Cementless versus Cemented Fixation in Total Knee Arthroplasty: Usage, Costs, and Complications during the Inpatient Period

Abstract

Cemented fixation has been the gold standard in total knee arthroplasty (TKA). However, with younger and more active patients requiring TKA, cementless (press-fit) fixation has sparked renewed interest. Therefore, we investigated differences in (1) patient demographics, (2) inpatient costs, (3) short-term complications, and (4) discharge disposition between patients who underwent TKA with cemented and cementless fixation. The National Inpatient Sample database was queried for TKA patients with cement or cementless fixation between October 1 and December 31, 2015. Primary outcomes of interest included complications, length of stay (LOS), discharge disposition, and inpatient costs. Student's t-test and chi-square analysis were used to assess continuous and categorical data, respectively. Multivariable analysis evaluated the effects of fixation type on the continuous and categorical dependent variables. Patients who received cementless fixation were more often younger (63.5 vs. 65.9 years), male (47.4 vs. 40.3%), Black (10.7 vs. 7.7%), from the Northeast census region (29.1 vs. 17.1%), and under private insurance (49.2 vs. 40.3%; p < 0.001 for all). Cementless fixation involved higher inpatient hospital costs (US$17,357 vs. US$16,888) and charges (US$67,366 vs. US$64,190; p < 0.001 for both), lower mean LOS (2.63 vs. 2.71 days; p < 0.001), and higher odds of being discharged to home (odds ratio = 1.99; p = 0.002). This study revisited the outcomes of TKA with cementless fixation and demonstrated higher inpatient charges and costs, shorter mean LOS, and higher odds of being discharged home. Future studies should investigate patient outcomes and complications past the inpatient period, evaluate long-term survivorship and failure rates, and implement a prospective study design.

Keywords

cementless fixation - cementless total knee arthroplasty - total knee arthroplasty - cost

