White Paper: On Joint Replacement

Hans-Holger Bleß
Miriam Kip Eds.
White Paper
on Joint
Replacement
Status of Hip and Knee
Arthroplasty Care in Germany
White Paper on Joint Replacement
H.-H. Bleß
M. Kip
(Eds.)
White Paper
on Joint Replacement
Status of Hip and Knee Arthroplasty Care in Germany
With 46 Figures
123
Editors
Hans-Holger Bleß
IGES Institut GmbH
Berlin, Germany
Dr. med. Miriam Kip

IGES Institut GmbH
Berlin, Germany
ISBN 978-3-662-55917-8 978-3-662-55918-5 (eBook)

https://doi.org/10.1007/978-3-662-55918-5
Springer
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V
Foreword
This White Paper on Joint Replacements aims to present an impartial review and a compre-
hensive overview of the current healthcare situation for hip and knee arthroplasty patients in
Germany.
White Papers present independent information on topics that are relevant to society. This
White Paper is based on comprehensive literature reviews and data research which have been
evaluated in collaboration with experts in the field of endoprosthetics to give a sound summa-
ry of the current situation. In addition, it identifies needs for action to improve care. It also
identifies various needs for action towards the improvement of care. White Papers on
health-related topics can therefore contribute to shaping medical care and healthcare policies.
The IGES Institute has presented White Papers on multiple sclerosis, stroke prevention in
atrial fibrillation, acute coronary syndrome and diabetes mellitus.
Hip and knee arthroplasty are amongst the most frequently performed procedures in German
hospitals. Common reasons for performing this surgery are joint wear or fractures which
occur considerably more frequently in old age. Surgical procedures are continuously being
refined and treatment pathways have to be adapted to increasing demands.
How successful are current surgical treatments? How have case numbers for hip and knee
surgery developed over the past few years? Which healthcare structures do we need in order
to meet the rising demands of an increasingly aging population in the future? What do
renowned experts call for with regard to future arthroplasty care?
The authors and experts investigate these questions and further issues in the following
chapters.
As the editors of this book, we would like to thank the authors of the individual chapters and
the participants of the expert panel workshop. We would especially like to thank Prof. Karsten
Dreinhöfer, Medical Director and Head of the Department of Orthopaedics and Traumatolo-
gy, Medical Park Berlin and Prof. Klaus-Peter Günther, Executive Director of the University
Center of Orthopaedics and Traumatology at the University Hospital Carl Gustav Carus of the
Technical University Dresden for the editorial revision of the manuscript.
We would also like to express our thanks to Sabine König and the Springer Verlag for their
careful review of the manuscript.
This book was commissioned by The German Medical Technology Association (BVMed).
Dr. Miriam Kip, Hans-Holger Bleß

IGES Institut
Berlin, June 2016
Table of Contents
1 Introduction to the Indications and Procedures . . . . . . . . . . . . . . . . . . . . 1

Cornelia Seidlitz, Miriam Kip
1.1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2 Etiology, Indications and Treatment Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2.1 Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2.2 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.2.3 Surgery Goals and Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.3 Materials, Surgical Procedures and Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.3.1 Material Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.3.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.3.3 Factors Influencing Treatment Success and Complications . . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2 Prevalence of Hip and Knee Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . 15

Florian Rothbauer, Ute Zerwes, Hans-Holger Bleß, Miriam Kip
2.1 Database . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.2 Utilization of Primary Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.3 Utilization of Revision Total Arthroplasty and Revision Surgery . . . . . . . . . . . . . . 21
2.4 Regional Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.5 Case Number Developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.5.1 Primary Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.5.2 Revision Total Arthroplasty and Revision Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 29
2.6 International Comparison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3 Status of Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Michael Weißer, Ute Zerwes, Simon Krupka, Tonio Schönfelder,
Silvia Klein, Hans-Holger Bleß
3.1 Basis of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
3.2 Ambulatory Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
3.3 Inpatient Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3.3.1 Primary Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3.3.2 Revision Total Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
3.3.3 Accompanying Measures during Inpatient Stay . . . . . . . . . . . . . . . . . . . . . . . . . . 59
3.3.4 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.4 Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
3.4.1 Therapy Recommendations and Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
3.4.2 Provision of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.4.3 Utilization of Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.4.4 Implementation of Therapeutic Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
3.4.5 Effectiveness of Subsequent Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
3.4.6 Post-Rehabilitation Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
3.4.7 Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
3.4.8 Outlook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
VII
Table of Contents
3.5 Quality Aspects of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

3.5.1 Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
3.5.2 Surgery and Perioperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
3.5.3 Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
3.5.4 Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
3.5.5 Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
3.5.6 Post-Discharge Treatment Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
3.5.7 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
3.5.8 Regional Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
4 Healthcare System Stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Hubertus Rosery, Tonio Schönfelder
4.1 State Actors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
4.2 Federal Joint Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
4.3 Quality Assurance Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
4.3.1 AQUA Institute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
4.3.2 Institute for Quality Assurance and Transparency in Healthcare . . . . . . . . . . . . . . . . 95
4.3.3 German Arthroplasty Registry »Endoprothesenregister Deutschland« . . . . . . . . . . . . 95
4.3.4 endoCert . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
4.3.5 Project on Quality Assurance of Inpatient Care using Routine Data . . . . . . . . . . . . . . 97
4.3.6 Quality Assurance Measures in Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
4.3.7 Review of Orthopedics and Trauma Surgery Research . . . . . . . . . . . . . . . . . . . . . . 98
4.4 Medical Societies and Professional Associations . . . . . . . . . . . . . . . . . . . . . . . . 99
4.5 Patient Support and Advice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
4.6 The German Medical Technology Association (BVMed) . . . . . . . . . . . . . . . . . . . . 101
4.7 Training and Further Education of Healthcare Staff . . . . . . . . . . . . . . . . . . . . . . 101
4.7.1 Basic and Specialty Training of physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
4.7.2 Training and Continuing Education for Nursing Staff . . . . . . . . . . . . . . . . . . . . . . . 102
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
5 Health Economic Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Michael Weißer, Hubertus Rosery, Tonio Schönfelder
5.1 Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
5.1.1 Direct Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
5.1.2 Indirect Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
5.1.3 Intangible Costs and Health Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
5.2 Financing, Remuneration and Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
6 Requirements for Adequate Arthroplasty Care (Expert Opinions) . . . . . . . 121

Hans-Holger Bleß
6.1 Prevalence of Hip and Knee Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
6.1.1 Fixation Techniques and Revision Total Replacement . . . . . . . . . . . . . . . . . . . . . . . 124
6.1.2 Regional Distribution and International Comparison . . . . . . . . . . . . . . . . . . . . . . . 125
6.2 Status of Hip and Knee Arthroplasty Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
6.2.1 Medical Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
6.2.2 Service Lives and Revision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
VIII Table of Contents
6.2.3 Adherence to Indication Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

6.2.4 Minimum Volume Regulations and Increasing Case Numbers . . . . . . . . . . . . . . . . . 130
6.3 Health Economic Aspects of Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Servicepart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
IX
List of Authors and Participants of the Expert

Panel Workshop for the White Paper on Joint
Replacements
Authors Expert workshop participants

Dr. Hubertus Rosery Univ.-Prof. Dr. med. Karsten Dreinhöfer
Florian Rothbauer Vice-President of the Professional Association
Michael Weißer of Orthopaedic Surgeons
Ute Zerwes (Berufsverband der Fachärzte für Orthopädie
AiM GmbH und Unfallchirurgie e. V. (BVOU))
Assessment in Medicine, Research and Consulting Professor of Musculoskeletal Rehabilitation,
Marie-Curie-Straße 8 Prevention and Health Services Research at the
79539 Lörrach center for musculoskeletal surgery »Centrum für
Muskuloskeletale Chirurgie (CMSC)«
Hans-Holger Bleß Charité – Universitätsmedizin Berlin
Dr. med. Miriam Kip Medical Director and Head of the Department
Dr. rer. medic. Silvia Klein for Orthopaedics and Traumatology
Simon Krupka Medical Park Berlin Humboldtmühle
Dr. rer. medic. Tonio Schönfelder An der Mühle 2–9
Cornelia Seidlitz 13507 Berlin
IGES Institut GmbH
Friedrichstr. 180 Prof. Dr. med. Klaus-Peter Günther
10117 Berlin Past President of the German endoprosthetics
society »Deutsche Gesellschaft für Endoprothetik
Editorial revision (AE)«
Univ.-Prof. Dr. med. Karsten Dreinhöfer Past President of the German Society of Ortho-
Charité – Universitätsmedizin Berlin and Medical pedics and Orthopedic Surgery (Deutsche
Park Berlin (Charité Universitätsmedizin und Gesellschaft für Orthopädie und Orthopädische
Medical Park Berlin Humboldtmühle) Chirurgie (DGOOC))
Berlin Humboldtmühle Executive Director of the University Center of
An der Mühle 2–9 Orthopedics and Traumatology at the University
13507 Berlin Hospital Carl Gustav Carus of the Technical Uni-
versity Dresden (Universitätsklinikum Carl Gustav
Prof. Dr. med. Klaus-Peter Günther Carus an der Technischen Universität Dresden)
University Hospital Carl Gustav Carus of the Fetscherstraße 74
Technical University Dresden (Universitäts- 01307 Dresden
klinikum Carl Gustav Carus an der Technischen
Universität Dresden) Dr. med. Dipl.-Ing. Hans Haindl
Fetscherstraße 74 Publicly appointed expert in medical devices
01307 Dresden Georgsplatz 1
30974 Wennigsen
X List of Authors and Participants of the Expert Panel Workshop for the White Paper on Joint Replacements
Prof. Dr. med. Karl-Dieter Heller Univ.-Prof. Dr. med. Rüdiger Krauspe
Secretary General of the German arthroplasty President of the German Society of Orthopedics
association »Deutsche Gesellschaft für Endo- and Orthopedic Surgery (Deutsche Gesellschaft
prothetik (AE)« für Orthopädie und Orthopädische Chirurgie
First Chairman of the German association of (DGOOC)) in 2015
senior orthopedists and trauma surgeons Director of the Department of Orthopaedics
»Verband leitender Orthopäden und Unfall- Düsseldorf University Hospital
chirurgen (VLOU)« Moorenstraße 5
Vice-President of the Professional Association of 40225 Düsseldorf
Orthopaedic Surgeons (Berufsverband für
Orthopädie und Unfallchirurgie e. V. (BVOU)) Univ.-Prof. Dr. med. Georg Matziolis
Board member of the German Society of Professor of Orthopedics at the Jena University
Orthopedics and Orthopedic Surgery Hospital, Campus Eisenberg
(Deutsche Gesellschaft für Orthopädie und Medical Director of the Clinic for Orthopaedics
Orthopädische Chirurgie (DGOOC)) and Accident Surgery at the Waldkrankenhaus
Vice President of the German hip society Eisenberg (Waldkrankenhaus »Rudolf Elle« GmbH)
»Deutsche Hüftgesellschaft (DHG)« Klosterlausnitzer Straße 81
Head of the Orthopedic Department 07607 Eisenberg
Herzogin Elisabeth Hospital
Leipziger Straße 24 Univ.-Prof. Dr. med. Henning Windhagen
38124 Braunschweig Medical Director of the Orthopaedic Clinic
of the Hannover Medical School in the
Dr. med. Andreas Hey DIAKOVERE Annastift Hospital
Managing Director of the German arthroplasty Anna-von-Borries-Straße 1–7
registry 30625 Hannover
»Deutsche Endoprothesenregister gGmbH Past President of the German Society of Ortho-
(EPRD)« pedics and Orthopedic Surgery (Deutsche Gesell-
Straße des 17. Juni 106–108 schaft für Orthopädie und Orthopädische Chirur-
10623 Berlin gie (DGOOC)), and the German Society for Ortho-
paedics and Trauma (Deutsche Gesellschaft für
Prof. Dr. Dr. Reinhard Hoffmann Orthopädie und Unfallchirurgie (DGOU))
Secretary General of the German Trauma Society
(Deutsche Gesellschaft für Unfallchirurgie (DGU))
Secretary General of the German Society for-
Trauma Surgery (Deutsche Gesellschaft für
Orthopädie und Unfallchirurgie (DGOU))
Medical Director of the BG Hospital Frankfurt am
Main (Unfallklinik Frankfurt am Main gGmbH)
Friedberger Landstraße 430
60389 Frankfurt am Main
XI
List of abbreviations
ACCP American College of Chest Physicians DGUV German Social Accident Insurance Deut-
ADL Activities of Daily Living sche (Gesetzliche Unfallversicherung)
AE German arthroplasty association »Deut- DIMDI German Institute of Medical Documenta-
sche Gesellschaft für Endoprothetik e. V.« tion and Information (Deutsches Institut
AHB Subsequent rehabilitation (Anschluss- für Medizinische Dokumentation und
heilbehandlung) Information)
AOK Statutory health insurance (Allgemeine DRG Diagnosis Related Groups
Ortskrankenkasse) DRV German Statutory Pension Insurance
AQUA- AQUA Institute for Applied Quality (Deutsche Rentenversicherung)
Institut Improvement and Research in Health DVT Deep vein thrombosis
Care (Institut für angewandte Qualitäts- EBM Uniform Value Scale (Einheitlicher
förderung und Forschung im Gesund- Bewertungsmaßstab)
heitswesen Institut GmbH) EPRD German joint replacement registry
AR Additional remuneration »Endoprothesenregister Deutschland
ARCO Association Research Circulation Osseous (EPRD)«
ASA American Society of Anesthesiology ESC European Society of Cardiology
AWMF Association of the Scientific Medical So- ETM Evidence-based treatment modules
cieties in Germany (Arbeitsgemeinschaft (Evidenzbasierte Therapiemodule)
der Wissenschaftlichen Medizinischen EULAR European League Against Rheumatism
Fachgesellschaften e. V.) FEISA Research and development institute for
BÄK German Medical Association (Bundes- social affairs and the healthcare system
ärztekammer) in Saxony-Anhalt »Forschungs- und
BfArM Federal Institute for Drugs and Medical Entwicklungsinstitut für das Sozial- und
Devices (Bundesinstitut für Arzneimittel Gesundheitswesen Sachsen-Anhalt«
und Medizinprodukte) G-BA Federal Joint Committee (Gemeinsamer
BMG Federal Ministry of Health (Bundes- Bundesausschuss)
ministerium für Gesundheit) G-DRG German Diagnosis Related Groups
BMI Body Mass Index GKV Statutory health insurance (Gesetzliche
BMWi Federal Ministry for Economic Affairs and Krankenversicherung)
Energy (Bundesministerium für Wirt- GOÄ Physicians’ fee catalog (Gebührenord-
schaft und Energie) nung für Ärzte)
BQS Institute for Quality and Patient Safety HIV Human immunodeficiency virus
(Institut für Qualität und Patientensicher- HKK Statutory health insurance »Handels-
heit GmbH) krankenkasse«
BVMed The German Medical Technology Asso- HV Curative procedure (Heilverfahren)
ciation (Bundesverband Medizintechno- IC Integrated care
logie e. V.) ICD International Statistical Classification of
BVOU Professional Association of Orthopaedic Diseases and Related Health Problems
Surgeons (Berufsverband der Fachärzte IgeL Individual health services paid for priva-
für Orthopädie und Unfallchirurgie e. V.) tely by the patient »Individuelle
CC Complications or comorbidities Gesundheitsleistungen«
DAH German association for osteoarthritis InEK German Institute for Hospital Reimburse-
support »Deutsche Arthrose-Hilfe e.V.« ment »Institut für das Entgeltsystem im
DALY Disability Adjusted Life Years Krankenhaus (InEK)«
DGOOC German Society of Orthopedics and Or- IQTiG Institute for Quality Assurance and Trans-
thopedic Surgery (Deutsche Gesellschaft parency in Healthcare (Institut für Quali-
für Orthopädie und Orthopädische tätssicherung und Transparenz im
Chirurgie e. V.) Gesundheitswesen)
DGOU German Society for Orthopaedics and IQWiG Institute for Quality and Efficiency in
Trauma (Deutsche Gesellschaft für Ortho- Health Care (Institut für Qualität und
pädie und Unfallchirurgie e. V.) Wirtschaftlichkeit im Gesundheitswesen)
DGU German Society for Trauma Surgery IRENA Intensified post-rehabilitation care
(Deutsche Gesellschaft für Unfallchirur- (Intensivierte Rehabilitations-Nachsorge)
gie e. V.)
XII List of abbreviations
IV Integrated care (Integrierte Versorgung) VKA Vitamin K antagonist

FJC Federal Joint Committee VTE Venous thromboembolism
KHEntgG Hospital Remuneration Act (Kranken- WHO World Health Organization
hausentgeltgesetz) WidO Research Institute of the statutory
KHG Hospital Financing Act (Gesetz zur wirt- health insurance AOK »Wissenschaftli-
schaftlichen Sicherung der Krankenhäu- ches Institut der AOK«
ser und zur Regelung der Krankenhaus- WIP Scientific institute of the private health
pflegesätze) insurances »Wissenschaftliches Institut
KSS Score Knee Society Score der Privaten Krankenversicherungen«
KTL Classification of therapeutic services WOMAC Western Ontario and McMaster Univer-
(Klassifikation therapeutischer Leistun- sities Arthritis Index
gen) YLD Years Lived with a Disability
LMWH Low-molecular-weight heparin ZE Additional remuneration
MDD Medical Device Directive ZLG Central Authority of the Länder for
Morbi-RSA Morbidity oriented risk adjustment Health Protection regarding Medicinal
scheme (Morbiditätsorientierter Risiko- Products and Medical Devices (Zentral-
strukturausgleich) stelle der Länder für Gesundheitsschutz
MPG Medical Devices Act (Medizinprodukte- bei Arzneimitteln und Medizinproduk-
gesetz) ten)
MTPS Mechanical thromboprophylaxis
stockings (compression stockings)
NICE National Institute for Health and Care
Excellence
NIH National Institutes of Health
NHP Nottingham Health Profile
NSA Non-steroidal antiphlogistic drugs
NUB New examination and treatment
methods »Neue Untersuchungs- und
Behandlungsmethoden«
OECD Organisation for Economic Cooperation
and Development
OPS German procedure classification »Opera-
tionen- und Prozedurenschlüssel«
OTA Surgical technician (Operations-
technischer Assistant)
PE Pulmonary embolism
PROM Patient-Reported Outcome Measures
QALY Quality-Adjusted Life Year
QSR Quality assurance using routine data
(Qualitätssicherung mit Routinedaten)
REDIA Rehabilitation and diagnosis-related
groups study (Rehabilitation und
Diagnosis Related Groups-Studie)
RKI Robert Koch Institute
SGB Social Security Code (Sozialgesetzbuch)
SHI Statutory health insurance
ST Surgical Technicians
SVR Advisory Council on the Assessment of
Developments in the Healthcare System
(Sachverständigenrat zur Begutachtung
der Entwicklung im Gesundheitswesen)
THA Total hip arthroplasty
TKA Total knee arthroplasty
TK Statutory health insurance (Techniker
Krankenkasse)
vdek Association of Substitute Health Insu-
rance Funds (Verband der Ersatzkassen
e. V.)
1 1
Introduction to the Indications

and Procedures
Cornelia Seidlitz, Miriam Kip
1.1 Definition –2
1.2 Etiology, Indications and Treatment Goals –2

1.2.1 Etiology – 2
1.2.2 Indications – 6
1.2.3 Surgery Goals and Objectives –8
1.3 Materials, Surgical Procedures and Risks –8

1.3.1 Material Requirements – 8
1.3.2 Surgery – 9
1.3.3 Factors Influencing Treatment Success and Complications – 10
References – 13
© The Editor(s) (if applicable) and The Author(s) 2018

H.-H. Bleß, M. Kip (Eds.), White Paper on Joint Replacement
DOI 10.1007/978-3-662-55918-5_1
2 Chapter 1 · Introduction to the Indications and Procedures
Summary The most common reason for joint replace-

1 Arthroplasty is defined as the surgical replacement of ments is joint surface destruction from wear of the
a joint with artificially produced material. Total ar- cartilage lining due to degenerative diseases such as
throplasty refers to the replacement of all joint sur- osteoarthritis, fractures and other changes in bone
faces concerned, while partial replacement involves and connective tissue structures. Under certain cir-
the replacement of only one or some of the surfaces cumstances, these can lead to permanent loss of
but not the entire joint. Hip and knee joints are those function, permanent pain and impaired mobility of
that are most frequently replaced. The most common the affected joint, as well as a decrease in quality of
indications for hip or knee arthroplasty are sympto- life. If these symptoms cannot be treated otherwise,
matic osteoarthritis and femoral neck fractures (hip). replacement with an artificial joint becomes neces-
When patients undergo hip or knee replacement for sary in order to avoid secondary complications and
the first time (due to osteoarthritis) they are usually to restore the patient’s ability to participate ade-
between 60 and 70 years of age. More than two quately in everyday life.
thirds of patients who undergo arthroplasty due to The causes and consequently also the risk of re-
femoral neck fractures are over 85 years of age. Pri- quiring joint replacements are largely dependent on
mary arthroplasty refers to the first hip or knee re- age. On average, patients are aged between 60 and
placement and revision arthroplasty refers to fol- 70 years when they receive an artificial hip or knee
low-up surgery on the same joint. The period of time joint replacement for the first time.
(without complications) between primary arthroplas-
ty and revision arthroplasty is termed as »service
life«. In symptomatic osteoarthritis, arthroplasty is 1.2 Etiology, Indications
performed after all conservative and joint preserving and Treatment Goals
therapy options have been exhausted. With regard to
femoral neck fractures, joint replacement is usually 1.2.1 Etiology
the primary treatment option. Surgery aims to im-
prove the quality of life, to restore the greatest possi- Symptomatic osteoarthritis constitutes the most
ble functionality, mobility and freedom from pain, to common reason for requiring hip joint replacement
assure a long service life with good weight-bearing (Claes et al. 2012; Wirtz 2011). Over 80 % of all pri-
capacity and to avoid secondary complications. mary hip surgery is due to osteoarthritis-related
These constitute important prerequisites for leading symptomatic degenerative changes in the articular
an independent life in old age. surfaces (osteoarthritis of the hip) (Barmer GEK
2010). Other reasons include periarticular fractures,
such as femoral neck fractures (Strohm et al. 2015),
1.1 Definition chronic inflammatory rheumatic diseases, mis-
alignments and pathological changes of the bone
Arthroplasty is defined as the essential surgical re- substance, due to tumors for example, metastases or
placement of a joint with artificially produced ma- osteoporosis, which increase the risk of periarticu-
terial which is fixated in the bone (joint replace- lar fractures (Claes et al. 2012).
ment, endoprosthetic surgery, alloarthroplasty) In the majority of cases, osteoarthritis also con-
(Claes et al. 2012; Wirtz 2011). Total replacement stitutes the main reason for requiring knee joint
refers to the replacement of all the joint surfaces replacement (osteoarthritis of the knee). Osteo-
concerned while partial replacement involves the arthritis is responsible for 96 % of all primary endo-
replacement of only one or some of the surfaces but prosthetic procedures on the knee (Barmer GEK
not the entire joint. Hip and knee joints are the most 2010). Other reasons for knee joint replacements are
frequently replaced, but endoprosthetic implants much less frequent (Wirtz 2011).
are also used to replace other joint functions, such
as shoulder or elbow joints (Claes et al. 2012; Wirtz
2011).
1.2 · Etiology, Indications and Treatment Goals
3 1
. Tab. 1.1 Osteoarthritis classification and risk factors (selection)
Classification Risk factors Description
Primary localized (hip, knee) or generalized (polyosteoarthritis, more than

(idiopathic) three joint regions affected)
Secondary congenital and acquired joint e.g. hip dysplasia, malalignments of the knee
defects
endocrine diseases e.g. diabetes mellitus
metabolic disorders e.g. hemochromatosis, hypercholesterolemia, hyperuricemia
posttraumatic e.g. following joint fractures, fractures near the hip, cruciate liga-
ment injury in the knee
other causes e.g. sepsis, inflammatory rheumatic disease, circulatory disorders

of the bone near the joint in avascular necrosis of the femoral head
and femoral condyle
Source: IGES – Günther et al. 2013
jOsteoarthritis Osteoarthritis is characterized by an imbalance

