges% of Medicare Inpatient Charges

TJR FailureDespite the success achieved with most primary TJR procedures, factors related to implant longevity and a younger, more active patient population have led to a steady increase in the number of failed TJRs

Problem with Current ICD-9-CM Diagnosis CodesCurrently, all failed TJRs are coded as either:996.4 Mechanical complication of an internal orthopedic device, implant, or graft:Mechanical complications involving external fixation device using internal screw(s), pin(s), or other methods of fixation; grafts of bone, cartilage, muscle, or tendon; internal fixation device such as nail, plate, rod, etc.

996.6 Infection and inflammatory reaction due to internal joint prosthesis

Problem with Current ICD-9-CM Diagnosis CodesNew technologies and surgical techniques are constantly being introduced into the marketplace

Despite careful laboratory testing, a certain percentage of new technologies are associated with higher rates of clinical failure

Current ICD-9-CM Diagnosis codes limit our ability to track clinical outcomes and complications related to new techniques and technologies in TJR

TJA: Indications

ArthritisBackgroundArthritis is the second most common chronic condition in the US (sinusitis is first)Most common among elderly

20-30% of people over age 70 suffer from osteoarthritis (OA) of the hip

Arthritis affects over 32 million people in the US

Total costs associated with arthritis are over $82B/year, including hospital and drug costs, nursing home costs, and lost productivity and work

Treatment Options: Non-operativeActivity ModificationWeight LossCane/walkerPhysical TherapyMedications:NSAIDsCOX-2 InhibitorsNutritional supplementsInjections:CorticosteroidViscosupplementation

Surgical Treatment OptionsJoint preserving operationsArthroscopyCartilage transplantationOsteotomy

Arthroplasty Options:HemiarthroplastyResurfacing arthroplastyTotal joint arthroplasty

Goals of Joint Replacement SurgeryRelieve pain!!!

Restore function, mobility

AnatomyHip

THA Implants

Implant ChoiceCemented:Elderly (>65)Low demandBetter early fixation? late loosening

Implant ChoiceCementless:YoungerMore activeProtected weight-bearing first 6 weeks? Better long-term fixation

Technique: Total Hip ReplacementFemoral neck resection

Technique: Total Hip ReplacementAcetabular reamingInsertion of acetabular component

Technique: Total Hip ReplacementReaming/broaching of femoral componentInsertion of femoral component

Technique: Total Hip ReplacementFemoral head impactionFinal implant

AnatomyKnee

Knee ReplacementImplantsPatellar component

Knee ReplacementBone Cuts

Knee ReplacementImplants

Causes of TJR FailureWear of articular bearing surfaceAseptic/mechanical looseningOsteolysisInfectionInstabilityPeri-prosthetic fractureImplant Failure

Timing of TJR FailureEarly ( 5 yrs post op)Wear of articular bearing surfaceOsteolysisMechanical looseningPeri-prosthetic fracture

Dislocation/Instability

Infection

Wear of Articular Bearing Surface

Osteolysis

Aseptic/Mechanical Loosening

Peri-Prosthetic FractureSri: PP fracture

Implant Failure

Major Osseous Defects

Benefits of Revised CodesMEDPAR databaseRobust source of data for evaluating clinical outcomes, complication rates, and resource utilization in TJR

However, current ICD-9 codes do not distinguish between the type of orthopedic device failure or the cause of TJR failure

Benefits of Revised CodesAbility to specify the cause of implant failure

Ability to evaluate implant-specific TJR failure rates => refine indications, surgical technique, and implant choice

Facilitates steady, continuous quality improvement by shortening the time span for detection of poor performance of new techniques and technologies

Benefits of Revised CodesAmerican Joint Replacement Registry(AJRR)GoalsAccurately define the epidemiology of TJR in the U.S.Identify risk factors for poor outcomesTo improve outcomes through continuous feedback to participating centers and surgeons

The success of this project is critically dependent on having revised ICD-9-CM Codes that differentiate between different modes of failure in TJA!!

Benefits of Revised CodesCredited with substantially reducing revision rates through early identification of failures Revision rate of 8% (vs. 17% in U.S.)Estimated that over 11,000 revisions have been avoidedDirect cost savings of $140 million

SummaryHip and knee replacement are commonly performed and highly successful operations

Most TJRs last 10-15 years or more

SummaryWhen failure does occur, the type and cause of failure will determine the type of revision joint replacement procedure performed (partial vs. total)

SummaryCurrent ICD-9-CM Diagnosis codes do not provide any information regarding the type or cause of implant failure

Revised codes will benefit patients, providers, and payors by facilitating continuous feedback and improvement in clinical outcomes in TJR

Thank You!!!

Questions??

att tjr oct04

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