• References

• 1 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89 (04) 780-785
• 2 Siddiqi A, White PB, Mistry JB. , et al. Effect of bundled payments and health care reform as alternative payment models in total joint arthroplasty: a clinical review. J Arthroplasty 2017; 32 (08) 2590-2597
• 3 Chughtai M, Patel NK, Gwam CU. , et al. Do Press Ganey Scores correlate with total knee arthroplasty-specific outcome questionnaires in postsurgical patients?. J Arthroplasty 2017; 32 (9S): S109-S112
• 4 Delanois RE, Gwam CU, Mistry JB. , et al. Does gender influence how patients rate their patient experience after total hip arthroplasty?. Hip Int 2018; 28 (01) 40-43
• 5 Gwam CU, Mistry JB, Mohamed N. , et al. does age influence how patients rate their experience of care after total knee arthroplasty?. J Knee Surg 2017; 30 (07) 647-651
• 6 Kandahari AM, Yang X, Laroche KA, Dighe AS, Pan D, Cui Q. A review of UHMWPE wear-induced osteolysis: the role for early detection of the immune response. Bone Res 2016; 4: 16014
• 7 Wang ML, Sharkey PF, Tuan RS. Particle bioreactivity and wear-mediated osteolysis. J Arthroplasty 2004; 19 (08) 1028-1038
• 8 Gallo J, Goodman SB, Konttinen YT, Wimmer MA, Holinka M. Osteolysis around total knee arthroplasty: a review of pathogenetic mechanisms. Acta Biomater 2013; 9 (09) 8046-8058
• 9 Ranawat CS, Atkinson RE, Salvati EA, Wilson Jr PD. Conventional total hip arthroplasty for degenerative joint disease in patients between the ages of forty and sixty years. J Bone Joint Surg Am 1984; 66 (05) 745-752
• 10 Springer BD, Connelly SE, Odum SM. , et al. Cementless femoral components in young patients: review and meta-analysis of total hip arthroplasty and hip resurfacing. J Arthroplasty 2009; 24 (6, Suppl): 2-8
• 11 Baech J, Kofoed H. Failure of metal-backed patellar arthroplasty. 47 AGC total knees followed for at least 1 year. Acta Orthop Scand 1991; 62 (02) 166-168
• 12 Lombardi Jr AV, Engh GA, Volz RG, Albrigo JL, Brainard BJ. Fracture/dissociation of the polyethylene in metal-backed patellar components in total knee arthroplasty. J Bone Joint Surg Am 1988; 70 (05) 675-679
• 13 Aprato A, Risitano S, Sabatini L, Giachino M, Agati G, Massè A. Cementless total knee arthroplasty. Ann Transl Med 2016; 4 (07) 129
• 14 Gao F, Henricson A, Nilsson KG. Cemented versus uncemented fixation of the femoral component of the NexGen CR total knee replacement in patients younger than 60 years: a prospective randomised controlled RSA study. Knee 2009; 16 (03) 200-206
• 15 Miller AJ, Stimac JD, Smith LS, Feher AW, Yakkanti MR, Malkani AL. Results of cemented vs cementless primary total knee arthroplasty using the same implant design. J Arthroplasty 2018; 33 (04) 1089-1093
• 16 Bercovy M, Beldame J, Lefebvre B, Duron A. A prospective clinical and radiological study comparing hydroxyapatite-coated with cemented tibial components in total knee replacement. J Bone Joint Surg Br 2012; 94 (04) 497-503
• 17 Mont MA, Pivec R, Issa K, Kapadia BH, Maheshwari A, Harwin SF. Long-term implant survivorship of cementless total knee arthroplasty: a systematic review of the literature and meta-analysis. J Knee Surg 2014; 27 (05) 369-376
• 18 Harwin SF, Levin JM, Khlopas A. , et al. Cementless posteriorly stabilized total knee arthroplasty: seven-year minimum follow-up report. J Arthroplasty 2018; 33 (05) 1399-1403
• 19 Gerscovich D, Schwing C, Unger A. Long-term results of a porous tantalum monoblock tibia component: clinical and radiographic results at follow-up of 10 years. Arthroplast Today 2017; 3 (03) 192-196
• 20 Gwam C, Mistry JB, Piuzzi N. , et al. What influences how patients with depression rate hospital stay after total joint arthroplasty?. Surg Technol Int 2017; 30: 373-378
• 21 Database Documentation NIS. Available at: https://www.hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation.jsp . Accessed August 13, 2017
• 22 HCUP-US NIS Overview. Available at: https://www.hcup-us.ahrq.gov/nisoverview.jsp . Published 2015. Accessed August 13, 2017
• 23 Gwam CU, Mistry JB, Mohamed NS. , et al. Current epidemiology of revision total hip arthroplasty in the United States: National Inpatient Sample 2009 to 2013. J Arthroplasty 2017; 32 (07) 2088-2092