Numerous potential risk factors for osteoarthri- in the cartilage metabolism in which catabolic pro-
tis-related joint changes exist (. Tab. 1.1). If these cesses prevail. Cartilage degeneration initially leads
risk factors cannot be clearly ascertained, the osteo- to the formation of new less resistant cartilage tis-
arthritis is classified as primary or idiopathic. In sue. Therefore, joint function is restored but the
contrast, secondary osteoarthritis has one or more joint is less resistant to strain. Over time, the carti-
identifiable risk factors that may contribute to the lage tissue can be completely destroyed and the
advancement of the disease. General risk factors in- exposed bone underneath becomes deformed and
clude age, sex as well as genetic, biomechanical and the joint thickens (Claes et al. 2012).
inflammatory factors. In addition body weight, os- In the advanced stage (active osteoarthritis) the
teoporosis, cardiovascular and metabolic diseases increasing destruction of cartilage tissue and conse-
can also negatively affect cartilage metabolism. Risk quent inflammation of the synovial membrane lead
factors resulting in local effects include injuries, cir- to acute episodes of pain, movement restriction,
culatory disorders, congenital or acquired malfor- swelling, joint warmth and sensations of tension.
mations and too much strain on only one side of the Sensitivity to weather, heat and cold are also typical
joint. As a result, multicausal rather than mono- symptoms during this phase. Generally, this stage of
causal explanatory models are therefore generally the disease can last several years and can include
favored nowadays (Günther et al. 2013). phases with and without symptoms (Claes et al.
The main symptoms of osteoarthritis are pain 2012) (. Fig 1.1).
and increased restriction in mobility of the affected During the late stage of the disease (decompen-
joints. In most cases, the disease usually progresses sated osteoarthritis), the progressive destruction of
chronically, initially with symptoms such as joint the joint is accompanied by permanent pain and
stiffness which at first only occur after a longer pe- functional restrictions. This leads to diminished
riod of strain on the affected joint. At first, pain only quality of life in patients as daily life activities (e.g.
occurs following certain movements or after longer washing, getting dressed) and mobility are affected.
periods of rest (pain on initial movement). At a later Pain then occurs during minor movements or even
stage, the pain is not associated with strain and be- at rest. Chronic pain can also develop, caused by
comes continuous (resting pain, nocturnal pain) cartilage destruction, sclerosis and the formation of
(Claes et al. 2012). bone projections (osteophytes) as well as damage to
1 60
51.9
Population 18+ years (%) 50
40 36.1
32.3
19.7
30 27.8 Women
26.1 23.8
Men
20
Total
9.2 8.9
10
2.7 1.9
0
18–29 30–44 45–64 65+ Total
Age (years)
. Fig. 1.1 Lifetime prevalence of osteoarthritis in Germany in 2012. (IGES – RKI 2014)
adjacent structures such as bones, muscles, capsules (Ewerbeck and Dreinhofer 2009) together with esti-
and ligaments. Osteoarthritis can ultimately lead to mates from the German Society for Orthopaedics
stiffness and instability of the affected joints result- and Trauma (Deutsche Gesellschaft für Orthopädie
ing in immobility of the patient and consequently in und Unfallchirurgie e. V.) (DGOU)) (Schmitt 2014)
the development of severe secondary diseases (Claes based on demographic trends and disease burdens
et al. 2012). give reason to expect an increase in these age-relat-
According to the Robert Koch Institute (RKI), ed diseases the future. An increase in the number of
the lifetime prevalence of osteoarthritis in Germany heavily overweight people in the population consti-
in 2012 was 27.8 % in women and 19.7 % in men. tutes another influencing factor that will play an
There was a noticeable rise in the prevalence of the important role with regard to knee joint replace-
disease in older age groups: In the 30 to 44 years age ments (Derman et al. 2014).
group, 9.2 % of the women surveyed and 8.9 % of
men reported to have osteoarthritis, in the 45 to 64 jFemoral neck fracture
years age group, 32.3 % and 26.1 % respectively re- Besides osteoarthritis, another important risk factor
ported to have osteoarthritis as did approximately for hip joint replacement is the femoral neck frac-
50 % all women and 36 % of men who were older ture. It gains growing importance with increasing
than 65 years of age (. Fig. 1.1). Previous studies patient age (Claes et al. 2012; Strohm et al. 2015).
have shown that the prevalence of symptomatic os- Femoral neck fractures are close to the joint and
teoarthritis in the population is estimated to be require surgical treatment in most cases. Conserva-
around 10 % in people over 60 years of age (Sun et tive therapy is only possible in cases of stable,
al. 1997). non-impacted fractures. The surgical procedures
Due to the expected future demographic trends available include procedures that preserve the joint
in Germany, a significant rise in degenerative joint and endoprosthetic procedures. The procedure se-
diseases and therefore in hip and knee osteoarthritis lected will depend on the type of fracture and the
requiring treatment can be expected (RKI 2009). age of the patient, amongst other factors. Usually, an
Corresponding estimates for the increased needs of endoprosthesis is implanted in patients over 65
endoprosthetic care for other countries (Culliford et years of age and in patients already suffering from
al. 2015; Kurtz et al. 2007) cannot be directly applied joint osteoarthritis (Pfeifer et al. 2001). Osteosyn-
to Germany. However, prognoses published in rela- thetic procedures aim to preserve the joint with the
tion to the development in musculoskeletal diseases help of locking nails, cannulated screws or dynamic
5 1
hip screws consisting of extramedullary plates and femoral neck fractures will also rise (Berufsverband
antirotation screws (Claes et al. 2012). der Fachärzte für Orthopädie e. V. 2004, Pfeifer et al.
The most common causes of femoral neck frac- 2001). Given the current demographic trends in Eu-
tures are falls that occur at home which in turn can rope, it is assumed that the incidence of femoral
be ascribed to underlying diseases, for instance neu- fractures will increase by at least fourfold over the
rological or heart diseases. next 60 years.
A femoral neck fracture is one of the most com- To date, only limited data from studies on the
mon late-stage complications of osteoporosis incidence of femoral neck fractures in Germany is
(Stöckle et al. 2005). The prevalence of osteoporosis available. An epidemiological investigation based
amongst the over 50 age group is approximately on hospital statistics from 2004 found an incidence
14 % (women: 24 %; men: 6 %) (Hadji et al. 2013). of 140.9 per 100,000 inhabitants. In correlation with
Factors which contribute to femoral neck frac- the age-dependency, the incidence in older popula-
tures include age-related reduced bone mineral tion groups (over 65 years) was significantly higher
density and a higher risk of falling. Risk factors for (662 per 100,000 inhabitants as opposed to 21.7 per
falls include vitamin D deficiency (which affects the 100,000 inhabitants in groups aged below 65 years)
muscles), coordination disorders (for example due and was also significantly higher in women than in
to medication), dizziness, defective vision, weak- men (Icks et al. 2008).
ness, multimorbidity or existing diseases of the According to the latest hospital diagnoses data,
musculoskeletal system. The average age of patients the number of inpatient cases in 2013 was 144 per
with femoral neck fractures is relatively high and 100,000 inhabitants (age standardized). The num-
hence rapid mobilization is particularly important ber of cases in the over 65 years of age group was at
in order to avoid further complications. Preserva- 875 cases per 100,000 inhabitants and as expected,
tion of the femoral head is given primary impor- women were affected more than twice as often as
tance solely in younger patients (Claes et al. 2012). men (. Fig. 1.2).
Femoral neck fractures in younger patients are
rare and are usually the result of so-called high-en- jFemoral head necrosis
ergy traumas, i.e. road traffic accidents and falls In femoral head necrosis the bone tissue of the fem-
from great heights. Additionally, malignant diseases oral head dies (osteonecrosis). This is a result of is-
that are accompanied by bone destruction can also chemia (circulatory disorder) of the affected area
lead to femoral neck fractures (pathological frac- (Meizer et al. 2007).
tures). Inadequate blood supply can result from trau-
Femoral neck fractures are associated with se- matic factors (posttraumatic osteonecrosis), such as
vere pain in the hip region, restricted mobility of the tearing or overstretching following a femoral neck
hip joint and on walking. Often, the affected leg is fracture, or various different risk factors and under-
noticeably shorter and rotated outwards. External lying diseases (nontraumatic osteonecrosis). There
signs of injury include hematomas or swelling above are several different risk factors and underlying dis-
the hip joint. In cases of impacted fractures, clinical eases which can lead to nontraumatic osteonecrosis.
signs can be very discrete in that patients may still Identifiable risk factors which are observed in 50 %
be able to walk for several days despite the fracture to 80 % of cases include alcohol and nicotine abuse,
(Claes et al. 2012). dyslipidemia, pregnancy and hereditary coagula-
The risk of femoral neck fractures in one’s life- tion disorders such as thrombophilia. In addition,
time is indicated to be between 11 % to 23 % in high-dose corticosteroid intake (for example, for
women and 5 % to 11 % in men (Stöckle et al. 2005). chronic inflammatory diseases) is associated with a
This incidence rises with increasing age with a high risk of disease development. Diseases that have
marked increase from the age of 74 years in particu- been observed to result in higher rates of femoral
lar (RKI 2009). Consequently, with a steadily in- head necrosis include systemic lupus erythemato-
creasing proportion of older people in the popula- sus, HIV, malignancies, and inflammatory bowel
tion, it can be assumed that the absolute number of diseases, amongst others.
1 Case numbers per 100,000 persons (2013) 900
800
700
600
500
400
300
200
100
0
0–14 15–44 45–64 65+ Total Women Men
Age (years)
. Fig. 1.2 Inpatient case numbers per 100,000 inhabitants with a femoral fracture (S72) by age group and by sex (age-
standardized) (2013). (IGES – Federal Statistical Office 2014)
Symptoms associated with femoral head necro- days to several years (ARCO classification) (AWMF
sis vary greatly between individuals and are non- 2014).
specific (Hofmann et al. 2002). Particularly at the In German-speaking countries, the incidence of
start of the disease, which advances bilaterally in femoral head necrosis is estimated at 0.01 %, which
30 % to 70 % of cases, there may initially be no corresponds to approximately 5,000 to 7,000 pa-
symptoms such as pain on weight bearing or diffi- tients a year (Hofmann et al. 2002). The disease oc-
culty walking. During the later stage, femoral head curs mainly between the ages of 25 and 55 years with
necrosis leads to movement restrictions and strong a peak at 35 years of age. Men are affected four times
recurrent hip pain radiating into the thigh and knee. as often as women. According to a routine data
With the progression of the disease, pain at rest may analysis conducted by the Barmer GEK, bone ne-
also occur and in the final stages of the disease os- crosis was indicated as the relevant main diagnosis
teoarthritis of the hip with complete destruction of upon discharge in approximately 3 % of primary
the joint may occur (AWMF 2009b). total hip arthroplasty (THA) cases (Barmer GEK
Early diagnosis of femoral head necrosis is cru- 2010).
cial to joint-preserving treatment and improved
long-term prognosis. In 85 % of patients, the disease
will progress within two years if the initial diagnosis 1.2.2 Indications
is left untreated and results in femoral head collapse
with complete destruction of the joint in over half of jPrimary arthroplasty
the patients (Hofmann et al. 2002). Based on the The indication for a hip or knee replacement is
criteria developed by the Association Research Cir- based on patient-relevant clinical and radiological
culation Osseous (ARCO), idiopathic femoral head criteria together with a thorough examination of the
necrosis (without any known cause) is categorized patient’s medical history (Claes et al. 2012, Wirtz
into five different stages (0 to IV). The progression 2011).
of each stage varies greatly between individuals and The clinical diagnosis includes an examination
the duration can also vary from a period of several of the affected joint as well as of the structures and
7 1
tissue surrounding the joint. It also includes func- jRevision arthroplasty
tional tests and pain assessments, for example, de- Revision arthroplasty entails the removal and re-
termining how far the patient can walk free of pain. placement of one or more components of the hip or
The mobility of the joint can only be assessed by knee endoprosthesis. It is therefore a follow-up sur-
clinical examination. In addition, pain and other gical procedure for primary hip or knee arthroplas-
complaints can be evaluated by means of standard- ty that is performed on the same joint.
ized patient surveys (AWMF 2009a, 2008; Claes et Follow-up surgery without replacement or re-
al. 2012; Wirtz 2011). moval of the (entire) artificial joint can also be per-
Besides objective criteria, a patient’s degree of formed if the endoprosthesis is not functioning en-
suffering and his or her requirements at the time of tirely correctly (EPRD 2015), for example to remove
the examination play a substantial role in the deci- a hematoma (revision without replacement). The
sion for or against replacement of the affected joint. time between primary replacement and t revision is
For instance, a replacement should not be recom- termed as »service life« (EPRD 2015).
mended if the radiological findings show a joint af- Usually, revision arthroplasty is performed after
fected by osteoarthritis but the patient does not have the »natural« service life of the endoprosthesis has
osteoarthritis-related symptoms or does not have come to an end. In some cases, however, earlier revi-
many complaints (AWMF 2009a, 2008; Claes et al. sion replacement might become necessary. Reasons
2012; Wirtz 2011). for revision arthroplasty include loosening of the
According to Claes et al. (2012), an indication implant, instability of the artificial joint, extensive
for a hip joint replacement exists if a patient’s qual- bacterial infections and progressive degeneration of
ity of life is severely affected by pain or functional parts of the joint that have not yet been replaced.
impairment. Additional factors include conserva- Revision can also become necessary if functional
tive therapies that are insufficiently effective (medi- impairments of the artificial joint severely restrict a
cation, avoiding strain on the affected joint, physio- patient’s activities and are often accompanied by
therapy, physical therapy, etc.) as well as visible pronounced pain. Additionally, acute or chronic in-
causative radiological changes such as morphologi- fections as well as traumatic fractures close to the
cal joint damage, which cannot be treated conserva- joint or the endoprosthesis as well as problems with
tively (Claes et al. 2012). Furthermore, indications the implant and the primary replacement procedure
for hip joint replacements exist for patients over the may make revision replacement necessary. Other
age of 60 years who have femoral neck fractures and reasons include local inflammatory tissue reactions,
in patients with femoral fractures due to pathologi- wear (micro-abrasive particles) of the endopros-
cal bone diseases (for example metastases, osteopo- thetic material and the quality of the endoprosthesis
rosis) (Claes et al. 2012). fixation. Patient compliance and characteristics
According to Wirtz (2011), an indication for to- such as age or weight also have a significant impact
tal knee arthroplasty (TKA) in primary and second- on the endoprosthetic service life (Section 1.3.3).
ary osteoarthritis of the knee exists if the conditions Documented arthroplasty in the German joint
are associated with severe pain and movement im- replacement registry »Endoprothesenregister
pairments which can be confirmed radiologically Deutschland (EPRD)« will enable a reliable deter-
(Wirtz 2011). Both the European League Against mination of the service life in future, which can be
Rheumatism (EULAR) and the US National Insti- related to the different levels of care such as to the
tutes of Health (NIH) consider the indication for a surgeon, the hospital performing endoprosthetic
knee joint replacement to exist if, alongside the ra- surgery, the individual endoprosthesis and the type
diological evidence of osteoarthritis, a patient has of endoprosthesis depending on the initial docu-
continuous pain that is not manageable with drugs, mentation.
or if the disease is accompanied by substantial func-
tional impairments (EULAR 2002, NIH 2004).
1.2.3 Surgery Goals and Objectives Meanwhile, many different variations of these
1 artificial joints exist. Therefore, a short overview of
Primary arthroplasty aims to restore joint function how they function and the most important features
as much as possible, to reduce pain caused by osteo- is provided in the following paragraphs.
arthritis (hip or knee) and by other diseases. It also Nowadays, hip endoprostheses usually consist
aims to rapidly mobilize patients after femoral neck of an acetabular cup and a femoral stem onto which
fractures. A further goal is to achieve a long service a modular endoprosthesis head is attached. The cup
life with good weight-bearing capacity and to avoid may consist of one piece (usually polyethylene) or of
(secondary) complications. On the whole, a pa- a metal cup with an inlay (modular cup). Frequent-
tient’s quality of life should be improved and their ly, fractures in elderly people are treated by solely
mobility enhanced (Claes et al. 2012; Wirtz 2011). replacing the femoral head with a so-called hemien-
Mobility is a basic prerequisite for leading an inde- doprosthesis without replacing the cup. In this case,
pendent life and preserving patients from social a (usually modular) head which has the size of the
isolation, especially in older age groups (Moon natural femoral head is attached to the endopros-
2014). thetic stem. Special procedures such as surface re-
placements are of minor relevance for hip joints
(Claes et al. 2012).
1.3 Materials, Surgical Procedures Parts of the knee joint or the joint surface are
and Risks replaced by bowl-shaped implants on the femoral
side and a tibial baseplate, which can be fixated into
1.3.1 Material Requirements the medullary cavity with or without a stem. The
bearing surface between the femur and the tibia can
Ideally, the primary endoprosthesis should be re- be connected with the baseplate or be mobile and
tained over a lifetime. Despite tremendous technical gliding. The back of the patella may be replaced with
advances and the availability of high-quality mate- an implant (Wirtz 2011).
rials, this cannot be achieved for all patients. In gen- The contact surface between the bone and im-
eral, both hip and knee endoprostheses are weight plant is of great importance for weight bearing on
bearing body parts and must be designed accord- the joint after surgery. This connection technique is
ingly, also with regard to the material selected (Claes generally referred to as fixation. An implant can be
et al. 2012, Wirtz 2011). fixated with or without bone cement – combined
The implants undergo extensive testing with solutions are termed hybrid fixation or partial ce-
regard to functionality, quality, reliability and safety mentation. The applied bone cement is a special
which constitutes a prerequisite for statutory prod- artificial cement (polymethylmethacrylate). Unce-
uct requirements. Corresponding requirements can mented endoprosthesis components can have a spe-
be found in international standards which are re- cial surface design or coating (e.g. titanium specifi-
viewed every five years (BVMed 2014). cations or hydroxylapatite) in order to support sec-
Regardless of the field of application, implants ondary bone ingrowth. Primary stable fixation is
must have the longest possible durability which why achieved by fixing the endoprosthesis to the bone
is hard-wearing materials with minimal wear even (so-called press-fit) (Claes et al. 2012; Wirtz 2011)
when used in combination with other materials are with the aim of permanently attaching the endopros-
employed. In addition, the materials must be ac- thesis to the bone bed. Opinions on the advantages
cepted by the body as there is risk of potential rejec- and disadvantages of cemented an uncemented fixa-
tion. It is recommended that metals (such as cobalt- tion vary and the choice of procedure depends on
chromium and titanium alloys) be used which are different factors (such as age and bone quality) (see
connected to the bone and tribologically paired Section 1.3.3) (Claes et al. 2012, Wirtz 2011).
with synthetic materials (polyethylene) or ceramics
(NICE 2014).
1.3 · Materials, Surgical Procedures and Risks
9 1
1.3.2 Surgery hemiarthroplasty or partial arthroplasty. An exam-
ple of this is the dual head prosthesis, which is par-
Prior to surgery the physician informs the patient of ticularly used in cases of femoral neck fractures in
any possible complications and risks. Specific treat- elderly patients (Claes et al. 2012).
ment planning includes selecting the appropriate The accuracy of the endoprosthetic fit is tested
endoprosthesis based on clinical and radiological regularly by means of a trial prosthesis while the
criteria as well as deciding on the surgical access joint is being surgically prepared. The surgeon must
route (. Fig. 1.3). ensure that there is enough tension on the ligaments
In hip arthroplasty, the natural structures of the and the soft tissue for the artificial joint to glide and
pelvis and the upper leg are usually replaced, i.e. the to avoid dislocation. The implantation of the actual
acetabulum in the pelvis and part of the femoral shaft endoprosthesis is performed either with or without
as well as the femoral head in the upper leg. When all bone cement. Subsequently, the surgical access
these structures are replaced, the procedure is re- route is closed. The position of the endoprosthesis
ferred to as total replacement or total arthroplasty. is checked by x-ray immediately after surgery (Claes
Total arthroplasty also includes short stem femoral et al. 2012).
head prostheses, which are usually used in younger Special care must be taken when positioning the
patients, as well as surface replacement prostheses. patient during arthroplasty. Cushioning materials
If the acetabular cup does not need replacing, are used to prevent pressure points on the patient
the procedure is termed as partial replacement, and warming systems are used to prevent hypother-
Preliminary Follow-up treatment

Surgical planning
examinations planning
(Digital) planning of the bio-

Medical history and clinical
mechanics of the hip joint prosthesis
examinations including gait,
and the prosthetic components, Mobilization,
leg length, range of motion of
taking into account individual use of medical aids
the hip joint, perhaps additional
patient particulars
functional tests
(e. g. bone defects)
Selection of the implant (type, size,

tribological pairing) and the fixation
technique (hip shaft, cementation) Prophylaxis:
Pelvic x-ray taking into account individual Thrombosis, ossification
patient particulars such as allergies
to certain materials (allergy test
if necessary)
Selection of the surgical access

To exclude existence of other
route (minimally invasive,
diseases of the spine and adjacent
conventional) and corresponding Follow-up X-ray
joints, via MRT scans if necessary
positioning of the patient
or by infiltration of the hip joint
(supine, lateral)
. Fig. 1.3 Elements of treatment planning based on hip arthroplasty. (IGES – Wilken et al. 2014)
mia. The patient can be placed in a lateral or supine holders are used allowing the leg to be positioned in
1 position. It is important to accurately secure the pa- an upright 90 degree position (Wirtz 2011).
tient in the selected position with the help of props Numerous studies on various surgical access
and straps in order to avoid any changes in position routes for both the hip and the knee joint exist.
during the surgery (Claes et al. 2012). However, no significant advantage in any one of the
In knee arthroplasty, parts of the upper leg (dis- particular procedures has been shown. Less invasive
tal femur) and the lower leg (proximal tibia) are re- access routes have been advocated in recent years, as
placed with artificial material. Different types of they reduce the extent of tissue incision. However,
implants are used depending on the nature and se- actual clinical effectiveness is a matter of debate and
verity of the underlying disease. Structures that are they may also bear a higher risk of complications. In
usually replaced include portions of the femoral hip revision surgery, for instance, the initial access
bone (femoral component) to substitute the defec- route used during primary surgery is often used
tive condyle as well as parts of the lower leg around again. Additionally, these procedures require more
the tibial plateau (tibial component) and the me- extensive imaging of tissue and bone structures
nisci. The patella may or may not be replaced. A (Claes et al. 2012; Wirtz 2011).
synthetic component is placed on the tibial compo-
nent in order to minimize friction between the tib- jAnesthesia
ial and femoral components (»inlay«) (Wirtz 2011). Two anesthetic techniques can be used for both en-
Unicondylar surface replacement, i.e. on one doprosthetic hip and knee surgery: general anesthe-
side of the joint only, is possible if knee function is sia and regional anesthesia. General anesthesia re-
not yet severely impaired by cartilage abrasion and quires artificial ventilation and is based on anxioly-
the bone is affected on only one side of the knee sis, analgesia, muscle relaxation and sedation. Un-
joint. Usually, the medial (inner) side is replaced. der certain circumstances, regional anesthesia, in
Besides the structure of the cartilage and bone, the which the patient is conscious, may also be used in
condition of the ligaments is also crucial to decision the form of spinal anesthesia or by blocking periph-
making. Unilateral surface replacement is often eral nerves or regions with a single injection or by
termed unicompartmental knee replacement using continuous application by means of a catheter. Gen-
a unicondylar sled prosthesis that may also be re- eral and regional anesthesia can be used alone or in
ferred to as sled prosthesis or mono-sled (Wirtz combination. Anesthesia aims to allow for pain-free
2012). surgery, rapid mobilization after surgery and as
Bicondylar and hinge prostheses are used for much pain reduction as possible in the early reha-
total knee arthroplasty. Here, the degree of coupling bilitation phase (Claes et al. 2012, Wirtz 2011).
is an important distinguishing factor. Hinge pros-
theses are axially supported. Usually, this type of
prosthesis is selected if the ligamentous apparatus is 1.3.3 Factors Influencing Treatment
severely impaired because the hinge significantly Success and Complications
restricts mobility. However, surface replacement
prostheses without coupling or with partial cou- A number of factors can influence the success of
pling are used more frequently. A prerequisite for joint replacement treatment (. Fig. 1.4). Besides the
using these types of endoprosthesis is sufficient design of the implant and surgical procedure, a pa-
functionality of the patient’s ligamentous apparatus. tient’s individual characteristics can impact total hip
The artificial knee is often fixated with bone ce- and knee arthroplasty outcomes. These characteris-
ment, but uncemented or hybrid fixation is also fea- tics include age, sex, degree of preoperative osteo-
sible (Wirtz 2011). arthritis and functional status of the joint in ques-
Positioning during knee arthroplasty is designed tion. Additionally, concomitant diseases (particu-
to allow frequent changes in position of the leg as larly obesity, cardiovascular diseases, diabetes mel-
specific steps during treatment require the extremi- litus and immune system disorders) can lead to
ties to be mobile. Therefore, rolls and special leg perioperative and postoperative complications.
1.3 · Materials, Surgical Procedures and Risks
11 1
Patient Treatment
Functionality and disability Perioperative and postoperative measures

– Functional and structural integrity or – Patient education and information
damage (e. g. degree of osteoarthritis, – Anaesthesia
mobility) – Perioperative prophylaxis (infection, DVT, etc.)
– Limitations in daily activities and social – Rehabilitation (medical/occupational)
participation (e. g. tasks, mobility, self- – Follow-up examinations
sufficiency) Clinic
pathw al
ays
Contextual factors Implant
– Personal environment (e. g. aids and – Endoprosthesis (and cement if necessary)
medical appliances, social relationships)
– Individual factors (e. g. age, personal issues
or problems, comorbidity) Surgeon
– Surgical access and technique
– Experience
– Communication
Result
. Fig. 1.4 Factors influencing treatment success. (IGES – Günther et al. 2015)
Social deprivation, personality traits and patient flammation (infection) because pathogens
expectations with regard to the surgery also play an (bacteria) that enter the body or that already
influencing role (Günther et al. 2015; Schäfer et al. exist therein tend to accumulate on the surface
2010). Patient compliance, i.e. the degree to which a of foreign bodies. Once a certain number of
patient correctly follows medical advice with regard bacteria have accumulated, pus may begin to
to daily care of the joint, constitutes a further impor- develop around the implant. These infections
tant factor in the success of joint replacement. can occur shortly after the operation (»early
Optimal presurgical planning is important, in- infection«) or later (»late infection«). The risk
cluding investigation into risk factors of a patient of infection can vary between different patient
that are potentially modifiable. Well-planned post- groups. Patients with diseases associated with a
operative rehabilitation treatment (ambulatory or weakened immune system in particular bear a
inpatient rehabilitation) contributes to treatment higher risk of infection. These diseases include
success (Claes et al. 2012; Wirtz 2011) and plays an diabetes mellitus and rheumatic diseases. Mo-
important role in attaining longer service life of an reover, patients who have a focus of infection
implant, high patient satisfaction and cost-effective- in other parts of the body or who suffer from
ness (Krummenauer et al. 2008; Krummenauer et obesity have a higher risk of infection. The risk
al. 2006). of infection is reduced through the administra-
Arthroplasty procedures are associated with po- tion of antibiotics during surgery.
tential risks caused by surgical and anesthetic 4 Blood clots (thrombosis and embolism): The
procedures in general or with the insertion of the im- formation of blood clots constitutes a general
plant itself. Joint replacement can involve the follow- risk in surgery of the knee and hip joints.
ing major risks (Anonymous, Günther et al. 2015): Antithrombotic drugs are recommended for
4 Inflammation and suppuration (periprosthetic the prevention of thrombosis.
infection): Artificial joint replacements are al- 4 Nerve damage: During surgery, inadvertent
ways associated with an increased risk of in- damage to the nerves may occur through phy-
sical manipulation such pressure or tension in early replacement of the prosthesis becomes
1 the regions concerned. Regional anesthesia necessary due to loose fit. Particulate wear
may also cause nerve damage. Congenital hip debris may be released during the course of
dislocation also constitutes a risk factor as the prosthesis use, which can contribute to loose-
leg may become over extended during hip joint ning of the implant. However, given the quality
surgery. of materials currently in use there is only a
4 Injury of blood vessels and postoperative blee- slight risk of such an abrasion occurring and
ding: Surgery on the hip or knee joint is gene- hence individual prosthesis components rarely
rally associated with the risk of injury to blood break for this reason. However, if they do
vessels close to the joint. Moreover, despite break, it is usually due to loosening of the
adequate hemostasis, postoperative bleeding prosthesis.
may occur due to antithrombotic therapy. 4 Allergies: Even though it is still currently
4 Leg length inequality and dislocations consti- unclear if allergies to parts of the prosthesis
tute specific risks during hip joint replacement: increase the risk of complications, specific
When hip joints are replaced, the aim is to materials in the prosthesis should be avoided
achieve equal leg lengths. However, the opera- should a patient be allergic to them. About
tion may lead to a lengthening and sometimes 10 % of the population is allergic to nickel, for
even a shortening of the affected leg. In addi- example.
tion, there is a risk of dislocation subsequent to 4 Persisting complaints: Besides the complica-
surgery as on the one hand, the implant is not tions described, bursitis or tendonitis, for
an identical copy of the joint and on the other example, may cause persisting complaints
hand, the surgical procedure involves opening following surgery. This, however, has been
and partially removing the stabilizing joint observed in comparatively few patients.
capsule.
4 Fractures: Necessary pressure exerted during Repeat surgery or revision replacement may be-
the course of this type of surgery may cause come necessary due to complications. Replacing an
fractures in rare occasions. The risk of frac- implant is considerably more complicated than the
tures is higher for in uncemented fixation as primary replacement (primary arthroplasty) as the
this requires higher pressure during insertion. surgeon has to deal with less bone substance there-
4 Calcification in the tissue near the prosthesis: fore increasing the likelihood of fractures and other
During the first few months following surgery, complications. A patient may also have to undergo
calcification may occur within the surgical revision surgery in which the prosthesis is not re-
wounds which can lead to reduced mobility placed or in which only a component is added to the
and pain. Administration of anti-inflammatory existing endoprosthesis (renewed operation with
drugs for two weeks after surgery is recom- addition). These revisions are usually performed on
mended in order to prevent this. Alternatively, the hip and knee to replace the bearing surfaces and
irradiation of the affected region is possible. to manage recurring hip dislocations. However, dis-
4 Loosening of the prosthesis and material wear: locations may also necessitate the replacement of an
It is rare for the prosthesis not to have success- implant should this occur repeatedly (Claes et al.
ful bone ingrowth. If the case should arise, 2012; Wirtz 2011).
References
13 1
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15 2
Prevalence of Hip and Knee

Arthroplasty
Florian Rothbauer, Ute Zerwes, Hans-Holger Bleß, Miriam Kip
2.1 Database – 16
2.2 Utilization of Primary Arthroplasty – 19
2.3 Utilization of Revision Total Arthroplasty and Revision

Surgery – 21
2.4 Regional Distribution – 23
2.5 Case Number Developments – 26

2.5.1 Primary Arthroplasty – 26
2.5.2 Revision Total Arthroplasty and Revision Surgery – 29
2.6 International Comparison – 31
References – 39

DOI 10.1007/978-3-662-55918-5_2
16 Chapter 2 · Prevalence of Hip and Knee Arthroplasty
Summary destruction or pain which can no longer be treated

The annual rate of primary hip and knee arthroplasty otherwise. They are also used to treat fractures near
has not increased since 2007. In the 70 years plus age the joint. The different types of arthroplasty pro-
2 group, the rate of primary hip arthroplasty was 1.1 % cedures aim to restore good joint function,
(in both 2007 and 2014) and the rate of primary knee weight-bearing capacity and quality of life. The
arthroplasty was 0.7 % in 2007 and 0.6 % in 2014. prevalence (utilization) of arthroplasty is an impor-
In 2014, the prevalence of surgery in relation to the tant aspect for planning ambulatory and inpatient
entire population was 0.26 % for the hip and 0.19 % care, as well as for estimating demands and subse-
for the knee. Approximately 219,000 primary hip quent demands such as rehabilitation measures and
replacements and 149,000 primary knee replace- questions with regard to resource allocation. The
ments were documented in Germany in 2014. The following chapter presents the utilization hip and
most common procedure performed on a joint was knee arthroplasty services in Germany and differen-
total replacement. Approximately 40 % of all primary tiates these according to age and gender, type of
hip or knee replacements are performed in patients procedure and fixation technique. The presentation
in the 70 to 79 year age group; women are more fre- distinguishes between primary and revision arthro-
quently affected than men (ratio 2:1). In 2014, the plasty. Furthermore, this chapter investigates re-
absolute number of revisions (including revisions gional differences in distribution of these medical
without replacements) amounted to approximately care services and in temporal developments with
30,000 for the hip and 20,000 for the knee. The num- regard to their utilization in Germany and compares
ber of revisions performed in any given year is not these internationally.
necessarily directly related to the number of primary
replacements performed in the same year. Instead,
the number of revisions should be considered in rela- 2.1 Database
tion to the cumulative number of primary replace-
ments performed over the past years and decades. The German procedure classification »Opera-
As with primary arthroplasty, approximately 40 % of tionen- und Prozedurenschlüssel (OPS)« enables
the revisions are performed on patients in the 70 to detailed observations of the annual inpatient prima-
79 years age group. However, the difference between ry and revision hip and knee replacements per-
men and women is less pronounced. formed in Germany. In the German healthcare
Between 2007 and 2014, the rate of hip and knee system, the OPS is primarily used for administrative
revision replacements (including revision without purposes to identify the services rendered to inpa-
replacements) also remained stable. In 2014, in the tients.
70 years plus age group, the rate of revision replace- Bone and joint replacements are classified in
ments (including revision without replacements) was Section 5-82 of the OPS (. Tab. 2.1). The coding
0.19 % for the hip and 0.10 % for the knee. The annu- system allows for reliable distinctions to be made
al utilization rate of primary hip and knee arthroplas- between primary arthroplasty, revision, revision to-
ty varies internationally. Regional differences also tal arthroplasty and the removal of hip joints (5-
exist within Germany itself, as evaluations conducted 820/5-821) and knee joints (5-822/5-823). In addi-
by the statutory health insurances for the period tion, age and sex of patients are specified. OPS 5-820
from 2005 to 2011 have shown. A comparatively low and 5-822 document primary endoprosthetic care
utilization rate was associated in particular with low (primary arthroplasty) for hip and knee joints re-
incidences of osteoarthritis, low social status, a high spectively. OPS 5-821 and 5-823 and further differ-
number of regional specialist physicians (orthope- entiated sub-codes refer to revision surgery, i.e. revi-
dists) and patients living in urban areas. sion total arthroplasty and revisions (follow-up
surgery and re-revisions) on joints that have already
Hip and knee arthroplasty constitute effective treat- undergone previous endoprosthetic surgery.
ments for patients with substantial (or impending)
permanently restricted joint function due to joint
2.1 · Database
17 2
. Tab. 2.1 OPS classification
OPS description OPS description
Hip: Primary arthroplasty
5-820.0 Total arthroplasty 5-820.2 Total arthroplasty, custom-made prosthesis
5-820.3 Femoral head prosthesis 5-820.4 Dual head prosthesis
5-820.5 Acetabular support cup 5-820.7 Acetabular liner locking cup
5-820.8 Surface replacement 5-820.9 Short-stem femoral head prosthesis
5-820.x Other 5-820.y Unspecified
Hip: Revision total arthroplasty and revision
5-821.0 Revision (without replacement) 5-821.1 Femoral head prosthesis replacement
5-821.2 Acetabular cup replacement 5-821.3 Revision cemented total arthroplasty
5-821.4 Revision uncemented total arthroplasty 5-821.5 Revision total arthroplasty, hybrid endo-
prosthesis
5-821.6 Revision total arthroplasty, custom-made 5-821.7 Total endoprosthesis removal

prosthesis
5-821.8 Femoral head prosthesis removal 5-821.9 Dual head prosthesis removal
5-821.a Femoral head cap removal 5-821.b Acetabular cup removal
5-821.c Acetabular support cup removal 5-821.d Acetabular liner locking cup removal
5-821.e Total endoprosthesis removal, custom- 5-821.f Dual head prosthesis replacement
made prosthesis
5-821.g Surface prosthesis replacement 5-821.h Surface prosthesis removal
5-821.j Femoral neck preserving femoral head 5-821.k Femoral neck preserving femoral head
prosthesis (short-stem femoral head prosthesis (short-stem femoral head
prosthesis) replacement prosthesis) removal
5-821.x Other 5-821.y Unspecified
Knee: Primary arthroplasty
5-822.0 Unicondylar sledge prosthesis 5-822.1 Bicondylar surface prosthesis, uncon-

strained, without patella replacement
5-822.2 Bicondylar surface prosthesis, uncon- 5-822.3 Bicondylar surface replacement prosthe-
strained, with patella replacement sis, partially constrained, with patella
replacement
5-822.4 Bicondylar surface prosthesis, partially 5-822.6 Hinged endoprosthesis, without patella
constrained, without patella replacement replacement
5-822.7 Hinged endoprosthesis, with patella 5-822.8 Patella replacement

replacement
5-822.9 Custom-made prosthesis 5-822.a Endoprosthesis with enhanced flexion,

without patella replacement
5-822.b Endoprosthesis with enhanced flexion, 5-822.c Interpositional non-anchored implant

with patella replacement
5-822.d Bicompartmental replacement, without 5-822.e Bicompartmental replacement, with

patella replacement patella replacement
. Tab. 2.1 OPS classification
OPS description OPS description

