# Presentation: 855136

## Modes of Failure in Revision Hip and Knee Replacement

- Kevin J. Bozic, MD, MBA
- Harry E. Rubash, MD
-  J. Berry, MD
- Khaled J. Saleh, MD, MPH
- Sridhar M. Durbhakula, MD

## “It’s like déjà vu all over again!”

## Background

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

## Background

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

## TJA Volume Estimates

## U.S. TJR Payer Mix

## DRG 209/471: 1998-2002

- % of Medicare Discharges

- % of Medicare Inpatient Charges

## TJR Failure

- Despite 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 TJR’s*_

## Problem with Current ICD-9-CM Diagnosis Codes

- Currently, all failed TJR’s 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 Codes

- New 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

## Arthritis—Background

- Arthritis 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-operative

- Activity Modification
- Weight Loss
- Cane/walker
- Physical Therapy
- _Medications:_
- NSAIDs
- COX-2 Inhibitors
- Nutritional supplements
- _Injections:_
- Corticosteroid
- Viscosupplementation

## Surgical Treatment Options

- Joint preserving operations
- Arthroscopy
- Cartilage transplantation
- Osteotomy
- Arthroplasty Options:
- Hemiarthroplasty
- Resurfacing arthroplasty
**Total joint arthroplasty**

## Goals of Joint Replacement Surgery

_***Relieve pain!!!***_
- Restore function, mobility

## Anatomy—Hip	

## THA Implants

## Implant Choice

_**Cemented**_**:**
- Elderly (>65)
- Low demand
- Better early fixation
- ? late loosening

## Implant Choice

_**Cementless**_**:**
- Younger
- More active
- Protected weight-bearing first 6 weeks
- ? Better long-term fixation

## Technique: Total Hip Replacement

- Femoral neck resection

## Technique: Total Hip Replacement

- Acetabular reaming

- Insertion of acetabular component

## Technique: Total Hip Replacement

- Reaming/broaching of femoral component

- Insertion of femoral component

## Technique: Total Hip Replacement

- Femoral head impaction

- Final implant

## Anatomy—Knee

## Knee Replacement—Implants

**Patellar component**

## Knee Replacement—Bone Cuts

## Knee Replacement—Implants

## Knee Replacement—Implants

## Causes of TJR Failure

- Wear of articular bearing surface
- Aseptic/mechanical loosening
- Osteolysis
- Infection
- Instability
- Peri-prosthetic fracture
- Implant Failure

## Timing of TJR Failure

- Early (<10%)
*Dislocation*
- Infection
- Implant failure
- Late (> 5 yrs post op)
*Wear of articular bearing surface*
- Osteolysis
- Mechanical loosening
- Peri-prosthetic fracture

## Dislocation/Instability

## Infection

## Wear of Articular Bearing Surface

## Osteolysis

## Aseptic/Mechanical Loosening

## Peri-Prosthetic Fracture

- Sri: PP fracture

## Implant Failure

## Major Osseous Defects

## Major Osseous Defects

## Benefits of Revised Codes

- MEDPAR database
- Robust 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 Codes

- Ability 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 Codes

_***American Joint Replacement Registry(AJRR)***_
- Goals
- Accurately define the epidemiology of TJR in the U.S.
- Identify risk factors for poor outcomes
- To 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 Codes

- Credited 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 avoided
- Direct cost savings of $140 million

## Summary

- Hip and knee replacement are commonly performed and highly successful operations
- Most TJR’s last 10-15 years or more

## Summary

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

## Summary

- Current 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??