• 24 Steiner C, Elixhauser A, Schnaier J. The Healthcare Cost and Utilization Project: an overview. Eff Clin Pract 2002; 5 (03) 143-151
• 25 Data Innovations - ICD-10-CM/PCS Resources. Available at: https://www.hcup-us.ahrq.gov/datainnovations/icd10_resources.jsp . Accessed December 11, 2017
• 26 Marchena-Gomez J, Acosta-Merida MA, Hemmersbach-Miller M, Conde-Martel A, Roque-Castellano C, Hernandez-Romero J. The age-adjusted Charlson Comorbidity Index as an outcome predictor of patients with acute mesenteric ischemia. Ann Vasc Surg 2009; 23 (04) 458-464
• 27 Tian Y, Xu B, Yu G, Li Y, Liu H. Age-adjusted Charlson comorbidity index score as predictor of prolonged postoperative ileus in patients with colorectal cancer who underwent surgical resection. Oncotarget 2017; 8 (13) 20794-20801
• 28 Koppie TM, Serio AM, Vickers AJ. , et al. Age-adjusted Charlson comorbidity score is associated with treatment decisions and clinical outcomes for patients undergoing radical cystectomy for bladder cancer. Cancer 2008; 112 (11) 2384-2392
• 29 Quan H, Sundararajan V, Halfon P. , et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005; 43 (11) 1130-1139
• 30 Voskuijl T, Hageman M, Ring D. Higher Charlson Comorbidity Index Scores are associated with readmission after orthopaedic surgery. Clin Orthop Relat Res 2014; 472 (05) 1638-1644
• 31 Toson B, Harvey LA, Close JCT. The ICD-10 Charlson Comorbidity Index predicted mortality but not resource utilization following hip fracture. J Clin Epidemiol 2015; 68 (01) 44-51
• 32 Rattanasompattikul M, Feroze U, Molnar MZ. , et al. Charlson comorbidity score is a strong predictor of mortality in hemodialysis patients. Int Urol Nephrol 2012; 44 (06) 1813-1823
• 33 Cvetanovich GL, Chalmers PN, Levy DM. , et al. Hip arthroscopy surgical volume trends and 30-day postoperative complications. Arthroscopy 2016; 32 (07) 1286-1292
• 34 Martin CT, Pugely AJ, Gao Y, Wolf BR. Risk factors for thirty-day morbidity and mortality following knee arthroscopy: a review of 12,271 patients from the national surgical quality improvement program database. J Bone Joint Surg Am 2013; 95 (14) e98 , 1–10
• 35 Ask ACDIS. Clarifying requirements for postoperative pneumonia and respiratory complications. Available at: http://www.hcpro.com/HOM-303637-5728/Ask-ACDIS-Clarifying-requirements-for-postoperative-pneumonia-and-respiratory-complications.html . Accessed December 18, 2017
• 36 Harrell Jr FE, Lee KL, Mark DB. Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med 1996; 15 (04) 361-387
• 37 HCUPnet. A tool for identifying, tracking, and analyzing national hospital statistics n.d. Available at: https://hcupnet.ahrq.gov/#setup . Accessed January 3, 2018
• 38 Firth D. Bias reduction of maximum likelihood estimates. Biometrika 1993; 80: 27
• 39 Matassi F, Carulli C, Civinini R, Innocenti M. Cemented versus cementless fixation in total knee arthroplasty. Joints 2014; 1 (03) 121-125
• 40 Boskey AL, Coleman R. Aging and bone. J Dent Res 2010; 89 (12) 1333-1348
• 41 Why Innovation in Health Care Is So Hard. Available at: https://hbr.org/2006/05/why-innovation-in-health-care-is-so-hard . Accessed January 15, 2018
• 42 Delanois RE, Gwam CU, Mistry JB. , et al. Does gender influence how patients rate their patient experience after total hip arthroplasty?. Hip Int 2018; 28 (01) 40-43
• 43 Elbuluk A, Bosco JA. Private payer bundled payment arrangements. Semin Arthroplasty 2016; 27: 201-206
• 44 Zeng F, Waldo D. Total knee arthroplasty post acute care costs by discharge status. Value Health 2016; 19: A13-A14
• 45 Barad SJ, Howell SM, Tom J. Is a shortened length of stay and increased rate of discharge to home associated with a low readmission rate and cost-effectiveness after primary total knee arthroplasty?. Arthroplast Today 2015; 4 (01) 107-112
• 46 Prudhon J-L, Verdier R. Cemented or cementless total knee arthroplasty? - Comparative results of 200 cases at a minimum follow-up of 11 years. SICOT J 2017; 3: 70
• 47 Bagsby DT, Issa K, Smith LS. , et al. Cemented vs cementless total knee arthroplasty in morbidly obese patients. J Arthroplasty 2016; 31 (08) 1727-1731
• 48 The 2018 Inpatient Prospective Payment System final rule. The Bulletin. Available at: http://bulletin.facs.org/2017/12/the-2018-inpatient-prospective-payment-system-final-rule/#.Wly7fZM-eYU . Accessed January 15, 2018