2 5-822.f Implantation of an endoprosthetic joint 5-822.x Other
without movement function 5-822.x
5-822.y Unspecified
Knee: Revision and replacement operation
5-823.0 Revision (without replacement) 5-832.1 Unicondylar sledge prosthesis replacement
5-823.2 Bicondylar sledge prosthesis replacement 5-823.3 Hinged endoprosthesis replacement
5-823.4 Custom-made prosthesis replacement 5-823.5 Patella prosthesis replacement
5-823.6 Unicondylar sledge prosthesis removal 5-823.7 Bicondylar surface prosthesis removal
5-823.8 Hinged endoprosthesis removal 5-823.9 Patella prosthesis replacement
5-823.a Custom-made prosthesis removal 5-823.b Replacement of an endoprosthesis with

enhanced flexion
5-823.c Replacement of an interpositional non- 5-823.d Removal of an endoprosthesis with

anchored implant nhanced flexion
5-823.e Removal of an interpositional non-an- 5-823.f Bicompartmental prosthesis replacement

chored implant
5-823.g Bicompartmental prosthesis removal 5-823.h Replacement of endoprosthetic joint

without movement function
5-823.j Removal of an endoprosthetic joint with- 5-823.x Other

out movement function
5-823.y Unspecified
Source: IGES – DIMDI (2015)
The German Federal Statistical Office (Statis- tients. The Federal Statistical Office dataset also
tisches Bundesamt) makes OPS data publicly avail- does not portray connections to underlying indica-
able as is stipulated by § 21 of the German Hospital tions (osteoarthritis, fractures and other causes).
Remuneration Act. Only case-based and not pa- Although hospitals report connections between
tient-based data can be accessed. Consequently, the diagnoses and procedures to the respective health
number of cases does not (necessarily) correspond insurances and the German Institute for Hospital
to the number of patients. Two-stage surgery is Reimbursement (InEK), combining this data pub-
documented as two separate cases and subsequently licly is not possible. Moreover, further clinical pa-
individual patients may be counted multiple times. rameters required for describing indications such as
The Federal Statistical Office dataset does not pain, joint function or quality of life are not depict-
permit statistical evaluations of the surgical access, ed. Connections with indications and procedures,
endoprosthetic material or of whether the surgery for example, will be made possible in the future
was planned or had to be performed as an emer- through the German joint replacement registry
gency. Determining the durability of the endo- »Endoprothesenregister Deutschland (EPRD)«
prostheses (service life) is also not possible as no (7 Chapter 4). As the risk of having to undergo joint
connection can be made between the actual implan- replacement is not uniformly spread across all pop-
tation and prosthesis removal for individual pa- ulation and age groups, reliable statements about
2.2 · Utilization of Primary Arthroplasty
19 2
9.0%
Partial joint replacement uncemented
22.1%
(n=19,016)
Partial joint replacement cemented
17.7%
(n=37,170)
Total arthroplasty uncemented
(n=107,727)
Total arthroplasty cemented
(n=46,432)
OPS 5-820*, n total = 210,384

51.2%
. Fig. 2.1 Distribution of hip joint arthroplasty utilization (n = 210,384) (OPS 5-820.*) by total and partial replacement and
fixation technique (2013). (IGES – Federal Statistical Office 2014)
the differences in prevalence (for example, in re- ment (Federal Statistical Office 2014) (. Fig. 2.1). In
gional and international comparisons) can only be 2014, the rate of surgery in the general population
made after adjusting or standardising the respective (as determined on 31 December 2014) was 0.26 %
databases for influencing characteristics such as age (own calculation, Federal Statistical Office 2014,
or sex. Regional evaluations of health insurance data Federal Statistical Office 2015).
(for example by Schäfer et al. 2013; Lüring et al. The absolute number of primary knee arthro-
2013) usually report prevalence rates that are stan- plasties was 149,126 in 2014 and 143,024 in 2013.
dardized to population structures. Furthermore, 84 % of the 143,024 primary knee arthroplasties
consistent survey methods should be employed to performed in 2013 were bicondylar replacements
ensure good reliability for making comparisons. (. Fig. 2.2). The rate of knee replacement surgery in
Presentations of patient-related OECD data that the total population (as determined on 31 Decem-
internationally compare prevalences of endopros- ber 2014) was 0.19 % in 2014 (own calculation, Fed-
thetic hip and knee surgery usually do not take these eral Statistical Office 2014, Federal Statistical Office
aspects into sufficient consideration (7 Chapter 6). 2015). In contrast to primary hip arthroplasty, the
majority of primary knee arthroplasties (79.6 %)
were fixated with cement. Entirely uncemented
2.2 Utilization of Primary fixation was documented in 10.5 % of all operations
Arthroplasty and hybrid/partially cemented fixation was docu-
mented in 9.6 % of the primary replacements (Fed-
According to data from the Federal Statistical Of- eral Statistical Office 2014).
fice, a total of 219,325 primary hip arthroplasties In the age group of over 60-year-olds, well over
were performed in 2014 and 210,384 in 2013 (abso- 65 % of primary hip or knee replacements were per-
lute numbers). Out of the 210,384 primary hip ar- formed in women (Federal Statistical Office 2014).
throplasties performed in 2013, 154,159 (73.3 %) A higher proportion of female hip and knee arthro-
were total arthroplasties (THA) and 56,225 (26.7 %) plasty patients has also been well documented else-
were partial arthroplasties. 60.2 % (126,743 cases) of where (Braun 2013; Lüring et al. 2013). The higher
all hip endoprostheses were implanted without ce- percentage of female patients is due to the higher
0.4% 0.3%
0.9%
2
13.5%
9.2%
9.6% TKA cemented (n=94,466)

TKA uncemented (n=13,723)
66.0% TKA hybrid (n=13,141)
Partial replacement cemented (n=19,318)
Partial replacement uncemented (n=1,304)
Partial replacement hybrid (n=617)
Other (incl. non-anchored) (n=455)
. Fig. 2.2 Distribution of primary knee arthroplasty utilization (absolute number, n = 143,024) (OPS 5-822.*) by total and
partial replacement and fixation technique (2013). (IGES – Federal Statistical Office 2014)
35,000
30,000
25,000
Number
20,000
15,000
10,000
5,000
0
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
90-94
95+
1-4
5-9
Age (years)
Hip: Total arthroplasty Hip: Partial replacement Knee: Total arthroplasty Knee: Partial replacement
. Fig. 2.3 Utilization (absolute number) of primary hip and knee arthroplasty by total and partial replacement and age
group (2013). (IGES – Federal Statistical Office 2014)
2.3 · Utilization of Revision Total Arthroplasty and Revision Surgery
21 2
prevalence of osteoarthritis in women (most com-
. Tab. 2.2 Utilization (absolute number) of revision
mon indication for hip or knee arthroplasty) in ad- total replacements and revisions on the hip and knee
dition to a significantly longer life expectancy for (2013)
women (Rabenberg 2013).
Primary surgery is clearly associated with patient Description Prevalence
age: Approximately 40 % of all primary hip or knee Hip joint n %
replacements documented in Germany are per-
Total arthroplasty
formed in the 70 to 79 year age group (. Fig. 2.3). In
2013, the average age at the time of the primary total Revision total arthroplasty 4,537 14.6
hip or knee arthroplasty was 69.7 and 69.2 years (uncemented)
respectively. Patients who underwent partial knee Revision total arthroplasty 2,325 7.5
replacement were slightly younger on average (mean (cemented)
age 65.8 years). In contrast, the highest number of Revision total arthroplasty (partially 871 2.8
patients who underwent partial hip replacement was cemented)
observed in the 85 to 89 year age group. This age Custom-made prosthesis replace- 837 2.7
group has more documented cases of primary partial ment
hip replacements than of total hip replacements.
Partial replacement
This is primarily due to the high prevalence of fe-
moral neck fractures which occur particularly often Acetabular cup component replace- 12,473 40.1
ment
in this age group and are predominantly treated with
partial replacements (Section 1.2.1 and Section 1.2.2) Femoral head prosthesis replacement 4,859 15.6
(. Fig. 2.3) (Federal Statistical Office 2014). Dual head prosthesis replacement 941 3.0
There is also a link between patient age and the
Surface prosthesis replacement 221 0.7
employed fixation technique: The proportion of ce-
mented total hip arthroplasties (THA) increases Femoral neck preserving femoral 219 0.7
head prosthesis replacement
with age in comparison to uncemented THA (Fed-
eral Statistical Office 2014). Revision (without replacement) 3,784 12.2
Revision total arthroplasty and 31,067 100

revisions, total
2.3 Utilization of Revision Total Knee n %
Arthroplasty and Revision
Bicondylar surface prosthesis 11,290 55.4
Surgery
Unicondylar sledge prosthesis 2,317 11.4
According to the Federal Statistical Office, a total of replacement
35,133 revision hip arthroplasties were performed Hinged endoprosthesis replacement 1,222 6.0
in 2014 and a total of 31,067 revision hip arthroplas- Endoprosthesis with enhanced 699 3.4
ties and 21,678 revision knee arthroplasties were flexion replacement
performed in 2013 (including revisions without re-
Custom-made prosthesis replacement 533 2.6
placements) (absolute numbers). In 2014, this cor-
responded to a prevalence of surgery of 0.04 % (hip) Bicompartmental prosthesis 459 2.3
replacement
and 0.06 % (knee) respectively in the general popu-
lation (as determined on 31 December 2014) (own Patella replacement 439 2.2
calculation, Federal Statistical Office 2014, Federal Other 212 1.0
Statistical Office 2015). 3,784 cases and 3,213 cases
Revision (without replacement) 3,213 15.8
were revisions without component replacements on
the hip and the knee respectively. Accordingly, revi- Total 20,384 100
sions without replacements accounted for approxi-
Source: IGES – Federal Statistical Office (2014)
mately 12 % and 16 % of all documented hip and
6,000
5,000
2
4,000
Number
3,000
2,000
1,000
+
4
4
9
9
4
4
9
4
4
4
-2
-5
-1
-5
-6
-7
-8
-8
-1
-2
95
-3
-3
-4
-4
-6
-7
-9
1-
5-
20
50
15
55
60
75
85
80
10
25
30
35
40
45
65
70
90
Age (years)
Knee: Revision arthroplasties, total Hip: Revision total arthroplasties

Hip: Revision partial replacement
. Fig. 2.4 Utilization of revision arthroplasty (absolute number) including revisions without replacements by type and age
group (2013). (Source: IGES – Federal Statistical Office 2014)
Revision THA
Revision partial replacement,

component revision (hip)
Revisiion (without replacement) (hip)
Revision TKA
Revision partial replacement,

component revision (knee)
Revisio
on (without replacement) (knee)
on
0 2,000 4,000 6,000 8,000 10,000 12,000

Number
Male Female
. Fig. 2.5 Utilization (absolute number) of joint replacement procedures on the hip and knee by type of revision replace-
ment (including revisions without replacements) and by sex (2013). (Source: IGES – Federal Statistical Office 2014)
2.4 · Regional Distribution
23 2
knee replacements respectively which were con- authors calculated age-standardized surgery rates
ducted in one year (2013). Replacements of acetab- (primary hip or knee arthroplasty per 100,000 insu-
ular cup components (partial replacement) or of rees per year). Only total arthroplasties were taken
bicondylar surface prostheses were the most com- into account. Age-standardized rates (European
mon revision replacements performed on the hip standard) were calculated in order to minimize dis-
and the knee respectively (. Tab. 2.2) (Federal Sta- tortions arising from demographic differences be-
tistical Office 2014). tween the regions and to enable comparisons be-
In 2013, the highest number of revision total tween regions and other studies (Schäfer et al. 2013).
arthroplasties and revisions (partial replacements) In 2009, a total of 148 primary hip replacements
were performed in the 75 to 79 year age group. 40 % and 132 primary knee replacements per 100,000
of all revision total arthroplasties and revisions on AOK insurees was performed. Marked differences
the hip and knee were performed in the 70 to 79 year were observed at federal state levels: The lowest rate
age group. In 2013, the average age of patients who of hip replacements was documented in Berlin with
underwent revision total arthroplasty and other re- 120 operations and the highest in Lower Saxony
vision surgery on the hip was 72.5 years and 69 years with 168, corresponding to a difference of approxi-
for those who underwent revision total arthroplasty mately 40 % (. Fig. 2.6). The rate of knee replace-
and other revision surgery on the knee. These aver- ments showed equally distinct regional variations at
age ages are slightly higher than the average ages of federal state level (78.4 %): The lowest rate of re-
patients who undergo primary surgery (. Fig. 2.4) placement was again observed in Berlin (90) and the
(Federal Statistical Office 2014). highest number of primary TKAs in the study pop-
As with primary arthroplasty, the absolute num- ulation was observed in Bavaria (160). Upon solely
ber of revision total arthroplasties and revisions is evaluating federal area states and excluding federal
higher in women than in men. Considering that the city states, the lowest rates of hip replacements can
absolute number of primary replacements in men is be observed in Saxony-Anhalt (143) and the lowest
markedly lower than in women, men undergo com- rate of knee replacements in Mecklenburg-Western
paratively more revisions and revision total replace- Pomerania (109). The highest are observed in Ba-
ments (. Fig. 2.5). varia, Lower-Saxony and Schleswig-Holstein and
However, a direct link between the number of Thuringia (Schäfer et al. 2013).
revision total replacements and primary replace- The AOK evaluation also demonstrated major
ments in a certain year cannot be ascertained. The differences at district levels. The lowest hip arthro-
number of revision total replacements should be plasty rate (average value for the period between
considered in relation to the cumulative number of 2005 and 2009) was 106 cases (in the district Neus-
primary replacements performed over the past tadt an der Weinstraße) and the highest rate was 216
years and decades because endoprostheses have cases per 100,000 insurees (in the district Neustadt
long mean service lives. 7 Chapter 6 presents expert an der Aisch). The regional differences for TKA
opinions on the different aspects of evaluating the were also higher than for hip procedures at district
prevalence of revision replacements (including revi- levels (Schäfer et al. 2013).
sions without replacements). The German Society for Orthopaedics and
Trauma (DGOU) published a report on behalf of
the foundation »Bertelsmann Stiftung« describing
2.4 Regional Distribution the regional differences and influencing factors on
knee arthroplasty. This report also describes dis-
The regional distribution of hip and knee arthro- tinct regional differences for knee arthroplasty pro-
plasty across the German federal states and districts cedures (. Fig. 2.7). The evaluation was also based
was evaluated by Schäfer et al. based on accounting on accounting data from AOK insurees but these
data (secondary data) of patients insured with the were obtained from the period between 2005 and
statutory health insurance AOK. This included 24 2011. This investigation also found that in 2011,
million insurees from the years 2005 to 2009. The age-standardized utilization of knee replacement
Age-standardized arthroplasty rates per 100,000 persons
180
160
2 140
120
100
80
60
40
20
0
y
rg
ria
en
rg
Po -W e
Lo era ern
ny
ia
nd
ny
lt
a
an
gi
ss
at
rli
ei
ur
ha
al
be
bu
xo
xo
va
em
w nia
la
in
st
He
tin
Be
m est
ph
nb
rm
An
ar
m
Ba
ol
Sa
Sa
ur
Br
la
st
de
Sa
Ge
y-
tte
-H
Ha
Th
Pa
er
n
an
ig
g
-W
ür
xo
d-
ur
w
Br
W
an
Sa
nb
es
in
n-
el
hl
Rh
kle
de
in
Sc
rth
ec
Rh
Ba
No
Federal state
. Fig. 2.6 Age-standardized primary hip arthroplasty rates per 100,000 AOK insurees in 2009. (Source: IGES – Schäfer et al. 2013)
180 30%
160
25%
Surgery rate per 100,000 persons
140
120 20%
Percentage
100
15%
80
60 10%
40
5%
20
0 0%
y
rg
ria
de n
en
Po -W se
w an n
ny
ia
nd
ny ny
lt
Th ein
a
an
gi
at
rli
Lo er ster
ur
ur
ha
al
be
xo
o
va
em
er ia
la
in
st
e
tin
Be
an tph
nb
b
rm
Sa Sax
An
H
ar
m
Ba
ol
Sa
ur
m e
Br
la
Sa
Ge
-
tte
-H
Ha
es
Pa
an
ig
g
W
ür
xo
d-
ur
w
e-
Br
W
nb
es
in
n-
el
hl
Rh
kle
de
in
Sc
rth
ec
Rh
Ba
No
Federal state
Age-standardized arthroplasty rates per 100,000 inhabitants, 2011 Rate of increase 2005-2011, %
. Fig. 2.7 Age-standardized primary knee arthroplasty rates per 100,000 AOK insurees in 2011, by federal state (patient domic-
ile) and as a national average in Germany, with increases of arthroplasty rates, 2005-2011. (Source: IGES – Lüring et al. 2013)
2.4 · Regional Distribution
25 2
Age-standarized rates of revision
25
per 100,000 persons
20
replacements
15
10
0
y
Ba rg
ria
de n
Br g
Ha en
rg
Po W se
w ni n
ny
Pa alia
Sa ate
nd
ny
ur n
a
al
an
gi
rli
Lo era ter
Th ei
ur
be
bu
g- es
er a
xo
xo
va
nh
em
la
in
t
tin
Be
h
nb
rm
s
m es
ur H
ar
m
an tp
m
ol
Sa
Sa
hl ny-A
la
Ge
tte
-H
es
an
ig
W
ür
xo
d-
w
-
Br
W
Rh ine
Sa
nb
es
n-
el
Rh
kle
de
in
Sc
rth
ec
Ba
No Federal State
. Fig. 2.8 Age-standardized revision knee arthroplasty rates per 100,000 inhabitants, by federal state (patient domicile) and
as the national average in Germany (2011). (Source: IGES – Lüring et al. 2013)
procedures was highest in Bavaria and lowest in ments on the knee per 100,000 inhabitants in 2011,
Berlin. According to the calculations, above-average according to federal states of patient domiciles and
increases in rates in the years 2005 to 2011 can be using the national average as a comparison. Revi-
observed for patients in the federal states of sion replacements were defined as »any renewed
Schleswig-Holstein, Rhineland-Palatinate, Bavaria, surgery on the same knee joint«.
Thuringia, Hamburg, Hesse and Berlin (Lüring The analysis shows that in 2011, the highest
et al. 2013). numbers of revision knee replacements in relation
In the East German regions, the numbers of to the number of inhabitants were performed in
both types of joint replacement procedures were Saxony-Anhalt, Thuringia, Bavaria and Lower-Sax-
generally below the average value (except Thuringia) ony. Patients in Mecklenburg-Western Pomerania
(Schäfer et al. 2013). had the lowest rates of revision.
The numbers correlated with the osteoarthritis . Fig. 2.9 clearly demonstrates that surgery rates
incidence (prevalence) whereby regions with high in the federal states have in part increased consider-
incidences had comparatively higher rates of THAs ably over the past ten years. However, the graph dif-
and TKAs. Further variables that could explain the ferentiates between the rates of increase for the pe-
regional differences in utilization were local num- riods between 2005 and 2008 and between 2008 and
bers of specialist physicians (orthopedists), regional 2011, illustrating that the rise in surgery rates was
socioeconomic status and patients living in urban considerably higher in the earlier period than in the
areas. The lower the regional number of orthope- later period (with the exception of Bremen). From
dists and the higher the socioeconomic status of the 2008, the rates of increase generally tend to be lower
population were in a region, the higher the rate of and even show declines in some federal states
total arthroplasty procedures amongst insurees liv- (Lüring et al. 2013).
ing in that region. Total arthroplasties were per- With this, federal states in the southeast had al-
formed considerably less frequently in urban areas most consistently higher rates of surgery than in the
than in rural areas (Schäfer et al. 2013). northeast. At district level, the differences are even
. Fig. 2.8 shows Lüring et al.«s calculations for more pronounced. With regard to primary replace-
age-standardized surgery rates for revision replacements, the district with the highest rate of replace-
120%
100%
2 80%
Change (%)
60%
40%
20%
0%
-20%
Bavaria
Rhineland-Palatinate
Saxony
Saxony-Anhalt
Baden-Württemberg
Berlin
Brandenburg
Bremen
Hamburg
Saarland
Schleswig-Holstein
Mecklenburg-Western
Lower Saxony
North Rhine-Westphalia
Pomerania
Thuringia
Germany
Hesse
Federal state
2005-2008 2008-2011
. Fig. 2.9 Rates of change in age-standardized revision knee replacement rates, 2005-2008 and 2008-2011. (Source: IGES –
Lüring et al. 2013)
ments had a 2.9-fold higher rate of knee arthroplas- 2.5 Case Number Developments
ty than the district with the lowest rate. With regard
to revisions, the greatest difference between two 2.5.1 Primary Arthroplasty
districts was 4.9-fold (Lüring et al. 2013).
The report discusses manifold reasons for the Since 2007, the absolute number of primary hip and
differences in prevalence. One aspect is that region- knee arthroplasties has been increasing, which is in
al differences in access to hospital care exist. Addi- line with the growing number of older people (risk
tionally, a bias is created in that patient domiciles population) in the population. From 2007 to 2014,
and the place of surgery are not in the same region. the prevalence of primary hip and knee replace-
Additional matters of discussion are revenue struc- ments amongst patients over the age of 70 years (as
ture and that the remuneration system may set determined on 31 December in the respective year)
wrong incentives and consequently also contribute did not increase and remained stable at 1.1 % for
to the regional differences. The authors, however, primary hip replacements (2007 and 2014) and be-
emphasize that the observed increasing case num- tween 0.7 % and 0.6 % (2007 and 2014 respectively)
bers which are not caused by demographic changes for primary knee replacements (. Fig. 2.10) (own
should not solely be attributed to wrong financial calculation, Federal Statistical Office 2014, Federal
incentives (Lüring et al. 2013). On the whole, how- Statistical Office 2015). After an increase in the ab-
ever, the data is insufficient for establishing causal solute number of primary replacements from 2007
relationships (Lüring et al. 2013). to 2011, the number of hip replacements showed a
slight decline from 213,935 cases in 2011 to 210,384
cases in 2013, followed by an increase to 219,325
cases in 2014. In 2009, the number of primary knee
replacements was 159,137, which remained almost
2.5 · Case Number Developments
27 2
Prevalence of primary arthroplasty in the population aged 70 plus
Hip (OPS 5-820.-) Knee (OPS 5-822.-)

1.20%
1.00%
0.80%
0.60%
0.40%
0.20%
0.00%
2007 2008 2009 2010 2011 2012 2013 2014
. Fig. 2.10 Prevalence of primary hip and knee replacements in the population aged 70 plus (2007 to 2014).
(Source: IGES – own calculation, Federal Statistical Office 2014, Federal Statistical Office 2015)
unchanged in 2010 and 2011 and subsequently An evaluation of the case number developments
declined. In 2013, 7.6 % fewer primary knee re- for primary hip and knee replacements in Germany
placements were performed than in 2008 and 10.1 % from 2005 to 2011 showed that the increase in the
fewer primary replacements (absolute number) number of primary hip replacements can largely be
than during the peak year 2009. ascribed to demographic developments. In contrast,
Changes in case numbers over time can be ob- non-demographic factors prevailed with regard to
served when examining the utilization of THA with the increase in primary knee replacements (Weng-
regard to the fixation technique selected. During the ler et al. 2014).
six-year observational period, the number of unce- If case number developments cannot be suffi-
mented total arthroplasties (not including custom- ciently explained by the demographic develop-
made prostheses) rose by 5 % in absolute numbers. ments, this may be an indication of an existing over-
The utilization of cemented procedures decreased supply or shortage of care (Barmer GEK 2010). Be-
in the same period: Cemented and partially cement- sides demographics, other factors and their respec-
ed total replacements declined by 33 % and 9 % re- tive changes (medical, economic, systemic, Section
spectively from 2008 to 2013. Custom-made pros- 2.4) influence the prevalence of utilization of medi-
theses only played a marginal role (. Fig. 2.11). cal services over time. Often, these effects cannot be
Case numbers for the four most common types sufficiently quantified (7 Chapter 6).
of primary knee arthroplasty have been declining
over the past few years (. Fig. 2.12). The decline in
the number of primary arthroplasties is primarily
due to a reduced utilization of cemented total re-
placements.
120,000
2 100,000
80,000
Number
60,000
40,000
20,000
0
2008 2009 2010 2011 2012 2013
Year
Total arthroplasty - uncemented Total arthroplasty - hybrid

Total arthroplasty - cemented Custom-made prothesis (uncemented, cemented, hybrid)
. Fig. 2.11 Absolute number of primary THAs performed, by fixation technique, over time (2008 to 2013). (Source: IGES –
Federal Statistical Office 2014)
120,000
100,000
80,000
Number
60,000
40,000
20,000
0
2008 2009 2010 2011 2012 2013
Year
Total replacement - cemented Total replacement - uncemented Total replacement - hybrid
Partial replacement - cemented Other
. Fig. 2.12 Absolute number of primary knee replacements performed, by fixation technique (2008 to 2013). (Source: IGES
– Federal Statistical Office 2014)
2.5 · Case Number Developments
29 2
Hip OPS 5-821.- Knee OPS 5-823.-

