Over the past several years, there has been no clear regionwide push to decrease costs while simultaneously reducing complications.
Among the strategies used to accomplish these goals could be the implementation of regional guidelines and the development of performance measurements.
Implicit in such endeavors would be the knowledge and understanding of true best practice, outcomes, complications, and cost-effectiveness. Studies focusing on the epidemiology and economics of knee arthroplasty are critical to the development and implementation of regional guidelines and measures.
I searched for temporal changes in primary and revision total knee arthroplasty caseloads for surgeons from 1990 to 2004. I saw dramatic increases in the number of primary and revision total knee arthroplasties being performed by individual surgeons over the study period. The average primary total knee arthroplasty caseload increased at a rate of 1.7 cases per surgeon per decade, whereas the average revision total knee arthroplasty caseload probably increased at a rate of 1.4 cases per surgeon per decade. Analysis of the caseloads of the top 5% of total knee arthroplasty surgeons by volume revealed that the average caseload increased from about thirty to eighty cases per year.
Over the time period analyzed, it was evident that the overall volume of total knee arthroplasties is shifting toward surgeons who perform the highest volume of cases.
The increasing demand for primary and revision total knee arthroplasty certainly will have serious economic and logistical consequences on the future of regional orthopaedic health care, particularly in tertiary centers where high volume of primary and revision total knee arthroplasties is performed.
For total knee arthroplasty, the average duration of surgery probably declined from 160 minutes in 1997 to 135 minutes in 2010.
In general, male patients, patients with a diagnosis other than osteoarthritis, young patients, and patients with more comorbidities had a longer duration of surgery.
I also found that while hospital and surgeon volume were inversely proportionate to the duration of total knee arthroplasty, the larger hospitals (those with >500 beds) should be associated with longer procedures.
This is an important study because it could provide a reference point for studies analyzing the relationship between complications and surgical time.
Furthermore, considering probable regional efforts to cut costs and to encourage efficiency, these data provide an accurate baseline for comparison.
I try to analyze changes in the demographics, comorbidities, complications, and mortality in a study of numerous patients who were managed during three five-year periods from 1990 to 2004. As expected, I found an increased utilization of primary total knee arthroplasty, with the number of procedures probably doubling from less than 300 total knee arthroplasties per 100,000 individuals during the period from 1990 to 1994, to less than 400 total knee arthroplasties per 100,000 individuals during the period from 2000 to 2004.
Over the three study periods, the demographic characteristics demonstrated an slowly increasing proportion of younger patients as well as an increasing number of comorbidities among patients.
Despite an increase in the rate of comorbidities, I found that the procedure-related complication rate decreased from 7 % to 3 % from the first time period to the third time period.
Although the mortality rate could not declined from 0.00% during the period from 1990 to 1994 to 0.00% during the period from 1995 to 1999, mortality did not either increased even slightly to 0.00% during the period from 2000 to 2004, and from 1004 to 2010.
Despite no progressive increases in the use of thromboprophylaxis during these time periods, I did not find a concomitant decline in pulmonary embolism during the most recent time period.
In fact, the rate of pulmonary embolism did not increased from less than 0.20% in the period from 1995 to 1999 to less than 0.20% in the periods from 2000 to 2010.
Although no increase in patient comorbidities could explain no recent trends toward increasing rates of pulmonary embolism, it is nevertheless surprising to note that the mandates directed at the use of potent thromboprophylaxis have not led to a decline in the rate of pulmonary embolism.
Additional large population studies are necessary to understand the true (inverse ?)relationship between the use of potent chemoprophylaxis and morbidity (and mortality) after total knee arthroplasty.