0.25%
Prevalence of revision replacements incl. revisions without
replacement among the population aged 70 plus
0.20%
0.15%
0.10%
0.05%
0.00%
2007 2008 2009 2010 2011 2012 2013 2014
. Fig. 2.13 Prevalence of revision total hip and knee replacements and revisions (without replacements) in the population
aged 70 plus over time (2007 to 2014). (Source: IGES – own calculation, Federal Statistical Office 2014, Federal Statistical
Office 2015)
2.5.2 Revision Total Arthroplasty ments increased by 8.5 % during the same period.
and Revision Surgery This increase can presumably also be ascribed to the
higher number of uncemented arthroplasties. Par-
The absolute number of all revision total arthroplas- tially cemented total arthroplasties and cus-
ties and revisions without replacement performed tom-made prostheses were also revised less fre-
on the hip and knee increased in the period between quently in 2013 than in 2008, with a decrease of
2007 and 2014. Since 2007, the prevalence of hip 24.9 % and 17.0 % respectively. When an uncement-
and knee revision replacement surgery (including ed total arthroplasty is revised, it is usually replaced
revisions without replacements) amongst people in with another uncemented total arthroplasty (33.2 %
the population aged 70 plus (population as deter- of uncemented total replacements) or with a cus-
mined on 31 December of the respective year) has tom-made prosthesis (38.7 %) (. Fig. 2.14).
remained stable at 0.19 % (2007 and 2014) for hip From 2008 to 2013, the most frequent revision
replacement surgery and at 0.10 % for knee replace- knee replacement performed by far was bicondylar
ment surgery (. Fig. 2.13) (own calculation, Federal surface replacement, followed by revisions without
Statistical Office 2014, Federal Statistical Office replacements and unicondylar sledge prosthesis re-
2015). During the observational period from 2008 placements (. Tab. 2.3).
to 2013, the absolute number of revision total hip 37.5 % of all the observed bicondylar surface
replacements in relation to total replacements de- prosthesis replacements are recorded with the syn-
creased by 12.2 %. This is predominantly due to a thetic inlay replacements. This procedure is easier
decrease in the number of cemented THAs which to perform and associated with fewer complications
declined steadily by altogether 32.8 % from 2008 to than replacements of other implant components
2013. In contrast, the number of DRG-coded revi- with bone fixation (Lüring et al. 2013). Inlay re-
sion replacements of uncemented total replace- placement was the most common type of revision
5.000
4.500
2 4.000
3.500
Number
3.000
2.500 Total arthroplasty - uncemented
2.000 Total arthroplasty - cemented
1.500
Hybrid - partially cemented
1.000
500 Custom-made prosthesis
0 Short-stem femoral head
2008 2009 2010 2011 2012 2013 prosthesis
Year
. Fig. 2.14 Absolute number of revision hip replacements performed, by fixation technique, over time (2008 to 2013).
(Source: IGES – Federal Statistical Office 2014)
. Tab. 2.3 Absolute number of revision replacements and revisions (without replacements) performed on the knee
over time (2008 to 2013)
OPS name 2008 2009 2010 2011 2012 2013
5-823.0 Revision (without replacement) 3,497 3,421 3,444 3,518 3,291 3,213
5-823.1 Unicondylar sledge prosthesis replace- 1,971 1,974 2,057 2,297 2,443 2,317
ment
5-823.2 Bicondylar surface prosthesis replace- 10,590 11,049 11,821 11,916 11,614 11,290
ment
5-823.3 Hinged endoprosthesis replacement 1,011 1,068 1,127 1,245 1,255 1,222
5-823.4 Custom-made prosthesis replacement 480 535 529 585 563 533
5-823.5 Patella prosthesis replacement 450 446 535 516 528 439
5-823.b Replacement of an endoprosthesis with 866 811 824 774 840 699
enhanced flexion
5-823.c Replacement of an interpositional non- 184 178 174 132 119 100
anchored implant
5-823.f Replacement of a bicompartmental 0 480 512 461 516 459

prosthesis
5-823.h Replacement of an endoprosthetic joint 0 0 0 63 84 112

without movement function
5-823.x Other 242 225 241 202 194 188
5-823.y Unspecified 31 41 25 19 32 16

2.6 · International Comparison
31 2
. Tab. 2.4 Absolute number of revision bicondylar surface prosthesis replacements, over time (2008 to 2013)
OPS Description 2008 2009 2010 2011 2012 2013
5-823.20 Same prosthesis type 305 247 255 228 241 247
5-823.21 With a different surface prosthesis, 47 53 50 31 32 38

uncemented
5-823.22 With a different surface prosthesis, 1,212 1224 1210 1167 1116 1101
(partially) cemented
5-823.23 With a hinged endoprosthesis, 39 58 56 59 67 68

uncemented
5-823.24 With a hinged endoprosthesis, (partially) 2,093 2275 2474 2557 2494 2362
cemented
5-823.25 With a custom-made prosthesis, 68 71 87 80 84 91

uncemented
5-823.26 With a custom-made prosthesis, 1,765 1938 2126 2110 1927 1763
(partially) cemented
5-823.27 Inlay replacement 3,796 3961 4240 4507 4539 4534
5-823.28 Partial replacement of femoral component 287 255 311 257 284 262
5-823.29 Partial replacement of tibial component 887 875 934 843 774 738
5-823.x Other 91 92 78 77 56 86
performed in 2008. By 2013, the number of inlay found that the rates of increase in surgery are par-
replacements had increased by 19.4 % whereas ticularly pronounced in the under 65 years age
other commonly performed types of surgery group and therefore expect a strong increase in revi-
showed lower rates of increase. In a revision proce- sion total replacements and revision surgery due to
dure, the entire surface prosthesis is usually re- this demographic change (Pabinger and Geissler
moved and replaced with cemented hinged or cus- 2014).
tom-made prostheses unless solely the inlay is being
replaced. Other procedures only play a minor role.
Only 3.2 % of all revision total replacements (i.e. not 2.6 International Comparison
including partial replacement) are performed with-
out using cement (. Tab. 2.4). Over the last decades, the absolute number of hip
Due to the described increase in primary knee and knee arthroplasties has increased in Germany
replacements up until 2009, Lüring et al. (2013) pre- as well as in other European countries and in the
dicted a corresponding increase in revision knee USA (Finkenstädt and Niehaus 2015; Merx et al.
replacements. According to Federal Statistical Of- 2003; Wengler et al. 2014). The demand for joint
fice OPS data, the predicted continuing increase of replacements has increased with the increasing
knee replacements (Haas et al. 2013; Lüring et al. prevalence of age-related underlying diseases and
2013) has not been observed to date (Federal Statis- other risk factors, such as osteoarthritis and osteo-
tical Office 2014). porosis, which are associated with a higher risk of
Pabinger et al. evaluated the utilization of hip femoral neck fractures (. Fig. 2.15, OECD 2014).
joint replacements in connection with economic Reasons for this are related to demographic changes
data from OECD countries from 1990 to 2011. They which are accompanied by an increase of people at
350
300
2 250
Number
200
150
100
50
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Germany France Great Britain

Italy Spain USA
. Fig. 2.15 International numbers of hip replacements per 100,000 inhabitants based on OECD data over time (2002 to
2012) (presentation of prevalence rates without age adjustments). (Source: IGES – OECD 2014)
risk for joint replacements, amongst other things have the oldest populations (United Nations 2013).
(Wengler et al. 2014). A populations« age distribution is relevant with re-
Analyses have demonstrated that after a bias gard to healthcare when the risk of a disease mark-
correction of demographic factors, endoprosthetic edly increases with age as this is accompanied by a
surgery only increased by 3 % between 2005 and higher likelihood of requiring certain therapeutic
2011; without this correction it increased by 11 % measures such as joint replacements.
(Wengler et al. 2014) (Section 2.5.1). A study conducted by the Scientific Institute of
In an international comparison based on OECD the Private Health Insurances (Wissenschaftliches
data, Germany ranks amongst the top positions for Institut der Privaten Krankenversicherung (WIP)),
the number of joint replacements performed (. Fig. evaluated the impact of different ages in populations
2.16 and . Fig. 2.17; OECD 2014). However, the of different countries on the prevalence of 15 differ-
OECD database does not take into account demo- ent types of surgery including hip and knee arthro-
graphic change, current population age structures plasty. The study was based on data published in the
and other factors influencing the utilization of sur- OECD health statistics (Finkenstädt and Niehaus
gery. As hip and knee replacements are strongly age- 2015). In the study, Germany, with a median age of
dependent, statements about country-specific 44.3 years, was the country with the oldest popu-
healthcare situations for these procedures derived lation amongst the countries observed, following
from this data (oversupply or shortage of care) are Japan (44.6) (. Fig. 2.19).
not particularly reliable, even solely because coun- Finkenstädt et al. demonstrated that including
try-specific age structures have not been taken into age structures of the German population in evalua-
consideration. tions has an impact on its international ranking
Age and age structures differ significantly inter- (hip: 32 countries, knee: 21 countries). When age
nationally (. Fig. 2.18). In 2012, around half the structure is taken into account for hip joint replace-
German population was 45.53 years or older (me- ments, Germany ranks 2nd instead of 5th following
dian age), making it the country with the second Switzerland, Norway, Austria and Luxemburg. For
oldest population amongst the OECD countries fol- knee joint replacements, Germany’s position shifts
lowing Japan. Within Europe, Germany and Italy from 5th to 8th (. Fig. 2.20 and . Fig. 2.21; Finken-
33 2
Case numbers per 100,000 inhibitants

0 50 100 150 200 250 300 350
Switzerland 292
Germany 287
Austria 272
Norway 250
Sweden 242
Finland 237
Belgium 237
France 230
Denmark 227
Luxemburg 217
Netherlands 216
USA 204
Slovenia 189
Great Britain 177
Iceland 173
Greece 168
Czech Republic 167
Italy 164
EU27 157
Hungary 137
Croatia 135
Lithuania 127
Ireland 118
Latvia 105
Spain 102
Slovakia 95
Estonia 92
Portugal 88
Poland 78
Malta 77
Romania 53
Cyprus 15
. Fig. 2.16 Numbers of hip joint replacements per 100,000 inhabitants in OECD countries and the USA, 2012 (or latest data)
(rates without age adjustments). (Source: IGES – OECD 2014)
städt and Niehaus 2015, 2013). A potential indicator rate of surgery with a comparatively low level of re-
of the status of healthcare that is currently subject to gional variance permits the assumption that the
discussion is a factor derived from the lowest and surgery indications and the standard of care have
the highest rates of surgery (Niethard et al. 2013). generally been accepted (Niethard et al. 2015).
Based on the OECD data, this factor is 2 for hip ar- Besides demographic factors, social, economic,
throplasty in Germany (Finkenstädt and Niehaus structural and medical aspects (Merx et al. 2003;
2015) and 4 for hip arthroplasty in the USA (Fisher Pabinger and Geissler 2014) as well as specific
et al. 2010). Knee arthroplasties in Germany differ characteristics of the individual national healthcare
regionally by a factor of 3.2 (Finkenstädt and Nie- systems, such as different coding systems and differ-
haus 2015) and in the USA by a factor of 3.8 (Fisher ences in data recording, have an impact on the uti-
et al. 2010). For hip operations in particular, a high lization of medical services and/or how they are
Case numbers per 100,000 inhibatants

0 50 100 150 200 250
2 USA 226
Austria 217
Germany 206
Finland 206
Belgium 184
4
Switzerland 176
Luxemburg 173
Denmark 171
Malta 162
Sweden 140
France 139
Great Britain 139
Norway 132
Netherlands 118
Czech Republic 116
EU24 113
Slovenia 112
Spain 105
Italy 104
Iceland 90
Lithuania 68
Portugal 62
Hungary 59
Cyprus 53
Croatia 48
Ireland 47
Latvia 46
Poland 24
Romania 17
. Fig. 2.17 Numbers of knee joint replacements per 100,000 inhabitants in the OECD countries and the USA, 2012 (or latest
data) (presentation of prevalence rates without age adjustment). (Source: IGES – OECD 2014)
35 2
Percentage (%)
0 5 10 15 20 25
Japan 23.0
Germany 20.6
Italy 20.3
Greece 19.1
Portugal 18.5
Sweden 18.3
Austria 17.7
Switzerland 17.4
Estonia 17.4
Finland 17.3
Belgium 17.1
Spain 17.0
France 16.9
Hungary 16.7
Denmark 16.6
Slovenia 16.5
Great Britain 16.0
Netherlands 15.4
Czech Republic 15.4
Norway 15.0
Canada 14.2
Luxemburg 13.9
Australia 13.6
Poland 13.4
USA 13.1
New Zealand 13.0
Slovakia 12.5
Iceland 12.1
Ireland 11.3
Korea 11.0
Israel 9.9
Chile 9.0
Turkey 7.1
Mexico 6.2
. Fig. 2.18 Percentage of people aged ≥ 65 years in the total population, 2010. (Source: IGES – OECD 2014)
depicted. Some countries, for example, only report This clearly illustrates that data from interna-
total hip arthroplasty (e.g. Estonia) and others in- tional comparisons should be interpreted with cau-
clude partial hip replacements (OECD 2014). In tion. Evaluations of national healthcare statuses
some countries, data from private hospitals are not based on international comparisons or OECD data
included in the statistics (for example, Ireland) or rankings are not reliable without making appropri-
only partially included (for example, Spain) ate adjustments.
(Finkenstädt and Niehaus 2015; OECD 2014). The
utilization of joint replacement procedures is also
related to the economic performance and the per
capita healthcare expenditure of a country (Pabin-
ger and Geissler 2014).
Median age in years

0 10 20 30 40 50
2 Japan 44.6
Germany 44.3
Italy 43.7
Austria 42.6
Finland 42.3
Greece 42.2
Slovenia 42.1
Belgium 42
Sweden 41.7
Switzerland 41.3
Netherlands 40.8
Canada 40.7
Denmark 40.7
Czech Republic 40.4
Estonia 40.2
Spain 40.1
Hungary 40
Great Britain 39.8
France 39.7
Norway 39.7
Portugal 39.7
Luxemburg 39.3
Poland 38.2
Korea 37.9
Australia 37.5
Slovakia 37.3
New Zealand 36.8
USA 36.8
Iceland 35.4
Ireland 34.5
Chile 31.7
Israel 29.3
Turkey 28.1
Mexico 26.7
. Fig. 2.19 Median ages in OECD countries, 2010. (Source: IGES – OECD 2014, Finkenstädt and Niehaus 2015)
37 2
Deviation (%)
-110% -90% -70% -50% -30% -10% 10% 30%
Switzerland 24.2%
Norway 12.0%
Austria 7.5%
Luxemburg 2.8%
Germany 0.0%
USA -0.6%
Sweden -6.1%
Denmark -6.3%
Belgium -6.8%
Iseland -8.3%
France -8.7%
Netherlands -9.0%
Finland -9.4%
Australia -16.2%
Slovenia -24.5%
Great Britain -26.2%
New Zealand -27.5%
Czech Republic -28.9%
Ireland -32.9%
Canada -41.0%
Italy -43.0%
Hungary -44.7%
Slovakia -52.5%
Spain -59.1%
-59.1%
Turkey -62.7%
Israel -63.6%
Estonia -64.2%
Poland -64.7%
Portugal -66.0%
Chile -74.7%
Korea -89.6%
Mexico -92.6%
. Fig. 2.20 Case number deviations for hip replacements in Germany following age-standardization. (Source: IGES – OECD
2014, Finkenstädt and Niehaus 2015)
Deviation (%)
-60% -40% -20% 0% 20% 40% 60%
2
USA 48.0%
Switzerland 18.5%
Australia 18.0%
Austria 18.0%
Luxemburg 12.1%
Finland 5.6%
Belgium 0.6%
Germany 0.0%
Canada -2.4%
Denmark --5.5%
5.5%
Great Britain -20.1%
Korea -20.7%
France --22.3%
22.3%
Sweden -25.0%
Turkey -28.0%
Netherlands -33.6%
Iceland -34.4%
Czech Republic -35.5%
New Zealand -35.6%
Slovenia -39.9%
Spain -40.8%
. Fig. 2.21 Case number deviations for knee replacements in Germany following age-standardization. (Source: IGES – OECD
2014, Finkenstädt and Niehaus 2015)
References
39 2
References Rabenberg M (2013): Arthrose. Gesundheitsberichterstattung
des Bundes. Heft 54. Berlin: Robert Koch-Institut, Statis-
BARMER GEK Report Krankenhaus 2010. Schwerpunktthema: tisches Bundesamt. ISBN: 978-3-89606-219-2.
Trends in der Endoprothetik des Hüft- und Kniegelenks. Schäfer T, Pritzkuleit R, Jeszenszky C, Malzahn J, Maier W,
Schriftenreihe zur Gesundheitsanalyse, Band 3. St. Augus- Gunther KP & Niethard F (2013): Trends and geographical
tin: Asgard-Verlag. ISBN: 978-537-44103-4. variation of primary hip and knee joint replacement in
Braun B (2013): Knie- und Hüft-(Total-) Endoprothesen 2008 Germany. Osteoarthritis and Cartilage 21(2), 279-288.
bis 2012 – hkk Gesundheitsreport. Bremen: hkk Erste DOI: 10.1016/j.joca.2012.11.006.
Gesundheit. https://www.hkk.de/fileadmin/doc/bro- Statistisches Bundesamt (2014): Gesundheit. Fallpauscha-
schueren_flyer/sonstiges/20131129_hkk_Gesundheits- len-bezogene Krankenhausstatistik (DRG-Statistik)
report_Knie-Hueft-Tep.pdf. [accessed: 03 November Operationen und Prozeduren der vollstationären Patien-
2015]. tinnen und Patienten in Krankenhäusern – Ausführliche
DIMDI (2015): Operationen an den Bewegungsorganen Darstellung – 2013. Wiesbaden.
(5-78...5-86). OPS Version 2015. Latest update: 17 October Statistisches Bundesamt (2015): https://www.destatis.de/DE/
2014. Köln: Deutsches Institut für Medizinische Doku- ZahlenFakten/GesellschaftStaat/Bevoelkerung/Bevoel-
mentation und Information. https://www.dimdi.de/ kerung.html [accessed: 31 May 2015].
static/de/klassi/ops/kodesuche/ onlinefassungen/ United Nations (2013): World Population Prospects: The 2012
opshtml2015/block-5-78...5-86.htm [accessed: 23 June Revision, Highlights and Advance Tables. Working Paper
2015]. No. ESA/P/WP.228. 2015/12/29/. United Nations, Depart-
Finkenstädt V & Niehaus F (2013): Rationierung und Ver- ment of Economic and Social Affairs, Population Division.
sorgungsunterschiede in Gesundheitssystemen. http://esa.un.org/unpd/wpp/Publications/Files/
Ein internationaler Überblick. Köln: Wissenschaftliches WPP2012_HIGHLIGHTS.pdf [accessed: 04 November
Institut der PKV. ISBN: 978-3-9813569-4-6. 2015].
Finkenstädt V & Niehaus F (2015): Die Aussagekraft von Wengler A, Nimptsch U & Mansky T (2014): Hip and knee
Länderrankings im Gesundheitsbereich. Köln: Wissen- replacement in Germany and the USA: analysis of indi-
schaftliches Institut der PKV. ISBN: 978-3-9813569-7-7. vidual inpatient data from German and US hospitals for
Fisher E, Bell J, Tomek I, Esty A & Goodman D (2010): Trends the years 2005 to 2011. Deutsches Arzteblatt international
and regional variation in hip, knee, and shoulder replace- 111(23-24), 407-416. DOI: 10.3238/arztebl.2014.0407.
ment. http://www.dartmouthatlas.org/downloads/
reports/Joint_Replacement_0410.pdf [accessed: 06 June
2015].
Haas H, Grifka J, Günther KP, Heller KD, Niethard FU, Wind-
hagen H, Ebner M & Mittelmeier W (2013): EndoCert.
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zentren in Deutschland. Stuttgart: Georg Thieme Verlag
KG. ISBN: 978-3-13-174081-6.
Lüring C, Niethard FU, Günther KP, Schäfer T, Hannemann F,
Pritzkuleit R, Meier W & Kirschner S (2013): Regionale
Unterschiede und deren Einflussfaktoren – Schwerpunkt
Knieendoprothetik. Report der Deutschen Gesellschaft
für Orthopädie und Orthopädische Chirurgie. Bertels-
mann Stiftung.
Merx H, Dreinhofer K, Schrader P, Sturmer T, Puhl W, Gunther
KP & Brenner H (2003): International variation in hip
replacement rates. Annals of the rheumatic diseases
62(3), 222-226. ISSN: 0003-4967.
Niethard F, Mahlzahn J, Schäfer T (2013): Endoprothetik und
Wirbelsäuleneingriffe - Uneinheitliches Versorgungs-
geschehen. Deutsches Ärzteblatt 110(27-28), 1362-1365.
OECD (2014): Health at a Glance: Europe 2014. OECD Publish-
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Pabinger C & Geissler A (2014): Utilization rates of hip arthro-
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joca.2014.04.009.
41 3
Status of Healthcare
Michael Weißer, Ute Zerwes, Simon Krupka, Tonio Schönfelder, Silvia Klein,
Hans-Holger Bleß
3.1 Basis of the Study – 42
3.2 Ambulatory Care – 43
3.3 Inpatient Care – 45

3.3.1 Primary Arthroplasty – 45
3.3.2 Revision Total Arthroplasty – 53
3.3.3 Accompanying Measures during Inpatient Stay – 59
3.3.4 Complications – 61
3.4 Rehabilitation – 65
3.4.1 Therapy Recommendations and Standards – 66
3.4.2 Provision of Care – 67
3.4.3 Utilization of Services – 67
3.4.4 Implementation of Therapeutic Measures – 69
3.4.5 Effectiveness of Subsequent Rehabilitation – 71
3.4.6 Post-Rehabilitation Care – 71
3.4.7 Challenges – 71
3.4.8 Outlook – 72
3.5 Quality Aspects of Care – 73

3.5.1 Materials – 73
3.5.2 Surgery and Perioperative Management – 73
3.5.3 Surgeon – 76
3.5.4 Hospital – 76
3.5.5 Patient – 76
3.5.6 Post-Discharge Treatment Outcomes – 78
3.5.7 Indications – 81
3.5.8 Regional Differences – 81
References – 83

DOI 10.1007/978-3-662-55918-5_3
42 Chapter 3 · Status of Healthcare
Summary shorter lengths of hospital stays, patients in rehabili-

Approximately half of all hospitals in Germany per- tation clinics have greater care requirements. Older
form primary hip and knee arthroplasty. Sympto- multimorbid patients in particular, require targeted
matic osteoarthritis is the cause of 80 % of primary geriatric, interdisciplinary care. Surveys carried out
hip replacements and 96 % of primary knee replace- on statutory health insurees have indicated that
ments. In accordance with mandatory external quali- most patients show a significant reduction in symp-
3 ty assurance measures for hospitals, an increase in toms after surgery and that this is still the case even
the documentation of appropriate indications has 5 years after surgery. In addition, a large majority of
been observed for a growing proportion of patients patients are satisfied with the procedure. These ef-
over the last few years and reached 96 % for both fects are more pronounced in hip surgery patients
types of surgery in 2014. A limiting factor, however, than in patients who have undergone knee replace-
is that some of the relevant indication criteria do not ments. The vast majority of patients return to work
yet exist in a standardized or evidence-based format. following the procedure.
Hip and knee replacements are amongst the most
commonly performed inpatient procedures. Patients Quality of care cannot be ascribed to an implant
who undergo primary hip or knee replacement alone as a number of other factors need to be taken
account for approximately 2 % of all full-time inpa- into consideration. To a greater degree, the entire
tients. Over the past years, the length of hospital stay ambulatory medical care chain, including medical
for arthroplasty patients has been declining continu- care before admission into hospital, acute care, fol-
ously with a greater decline relative to the average low-up care and rehabilitation, are crucial to the
length of stay for all other types of hospital treat- quality of care. Nationwide quality initiatives in
ments. In 2014, the average length of stay was ap- Germany aim at improving the transparency and
proximately 11.8 days and 10.6 days for total hip and analysis of medical services as well as improving the
for total knee arthroplasty respectively. Surgical com- quality in the provision of care. The following chap-
plications during inpatient stays for primary arthro- ter describes the chain of care and quality aspects of
plasty have been declining for years and are now in care.
the lower single-digit percentage range. Routine
statutory health insurance data between 2005 and
2006 show that that 3.5 % of primary hip arthroplasty 3.1 Basis of the Study
patients and 3.8 % of primary knee arthroplasty
patients underwent premature revision total replace- Illustrations of the use and quality aspects of re-
ment within the first 2 years after surgery. The risk of placement surgery in Germany are founded on nu-
complications from endoprosthetic surgery depends merous expert reviews and reports, as well as on
on numerous factors. Influencing factors include the different data sources. The expert reviews refer to
implant itself and the type surgery performed three data sources:
(including the surgeon’s experience, surgical tech- 1. Data based on § 21 of the German Hospital Re-
niques, the duration of surgery, etc.), the patient’s muneration Law.
medical characteristics (concomitant diseases, com- 2. Routine data from individual statutory health
pliance, etc.) as well as the type of rehabilitation care insurances.
and ambulatory follow-up care. To date, no relevant 3. Routine data on the prevalence of all reported
data on service lives and influencing factors have procedures according to the German proce-
been systematically collected in Germany. However, dure classification »Operationen- und Proze-
this is expected to change thanks to the German durenschlüssel (OPS)« compiled by the Federal
arthroplasty registry »Endoprothesenregister Statistical Office of Germany.
Deutschland« which was established in 2011. Reha-
bilitation treatment should start soon after surgery On the whole, different primary and secondary data
and in the majority of cases this is commenced a few studies based on the volume and quality of care exist
days after discharge from hospital. However, due to (. Tab. 3.1).
3.2 · Ambulatory Care
43 3
. Tab. 3.1 Overview of selected publications, focusing on case numbers and database analysis of hip and knee
arthroplasty
Author Publication Analysis topic Sample Period Focus
AQUA Bundesaus- Hip and knee Accounting data acc. to 2009–2014 Quality indicators
Institute wertungen endoprostheses § 301 Volume V of the Ger-
man Social Security Code
AQUA Hüftendopro- Hip endo- Settlement data acc. to 2004–2010 Development of

Institute thesenversorgung prostheses § 301 Volume V German quality indicators
Abschlussbericht Social Security Code
AQUA Knieendoprothe- Knee endo- Accounting data acc. to 2004–2010 Development of

Institute senversorgung prostheses § 301 Volume V German quality indicators
Abschlussbericht Social Security Code
Barmer Barmer GEK Kran- Hip and knee SHI routine data, patient 2003–2009 Case number
GEK kenhaus-Report endoprostheses survey approx. 8 million development
2010 patients
Braun hkk-Gesund- Hip and knee hkk routine data; Federal 2008– 2012/ Development of
heitsreport 2013 endoprostheses Statistical Office data 2006–2011 revision surgery
over time; services
associated with
joint replacements
Haas EndoCert®-Zertifi- Hip and knee Federal Statistical Office 2004–2010 Factors influenc-
et al. zierung von endo- endoprostheses data ing the quality of
prothetischen care
Zentren in
Deutschland 2013
Lüring Report der Knee endopros- AOK routine data; approx. 2005–2011 Regional differ-
et al. DGOOC/Bertels- theses 25 million insurees ences
mann Stiftung
2013
Raben- Robert Koch Hip and knee Federal Statistical Office 2010 Endoprostheses
berg Institut, Arthrose endoprostheses data (in addition to GEK prevalence (case
2013 and AOK) number develop-
ment)
Schäfer Krankenhaus Hip and knee AOK routine data; approx. 2005–2009 Regional differ-
et al. Report 2012 endoprostheses 25 million insurees ences
Source: IGES – own presentation
3.2 Ambulatory Care therapists and occupational therapists are also in-
volved.
Different groups of specialist physicians are The indication for joint replacement surgery is
involved in the ambulatory care of patients who made by specialists in orthopedics and trauma sur-
have undergone hip and knee replacements. The gery, based on clinical and radiological criteria that
chain of care comprises primary care physicians take into consideration the related benefits and risks
(general practitioners and internists working as (Section 1.2).
primary care physicians), orthopedic and trauma Usually, patients suffering from arthrosis have
surgery specialists in as well as radiologists. Physio- been in ambulatory medical care for years before a
An analysis of routine data from the SHI Han-

Physiotherapy Physical therapy delskrankenkasse (hkk) found that ambulatory ser-
e. g. (conventional) e. g. massages, cold and vices prior to joint replacement surgery accounted
movement therapy heat therapy for around two thirds of all ambulatory services (i.e.
pre- and postoperative, for 6 months each). This was
Occupational therapy Orthopedic aids the case for both total hip and total knee arthroplas-
3 e. g. information on e. g. walking aids, ty (Braun 2013).
appropriate joint orthopedic show Owing to the remuneration and visiting con-
protection finishings/insoles
sultant system, the orthopedic specialist who treat-
ed the patient in ambulatory care and who made the
. Fig. 3.1 Factors of conservative, non-drug treatment of recommendation for surgical inpatient care has the
osteoarthritis. (Source: IGES – Claes et al. 2012 and Wirtz
option of performing the surgery.
2011)
Visiting consultants with admission privileges
are »(...) statutory health insurance physicians who
hip or knee replacement becomes necessary. Con- are not employed by the hospital and are entitled to
servative arthrosis therapy comprises the use of treat their patients in hospital as inpatients or day-
therapeutic products and medical aids (. Fig. 3.1) as care patients using the services, facilities and mate-
well as pain management drugs (AWMF 2009a, b). rials available without receiving any remuneration
In many cases, joint replacement constitutes the from the hospital (§ 121 [2] Volume V German So-
primary treatment of femoral neck fractures. In cial Security Code). Fee-based physicians are also
contrast to the case of osteoarthritis, surgical care not employed by the hospital but make their servic-
here is urgent (acute), i.e. should take place shortly es available to the hospital for a fee.
after the event as otherwise an imminent and con- The number of cases of hip joint replacements
siderable deterioration of the patient’s state of health and revisions (including partial replacements) and
is to be expected (Claes et al. 2012). knee joint replacements in visiting consultant wards
. Tab. 3.2 shows the use of ambulatory treat- are declining (. Fig. 3.2).
ment of statutory health insurance patients prior to
joint replacement for the period 2003 to 2009. Ac-
cording to patient reports, e.g. 74 to 85 % of patients
who received a hip or knee joint replacement had
taken medication for joint pain prior to surgery
(Barmer GEK 2010).
. Tab. 3.2 Annual patient use of ambulatory treatment services prior to joint replacement (questionnaire survey)
Joint Hip Knee
Population Barmer GEK insurees
Evaluation period 2003 (n = 555) 2009 (n = 1,080) 2003 (n = 301) 2009 (n = 940)
Pain management 76.4% 74.1% 82.4% 85.0%

with drugs
Physiotherapy 50.6% 46.4% 39.5% 40.2%
Massage 19.8% 14.3% 14.6% 12.3%
Physical therapy 20.0% 13.4% 17.6% 9.3%
Source: IGES – Barmer GEK 2010

3.3 · Inpatient Care
45 3
12,000
consultant wards
10,000
8,000
Case numbers on visiting
6,000

4,000
2,000
0
2006 2007 2008 2009 2010 2011 2012 2013
Year
DRG I44B DRG I47B DRG I47A
Knee arthroplasty without Hip arthroplasty without Hip arthroplasty with
very serious comorbidity or complicang surgery complicang surgery
complicaons (CC)
. Fig. 3.2 Number of cases of the most common DRGs for hip and knee joint replacements in visiting consultant wards,
patients with normal length of stays, 2006–2013. (Source: IGES – InEK 2015)
3.3 Inpatient Care arthroplasty. It must be noted, however, that there

was a decline in the overall number of hospitals as
3.3.1 Primary Arthroplasty well (. Tab. 3.3).
Between 2009 and 2010, the number of hospitals
Capacity of care, proximity to domicile and that performed primary TKA increased slightly, af-
waiting times ter which it remained relatively steady until 2013
Hip and knee joint replacements rank amongst the (AQUA-Institut 2012c, 2013c, 2014c, 2015d, 2010c,
most common procedures performed in the inpa- 2014c). The percentage of centers performing endo-
tient care sector. According to 2013 DRG statistics, prosthetic surgery in relation to the total number of
out of a total of 18,531,819 patients in inpatient care, hospitals increased from 49.0 % to 51.7 %.
approximately 2% of these underwent primary hip In 2014, the method used to count hospitals for
and knee joint replacements (Destatis 2014). inpatient quality care assurance purposes changed,
The AQUA Institute conducted a national »Ex- whereby additional locations of each hospital were
ternal Quality Assurance for Inpatient Care« assess- also included in the count. Hence, as of 2014, the
ment for elective primary total hip arthroplasty number of recorded hospitals performing THA re-
(THA), recorded 1,075 hospitals performing prima- placement surgery increased to 1,229 hospitals
ry THA (AQUA-Institut 2013a). 1,031 hospitals (AQUA-Institut 2015b) and to 1,160 hospitals per-
performed primary total knee arthroplasty (TKA) forming TKA (AQUA-Institut 2015d).
(AQUA-Institut 2013c). In total, more than half of A study evaluated the distance patients traveled
all German hospitals performed primary hip or to hospitals for hip joint replacements (OPS 5-820,
knee joint replacement surgery in 2013 (Destatis including partial prostheses), for both elective sur-
2015a). Between 2009 and 2013, there was a decline gery and emergency treatment, based on data from
in the number of hospitals that performed total hip hospital cases of 71,870 AOK insurees in 2006 (Fried-
. Tab. 3.3 Total number of hospitals in Germany, centers that performed hip and knee joint replacements, and per-
centage of hospitals performing endoprosthetic surgery 2009–2014
2009 2010 2011 2012 2013
Number of hospitals in Germany1) 2,084 2,064 2,045 2,017 1,996

3 Number of hospitals that performed primary THA2) 1,156 1,149 1,112 1,091 1,075
Proportion of hospitals that perform THA out of all 55.5% 55.7% 54.4% 54.1% 53.9%
hospitals in Germany1), 2)
Number of hospitals that performed primary TKA3) 1,022 1,036 1,030 1,033 1,031
Proportion of hospitals that perform TKA out of all 49.0% 50.2% 50.4% 51.2% 51.7%
hospitals in Germany1), 3)
Source: IGES calculations – 1) Destatis 2015a, 2) AQUA-Institut 2010b, 2011b, 2012a, 2013a, 2014a, 3) 2010c, 2011c,
2012c, 2013c, 2014c
rich and Beivers 2009). The average distance to the between 1 month and 12 months. In Switzerland,
service-providing hospitals was 17.6 kilometers the waiting period was between less than 1 month
(elective surgery 19.7 km, emergency procedures and 6 months, and in Great Britain approximately 8
12.4 km). A total of 41% of the patients had the pro- months (Effenberger et al. 2008).
cedure performed in the hospital closest to their More up-to-date data on waiting times, provi-
domicile (elective surgery 34.3 %, emergency pro- sion of care close to the patient’s domicile and wait-
cedures 56.8 %). Older patients in particular were ing times specifically for patients with indications
treated close to their homes and had the lowest av- for knee replacements could not be sourced. Over-
erage travel distances. For elective surgery, the pa- all, the decision with regard to waiting times for hip
tient travel distances in rural areas were the longest. or knee joint replacements must take into consider-
Moreover, patients in urban areas often did not ation minimizing the time the patient has to live
choose the nearest hospital. On the whole, the study with diminished quality of life and avoiding revision
results indicate that hospital care close to the domi- surgery over their lifetime and/or an as long as pos-
cile of the patient becomes more important with sible service life of the endoprosthesis. Additionally,
increasing age. Hospitals located further away are study results suggest that a realistic waiting period
particularly chosen for specific elective surgery. as well as regular and transparent communication
These are usually smaller establishments specialized during the waiting period have a positive influence
in performing specific procedures (Friedrich and on patient satisfaction with regard to waiting times
Beivers 2009). (Conner-Spady 2011).
Waiting times for surgery are not systematically
recorded in Germany (Finkenstädt and Niehaus jIndication (underlying disease)
2013). A telephone survey conducted in 2010 by the Symptomatic osteoarthritis constitutes the most
American foundation »Commonwealth Fund« common underlying disease in patients who are ad-
found that patients in Germany have a waiting time mitted to hospital for hip or knee joint replace-
of 4 months at most for elective surgery (of any ments. A study based on routine data from a statu-
kind). 78 % of those surveyed had this surgery per- tory health insurance fund found that osteoarthritis
formed within one month (The Commonwealth of the hip joint accounted for 80.1% of all proce-
Fund 2010). dures and osteoarthritis of the knee joint accounted
Overviews of health economic data show broad for 96 % (. Tab. 3.4). Femoral neck fractures consti-
spans of waiting times for hip joint replacements. In tuted 12.5 % of all indications for hip joint replace-
2008, the waiting time in Germany and Austria was ments (Barmer GEK 2010).
47 3
. Tab. 3.4 Frequency of treatment diagnosis for hip . Tab. 3.5 Examples of common concomitant dis-
or knee joint replacements (primary replacement) eases of hip and knee joint replacement patients
amongst statutory health insurees (Barmer GEK, (n = 149,717)
2007–2009)
Concomitant disease Prevalence
Diagnosis Description Percentage
Diabetes mellitus 16.0%
Hip
Heart failure 7.7%
M16 Osteoarthritis of hip 80.1%
Chronic renal failure 5.9%
S72 Fracture of femur 12.5%
COPD 5.2%
M87 Osteonecrosis 3.1%
Asthma 1.9%
T84 Complications of inter- 2.1%
Arteriosclerosis 1.7%
nal orthopedic pros-
thetic devices Malignant neoplasms 1.0%
M Other diseases of the 1.0% Acute renal failure 0.4%
musculoskeletal system
Barmer GEK (2010), Initial Hip Knee
C Malignant neoplasms 0.5% survey 2009 (n = 1,120) (n = 1,033)
Other diagnoses 0.6% Diabetes mellitus 10% 12.7%
Knee Cancer excluding leukemia 9% 8.6%
M17 Osteoarthritis of knee 96.0% COPD 7.7% 8.7%
T84 Complications of inter- 2.0% Stomach ulcer 7.6% 9.9%
nal orthopedic pros-
thetic devices Heart failure 7.1% 10.2%
M Other diseases of the 1.6% Source: IGES – Barmer GEK 2010; Jeschke and Günster
musculoskeletal system 2014
Other diagnoses 0.3%
The studies showed that patients with hip or knee
replacements suffered from diseases such as diabe-
tes mellitus and heart failure, which are particularly
common at an older age (RKE 2015).
However, with the patients« increasing age, an In the survey for TKA care documented in the
increase in the percentage of hip joint replacements »2010 Barmer GEK Hospital Report« (Barmer GEK
due to fractures can be observed. In the 65 to 74 Krankenhaus-Report 2010), 46.5 % (initial survey
years age group, femoral neck fractures were the 2009) and 56.6 % (follow-up survey 2009) of pa-
surgical indication for hip joint replacement in 8.6% tients reported suffering from at least one concom-
of cases and in the 75 to 84 years age group femoral itant disease. Amongst the patients with THA,
neck fractures accounted for 26.8%. In addition, it 39.8 % (initial survey 2009) and 50.2 % (follow-up
was found that 66.1 % of those receiving hip joint survey 2009) suffered from at least one concomitant
replacements due to femoral neck fractures were disease. The prevalence of individual concomitant
over the age of 85 (Barmer GEK 2010) (. Fig. 3.3). diseases was comparable for patients with THA and
TKA (Barmer GEK 2010).
jComorbidity and perioperative risk Each surgical procedure involves certain risks
The most common concomitant diseases of patients that are not only related to the operation itself but also
undergoing hip or knee joint replacement were de- the required anesthesia. These added risks prevail for
termined by several studies based on administrative the duration of the surgery as well as for a certain
data from statutory health insurances (. Tab. 3.5). period subsequent to the surgery (perioperative com-
70
60
50
Percentage (%)
40
3
30
20
10
0
65−74 75−84 85+
Age group (Year)
. Fig. 3.3 Age distribution of femoral neck fractures (S72) treated with hip joint replacements (Source: IGES –
Barmer GEK 2010)
plication risk). Amongst other things, surgical risk tion (ASA classification system) has been used to
depends on the extent of the surgery, the expected estimate patients« perioperative risks for a long
duration, anatomical conditions, blood loss and pa- time. The treating anesthetist documents the ASA
tient positioning. Anesthetic risk is described as the classification during premedication, based on the
risk associated with the anesthetic method applied. American Society of Anesthesiology (ASA) classifi-
For elective surgery in particular, the benefits must be cation requirements. The ASA classification groups
carefully weighed against the risks of the surgery and patients into up to six classes (7 Chapter 1). Pa-
anesthesia (Claes et al. 2012; Wirtz 2011). tients« ASA classifications were also included in the
Furthermore, the comorbidity of patients who external quality assurance conducted by the AQUA
undergo endoprosthetic surgery constitutes a signi- Institute (AQUA-Institut 2015d). The majority of
ficant influencing factor for the overall risk associ- patients were assigned to ASA class 2 (with mild
ated with the procedure (Singh 2013, Lau 2016). systemic disease) or class 3 (with severe systemic
The American Society of Anesthesiology classifica- disease and functional limitations) (. Tab. 3.6).
. Tab. 3.6 ASA classification for primary THA (n = 160,559) and TKA (n = 130,802) (2014) documented for External
Quality Assurance for Inpatient Care
ASA Description THA classification [%] TKA classification [%]
ASA 1 A normal, healthy patient 8.4 5.5
ASA 2 A patient with mild systemic disease 61.3 61.1
ASA 3 A patient with severe systemic disease and functional 29.8 33.0
limitations
ASA 4 A patient with severe systemic disease that is a 0.5 0.4

constant threat to life
ASA 5 A moribund patient 0.01 0.01
ASA = American Society of Anesthesiology

Source: IGES – AQUA-Institut 2015b and AQUA-Institut 2015d
49 3
This seems plausible in view of the fact that only underlying diseases were observed. 21.4% of pa-
healthy patients are classified into ASA 1 and patients with a femoral fracture died within one year
tients who undergo hip or knee joint replacement after discharge from hospital. In contrast, only 0.7 %
already have an underlying symptomatic disease. of the patients with osteoarthritis of the hip died
Over the period 2009 to 2014, the distribution of the within one year after discharge from hospital (Bar-
documented patient population within the ASA mer GEK 2010).
classifications remained almost constant (AQ- An inpatient mortality of 0.1% was observed in
UA-Institut 2010b, c, 2011b, c, 2012a, c, 2013a, c, patients who had undergone knee joint replace-
2014a, c, 2015b, d). ments. 1.3 % of the patients died within one year
A limiting factor, however, is that the ASA clas- after discharge from hospital. In individual sub pop-
sification has been subject to strong criticism for ulations, hardly any differences could be identified
several decades. One particular point of criticism is with regard to mortality (Barmer GEK 2010).
the lack of distinct criteria for classifying patients
into the ASA categories. This especially affects ASA jSurgical procedures
classes 2 and 3, to which most patients are assigned. Jaschinski et al. (2014) conducted a nationwide sur-
Study results suggest that the allocation to a given vey in Germany on elective total hip and knee
ASA class is often undertaken subjectively and phy- arthroplasty based on data from hospitals that re-
sicians’ evaluations often differ in this respect (Shah corded a minimum of 100 primary operations in
et al. 2013). In addition, the ASA classification is their 2010 quality reports. Chief physicians from
hardly relevant to later patient pathways. 694 orthopedics/trauma surgery departments and
In contrast, specific comorbidities or clinical the respective anesthetists were contacted in writing
parameters, such as blood sugar values, tachypnea with the aim of gaining insight into treatment pro-
and lack of sinus rhythm, are of much higher impor- cesses and medical approaches as well as obtaining
tance for clinical decision-making and periopera- suggestions for optimizing care. 31.8 % of the hos-
tive risk assessment. With regard to the long-term pitals contacted responded. 303 questionnaires
complication risks and/or the long-term success of from 221 hospitals were statistically evaluated,
treatment following endoprosthetic surgery, other based on which the authors concluded that the
specific concomitant diseases seem to have a signif- study was representative (Jaschinski et al. 2014).
icant influence. For example, it was demonstrated 50% of the surgery was performed by the chief
that obesity, diabetes mellitus and hyperglycemia physicians, 40% by senior physicians and approxi-
are associated with an increased risk of joint inflam- mately 10% by other physicians in senior positions
mation during the first post-operative year (Jämsen (heads of division, lead physicians, assistant physi-
et al. 2012). cians) on the day of admission or no later than one
On the whole, studies suggest that using scores day after admission (Jaschinski et al. 2014). Other
which enable differentiated and objective assess- study results show that the duration of surgery was
ments of a patient’s general comorbidity, such as the on average 75 minutes (hip) or 85 minutes (knee)
Charlson Comorbidity Score (Charlson et al. 1987), (AQUA-Institut 2012a, c, 2013a, c, 2014a, c, 2010b,
enable good predictions of postoperative mortality c, 2011b, c). Postoperative pain management and
and morbidity (Singh et al. 2013, Lau et al. 2016). perioperative antibiotic prophylaxis were docu-
In addition, analyses of mortality after endo- mented for almost all patients (. Tab. 3.7; Jaschinski
prosthetic surgery do exist. Based on Barmer GEK et al. 2014; AQUA-Institut 2012a, c, 2013a, c, 2014a,
routine data, patients who received primary joint c, 2010b, c, 2011b, c).
replacements were identified and analyzed with re-
gard to cases of death (Barmer GEK 2010). The jLength of stay
study shows that 1.0 % of patients who underwent a According to a nationwide analysis conducted in
hip joint replacement died during the inpatient stay. Germany by the AQUA Institute, the length of stay
4.3 % of the patients died within 365 days after dis- and the length of postoperative stay for primary
charge from hospital, but distinct differences in the THA and TKA surgery have been declining for
2013, the length of stay for THA and TKA showed a

. Tab. 3.7 Description of inpatient care for THA and
TKA
greater decline than the average length of stay for all
other types of hospital treatment in Germany
Description THA (per- TKA (per- (. Fig. 3.4 and . Fig. 3.5).
centage of centage of
patients) patients) jDischarge from hospital
3 The AQUA Institute’s External Quality Assurance
Jaschinski et al. (2014)
for Inpatient Care assessment examines quality in-
Surgery on day of 16% 17% dicators for treatment (nationwide). One of the pre-
admission
determined quality goals for at the time of hospital
Surgery one day after 84% 83% discharge is that 80% of the primary TKA patients
admission
are able to bend the knee joint by >90° in addition
Drainage of the surgical 93% 94% to being able to fully stretch it. In addition, two pa-
site rameters for patient independence were examined:
Removal of drain on the 80% 83% independent walking and autonomous daily hy-
second postoperative day giene (AQUA-Institut 2015d).
Pain management: With regard to the ability to walk, it was ob-
served in 2014 that after TKA 99.5 % of the patients
- Opiates 97% 91%
were able to walk independently upon discharge
- NSA 85% 85% (AQUA-Institut 2015d). Of the 0.4 % of patients
- COX-2 inhibitors 60% 58% who were unable to walk independently upon dis-
charge, 56.6 % had been able to walk independently
- Paracetamol 20% 19%
prior to the surgery.
- Epidural catheter 10% 12% In addition, the data shows that 99.4 % of pa-
- Peripheral nerve blocks 30% 91% tients were able to perform their daily hygiene rou-
- Cooling 0% 37% tine independently upon discharge. Of the 0.5 % of
patients who were unable to carry out their daily
AQUA-Institut 2014
hygiene routine independently upon discharge,
Medium duration of 74.5 min 85.2 min 48.8 % had been able to do so prior to surgery
surgery (AQUA-Institut 2015d).
Use of special navigation 1.3% 10% The reported ability to walk independently and
systems to perform a daily hygiene routine upon discharge
Perioperative antibiotic 99.7% 99.7% only fluctuated slightly over the past few years
prophylaxis (AQUA-Institut 2012a, 2013a, 2014a, b, 2010b,
Application of minimally 13.9% 1.8% 2011b).
invasive surgical A current survey of rehabilitation hospitals in
techniques North Rhine-Westphalia found that the percentage
Application of surgery 1 case 4 cases of patients who were unable to care for themselves
robots independently was significantly higher: Only 20.4 %
of the patients who had undergone TKA were able
Source: IGES – AQUA-Institut (2012c, 2013c, 2014c, to walk on admission (> 50 m), 17 % were able to
2015d, 2010c, 2014c)
bend the operated knee by > 90°and a further 63 %
of the patients by between 70° to 90° (Quack 2015).
The specific location into which a patient is dis-
years. In Germany, the average length of stay for a charged following his/her inpatient stay for primary
patient who has undergone a hip or knee replace- THA can be identified based on the »Reason for
ment is about 5 days longer than that of a patient discharge« documented in the External Quality As-
admitted to hospital for other reasons. From 2009 to surance for Inpatient Care assessment. Two main
51 3
16
13.6 13.1
14 12.8 12.5 12.2 11.8
12
Number of days
10
8.0 7.9 7.7 7.6 7.5
8
6
4
2
0
2009 2010 2011 2012 2013 2014
Year
Primary replacement Impatient stays for all indications in Germany
. Fig. 3.4 Length of stay for THA and in general in Germany, in days (2009–2014). (Source: IGES – AQUA-Institut 2012a,
2013a, 2014a, 2014b, 2010b, 2011b and Destatis 2015a)
16
14
12.2 11.8 11.5 11.1 10.9 10.6
12
Number of days
10
8.0 7.9 7.7 7.6 7.5
8
0
2009 2010 2011 2012 2013 2014
Year
Primary replacement Impatient stays for all indications
. Fig. 3.5 Length of stay for TKA and in general in Germany (2009–2014). (Source: IGES – AQUA-Institut 2012c, 2013c, 2014c,
2015d, 2010c, 2011c and Destatis 2015a)
discharge scenarios exist. In 2014, »Normal termi- tients is initially discharged into their home envi-
nation of treatment« was the reason provided for ronment. This distribution of figures had been sim-
47.3 % of patients and »Discharge into in a rehabil- ilar in the previous years (AQUA-Institut 2012a,
itation establishment for follow-up care« for 48.3 % 2013a, 2014a, b, 2010b, 2011b).
of the patients. This shows that about half the pa- The AQUA evaluation results are in accordance
tients are transferred directly into rehabilitation with the 2010 Barmer GEK Hospital Report survey
follow-up care and almost the same number of pa- results. Amongst the patients who received a new
hip joint in 2008/2009 and who were interviewed in

2009, 48.5 % were transferred directly into a rehabil-
itation establishment upon discharge. 11.5 % were 14.4%
discharged into a home environment and 39.1 %
initially went home and subsequently into a rehabil-
itation hospital (Barmer GEK 2010).
3 According to AQUA Institute data based on dis- 14.5% 46.7%
charge after primary TKA in 2014, treatment of
50.2 % of patients was terminated normally, i.e. they
were discharged to return home. 45.8 % of the pa-
tients were discharged directly into a rehabilitation
facility. Further reasons for discharge were the nor- 24.4%
mal termination of treatment with planned fol-
low-up care (2.2 %), transfer to another hospital
(1.1 %) and discharge to a care establishment (0.2 %)
Immediate transfer (admitted on the same day)
(AQUA-Institut 2015d). Early transfer (1 to 4 days)
The AQUA evaluation results are also con- Late transfer (5 to 14 days)
firmed by the 2010 Barmer GEK Hospital Report Not specified
study results (Barmer GEK 2010). 48.2 % of the pa-
tients who underwent TKA in 2008/2009 were . Fig. 3.6 Time between hospital discharge and admission
transferred directly into a rehabilitation hospital to a rehabilitation hospital following THA (2007). (Source:
upon discharge. 41.7 % of the patients initially went IGES – Deutsche Rentenversicherung Bund 2010)
home and were admitted into a rehabilitation hos-
pital later. The remaining patients were discharged
to return home or into another establishment.
An analysis conducted by the statutory pension
insurance DRV Bund elucidates that about half of 16.8%
THA patients and over a third of all TKA patients
were transferred straight into a rehabilitation hospi- 37.2%
tal after surgery (. Fig. 3.6 and . Fig. 3.7).
In the 2010 Barmer GEK Hospital Report, pa-
17.0%
tient surveys from 2004 and 2009 also provide data
on the frequency of follow-up rehabilitation care. In
the initial interview in 2009, 88.6 % of all primary
hip or knee arthroplasty patients reported having
undergone rehabilitation treatment. Amongst pa-
29.0%
tients who had received revision surgery, the per-
centage was 75.6 %. In the initial 2004 survey, the
values were markedly closer together (88.9 % vs. immediate transfer (admitted on the same day)
85.7 % respectively). This report also does not pro- Early transfer (1 to 4 days)
vide information on whether all the surveyed pa- Late transfer (5 to 14 days)
tients were capable of undergoing rehabilitation and Not specified
required it, so it is not apparent as to why post-
operative rehabilitation did not take place. . Fig. 3.7 Time between hospital discharge and admission
From these different datasets, it can be conclud- to a rehabilitation hospital following TKA (2007). (Source:
IGES – Deutsche Rentenversicherung Bund 2010)
ed that not all patients actually receive follow-up
rehabilitation, and not all patients are transferred
from acute hospital treatment to a rehabilitation
53 3
. Tab. 3.8 Percentage of hospitals that performed primary replacement surgery and percentage of hospitals that
performed revision surgery
Description 2009 2010 2011 2012 2013
Number of hospitals in Germany 2,084 2,064 2,045 2,017 1,996
Hip
Percentage [%] of hospitals that performed primary 55.5 55.7 54.4 54.1 53.9
replacements out of the total number of hospitals
Percentage [%] of hospitals that performed revision 51.8 52.4 51.1 52.0 51.4
surgery out of the total number of hospitals
Knee
Percentage [%] of hospitals that performed primary 49.0 50.2 50.4 51.2 51.7
replacements of the total number of hospitals
Percentage [%] of hospitals that performed follow- 44.6 45.6 46.0 48.0 48.7
up surgery of the total number of hospitals
Source: IGES – Destatis 2015a, AQUA-Institut 2011a, 2012a, 2012b, 2013a, 2013b, 2014a, 2014b, 2010b, 2011b, AQUA-
Institut 2013d, 2014d, 2010d, 2011d, 2012d
hospital »As soon as possible after achieving early that perform primary THA (. Tab. 3.8). The abso-
mobilization« (Deutsche Rentenversicherung Bund lute number of these hospitals is also decreasing, in
2009). line with trends seen in the number of hospitals in
After the introduction of DRGs in 2003, the general. The percentage of hospitals that perform
length of stay in acute-care hospitals reduced signif- revision surgery after TKA shows a slight upwards
icantly. The »REhabilitation und DIAgnosis Related trend.
Groups« study (REDIA-Studie), a prospective, mul- The reasons why not all hospitals that perform
ti-center, randomized, long-term study, investigated primary replacement surgery do perform revision
the effects of introducing DRGs into acute care on total arthroplasty are largely unclear. Nonetheless,
the medical service requirements and rehabilitation endoprosthetic implant and implant component re-
costs. During the observational period from 2003 to placements are significantly more demanding tech-
2009, the average length of stay for THA patients, nically and more complicated than primary replace-
for instance, decreased by 3.6 days from 17.7 days to ments (AQUA-Institut 2014d, 2012f). Perhaps not
13.3 days. Furthermore, during the period of study, all hospitals are capable of performing this surgery.
it was observed that the patients« condition at the
start of the rehabilitation phase deteriorated with jReasons for revision total arthroplasty
regard to postoperative general condition and pain Both primary replacements and/or the replacement
levels (van Eiff 2011). of endoprosthetic hip implants and implant compo-
nents are recorded for the External Quality Assur-
ance for Inpatient Care procedures in Germany.
3.3.2 Revision Total Arthroplasty Replacing an endoprosthesis may become necessary
if the individual prosthesis components loosen due
jCapacity for provision of care to wear and tear, amongst other things. In the Exter-
The number of hospitals in Germany that perform nal Quality Assurance for Inpatient Care proce-
hip joint revision surgery based on standards set by dures, the reasons for these replacements are docu-
the External Quality Assurance for Inpatient Care mented in the form of preoperative radiological
procedures is lower than the number of hospitals findings. The prevalence of each particular reason is
Periprosthetic (near
17.3%
the prosthesis) fracture
Femoral
19.2%
bone loss
Recurrent (sub)luxation
20.5%
3 of the prosthesis
Acetabular
28.6%
bone loss
Loosening of femoral
29.8%
stem component
Loosening of acetabular
33.8%
component
Implant migration/
failure 39.0%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Percentage
. Fig. 3.8 Preoperative, radiological findings for revision THA (2014). *Multiple answers possible. (Source: IGES – AQUA-
Institut 2014b)
illustrated in Figure 3.8. Based on this, significant and tear, other factors such as the surgeons’ experi-
reasons include (recurring) (sub)luxation of the en- ence constitute a significant risk of revision surgery.
doprosthesis, implant migration, implant failure, Likewise, the revision surgery itself and the service
implant or joint wear, pain, bacterial infections and life constitute important quality indicators for pri-
inflammation of the joint (AQUA-Institut 2014b). mary replacement, as well as for the overall long-
From a data interpretation perspective, it must term success of the treatment.
be noted that multiple responses are possible. Loss Men are at a higher risk of requiring revision
of the femoral bone, for example, may be accompa- total arthroplasty due to aseptic implant loosening
nied by a loosened femoral stem component and or infection. Longer operation times constitute an-
implant migration while a periprosthetic fracture or other risk factor for revision surgery due to infec-
luxation is frequently cited as the sole indication for tion. The results also show that smaller femoral
revision hip replacement. heads (≤28 mm) of the femoral component consti-
A systematic review conducted by Prokopetz et tute a risk factor for revision surgery due to disloca-
al. (2012) investigated the risk factors for revision tions (Prokopetz et al. 2012).
total arthroplasty after primary THA. The risk fac- In the External Quality Assurance for Inpatient
tors identified, which were consistent and statisti- Care in Germany, conducted by the AQUA Insti-
cally significant across the studies evaluated, includ- tute, the replacement of knee endoprostheses and/
ed younger patient ages at the time of primary re- or prosthesis components are also evaluated. All
placement, increased comorbidity, the presence of surgeries performed on patients from the age of 20
bone necrosis (rather than osteoarthritis) and the are recorded. At least one of the indication criteria
surgeon’s experience (number of joint operations in the following overview must be present for the
carried out) and larger femoral heads. The review operation to be included in the quality assurance
does not state the size of the femoral head from evaluation (AQUA-Institut 2015a).
which point the level of risk increases. In two of the
three studies examined, the maximum femoral head
size of the implanted femoral component was 28
mm (Prokopetz et al. 2012). The review conducted
by Prokopetz et al. (2012) shows that alongside wear
55 3
Loosening of the patelle component 3.1%

Periprosthetic fracture 5.0%
(Sub)luxation of the prosthesis 8.6%
Increasing osteoarthritits 19.0%
Implant migration/failure and
isolated change of inlay 23.9%
Femoral bone loss 25.4%
Wear and tear of the bearing surface 26.0%
and isolated change of inlay
Loosening of femoral component 28.6%
Tibial bone loss 30.2%
Loosening of tibial component 37.2%
Knee joint instability 45.9%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Percentage

. Fig. 3.9 Radiological findings for revision TKA in the External Quality Assurance for Inpatient Care evaluation (2014).
(Source: IGES – AQUA-Institut 2015a)
until the end of 2009, based on patients who had

Indication criteria for including cases in undergone THA and TKA between 2006 and 2008.
the quality assurance evaluation conduct- Within 90 days after discharge from hospital, 1.0 %
ed by the AQUA Institute of THA patients and 0.6% of TKA patients conse-
5 (Sub)luxation of the prosthesis quently had to undergo surgery on the same side, i.e.
5 Implant migration, implant failure and iso- revision surgery including revisions without re-
lated change of inlay (OPS: 5-823.19, placements. Within one year following primary
5-823.27, 5-823.b0, 5-823.f0) replacements, 2.0% of THA patients and 3.7% of
5 Wear and tear of the bearing surface and patients with osteoarthritis who were being fol-
isolated change of inlay (OPS: 5-823.19, lowed up underwent another operation on the same
5-823.27, 5-823.b0, 5-823.f0) joint. In a small group of patients with atypical diag-
5 At least one pain criterion and at least one noses, the revision rate was 6% (Barmer GEK 2010).
radiological criterion A survey based on routine data from the SHI Tech-
5 At least one pain criterion and at least one niker Krankenkasse found that 3.5% of patients
positive pathogen detection after primary THA and 3.8% of patients after pri-
5 Laboratory signs of inflammation and one mary TKA underwent revision total arthroplasty
positive pathogen detection within the first two years (Linder et al. 2012).
The correlation between the time of revision
(Source: IGES – AQUA-Institut 2015a) surgery and the quality of the resulting outcome was
investigated in a further study (Hardeman et al.
2012). Early revision total arthroplasty taking place
The common reasons for revision TKA in 2014, de- less than two years after primary replacement had
termined by the AQUA Institute’s external quality higher failure rates than revision total arthroplasty
assurance using objective radiological criteria, are carried out later. Better results were observed in old-
shown in Figure 3.9. er patients (> 65 years) and in partial revision sur-
The 2010 Barmer GEK Hospital Report evaluat- gery. Patients with low KSS scores (Knee Society
ed revision hip and knee joint surgery data recorded Score) before revision total arthroplasty also had
THA
3
TKA
0% 20% 40% 60% 80% 100%

Percentage
ASA 1 normal, healthy patient
ASA 2 mild systemic disease
ASA 3 severe systemic disease and limited function
ASA 4 severe systemic disease that is a consult threat to life
ASA 5 moribund patient
. Fig. 3.10 ASA classification of revision THA and TKA recorded for the External Quality Assurance for Inpatient Care evalua-
tion (2014). ASA = American Society of Anesthesiology. (Source: IGES – AQUA 2015c, e)
lower scores after the revision. However, the im- Wirtz 2011). The surgeon performing the proce-
provement in score in this group was significantly dure has to take into account primary replacement
higher than for patients who had had higher values surgery, the procedure and materials used. The cur-
at the start of the study (Hardeman et al. 2012). rent status of the patient, in particular with regard
to the periarticular status (bone structure, soft tis-
jPerioperative risk sue) must also be taken into account. If an infection
The 2014 quality assurance of inpatient care analyses is suspected, additional laboratory tests must be
recorded ASA classifications, which are aimed at giv- conducted. In contrast to primary replacements, the
ing a point of reference in the assessment of periop- entire joint may not need replacing but potentially
erative risk. Here, the analyses indicated that the only the defective parts. Both cemented and unce-
majority of patients who underwent revision THA mented fixation of the new endoprosthesis are pos-
were allocated to ASA class 3 (patients with severe sible (AQUA-Institut 2012f).
systemic disease and functional limitations) (50.5 %). According to information from the External
Patients who underwent revision TKA were propor- Quality Assurance for Inpatient Care assessments,
tionately more frequently grouped into class 2 (mild the average duration of both revision THA and TKA
systemic disease) (52.7 %) (. Fig. 3.10). Compared to has been about 2 hours for several years, which is
primary replacement (hip and knee), patients under- considerably longer than the time taken for primary
going hip or knee revision surgery often have a high- replacements (75 or 85 minutes) (AQUA-Institut
er ASA score (AQUA-Institut 2015c). Differences in 2010a, 2011a, 2012b, 2013b, 2014b, 2015d).
ASA scores between primary and revision surgery
patients are particularly due to the higher average jLength of stay
age of hip replacement patients and hence also asso- Patients undergoing revision total arthroplasty usu-
ciated with a higher age-related comorbidity. ally have a considerably longer length of hospital
stay than for primary replacements.
jSurgical procedures Just as is the case for primary TKA, the length of
Compared to primary replacements, revision total stay in hospital after revision TKA is longer (by ap-
arthroplasty is described as technically more de- proximately 8 days) than the general average length
manding and more complicated (Claes et al. 2012; of stay in German hospitals. After revision surgery,
57 3
25
20.4 20.2 20.1 20.4 20.4 20.7

20
Number of days
15 13.6
13.1 12.8 12.5 12.2 11.8
10
8.0 7.9 7.7 7.6 7.5
0
2009 2010 2011 2012 2013 2014
Year
Revision surgery Primary replacement Inpatient stays for all indications in Germany
. Fig. 3.11 Length of stay of patients undergoing revision surgery, primary THA, and the average length of stay in Germany,
in days. Note: At the time of writing, the average length of stay in Germany for 2014 was not yet available. (Source: IGES –
AQUA-Institut 2010a, 2011a, 2012b, 2013b, 2014b and Destatis 2015a)
25
20
16.8 16.2 16.1
15.9 16.0 16.0
Number of days
15
13.5 13.0 12.7 12.2 12.1 11.8
10
7.0 6.8 6.7 6.6 6.5
5
0
2009 2010 2011 2012 2013 2014
Year
Revision surgery Primary replacement Inpatient stays for all indications in Germany
. Fig. 3.12 Mean length of stay in days for revision surgery after TKA, 2009 to 2014. Note: At the time of writing, the average
length of stay in Germany for 2014 was not yet available. (Source: IGES – AQUA-Institut 2013d, 2014d, 2015e, 2010d, 2011d,
2012d and Destatis 2015c)
patients remained in hospital for 3 to 4 days longer and 7.1 % vs. 0.5 % respectively) (. Fig. 3.13 and
than after primary replacement surgery (. Fig. 3.11 Section 3.3.1).
and . Fig. 3.12). As with primary arthroplasty, the results showed
only minor variations over the previous years
jDischarge from hospital (AQUA-Institut 2010a, 2011a, 2012b, 2013b, 2014b,
In Germany, patient independence upon discharge 2015c).
3 after revision total arthroplasty differed from pa- 97.6% of patients who had undergone revision
tient independence after primary total arthroplasty. TKA were able to walk independently upon discharge
With regard to THA, more patients were unable (99.5% after primary arthroplasty) (AQUA-Institut
to walk independently or perform daily hygiene in- 2015e). 97.6% of the patients were able to perform
dependently upon discharge after revision THA their daily hygiene themselves upon discharge (pri-
than after the primary replacement (6.3 % vs. 0.4 % mary arthroplasty: 99.4%) (. Fig. 3.14).
Independent walking upon discharge Autonomous daily hygiene upon discharge

6.3% 7.1%
91.9% 91.1%
Possible Not possible


. Fig. 3.13 Ability to walk independently and carry out autonomous daily hygiene after revision THA at the time of dischar-
ge in 2014. (Source: IGES – AQUA-Institut 2015c)
Independent walking upon discharge Autonomous daily hygiene upon discharge

2.0% 2.0%
97.6% 97.6%


. Fig. 3.14 Ability to walk independently and to carry out autonomous daily hygiene after revision TKA at the time of
discharge in 2014. (Source: IGES – AQUA-Institut 2015e)
59 3
. Tab. 3.9 Reasons for discharge following primary and revision total arthroplasty (2014)
Reasons for discharge in 2014 (acc.to § 301 Primary THA Revision THA Primary TKA Revision TKA
Volume V German Social Security Code)
Discharge into a rehabilitation establishment (%) 48.3 32.1 45.8 32.9
Treatment ended normally (%) 47.3 52.6 50.2 59.0
Transfer to another hospital (%) 1.4 5.6 1.1 2.6
Discharge into nursing care (%) 0.3 3.7 0.2 0.9
Death (%) 0.2 1.8 0.1 0.4
Source: IGES – AQUA-Institut 2015b, 2015c, 2015d, 2015e
The External Quality Assurance for Inpatient tions. In addition, evidence shows that peripheral
Care assessment shows that as with primary re- catheter procedures can lead to early mobilization
placement, only a small number of patients are and better functionality compared to the general
transferred straight into a rehabilitation facility after administration of systemic opioids (Cappelleri et al.
revision surgery (. Tab. 3.9). 2011).
The S3 guideline »Treatment of acute periopera-
tive and posttraumatic pain«1 recommends the use
3.3.3 Accompanying Measures during of non-opioid analgesics after both THA and TKA
Inpatient Stay for pain management after discharge from hospital
(Laubenthal and Neugebauer 2009). Randomized
jPain management studies have demonstrated the effectiveness of
Regardless of the surgical access route, endopros- conventional, non-steroidal antiphlogistics and
thetic surgery for osteoarthritis of the hip (THA) non-opioid analgesics, such as paracetamol for post-
and osteoarthritis of the knee (TKA) is associated operative pain control (Lohom et al. 2002; Peduto et
with a high intensity of pain (Laubenthal and Neu- al. 1998; Silvanto et al. 2002). For high intensity pain
gebauer 2009). Effective pain management contrib- these can be combined with strong opioids in multi-
utes to improved convalescence, rapid mobilization modal analgesic therapy (Simanski 2008).
and a reduced rate of complications such as deep
vein thrombosis (DVT) (Simanski 2008). Pain man- jThromboprophylaxis
agement comprises pre-, intra- and postoperative Besides appropriate pain management and mobili-
phases and also plays an important role for the pa- zation, thromboprophylaxis plays an important role
tients« in long-term ambulatory care (Laubenthal in THA and TKA procedures. Hip and knee joint
and Neugebauer 2009). replacements are amongst the primary causes of ve-
Particularly after TKA, individually tailored and nous thromboembolism (VTE) (European Society
continuous pain management is considered crucial of Cardiology 2014). VTE includes deep vein
in the success of treatment. Various studies show thrombosis (DVT) and pulmonary embolism (PE),
that continuous postoperative pain management is which are the most serious complications of DVT.
better relative to single injections or to the adminis- The PE mortality rate within the first few weeks fol-
tration of medication as required. Moreover, it has lowing THA is between 0.09 % and 0.19 % (Fender
been demonstrated that continuous analgesia by
means of peripheral catheter procedures reduces 1 The implementation of the S3 guideline on the »Treatment
the use of postoperative morphine and contributes of acute perioperative and posttraumatic pain« is currently
to quicker rehabilitation compared to single injec- under review.
et al. 1997; Howie et al. 2005; Khan et al. 2007; Shep- for at least 10 to 14 days after knee joint surgery
herd and Mills 2006). (AWMF 2015; Falck-Ytter et al. 2012). For TKA, the
Thrombosis is a vascular disease that occurs current American College of Chest Physicians
when a blood vessel is narrowed or occluded by a (ACCP) guidelines recommend extending pharma-
blood clot. Causes include damage to the vascular cological prophylaxis for a period of up to 35 days
walls through surgery (Perka 2011). In order to after the inpatient stay (Falck-Ytter et al. 2012). If
3 avoid such complications, blood coagulability is re- the VTE risk is increased, especially due to addi-
duced through medication (anticoagulation) tional concomitant diseases, VTE prophylaxis
(AWMF 2015). Anticoagulants are used to inhibit should be continued for as long as the disease per-
the growth of the thrombus and constitute a prereq- sists (AWMF 2015).
uisite for physiological fibrinolysis which dissolves A recent prospective study by Jorgensen et al.
the thrombus. The period of risk period associated indicates that thromboprophylaxis for the duration
with VTE begins with surgery. Several days or weeks of inpatient stay is sufficient for patients who are
can elapse before a thrombus develops and as a re- treated according to a »fast track« THA and TKA
sult most cases of symptomatic vein thrombosis treatment concept, and that there are no additional
occur after the inpatient stay. As a result, thrombo- benefits exist in continuing the treatment during
embolism prophylaxis is also necessary after dis- ambulatory care (Jorgensen et al. 2013). In this
charge (AWMF 2015). study, approximately 4,700 patients with a length of
Although in principle VTE is associated with all stay of ≤ 5 days received VTE prophylaxis. During
types of surgery, orthopedic patients are at a higher the 90 day follow-up period, thromboembolic
risk owing to the activation of coagulation due to events occurred in 0.84 % of the patients and VTE
tissue and bone injuries, vein damage, immobiliza- was found in 0.41 %. These complication rates cor-
tion and heat generation from the use of bone respond to those observed in other studies in which
cement (Perka 2011). Further distinctive factors VTE prophylaxis was conducted over a longer pe-
include advanced age (above 60 years), weight (BMI riod. However, due the study design, it cannot be
> 30), tumor diseases and previous venous throm- ultimately concluded that conducting VTE prophy-
boembolism in the patient or the patient’s family laxis solely during the period of inpatient stay is
history (AWMF 2015, Cionac Florescu et al. 2013; sufficient. The study by Jorgensen et al. did not com-
Falck-Ytter et al. 2012). pare its findings with an internal control group but
Without thromboprophylaxis, approximately with data from different studies in which the patient
40 %–60 % of all patients who undergo elective populations might have differed with regard to rele-
THA and TKA develop VTE (Perka 2011). With vant risk factors (e.g. comorbidity, immobilization,
thromboprophylaxis, this is reduced to 1.09 % in length of stay).
patients who undergo knee replacement surgery Currently recommended, effective VTE phar-
and 0.53 % of patients who undergo hip replace- macoprophylaxis after joint replacement includes
ment surgery (Januel et al. 2012). factor Xa inhibitors, (low-molecular-weight) hepa-
rins (LMWH), thrombin inhibitors, vitamin K an-
kPharmacological VTE prophylaxis tagonists (VKA) and other anticoagulants (AWMF
The rate of VTE complications can be reduced 2015; European Society of Cardiology 2014).
significantly through medication (AWMF 2015) Acetylsalicylic acid should not be used as a
(European Society of Cardiology 2014; Falck-Ytter monotherapy due its low prophylactic effect against
et al. 2012). Pharmacological prophylaxis can also VTE compared to the other medications mentioned
be accompanied by physical and mobilization meas- above (AWMF 2015; Falck-Ytter et al. 2012). The
ures to further reduce the risk of VTE. The same Association of the Scientific Medical Societies in
approach should be taken for VTE prophylaxis for Germany (AWMF) does not recommend the use of
both inpatient and ambulatory care. Certain guide- VKA such as warfarin and phenprocoumon, after
lines recommend pharmacological prophylaxis for taking into consideration the effectiveness and the
hip joint surgery over a period of 28 to 35 days and risk of bleeding compared to the heparins (Encke et
61 3
al. 2015). The AWMF refers to a study conducted by jPhysiotherapeutic measures and mobility
Samana et al., amongst others, which demonstrated In general, physiotherapeutic and physical therapies
that there was no difference between VTE prophy- such as balneotherapy, massage, gait training and
laxis with warfarin or LMWH in patients with hip cooling should be carried out after joint surgery.
surgery with regard to DVT rates, but that the pa- According to the S3 guideline »Prophylaxis of ve-
tients treated with warfarin showed a much higher nous thromboembolism (VTE)« further physical
prevalence of bleeding complications (5.5 % versus measures for the preventing VTE include medical
1.4 %) (Samana et al. 2002). In contrast, the ACCP compression stockings, e.g. thigh-length and knee-
and European Society of Cardiology (ESC) guide- length stockings that increase venous blood velocity
lines advocate the use of VKA for VTE prophylaxis and consequently prevent thrombus formation.
(European Society of Cardiology 2014; Falck-Ytter Such measures are particularly prudent when a con-
et al. 2012). traindication for pharmacological VTE prophylaxis
Contraindications for thromboprophylaxis are: exists, e.g. due to an increased bleeding risk (AWMF
the known risk of bleeding, hemorrhagic and is- 2015).
chemic strokes within the previous six months and Physiotherapy aims to assist mobilization and in
gastrointestinal bleeding within the previous month the prevention of functional impairments, as well as
(European Society of Cardiology 2014). If contrain- in pain relief, and therefore an integral part of com-
dications exist, intermittent pneumatic compres- prehensive pain management regimes (Laubenthal
sion (e.g. foot, calf and thigh) should instead be used and Neugebauer 2009). A recent review showed that
for patients who have had THA and physical meas- particularly early mobilization (defined as »getting
ures (e.g. medical compression stockings) for pa- out of bed« and »walking« as soon as possible after
tients after TKA (AWMF 2015). hip or knee replacement surgery) can result in
shortening the length of stay by approximately 2
kBleeding risk in patients on anticoagulant days (Guerra et al. 2015; Tayrose et al. 2013). More-
therapy over, improvements were noted with regard to free
The primary risk of anticoagulant therapy for VTE movement, muscle power and health-related quality
prophylaxis is bleeding, which accounts for 2 % to of life. Undesired events caused by early mobiliza-
3 % over a period of 3 months (Scherz et al. 2013). tion, such as hemodynamic instability or the in-
Specific patient characteristics that are associated creased risk of falling, did not occur significantly
with an increased bleeding risk during anticoagulant more frequently when compared to control groups
therapy are renal failure, a history of bleeding and a without early mobilization (Guerra et al. 2015).
simultaneous intake of platelet aggregation inhibitors Other studies were able to demonstrate lower risks
(Decousus et al. 2011; Falck-Ytter et al. 2012). The of DTV, PE, chest infections and urinary retention
level of risk doubles in older patients (≥ 65 years) during early mobilization (Renkawitz et al. 2010).
compared to younger patients (Spencer et al. 2008).
Different scoring methods have been developed
to assess an individual patient’s risk of bleeding 3.3.4 Complications
(Beyth et al. 1998; Kearon 2003; Kuijer et al. 1999;
Ruíz-Giménez et al. 2008). These scores stratify the Intra- and postoperative surgical complications
patients according to their bleeding risk. However, during inpatient stays are recorded for the External
these risk scores have not been sufficiently tested in Quality Assurance for Inpatient Care assessments in
patients in orthopedic surgery (Falck-Ytter et al. Germany. The case rates for primary total arthro-
2012), and do not differentiate between low and plasty in 2014 are summarized in . Tab. 3.10.
high bleeding risks precisely enough, particularly in The documented rate of operations that in-
older patients (≥ 65 years) (Scherz et al. 2013). volved at least one complication during the inpa-
Hence, there is a need to develop and validate tools tient stay lies in the single-digit percentage range.
to stratify risks in patient populations after THA Over the last few years, this rate has been declining,
and TKA. as has the rate of all cases, except for fractures. How-
. Tab. 3.10 Intra-/postoperative surgical complications requiring treatment after primary and revision total arthro-
plasty during hospital stays in Germany in 2014
Intra-/postoperative surgical complications Primary THA Revision hip Primary TKA Revision knee
requiring treatment
3 Number of operations with at least one com- 2.76 9.00 1.91 4.29
plication (%)
Malposition of the implant (%) 0.05 0.19 0.03 0.12
Dislocation of the implant (%) 0.10 0.40 0.03 0.06
Luxation of the endoprosthesis (%) 0.27 1.94 – 0.09
Misalignment of the patella (%) 0.02 0.1
Wound hematoma/postoperative bleeding (%) 0.86 2.95 0.86 2.17
Vascular lesion (%) 0.03 0.16 0.02 0.07
Nerve damage (%) 0.25 0.56 0.1 0.09
Fracture (%) 0.82 1.73 0.15 0.39
Other (%) 0.54 2.09 0.8 1.69
ever, a change in the counting method since 2013 . Tab. 3.13 and . Tab. 3.14 show that the rate of
(number of operations rather than of patients) only complications in revision total arthroplasty is
permits a limited comparison with the case rates in several times higher than the rate of complications
previous years. in primary replacements. The same applies to the
The percentage of patients with at least one rate of registered, revision surgery required due to
general postoperative complication that required complications. For revision total arthroplasty, these
treatment following joint replacement (primary and varied between 5.6 % and 7.5 % between 2009 and
revision surgery) is in the single digit range, as with 2014. In contrast to primary replacements, a
the rates for the other cases (. Tab. 3.11). noticeable declining trend in case rates is not
Compared to 2009, a decline in the rate of post- apparent. It should be noted that the rate of com-
operative wound infections can be observed, al- plications mentioned so far refer to the period dur-
though the overall case rates (other wound infec- ing which the patient is treated in an acute-care
tions) stagnated or rose during the same period hospital.
(. Tab. 3.12). Up to a third of the complications following hip
In addition, for primary arthroplasty, it is im- joint replacements occur after an inpatient stay, as
portant to note the rate of registered, revision sur- shown by an analysis conducted by the AOK Re-
gery required resulting from complications related search Institute (Wissenschaftliches Institut der
to hip endoprostheses during the inpatient stay. AOK, WIdO) (Jeschke and Günster 2014). The
This also showed a decrease from 2009 (1.7 %) to analysis used AOK routine data while conducting
2014 (1.4 %). The rate of revision surgery required »Quality Assurance with Routine Data« procedures
due to complications with the knee endoprostheses (Section 3.3.4)
ranged between 1.4 % of patients in 2009 and 0.87 % The evaluation included 154,470 patients from
of patients in 2012. In 2013 and 2014, revision sur- 930 hospitals who had undergone primary hip joint
gery due to complications was at 1.3 % and/or replacements (THA and partial replacements) be-
1.15 % for hip and knee surgery respectively. tween 2007 and 2009 whose treatment diagnosis
63 3
. Tab. 3.11 General postoperative complications requiring treatment following primary and revision total arthro-
plasty during hospital stays in Germany in 2014
General postoperative complications Primary hip Revision hip Primary knee Revision
requiring treatment replacement replacement knee
Number of patients with at least one 2.92 7.98 3.02 4.91

complication (%)
Pneumonia (%) 0.16 0.86 0.17 0.38
Cardiovascular complications (%) 0.67 2.44 0.62 1.22
Deep vein thrombosis in leg/pelvis (%) 0.09 0.16 0.40 0.26
Pulmonary embolism (%) 0.08 0.28 0.17 0.24
Other (%) 2.11 5.40 1.89 3.31
. Tab. 3.12 Postoperative wound infection after primary and revision total arthroplasty during inpatient stays in
Germany in 2014
Postoperative wound infection Primary hip Revision hip Primary knee Revision
replacement replacement knee
Surgery with wound infections (%) 0.42 4.18 0.26 1.8
Of which according to CDC classification:
A1 (superficial infection) (%) 39.47 22.56 53.22 24.92
A2 (deep infection) (%) 53.02 66.61 38.01 60.57
A3 (cavities/organs) (%) 7.51 10.83 8.77 14.51
. Tab. 3.13 Rate of complications after acute-inpatient treatment following hip joint replacement
Quality indicator Total number Follow-up obser- Inpatient phase pri- Overall
of cases (n) vation period (%) mary replacement (%) period (%)
Revision surgery within 365 days 149,637 1.88 1.65 3.53
Surgical complications within 90 days 152,567 1.96 5.29 7.25
Thrombosis/pulmonary embolism 152,354 0.43 0.69 1.12

within 90 days
Femoral fracture within 90 days 152,885 0.25 1.74 1.99
Mortality within 90 days 154,220 0.48 0.43 0.91
Complication index* 154,240 3.36 7.73 11.09
* Sum of individual quality indicators, cases in which a patient had several complications were counted as a single
event.
Source: IGES – Jeschke and Günster 2014
. Tab. 3.14 Postoperative complications of AOK patients after TKA
Description Patients Percentage [%]
Total 40,483 100
3 Pneumonia 149 0.4
Pulmonary embolism 215 0.5
Thrombotic events 828 2.0
Bleeding complications 5,267 13.0
Ventilation for over 24 h 69 0.2
Postoperative infection 143 0.4
Other postoperative complications 514 1.3
Complications through orthopedic endoprostheses, implants or transplants 689 1.7
Luxation, sprain and strain of the knee joint and knee joint ligaments 67 0.2
Source: IGES – WiDO 2007
was documented as »osteoarthritis of the hip« (97 % pital Care using Routine Data (QSR) analyzed 2003
of patients). Patients who had already undergone a routine data of postoperative complications of
hip joint replacement two years prior to the index AOK insurees who had undergone knee replace-
surgery were excluded, as well as hospitals with few- ments (bicondylar surface replacement prosthesis
er than 30 cases in the above-mentioned period or hinged endoprosthesis) (WiDO 2007). In total,
(. Tab. 3.13). data from 40,483 patients who had undergone knee
With regard to primary replacements, the study joint replacements in 2003 were analyzed (73.8 %
shows that complications caused by the surgery can women, average age of 70.1 years). Patients of 30
especially develop in the period of up to 90 days years of age or younger were excluded. The most
following discharge from hospital. The »Surgical frequently documented complications were general
complications« quality indicator was defined by the surgical risks, such as bleeding or a thrombotic
ICD-10 diagnosis codes »Luxation« (ICD-10: S73), event (. Tab. 3.14).
»Complications of internal orthopedic prosthetic During the inpatient stay, revision TKA with
devices« (ICD-10: T84.0/5/8/9) and »Complica- replacement or removal was performed in 0.3 % of
tions of procedures« (ICD-10: T81.2/3/5/8/9). The the patients (WiDO 2007).
evaluation primarily investigated the connection An analysis based on pre-defined reasons for
between complications occurring during inpatient readmission to hospital showed that in the first year
stays and during the follow-up period of observa- after TKA, 1.8 % of patients were readmitted for re-
tion. The publication makes the following general vision with replacement or removal of the prosthe-
statement: »With regard to hospital-related compli- sis. Revisions without replacement or removal were
cations, barely any links can be observed between performed on an inpatient basis in 0.6 % of patients
the events during the initial inpatient stay and dur- within the period of one year (WiDO 2007).
ing the follow-up period for any of the indicators
investigated […]« (Jeschke and Günster 2014).
Similar analyses are available for knee endo-
prostheses. The Federal Association of the AOK’s
final 2007 report on the Quality Assurance of Hos-
3.4 · Rehabilitation
65 3
3.4 Rehabilitation is to be conducted »Subsequent to postoperative
care« and that »Persistent postoperative functional
According to § 26 of the German Social Security restrictions« exist (Deutsche Rentenversicherung
Code Volume IX, the overall goals of medical reha- 2005).
bilitation services are: The German Statutory Pension Insurance con-
1. To prevent, overcome, minimize, stabilize and siders patients to be in need of rehabilitation if the
inhibit the deterioration of a disability, includ- ability to work is severely jeopardized or already
ing chronic disease. impaired. Statutory health insurances consider pa-
2. To avoid, overcome and minimize restrictions tients to be in need of rehabilitation if everyday
in the ability to work, reduce nursing care re- functions are impaired for a longer period of time
quirements, prevent deterioration of the disa- than normal. If there is solely residual muscle weak-
bility and thwart a premature need for contin- ness and restriction of movement, ambulatory ther-
uous social security benefits and/or reduce apeutic products and functional training are
the amount of ongoing social security benefits. deemed sufficient (Maier-Börries and Jäckel 2013).
An indication for postoperative rehabilitation
Medical rehabilitation comprises treatment by the should therefore be made if patients have restric-
physician, drugs and wound dressings, therapeutic tions in performing activities of daily living and
products, orthopedic devices and other medical participating in daily life, which require medically
technical aids and if necessary, endurance tests. The led and supervised interdisciplinary multimodal
major medical rehabilitation payers are statutory treatment.
health insurances (SHI), the German Statutory A patient’s ability to undergo rehabilitation en-
Pension Insurance (Deutsche Rentenversicherung compasses both the physical and psychological abil-
(DRV)) and the German Statutory Social Accident ity to use all of the therapeutic services offered as
Insurance (Deutsche Gesetzliche Unfallversiche- well as a willingness to do so. A patient undergoing
rung (DGUV)). According to the German Social rehabilitation treatment must
Security Code Book policy »Rehabilitation before 4 have undergone early mobilization and be able
Nursing Care«, statutory health insurances are to eat without assistance, wash themselves and
obliged to fund rehabilitation treatment for patients to move about in the ward;
who are no longer of working age. The DRV funds 4 be strong enough to endure effective rehabili-
treatment for patients of working age according to tation treatment;
the »Rehabilitation Before Pension« policy (Kladny 4 be motivated and have the mental capacity and
2013). necessary physical strength to actively partici-
Rehabilitation measures that are initiated with- pate in rehabilitation treatment (DRV-Indika-
out prior hospital treatment are termed »Heilver- tionsliste AHB).
fahren (HV)« (curative procedure) in German. Re-
habilitation after surgery is termed »Anschlussreha- Overall basic prerequisites for inpatient rehabilita-
bilitation« or »Anschlussheilbehandlung (AHB)« tion treatment after hip and knee replacement sur-
(subsequent rehabilitation). Socio-medical prereq- gery usually include:
uisites for subsequent rehabilitation (AHB) are that 4 non-irritated wound without any indication of
the diagnosis is included in the AHB indication local infection,
group list, that there is an existing need of rehabili- 4 being predominantly independent with regard
tation, that the patient is able to undergo rehabilita- to the most important activities of daily living
tion and a has positive rehabilitation prognosis. (Barthel ADL index score of at least 65),
»Status post endoprosthetic surgery of the hip joint, 4 having sufficient and safe mobility, at least for
knee joint, shoulder joint and the ankle joint« is short walking distances in the ward (with the
considered to be a diagnosis eligible for subsequent help of walking aids),
rehabilitation (AHB). Further prerequisites for sub- 4 having already attained minimum satisfactory
sequent rehabilitation (AHB) are that rehabilitation functionality of the operated joint:
4 hip: extension/flexion 0/0/80° sible for assessing the necessary prerequisites and
4 knee: extension/flexion 0/5/80–90°, for making recommendations for the need for sub-
4 having sufficient personal motivation to sequent rehabilitation (AHB) to the relevant social
undergo rehabilitation and insurance institution.
4 being in a sufficient cognitive state (no severe Existing data with regard to (medical) rehabili-
dementia). tation is generally considered to be very limited,
3 fragmented and in need of improvement (Augurzky
The aim of subsequent rehabilitation (AHB) is to et al. 2011; SVR Gesundheit 2014). The following
prepare the patients for the demands of their every- chapters aim to portray the circumstances for pa-
day and working lives. An important focus is the tients who have undergone total arthroplasty.
regain of lost functions and/or learning to compen-
sate for them as much as possible. Rehabilitation
prognosis is an assessment of the likelihood of a 3.4.1 Therapy Recommendations
patient reaching set rehabilitation goals. Reaching and Standards
of these goals must be highly likely, and should take
into consideration both the type as well as the dura- In general, hardly any guidelines exist with recom-
tion of the treatments required in order to enable mendations for specific rehabilitation therapy for
the patient to participate in daily life. individual diseases (SVR Gesundheit 2014). How-
Ambulatory rehabilitation services have re- ever, extensive textbooks (Heisel and Jerosch 2007;
ceived special funding with the range of services Imhoff et al. 2015; Stein and Greitemann 2015) and
having been expanded over the past few years specific scientific publications (Heisel 2012; Kladny
(Deutsche Rentenversicherung Bund 2009) which 2007; Rupp and Wydra 2012) exist which describe
are based on certain legal requirements (cf. § 19, the basics in detail.
section 2, Volume IX of the German Social Security The German Statutory Pension Insurance
Code). Prerequisites for participation in ambulatory (DRV) has developed standards for subsequent re-
rehabilitation are that patients are physically and habilitation (AHB) therapy following THA and
emotionally capable and have a degree of mobility TKA. These standards constitute part of the DRV’s
that is higher than the degree required for inpatient quality assurance. They differ from the general
rehabilitation. Patients must be able to reach the guidelines in that they do not include any therapy
facility by means of public transport within a rea- algorithms. They aim to put forward »Evi-
sonable amount of time. The following aspects sup- dence-based care provision of therapeutic rehabili-
port the case for inpatient rehabilitation (Heisel and tation services«. The standards are predominantly
Jerosch 2007): based on scientific guidelines, literature reviews,
4 walking distance under 100 m, expert surveys as well as on an analysis of rehabili-
4 use of public transport and use of a private tation services that have actually been covered in
vehicle not possible, Germany by the pension insurance (Deutsche
4 danger of falling due to insecure gait, Rentenversicherung Bund 2010). The standards
4 unable to climb stairs, apply to both THA and TKA indication fields.
4 increased need of nursing care, Evidence-based treatment modules (ETM) were
4 provision of care at home not guaranteed, derived from this. These individual modules in-
4 comorbidities in need of treatment, clude a list of services in accordance with the stan-
4 driving distance to an ambulatory rehabilita- dardized classification of therapeutic services (KTL)
tion center of longer than 30 minutes. with a minimum of specific ETM (Deutsche Ren-
tenversicherung Bund 2011). Fields of major signi-
Applications for subsequent rehabilitation (AHB) ficance include movement therapy, training in ac-
are made by the treating physician on behalf of the tivities of daily living, as well as educating patients
patient. Consequently, the applicant is the person in matters related to total arthroplasty and health
undergoing rehabilitation. The physician is respon- (. Tab. 3.15).
67 3
. Tab. 3.15 Evidence-based rehabilitation therapy standards for THA and TKA developed by the German Statutory
Pension Insurance
ETM Description Minimum percentage of patients to be treated

accordingly (%)
01 Movement therapy 90
02 Activities of daily living training 90
03 Physical therapy 50
04 THA/TKA patient education 80
05 Health education 80
06 Nutritional education 20
07 Psychological counseling and therapy 10
08 Relaxation training 10
09 Social and social security law counseling 30
10 Job integration support 20
11 Follow-up care and social integration 50
ETM = Evidence-based therapy modules

Source: IGES – Deutsche Rentenversicherung Bund (2011)
3.4.2 Provision of Care ania and Schleswig-Holstein than are residents of

those federal states (GBE-Bund 2015).
In 2014, almost 2 million patients underwent inpa- According to the Integrated Care Policy (§ 140,
tient rehabilitation. No explicit data is available for Volume V German Social Security Code), contracts
the indications and case numbers for hip and knee are concluded between statutory health insurance
joint replacements. In 2014, there were 399 rehabil- funds and service providers of acute and rehabilita-
itation hospitals with specialist orthopedic depart- tion care. The contracts aim to better interlink acute
ments in Germany which treated approximately inpatient treatment and the subsequent hospital or
650,000 patients in total (Destatis 2014). ambulatory rehabilitation measures. A study on im-
For some indications, particular emphasis is proving care demonstrated that integrated care con-
placed on the importance of having access to reha- cepts, which ensure a seamless connection between
bilitation services close to the patient’s domicile, as the acute phase and inpatient rehabilitation for hip
this allows for incorporating family and social envi- and knee joint replacement patients, had positive
ronments into the treatment. However, rehabili- effects on patient satisfaction and outcome quality
tation does not necessarily take place close to a pa- (Bethge et al. 2011).
tient’s home. The German Statutory Pension Insur-
ance figures for 2014 demonstrate that, within the
country, a patient’s domicile and the rehabilitation 3.4.3 Utilization of Services
hospital are not always in the same region. For ex-
ample, many patients living in Berlin, Hamburg or The Federal Statistical Office publishes the number
Bremen undergo inpatient rehabilitation treatment of full-time inpatients in preventive medicine facili-
in other federal states, while, on the other hand for ties and rehabilitation establishments with over 100
example, more patients undergo rehabilitation beds, classified according to the main diagnoses
treatment in Hessen, Mecklenburg-Western Pomer- groups (Destatis 2015b). In 2014, a total of 1.66 mil-
400,000
Number of services provided
350,000
300,000
250,000
200,000
3 150,000
100,000
50,000
0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Year
Total number of services provided
Service provided for men in the main diagnosis group »Skeletal system/muscles/connective tissue«
Service provided for women in the main diagnosis group »Skeletal system/muscles/connective tissue«
. Fig. 3.15 Services provided in subsequent rehabilitation treatment (AHB) in the DRV (2004 to 2014) (Source: IGES – Deut-
sche Rentenversicherung Bund 2014b)
lion patients were treated, of which 606,000 were procedures are performed for musculoskeletal indi-
treated in orthopedic departments. 518,000 patients cations (Deutsche Rentenversicherung Bund
had diseases of the musculoskeletal system, a further 2014b). Figure 3.15 illustrates the developments
102,000 suffered from injuries. The most common since 2004 as well as the number of services per-
main diagnosis in 2014 was osteoarthritis of the hip formed for indications in the main diagnosis group
(coxarthrosis), followed by osteoarthritis of the knee for »Skeletal system/muscles/connective tissue« dis-
(gonarthrosis). Approximately 104,500 patients with orders according to gender. Besides hip and knee
an indication of osteoarthritis of the hip (ICD-10 replacements, the 56,603 procedures recorded for
M17) were treated in these facilities. The highest pa- men and 52,652 for women in 2014 also include fur-
tient numbers were recorded for the age group be- ther procedures on the spine and other extremities.
tween 70 and 75 years (21,099) and between 75 and Ambulatory rehabilitation services account for
80 years (20,808). With further increasing age, pa- 13 % of the entire range of medical rehabilitation
tient numbers decreased significantly. In total, sig- services funded by the DRV, of which around two
nificantly more women than men with osteoarthritis thirds of the indications are in the musculoskeletal
of the hip (approx. 63,000 vs approx. 41,000 respec- domain. In the main diagnosis group »Skeletal sys-
tively) underwent rehabilitation treatment. This ra- tem/muscles/connective tissue«, the percentage of
tio was even more pronounced for osteoarthritis of ambulatory services out of the entire volume of
the knee (66,000 vs. 38,000) (Destatis 2015b). These medical rehabilitation services is under 25 %. This
figures take into account all payers, but no distinc- accounts for about 76,000 measures (Deutsche
tion is made between curative procedures for osteo- Rentenversicherung Bund 2014a).
arthritis and subsequent rehabilitation (AHB) after According to the Federal Statistical Office, in
replacement surgery. 2014 patients within the main diagnosis group »Mus-
DRV statistics show that in 2014 over 1 million culoskeletal system and connective tissue«, had an
medical rehabilitation services were provided for average length of stay of 22.1 days in (inpatient) pre-
people in employment, of which 350,655 (36 %) ventive medicine and rehabilitation facilities with
were related to »Skeletal system/muscles/connec- over 100 beds. The length of stay was 21.1 days for
tive tissue« disorders. Follow-up services for reha- cases within the more specific main diagnosis group
bilitation constituted about one third of all medical »Polyosteoarthritis and osteoarthritis« (ICD-10 M05-
rehabilitation services (337,618). One in three of the 06 and M15-19) (Statistisches Bundesamt 2013).
69 3
100%
90%
80%
70%
Percentage
60%
50%
40%
30%
20%
10%
0%
py
py
py
re
rt
re
ng
PM
tio
tio
io
po
ap
ca
ca
ra
ra
ra
at
eli
(C
ca
ca
er
up
e
he
he
up
uc
ns
th
sin
th
du
du
ce
ns
tt
lt
w-
d
io
ra
ica
d
he
te
le
ur
en
o
ys
tio
lo
an
c
tb
/n
a
n
em
ys
Ph
ol
alt
w
n
ra
tie
py
ng
en
tio
ff
Ph
g
He
ov
l
pa
no
ra
te
eli
em
ity
tri
M
in
ns
A
Nu
ur
tio
th
ov
TK
b
ou
ec
Jo
al
za
M
A/
ls
lc
n
ni
tio
TH
cia
ca
ga
pa
gi
so
Or
lo
cu
nd
ho
Oc
la
yc
cia
Ps
TKA THA
So
. Fig. 3.16 KTL analysis: Percentage of patients undergoing rehabilitation with at least one therapy unit/ rehabilitation.
(Source: IGES – Deutsche Rentenversicherung Bund 2010). Note: KTL = classification of therapeutic services (Klassifikation
therapeutischer Leistungen); the data presented is derived from the commonly used German Statutory Pension Insurance
classification system for therapeutic services. The system uncodes all the services rendered with the help of four-figure
codes. The data is collected routinely every year and serves the purpose of documentation and quality control within the
German Statutory Pension Insurance.
3.4.4 Implementation of Therapeutic and 41,459 KTL datasets from 2,186 patients after
Measures knee replacement were recorded (Deutsche Renten-
versicherung Bund 2010).
The »Therapy standards for medical rehabilitation The KTL data analysis contains information on
following THA and TKA« developed by the Ger- the percentages of patients who received treatment
man Statutory Pension Insurance provides an over- with the evidence-based therapy modules in ques-
view of therapeutic measures performed during tion and the average number of therapy units that
subsequent rehabilitation (AHB) (Section 3.4.1) were performed in one week (Gülich et al. 2010).
(Deutsche Rentenversicherung Bund 2011). The The results are summarized in Figure 3.16 and Fig-
standards were developed based on an analysis of all ure 3.17.
rehabilitation measures funded by DRV Bund According to this table, the majority of patients
which were completed between 1 January 2007 and received physiotherapy (99.5 %), physical therapy
the cut-off date of November 10, 2007 (Deutsche (96.0 %), movement therapy (89.0 %) and health
Rentenversicherung Bund 2010). education (89.0 %). Over half the patients received
This analysis included patients in subsequent occupational therapy/nursing care (61.0 %), THA/
rehabilitation (AHB) who received therapy and who TKA education (51.0 %) and therapy with a move-
had a primary or secondary diagnosis of »osteo- ment brace (CPM) (51.0 %). It is important to note
arthritis of the hip« (ICD-10 M16) or »osteoarthritis that the DRV therapy standards were revised in
of the knee« (ICD-10 M17) recorded in their dis- 2011 and in part include some reworded evi-
charge summary and who had had a joint implant dence-based therapy module titles and different
(Z96.6 or Z98.8). Under these criteria, 66,842 KTL KTL code allocations. However, the titles of some
datasets from 3,652 patients after hip replacement modules remain the same and the core contents
9
8
7
6
Number
5
4
3 3
2
1
0
py
py
py
re
rt
re
ng
PM
tio
tio
io
po
ap
ca
ca
ra
ra
ra
at
eli
(C
ca
ca
er
up
e
he
he
up
uc
ns
th
sin
th
du
du
ce
ns
tt
lt
w-
d
io
ra
ica
d
he
te
le
ur
en
co
ys
tio
lo
an
tb
/n
na
n
em
ys
Ph
ol
alt
aw
ra
tie
py
ng
en
tio
ff
Ph
g
He
ov
l
pa
no
ra
te
eli
em
ity
tri
M
in
ns
A
Nu
ur
tio
th
ov
TK
b
ou
ec
Jo
al
za
M
A/
ls
lc
n
ni
tio
TH
cia
ca
ga
pa
gi
so
Or
lo
cu
nd
ho
Oc
la
yc
cia
Ps
So
TKA THA
. Fig. 3.17 KTL analysis: Therapy units per week (mean values). (Source: IGES – Deutsche Rentenversicherung Bund 2010).
Note: KTL = classification of therapeutic services (Klassifikation therapeutischer Leistungen); the data presented is derived
from the commonly used German Statutory Pension Insurance classification system for therapeutic services. The system un-
codes all the services rendered with the help of four-figure codes. The data is collected routinely every year and serves the
purpose of documentation and quality control within the German Statutory Pension Insurance.
are comparable (cf. Deutsche Rentenversicherung patients. The average ages were 75 and 74 years re-
Bund 2011, 2010). This means that the current pro- spectively. The final quality outcome of rehabilita-
vision of care, if provided according to the revised tion outcome quality was measured based on the
therapy standards, may differ slightly from the re- Staffelstein-score which takes into account both
sults presented. objective clinical findings and subjective aspects.
It should be noted that the analyses only include »Pain«, »Activities of daily living« and »Range of
working people. Accordingly, the patients« ages are movement« are each weighted one third. A total
comparatively low (THA: 54.1; TKA: 55.7) and can- score of 120 points can be achieved. The evaluation
not be considered representative of all patients un- was conducted with reference to an achievable reha-
dergoing rehabilitation after endoprosthetic surgery bilitation potential. It is suitable for both THA and
(Gülich et al. 2010). TKA. The Staffelstein-score improved from 64 to 92
Statutory health insurances are responsible for in the group of investigated THA patients and from
funding subsequent rehabilitation (AHB) of a ma- 57 to 87 in the group of TKA patients. On average,
jority of patients who are not working. However, to the greatest progress in rehabilitation determined
date, only little data on rehabilitation for SHI insu- by this score was observed in the first 2 weeks of
rees has been published. therapy. The rehabilitation goal for both groups was
The Barmer GEK reports that in 2009 almost set at a score of 86, which was achieved by 76 % of
90 % of approximately 2,200 insurees who had un- THA patients and by 57 % of TKA patients. The av-
dergone THA or TKA underwent inpatient rehabil- erage length of stay was 19.1 and 19.8 days respec-
itation. Their average age was 65 years, two thirds tively. However, in both groups almost 10 % of the
were over the age of 60 (Barmer GEK 2010). patients needed significantly more than 21 days
The AOK Rheinland conducted a pilot project (Tuncel et al. 2015b).
with the intention of establishing rehabilitation An investigation conducted by the Techniker
timelines and investigated 120 THA and 110 TKA Krankenkasse as part of the »TK EVA« rehabilita-
71 3
tion project investigated over 8,600 THA and 8,100 3.4.6 Post-Rehabilitation Care
TKA patients in 9 rehabilitation hospitals in Rhine-
land-Palatinate between 2007 and 2009. The aver- Post-rehabilitation care aims to guarantee the long-
age patient age was just under 75 years. By means of term outcome and presents an ongoing challenge.
a modified Staffelstein-score, the measured THA Most patients require further treatment after their
outcomes improved from 53 % to 78 % and the TKA rehabilitation treatment is completed. To this end,
outcomes from 50 % to 76 % (Baulig et al. 2015). the German Statutory Pension Insurance has initi-
ated a post-rehabilitation care system called »IRE-
NA« (Intensivierte REhabilitations NAchsorge)
3.4.5 Effectiveness of Subsequent which, however, has not yet been adopted by other
Rehabilitation payers. The system permits the patient to continue
with movement therapy measures after completion
Rehabilitation is generally regarded as a multi- of the DRV-funded rehabilitation. These measures
dimensional intervention and is consequently diffi- usually take place in groups in rehabilitation facili-
cult to evaluate. Literature reviews have described ties close to the patient’s domicile. Alternatively, the
that numerous small-scale controlled studies illus- practice-based treating physician prescribes 3 to 8
trate the positive effects of subsequent rehabilitation weeks of physiotherapy or device-based physiother-
treatment (AHB) after total hip and knee replace- apy. However, not all patients need this therapeutic
ment (Aliyev 2010; Baulig et al. 2015; Kladny et al. prescription in which case continuing with the
2002, 2001; Middeldorf and Caaer 2010; Müller et training program learned during rehabilitation for
al. 2015; Tuncel et al. 2015a, 2015b). Clear indica- a period of about 6 weeks sufficiently compensates
tions of improved pain reduction, improved joint for any remaining deficits. Patients can also be inte-
mobility, increased mobility and independence, re- grated into functional training which, for example,
duced falls, self-management as well as improve- is organized by the German league against rheuma-
ments in performing activities of daily living and tism (Rheumaliga).
participation in daily life have been observed.
A systematic literature review on the effective-
ness of different rehabilitation therapies in patients 3.4.7 Challenges
who have undergone hip and knee joint replace-
ments have shown that the studies conducted are After the introduction of DRGs in 2003, the length
vastly heterogeneous, and do not contain enough of acute-care hospital stays reduced significantly.
significant data. Up to now, it has been demonstrated The »REhabilitation und DIAgnosis Related
that individual therapy measures, such as sports and Groups« study (REDIA-Studie) is a prospective,
movement therapy as well as physiotherapy, are multi-center, randomized long-term study on the
effective. However, the data did not allow for conclu- effects of DRG introduction into acute care on med-
sions about the required frequency and duration of ical service requirements and the costs of rehabilita-
the measures (Müller et al. 2009). In 2014, the Advi- tion (von Eiff et al. 2011). 10 years later, admission
sory Council on the Assessment of Developments in to rehabilitation hospitals after hip or knee replace-
the Healthcare System (Sachverständigenrat zur Be- ment is, on average, one week earlier. Due to this
gutachtung der Entwicklung im Gesundheitswesen premature start of rehabilitation, a significant dete-
(SVR)) established that »the lack of an evidence base rioration in the patients« condition at the start of the
common to many cases does not automatically prove rehabilitation was observed. This, in turn, led sig-
that rehabilitation is ineffective«. Even though there nificantly higher costs for the rehabilitation hospi-
is predominantly no proof of efficacy under con- tals, i.e. for more staff to assist with the therapy,
trolled conditions, it can indeed be assumed that changing dressings and wound treatment as well as
benefits exist. However, it is often questionable as to for more pain medication, antibiotics, thrombo-
whether they have an added benefit over alternative prophylaxis and laboratory tests. Patient resilience
treatments (SVR Gesundheit 2014). was affected owing to the reduced overall condition
after surgery. The Staffelstein-score decreased from expected patient numbers in orthopedics and trau-
78 to 70. The number of complications also in- ma surgery, covering this demand through geriatric
creased steadily. Therefore, between 2003 and 2009, departments will be very challenging. In addition,
the number of wound healing complications in- not all elderly patients benefit from geriatric treat-
creased from 1.6 to 6.5 %, the number of hemato- ment because they do not require it (Kladny 2015).
mas from 4 to 10.8 % and mobility impairments due More often, specialist rehabilitation by a multidisci-
3 to complications from 1.6 to 12.3 %. A consequent plinary team with competency in geriatric medical
increase in the number of patient transferals back care will be required. Specialist rehabilitation treat-
into acute care constituted a significant cost factor ment will have to adapt to the specific requirements
for the rehabilitation institutions involved, as the of a patient group which is growing increasingly
transport costs are usually included in the rehabili- older (Dreinhofer and Schwarzkopf 2010).
tation case fees. This urgently requires structural and financial
While these figures undoubtedly demonstrate a adaptations. At present, there is only one so-called
higher financial burden on the rehabilitation insti- rehabilitation phase in orthopedic treatment,
tutions, no increase of the remuneration rates for which, as described earlier, has prerequisites such
subsequent rehabilitation treatment (AHB) can be as the ability to undergo rehabilitation and is large-
seen in practice, not even for the nursing rates paid ly based on patients who are mobile and can look
by the statutory health insurance funds. after themselves. Meanwhile, however, this is un-
Process changes could potentially lead to im- doubtedly no longer the case. A multi-phase care
provements: The immediate start of so-called »fast- system with several levels of care, as has already
track rehabilitation« in the acute-care hospital could been introduced in neurology, also seems worth-
become an interesting option. A recent literature while for orthopedics. The patient is assigned to a
review found that this can reduce the length of hos- specific rehabilitation phase depending on the in-
pital stays. In addition, there were indications that tensity of the required assistance and nursing care.
early intervention can improve the patient’s physical With increasing independence, the rehabilitation
state at the start of rehabilitation treatment (Quack the phase may be changed to the next phase. Natu-
et al. 2015). rally, the required resources for phases that require
a high intensity of nursing care are significantly
higher and are consequently accompanied by high-
3.4.8 Outlook er nursing care fee rates.
From a scientific perspective, the data situation
The demographic change with its increasingly aging for assessing the effectiveness and cost-effectiveness
population and simultaneous improved care has led for rehabilitation measures, including their duration
to a marked rise in the number of patients who and intensity, is limited for subsequent rehabilitation
undergo elective joint replacement surgery and in (AHB) following replacement surgery as well as for
endoprosthetic treatment of femoral neck fractures most other procedures. Moreover, no clear criteria
(Dreinhofer and Schwarzkopf 2010). Evidently, this for allocating patients to ambulatory or inpatient re-
has a significant impact on acute-care hospitals and habilitation exist. In 2014, the Advisory Council on
particularly also on the rehabilitation hospitals: An the Assessment of Developments in the Healthcare
increasing number of multimorbid patients with System found: »There is a lack of high-quality, multi-
significant mobility restrictions and who are in need armed, prospective studies which could be conduc-
of nursing care need to be looked after. ted in a rehabilitation setting despite some metho-
This demands a structural change: The develop- dological challenges. In order to realize such studies,
ment of geriatric traumatology centers can be un- more rehabilitation research funding is needed so
derstood as a response to the increasing number of that appropriate high-quality study designs can be
fragility fractures and is characterized by the inter- applied to large patient cohorts. To this end, rehabili-
disciplinary treatment through surgical depart- tation research should be organized across the payer
ments and geriatric institutions. However, given the institutions in future« (SVR Gesundheit 2014).
3.5 · Quality Aspects of Care
73 3
3.5 Quality Aspects of Care The meanwhile established German joint
replacement registry »Endoprothesenregister
Quality of care can be considered from different Deutschland (EPRD)« (Section 4.3) aims to inform
perspectives. From the angle of attaining treatment manufacturers »through an early warning system
outcomes which are relevant to the patient, factors that provides early feedback on potential problems,
such as avoiding complications and improving innovation risks and outcome shortfalls« as well as
quality of life are in the foreground. From a statu- longer-term results for the implants used (Hassen-
tory health insuree perspective, maintaining high pflug and Liebs 2014). For example, for hip and knee
average treatment outcomes throughout Germany, prostheses, the Australian National Joint Replace-
avoiding unnecessary primary replacements and ment Registry separately details specific, concrete
premature revision surgery are important for ma- products with higher than anticipated rates of revi-
king efficient use of financial resources. On the sion (AOA 2014). As different registries use differ-
other hand, the providers of core medical services ent systems, detailed knowledge of the registry’s
(replacements/ revision surgery) and rehabilitation methodology is necessary for evaluating and com-
establishments are interested in avoiding compli- paring the results.
cations in patients and attaining optimal results
with limited funds. In doing so, they aim to fulfill
their medical responsibility, successfully acquire 3.5.2 Surgery and Perioperative
patients in competition with other establishments Management
and, beyond this, fulfil statutory quality assurance
standards. The following section will discuss fac- There are no conclusive study results which permit
tors that could have an influence on the quality of definite comparisons and demonstrate a specific
care. procedure to be fundamentally superior. For hip
joint replacements, less invasive access routes with
techniques that are sparing with the soft tissue (no
3.5.1 Materials detachment of the muscle insertions) are consid-
ered advantageous. There are some studies which
The materials used in replacement surgery have suggest that using such techniques subsequently
been subject to continuous step-by-step innovation result in less pain, shorter lengths of stay and fewer
for a long time. All materials used in endoprosthet- blood transfusions. However, a higher learning
ics are subject to mechanical strain, especially the curve must be taken into account on introducing
articular joint surfaces, i.e. the bearing, high-fric- less invasive access techniques and their overall sig-
tion surfaces. Over time, friction will inevitably lead nificance is ultimately still unclear (Ibrahim et al.
to wear and tear of the material, through which par- 2013). To date, for knee joint replacements, it has
ticles can also be released into the surrounding tis- not been shown that less invasive access techniques
sue. This can lead to tissue reactions and bone loss with reduced muscular trauma and less impact on
which, in turn, lead to loosening and failure of the the tissues surrounding the joint are advantageous
joint implant. Materials are advanced with the help compared to conventional access techniques (Ibra-
of tribology research, as has been the case, for in- him et al. 2013). Precise implant alignment plays a
stance, with more wear-resistant materials (Mit- major role in knee replacement. A wrong alignment
telmeier et al. 2012). and incorrect rotation can result in an abnormally
Joint replacement registries can contribute to high degree of implant abrasion, early loosening
the early detection of undesired features or anoma- and patellofemoral problems (Ibrahim et al. 2013).
lies in certain product types and devices, even A retrospective analysis of over 1,100 cases of
though validation through direct comparison is not primary hip replacements in a German university
possible and despite the fact that international reg- hospital suggests that a longer duration of surgery
istries have neither consistent nor uniform early significantly increases the probability of postopera-
warning concepts (Liebs et al. 2014). tive complications, particularly if the surgery takes
longer than 90 minutes (6.4-fold increased risk of things. In studies and meta-analyses, regional anes-
complication). Therefore, a shorter duration of sur- thesia for hip replacements is considered superior to
gery is more favorable for the treatment outcome general anesthesia with regard to the duration of
(Zenk et al. 2014). surgery, blood loss, the need for transfusions, the
In addition, Prokopetz et al. (2012) report a link risk of thromboembolic events, postoperative nau-
between longer surgery duration and revision sur- sea and vomiting. A positive effect on functional
3 gery and the occurrence of infections. In Germany, outcomes 3, 6 and 12 months after surgery is unclear
performing a TKA takes an average of 74.5 minutes. (Atchabahian et al. 2015). The intraoperative injec-
In contrast, average revision surgery, as defined by tion of local anesthetics into the area surrounding
External Quality Assurance for Inpatient Care the joint can have a positive effect on the postoper-
standards, takes over 2 hours and has higher com- ative pain (Andersen and Kehlet 2014; Kerr and
plication rates during the inpatient stay compared Kohan 2008).
with inpatient stays for primary replacement. Antibiotic prophylaxis, which is also performed
Hip revision can be performed in one-stage or in the majority of cases in Germany, is deemed nec-
two-stage (i.e. in two steps over time) procedures. essary and reduces the risk of postoperative wound
According to the report on External Quality Assur- infections, particularly when administered as a sin-
ance for Inpatient Care in Germany, 9.4 % of all gle shot, regardless of whether this is done locally
revision surgery in 2014 was reported to have been (in the cement) or systemically (Gollwitzer et al.
performed in a two-stage procedure (AQUA-Insti- 2011). Multimodal (interdisciplinary) care concepts
tut 2015b). (such as »fast track« or »enhanced recovery«) en-
In cases of aseptic loosening, one-stage surgery compass the inpatient treatment period from ad-
is generally accepted, whereas revision surgery for mission to discharge. The concepts aim to shorten
infected endoprostheses (septic endoprosthesis) is the time required for functional recovery and in-
usually performed in a two-stage procedure. At any crease patient satisfaction by reaching functional
rate, early and radical wound debridement with re- goals more rapidly during inpatient treatment and
moval of the infected implant is considered impor- consequently shortening the length of stay. More-
tant in the treatment of septic endoprostheses. The over, they aim at reducing the overall patient mor-
two-stage procedure permits identifying the patho- tality and morbidity. Additionally, avoiding com-
gen and potential resistance between removing the plications while accelerating convalescence can
endoprosthesis and the actual revision. A disadvan- contribute to improved cost efficiency (Husted
tage here is a higher morbidity and lower quality of 2012). The multimodal care concepts implement
life during the time when the patient is without an clinical elements such as pain management, throm-
endoprosthesis (Gravius et al. 2011). boembolism prophylaxis and mobilization. They
Preoperative patient information ranks highly also integrate individual patient characteristics and
amongst the non-surgical quality assurance meas- aspects of their home life into structured interdisci-
ures. This not only involves providing information plinary treatment pathways with clearly defined and
about risks, advantages, the procedure and fol- documented outcome parameters (therapy goals)
low-up care for the respective surgery, which alone (Husted 2012).
can lead to reduced pain and less anxiety for the In a meta-analysis (n = 22 studies), Barbieri et
patient. Matching the surgeon’s and the patient’s ex- al. (2009) investigated the effect of structured treat-
pectations for the treatment outcome is of greater ment pathways for hip and knee joint replacements.
importance as these often diverge and, additionally, For the observed treatment pathways the rate of in-
there is a link between patient satisfaction and ful- patient complications was significantly lower and
filled expectations. the length of stay shorter compared to the normal
The anesthetic method is individually selected care pathway (Barbieri et al. 2009).
for the patient and takes into account the perioper- A retrospective cohort study conducted in the
ative risk, the surgical procedure and the expected Netherlands demonstrated a clear reduction in the
(postoperative) pain and mobility, amongst other length of stay for hip joint replacements after the
75 3
. Tab. 3.16 Surgeons and anesthetists’ assessments and prognosis of the degree of influence of individual factors on
length of stay reduction for hip and knee joint replacement
Area Evaluation for the period
2010–2012 Prognosis (2013–2015) 2010–2012 Prognosis (2013–2015)
Hip
Surgeon Anesthetist
Anesthetic method Low Low Medium Low
Treatment pathways High High High High
Fixed discharge criteria Medium Medium Medium Medium
Reduction of complications Medium Medium Medium Medium
Surgical technique Medium Medium High Medium
Economic factors High Medium Medium High
Patient education Medium High Low Low
Patient selection Low Low Low Medium
Pain management High High High High
Knee
Surgeon Anesthetist
Anesthetic method Medium Medium Medium Low
Treatment pathways High High High High
Fixed discharge criteria High High Medium Medium
Reduction of complications Medium Medium Medium Medium
Surgical technique Medium Medium High Medium
Economic factors Medium Medium Medium High
Patient education Medium Medium Low Low
Patient selection Low Low Low Medium
Pain management High High High High
Source: IGES – Jaschinski et al. 2014
implementation of an enhanced recovery treatment In 2014, Jaschinski et al. published a nationwide

pathway compared to before or after the implemen- survey of hospital physicians in Germany, asking
tation phase (den Hartog et al. 2015). which factors the physicians considered relevant for
A registry study showed that in Norway, a fast reducing the length of stay (in the past and in fu-
track treatment concept was also associated with ture). The assessments of surgeons performing hip
low rates of complication and revision and high pa- and knee replacements and those of the anesthetists
tient satisfaction after primary and revision hip and are presented in . Tab. 3.16, grouped into three de-
knee surgery, even in the 1 year follow-up (Winther grees of impact (high, medium, low) for each poten-
et al. 2015). tial influencing factor.
This shows that especially treatment pathways 3.5.4 Hospital

and pain management are considered to be factors
that significantly influence the reduction of the Given the major role surgeons play and the impor-
length of stay. Patient selection (i.e. the careful selec- tance of their degree of experience for treatment
tion of patients for surgery) and the anesthetic outcomes gives rise to the question of whether a
method chosen, on the other hand, are considered minimum number of replacement surgery cases
3 to have the lowest level of influence according those should be made a requirement in hospitals as well.
surveyed (Jaschinski et al. 2014). Studies demonstrate a link between a surgeon’s
number of performed cases and postoperative mor-
tality, and suggest that the mortality associated with
3.5.3 Surgeon hip replacements is related to the number of pa-
tients treated in the hospital (Haas et al. 2013).
The surgeon plays a major role. He/she is responsi- In Germany, a minimum number of cases per
ble for planning treatment and performing the sur- hospital has been set as a requirement for total knee
gery, through which he/she substantially influences arthroplasty (7 Chapter 4), but not yet for hip re-
all aspects specific to the procedure which are replacements.
flected in the treatment outcome. Regardless of minimum case number regula-
In their systematic review, Prokopetz et al. tions, the hospital structures are of significant im-
demonstrated that surgeons who have conducted portance for setting discharge criteria. Discharge
low numbers of operations constitute a risk factor criteria can contribute to shorter length of stays
for revision total arthroplasty after primary THA. when used in multidisciplinary settings but they
Conversely, this signifies a lower risk of revision to- have only been established in 40 % of hospitals in
tal arthroplasty when the surgeon has more experi- Germany (7 Chapter 4).
ence. The surgeon’s (practical) experience therefore Meanwhile, many hospitals have been certified,
seems to be of significant importance. Regardless of with which they aim to validate and improve their
the precise anchoring technique for hip replace- quality assurance measures and to inform their pa-
ments (hybrid, cemented, cementless), the most tients about their good quality of care. Particularly
experienced surgeons only took an average of 53.2 the EndoCert system described in 7 Chapter 4 is
(± 17.4) minutes, surgeons with medium-level ex- particularly worth mentioning here.
perience took on average 74.5 (± 25.5) minutes and
surgeons with the least experience took an average
of 80.8 (± 21.9) minutes. 3.5.5 Patient
The rate of postoperative complications was
highest for the least experienced surgeons with Fulfilled patient expectations with regard to the sur-
5.0 %, as opposed to 3.0 % for the more experienced gery have a significant impact on treatment out-
and 2.7 % for the most experienced surgeons. The come satisfaction. Therefore, it is important that the
analysis shows that for surgeons with the least expe- surgeon and the patient discuss expectations prior
rience, the risk of complications is always funda- to surgery. Patient and surgeon surveys suggest that
mentally higher, regardless of the actual duration of patients with total hip replacements have particu-
the surgery (Zenk et al. 2014). larly higher expectations of being able to do sports
Overviews of studies on surgeons performing after the operation than their surgeons. In general,
knee and hip replacements demonstrate a predomi- patients with more physical restrictions and those
nantly positive correlation between the case numbers with lower incomes tend to be more optimistic than
of performed operations performed by a surgeon and their surgeons with regard to the treatment out-
the outcome with regard to complications or revision comes (Jourdan et al. 2012).
(Haas et al. 2013). Experienced (specialist) surgeons A study involving more than 1,300 patients who
who have performed a higher number of operations underwent primary total hip replacement across a
have a positive effect on the treatment outcome. total of twelve European countries demonstrated
77 3
that patients with higher expectations prior to sur-
. Tab. 3.17 Range of patient expectations related to
gery are more likely to have improvements after the THA
operation (measured by means of functionality
scores). Especially joint function and/or joint stiff- Subject and related patient percentage [%]
ness as well as pain perception correlated positively expectation (n = 1,035)
with the expectations (Judge et al. 2011). . Tab. 3.17
Long walking distance 46.0
shows the different expectations of the patients sur-
veyed in the study in the order of frequency of re- Housework 26.7
sponse. Activities of daily living 25.7
Further patient-related factors that can influ-
Sport and leisure activities 25.1
ence treatment outcomes can evidently be found in
the patient prerequisites (Günther et al. 2015). In Feeling less pain 23.6
the past, for instance, a patient’s body mass index Being pain-free 23.0
(BMI) was often discussed, i.e. how far being over- Gardening 19.1
weight has an impact on the treatment outcome. A
Shopping 10.9
review, which included a quantitative analysis, con-
cluded that obese THA patients more frequently Work 8.2
have dislocations, aseptic loosening, infections and Leading an independent life 8.0
venous thromboembolism (Haverkamp et al. 2011).
Returning to normal activities as 7.3
A higher body mass index (BMI) in knee joint far as possible
replacement patients can cause higher rates of post-
Driving 5.4
operative complications and a lower prosthesis ser-
vice life. Additionally, this has a negative impact on Holidays 3.5
the (subjective) patient satisfaction (Lüring et al. Looking after others 3.4
2013). Therefore, obesity seems to tend to have a
Sleeping 1.9
negative effect on the treatment outcome with re-
gard to complications. In individual studies, obesity Sexual activity 0.5
was also observed to have a negative effect on hip No expectations 1.0
revisions (Lübbeke et al. 2007).
Other investigations, which included several Source: IGES – Judge et al. 2011
thousand THA patients from different studies, show
that even with a high BMI, there were significant im-
provements in patient-reported treatment outcomes It is unclear whether exercise has a positive or
and from this point of view, a high BMI should not be negative impact on the (medium to long-term)
an obstacle for total arthroplasty (Judge et al. 2014). treatment outcome. Patient surveys indicate that
Concomitant diseases are discussed as frequent- THA patients who do sports have a higher overall
ly as patient-related influencing factors. They are satisfaction with the surgery (Simmel et al. 2008).
considered to be cofactors for the THA implant sur- Regardless of the types of exercise »permitted« by
vival period and have a direct impact on the rate of international guidelines, literature recommends
complications. Especially diabetes mellitus and advising patients individually on the possibilities
other diseases that negatively influence the patient’s and risks of specific sport activities after THA, also
immune response increase the rate of postoperative with regard to specific rehabilitation measures
infections (Günther et al. 2015; Zhu et al. 2015). This that can help prepare the patient for a specific
is confirmed by calculations conducted by the Bar- sport activity (Jacobs et al. 2009). Early revision
mer GEK based on surveys and routine data. They total arthroplasty for younger patients is dis-
identified that a higher patient age and the presence cussed, as they exercise a comparably higher strain
of concomitant diseases constitute negative factors on the endoprosthesis (Claes et al. 2012, Wirtz
for successful surgery (Barmer GEK 2010). 2011).
Smokers are advised to refrain from smoking for 3.5.6 Post-Discharge Treatment
at least 4 weeks before and after the surgery, as this Outcomes
has shown advantages for hip and knee joint surgery
complication risks (Gollwitzer et al. 2011). Beyond In general, about 6 to 7 weeks following (primary)
this, alcohol abuse is considered a patient-related hip or knee joint replacement patients should largely
risk factor, i.e. a behavior that is entirely within the be able to move the affected leg free of pain and bear
3 patient’s responsibility, for aseptic loosening full weight on it. Walking without any support at all
(AQUA-Institut 2012e). The prescribed postopera- is usually possible after 10 to 12 weeks. However,
tive medication, e.g. for pain management, should annual medical follow-ups should be conducted to
be taken consistently so that the patient is as symp- examine the patient’s gait, any residual symptoms as
tom-free as possible (Section 3.3.3). well as to assess the need for medical technical aids,
Furthermore, there seems to be a link between amongst other things (Heisel 2008). Whether sport-
high ASA scores and the frequency of postoperative ing activities outside of medical rehabilitation (e.g.
complications. Being over the age of 70, male and fitness workouts, cycling, swimming) can be under-
having a concomitant disease also lead to a higher taken after a total replacement, particularly after
complication profile for knee joint replacements THA, mostly depends on individual patient charac-
(Lüring et al. 2013). teristics such as age, concomitant diseases, bone
There also seems to be a connection between quality and condition of the muscles. Psychological
the preoperative stage of the disease and postoper- factors, including risk awareness and ambition,
ative patient satisfaction with knee replacements in should also be taken into account when making any
that patients who suffer from only mild osteoar- recommendations. As a rule, patients are recom-
thritis are less satisfied (excluding mechanical rea- mended to abstain from undertaking medically un-
sons). Additionally, existing osteoporosis could be supervised (leisure) sports activities for 3 to 6 months
a negative factor for treatment outcome. Other fac- (Schmitt-Sody et al. 2011). In addition, a recent me-
tors that have a negative influence, at least in the ta-analysis found evidence that the behavioral and
short term, could be the patient’s life circumstances movement restrictions which are, in part, still fre-
(being single, separated, widowed, unemployed, quently prescribed for the first few weeks or months
pensioned) or suffering from depression (Schäfer et following hip replacements (e.g. supine lying posi-
al. 2010). Ultimately, however, these connections tion, using walking aids, avoiding bending the hip
have not been validated, as individual studies have joint by over 90 degrees) do not lead to lower rates of
reported the opposite and the complex intercon- luxation. On the contrary, patients who were given
nections have not yet been fully elucidated (Lüring more lenient behavioral restriction recommenda-
et al. 2013). tions (»not sitting with crossed legs«) or none at all
Providing good preoperative patient informa- resumed activities earlier and showed a greater level
tion not only enables discussion of expectations, of satisfaction (van der Weegen et al. 2015).
advantages and risks of the surgery, but also informs The 2010 Barmer GEK Hospital Report investi-
the patient about the demands of postoperative re- gated the quality of life of selected insured patients
habilitation and the necessity of his or her active and their level of outcome satisfaction following
participation in the recovery process. The patient’s THA or TKA treatment by means of a written, ret-
compliance and motivation are of major impor- rospective and multidimensional survey.
tance, particularly for complex rehabilitation meas- The results show that the quality of life for THA
ures (AQUA-Institut 2012f). patients who were operated in 2003 was compara-
ble to that of patients who had surgery later in
2008/2009 (determined at an average of 9.2 and 9.3
months after the index surgery respectively). This
demonstrates that the quality of surgery remained
consistent over a period of several years. The report
uses scores based on the so-called Nottingham
79 3
. Tab. 3.18 Patient satisfaction results after hip surgery, survey on behalf of Barmer GEK
Hip Knee
Initial survey 2004 Initial survey 2009 Initial survey 2004 Initial survey 2009
Satisfaction with the n = 556 n = 1,106 n = 334 n = 1,016

artificial hip joint:
- (entirely) satisfied 58.3% 63.4% 44.9% 43.2%
- partially satisfied 33.3% 28.7% 38.0% 38.5%
- not satisfied 8.5% 8.0% 17.1% 18.3%
Willing to undergo n = 559 n = 1,109 n = 335 n = 1,020

another total arthro-
plasty if required:
- fully 76.9% 75.4% 62.7% 60.7%
- with limitations 18.2% 20.9% 29.6% 27.6%
- no 4.8% 3.7% 7.8% 11.7%
Willing to recommend n = 552 n = 1,102 n = 332 n = 1,020

total arthroplasty:
- fully 80.3% 81.1% 68.7% 65.5%
- with limitations 15.9% 15.5% 20.8% 21.8%
- no 3.8% 3.4% 10.5% 12.7%
Health Profile (NHP), a tool for collecting subjec- mend the procedure. However, a small number of
tive patient reports (patient-reported outcome the interviewees had undergone revision surgery
measures, PROM) for the domains energy, pain, and not primary surgery.
emotional reaction, sleep, social isolation and phys- Additionally, response results from patients
ical mobility. The highest scores and hence the who had been interviewed for the first time in 2004
most marked limitations, were assessed for the do- and who were again interviewed in 2009 (n = 424, n
mains energy, pain, sleep and physical mobility = 425, n = 421) differed only slightly to the previous
(highest score, i.e. worst result: 20.4 out of a maxi- results, showing that the overall level of symptoms
mum of 100 for sleep in the initial 2004 survey) remained distinctly low, even 5 years after primary
(Barmer GEK 2010). surgery (Lequesne index). Results for patient satis-
Three aspects were surveyed for outcome satisfaction were also comparable to the first survey
faction: satisfaction with the artificial hip joint, will- (Barmer GEK 2010).
ingness to undergo another total arthroplasty if A similar analysis is available for TKA patients.
required, and willingness to recommend total ar- In initial surveys conducted in 2004 and in 2009,
throplasty. The results of the initial 2004 and 2009 health-related quality of life and satisfaction of the
surveys are presented in . Tab. 3.18. According to selected patients were recorded approximately 9
these results, the majority of patients who had un- months after surgery (Barmer GEK 2010). To this
dergone surgery in 2003 and in 2008/2009 were sat- effect, the Nottingham Health Profile was used, en-
isfied with the joint replacement and were willing to abling the patients to self-rate their subjective health
undergo another total arthroplasty or to recom- in six domains: energy, pain, emotional reaction,
. Tab. 3.19 Mean values and standard deviations as percentages of satisfied/dissatisfied patients after TKA
Satisfaction (%) Dissatisfaction (%)
1990–1999 81.2 (±9.5) 16.9 (±10.5)
2000-2012 85.0 (±7.9) 8.5 (±5.6)

3
Europe (13 publications) 83.8 (±8.0) 8.9 (±6.6)
North America (10 publications) 85.2 (±6.9) 12.5 (±4.2)
Source: IGES – Schulze and Scharf 2013
sleep, social isolation and physical mobility. The after TKA for periods from 1990 to 1999 and from
highest scores, and hence the greatest limitations 2001 to 2012. . Tab. 3.19 shows the most signifi-
were rated for pain, sleep, physical mobility and en- cant results and illustrates the patients« overall
ergy. The health-related quality of life scores in 2004 higher level of satisfaction and lower level of dis-
and 2009 remained almost unchanged. The overall satisfaction following surgery compared to the
highest score (31.8 out of a maximum of 100 points) previous decade. The main influencing factors
was observed for pain in the initial 2004 survey. Six with regard to postoperative satisfaction were
and a half years after the index surgery, minor to body mass index, postoperative joint function, ex-
moderate declines were observed in all domains pectations, pain, mental function and employment
compared to the survey conducted 9 months after status (Schulze and Scharf 2013). In addition, pre-
surgery. Noticeable deteriorations were observed in operative expectations, particularly with regard to
the domains of energy (+5.9) and physical mobility functional improvement, influenced treatment
(+4.0), which are not, however, statistically signifi- outcomes and consequently patient satisfaction
cant. The scores for pain remained at a higher level (Judge et al. 2011). Improved outcome quality is
and relatively stable. linked to providing patients with realistic informa-
The results also show that almost half of the pa- tion, patients« attitudes towards the procedure as
tients with artificial knee joints were entirely satis- well as the careful selection of patients. (Halawi et
fied and that the majority of patients were prepared al. 2015).
to undergo another total arthroplasty and were will- Additionally, the success of joint replacement
ing to recommend the procedure to others. These surgery can be measured based on whether a patient
levels of satisfaction, however, tended to be lower reintegrates into working life. An analysis of routine
than those for THA. data from the German Statutory Pension Insurance
The results of the follow-up survey in 2009 are shows that 85 % of patients aged between 18 to 60
also available. The responses of the patients who years, who had undergone hip joint replacements
were followed-up in 2009 and had been interviewed and subsequent rehabilitation (AHB), were able to
for the first time in 2004 differed only slightly from resume work within 2 years after rehabilitation
the earlier results (n = 261 for satisfaction with the treatment. Particular risk factors for failing to re-
artificial knee joint, n = 260 for willingness to under- turn to working life were older age and having a
go another total arthroplasty, n = 206 for willingness manual occupation. The analysis also shows that
to recommend total arthroplasty). Consequently, the after rehabilitation approximately 37 % of the pa-
reduction of symptoms and the satisfaction 5 years tients observed earned a lower salary and hence had
after surgery were comparable to the values obtained lower social security contributions. Moreover, the
9 months after surgery (Barmer GEK). authors demonstrated that 17 % of the patients ob-
A systematic review based on existing stud- served changed jobs after hip joint replacement
ies investigated postoperative patient satisfaction (Krischak et al. 2013).
81 3
. Tab. 3.20 Surgery with documented, fulfilled indication criteria, primary arthroplasty and revision total arthro-
plasty. Nationwide results based on operations performed in Germany (2014)
Quality indicator Result 2014 Trend
Primary hip replacement with fulfilled indication criteria 95.84 % 
Revision hip replacement with fulfilled indication criteria 93.10 % 
Primary knee replacement with fulfilled indication criteria 96.86 % 
Revision knee replacement with fulfilled indication criteria 92.31 % 
Note: The arrows in the »Trend« column describe »whether progress in quality of care in 2014 compared to 2013 is
positive (upward pointing arrow), negative (downward pointing arrow) or unchanged (horizontal arrow)«.
Source: IGES – AQUA-Institut 2015b, c, d, e
3.5.7 Indications surgery, do not yet exist in standardized or evi-

dence-based forms (Claes et al. 2012, Wirtz 2011,
A German federal group of experts defines the indi- Günther et al. 2013). In addition, cases with defined
cator used for external quality assurance for inpa- standardized indications such as trauma cases,
tient care purposes, for both primary THA and amongst others, are not represented in the external
TKA. This is standard procedure for defining qual- quality assurance (7 Chapter 6).
ity indicators in general. The defined quality goal is For revision total arthroplasty, the rate of appro-
that »an appropriate indication be used frequently«, priate indications documented is lower than for pri-
which is why the indicator selection is based on mary surgery and shows a consistent trend. The
equivalent features found in literature and in inter- indicator is defined differently than in primary sur-
national guidelines. For primary hip replacements, gery. The quality goal for hip and knee arthroplasty
data is recorded in patients with at least one pain here is »a frequently used appropriate indication
criterion or at least one movement restriction crite- based on clinical symptoms, radiological criteria or
rion as well as one specific documented value for the signs of inflammation«. Operations in patients with
degree of severity of osteoarthritis. For primary the defined criteria are assessed in relation to the
knee replacements, data is recorded in patients who total number of recorded operations (. Tab. 3.20;
have at least one pain criterion and a specific docu- AQUA-Institut 2015c, e).
mented value for the degree of severity of osteoar-
thritis. The number of operations that meet these
documented criteria are assessed in relation to the 3.5.8 Regional Differences
total number of recorded operations (AQUA-Insti-
tut 2015b, d). Studies suggest that there are regional differences
According to in a national survey on primary in quality of care. Figure 3.18 shows the rates for
hip and knee replacements, the overall results have each federal state of unfulfilled indication criteria
been within the target range and have been improv- developed by the AQUA Institute based on THA
ing continuously for several years. The increase in patients. For comparison purposes, the average
documentation of appropriate indications for the rates in Germany are also presented. This shows
national survey shows that surgery with document- that in Lower-Saxony, the number of unfulfilled (or
ed, previously undefined indication criteria was not recorded) indication criteria is almost twice as
performed in individual cases only (2014: < 5 %). A high as the German average of 4.8 % or 3.4 % for
limiting factor, however, is that the fundamental THA and TKA respectively. Besides Lower-Saxony,
criteria such as the degree of pain or the time of the Bavaria, Saxony-Anhalt and Rhineland-Palatinate
12%
10%
8%
3 6%
Percentage
4%
2%
0%
y
rg
ria
de n
g
Ha en
rg
se
ia
ela estp y
-P alia
Sa e
Sc xon ony
Ho lt
Th in
a
an
Rh e-W xon
gi
at
an rli
ur
lan
ha
rth Low eran
e
be
bu
es
va
em
in
lst
tin
Br Be
nb
h
rm
Sa Sax
es -An
H
ar
m
m
Ba
Sa
ur
Br
ala
m
Ge
tte
y
Rh er
Po
g-
ür
wi
nd
rn
W
in
te
n-
hl
es
de
in
W
Ba
g-
No
ur
nb
kle
Primary THA
ec
M
Federal state Primary TKA
. Fig. 3.18 Percentage of unfulfilled indication criteria used for external quality assurance for inpatient care for primary THA
and TKA in German federal states (2013). (Source: IGES – AQUA-Institut 2014a, 2014c)
12%
10%
8%
6%
Percentage
4%
2%
0%
y
rg
ria
de n
g
Ha en
rg
ia
ela estp y
-P alia
Sa e
hl ny-A y
Ho lt
Th in
a
an
Rh e-W xon
gi
s
at
an rli
ur
lan
wi nha
rth Low eran
e
be
bu
rn Hes
o
va
in
lst
tin
Br Be
nb
h
rm
Sa Sax
ar
e
m
m
Ba
Sa
ur
r
ala
m
Ge
B
tte
Rh er
Po
g-
ür
o
nd
x
W
es
in
te
n-
es
de
in
Sc
W
Ba
g-
No
ur
nb
kle
Hip revision total hip repacement surgery

ec
M
Federal state Knee revision total knee replacement surgery
. Fig. 3.19 Percentage of unfulfilled indication criteria used for external quality assurance of inpatient care for revision THA
and TKA in German federal states. (Source: IGES – AQUA-Institut 2014b, 2014d)
References
83 3
are above the national average with regard to the are above the nationwide average of 6.4 % and 7.1 %
rate of unfulfilled of indication criteria for both hip with regard to unfulfilled indication criteria for the
and knee replacement surgery. These rates have hip and knee respectively.
shown relatively constant trends in most of the The general trend of these rates has remained
federal states. The results for entire Germany, relatively constant in most federal states. The results
Baden-Württemberg, Bavaria and Schleswig-Hol- for entire Germany, Baden-Württemberg, Bavaria
stein improved relative to the previous year (AQUA- and Schleswig-Holstein improved relative to the
Institut 2013a). previous year (AQUA-Institut 2014a).
The same analysis with regard to revision total While the trends for individual federal states do
arthroplasty shows a different regional distribution not show any significant changes compared to the
(. Fig. 3.19). Saxony-Anhalt, Mecklenburg-Western previous year, a decrease by 0.7 percentage points
Pomerania, Saxony, Thuringia, Rhineland-Palati- was documented in the average for Germany
nate, Schleswig-Holstein as well as Lower-Saxony (AQUA-Institut 2014b).
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91 4
Healthcare System
Stakeholders
Hubertus Rosery, Tonio Schönfelder
4.1 State Actors – 92
4.2 Federal Joint Committee – 93
4.3 Quality Assurance Initiatives – 94

4.3.1 AQUA Institute – 94
4.3.2 Institute for Quality Assurance and Transparency in Healthcare – 95
4.3.3 German Arthroplasty Registry »Endoprothesenregister
Deutschland« – 95
4.3.4 endoCert – 96
4.3.5 Project on Quality Assurance of Inpatient Care using
Routine Data – 97
4.3.6 Quality Assurance Measures in Rehabilitation – 98
4.3.7 Review of Orthopedics and Trauma Surgery Research – 98
4.4 Medical Societies and Professional Associations – 99
4.5 Patient Support and Advice – 100
4.6 The German Medical Technology Association (BVMed) – 101
4.7 Training and Further Education of Healthcare Staff – 101

4.7.1 Basic and Specialty Training of physicians – 101
4.7.2 Training and Continuing Education for Nursing Staff – 102
References – 102

DOI 10.1007/978-3-662-55918-5_4
92 Chapter 4 · Healthcare System Stakeholders
Summary Alongside representing the interests of their mem-

In order for a medical device to be marketable in bers and offering basic and specialty training, medi-
Europe it must bear the CE mark. CE certification is cal societies also assume an important role with re-
granted if the device conforms to specific safety and gard to research and towards improving the quality
performance requirements. Monitoring is conducted of healthcare. The trauma registry »TraumaRegister of
by so-called »Notified Bodies«. Manufacturers can the German Society for Trauma Surgery (Deutsche
select any one of these certification bodies to certify Gesellschaft für Unfallchirurgie (DGU))« is affiliated
a medical device. In Germany, the certification proce- with hospitals specializing in trauma surgery and
4 dure for endoprostheses is regulated in the Medical aims to evaluate the effectiveness of methods used
Device Directive 93/42/EEC and is implemented in medical treatment. The German arthroplasty asso-
through the Medical Devices Act and further decrees. ciation »Deutsche Gesellschaft für Endoprothetik
Up to now, the AQUA Institute for Quality Improve- (AE)« is a division of the German Society for Ortho-
ment and Research in the Healthcare System (AQUA- paedics and Trauma (Deutsche Gesellschaft für
Institut für angewandte Qualitätsförderung und Orthopädie und Unfallchirurgie (DGOU)) and is
Forschung im Gesundheitswesen) has been responsi- involved in quality assurance of endoprosthetic care
ble for external inpatient quality assurance which is and in the development of new technologies.
mandatory in Germany. The institute publishes
detailed reports concerning the quality outcomes of
patient care, which both hospitals and patients can 4.1 State Actors
use for comparisons with other establishments. As of
2016, the Institute for Quality Assurance and Trans- In order for a medical device to be marketable in
parency in the Healthcare System (Institut für Qual- Europe it must bear the CE mark. CE mark certifi-
itätssicherung und Transparenz im Gesundheits- cation can be obtained if the device conforms to
wesen (IQTiG)), which was founded by the Federal specific safety and performance requirements.
Joint Committee, has assumed this responsibility. Medical devices are categorized into four classes (I,
The German arthroplasty registry »Endoprosthen- IIa, IIb, III) in addition to active implants. The clas-
register Deutschland« was initiated in 2013 and aims sification is based on the potential safety risk that
to document quality outcomes of knee and hip ar- the medical device bears when it is used. A walking
throplasty across Germany. The purpose of the regis- aid (class I) is categorized in a lower class than a
try is to enable the tracking of typical service lives of dental implant (class IIb) or a hip implant (class III).
implants used and to investigate reasons for unde- The medical device’s class determines the types of
sired treatment outcomes. The validity of the registry conformity assessments that are to be conducted.
is still limited as about only half of the hospitals that Hip and knee endoprostheses are class III devices
perform arthroplasty currently contribute to it and and are therefore subject to stringent testing (BMG
only a limited number of primary hip and knee 2010).
arthroplasties are recorded. Conformity assessment procedures are con-
EndoCert is a certification system that was estab- ducted by so-called »Notified Bodies«. As of No-
lished by the German Society of Orthopedics and vember 2015, 62 Notified Bodies have been operat-
Orthopedic Surgery (Deutsche Gesellschaft für Or- ing in Europe of which 13 are based in Germany
thopädie und Orthopädische Chirurgie (DGOOC)) (European Commission 2015). Endoprosthesis
and the German arthroplasty association »Deutsche manufacturers are free to choose any Notified Body
Gesellschaft für Endoprothetik (AE)« and the Profes- that has been notified to certify their products in a
sional Association of Orthopaedic Surgeons particular device category. Notified Bodies are
(Berufsverband der Fachärzte für Orthopädie und state-accredited and state-monitored. An expert
Unfallchirurgie e. V. (BVOU)). group for certification bodies from the Central Au-
Initial results show a decline in complication rates thority of the Länder for Health Protection with
and an improvement in outcome quality amongst a regard to Medicinal Products and Medical Devices
few certified institutions. (Zentralstelle der Länder für Gesundheitsschutz bei
4.2 · Federal Joint Committee
93 4
Arzneimitteln und Medizinprodukten (ZLG)) is re- desausschuss (G-BA)) is the highest decision-mak-
sponsible for notifying and monitoring the certifi- ing body for this structure.
cation bodies as stipulated by the Medical Devices
Act.
Devices bearing the CE mark are available on 4.2 Federal Joint Committee
the market for a limited period only. After five years
at most the quality management systems of both the The Federal Joint Committee (G-BA) is the highest
manufacturer and the devices must be recertified decision-making body of the joint self-government
according to § 11 section 11 of the Medical Device consisting of healthcare providers and payers in
Directive (MDD). Following an initial certification, Germany. The G-BA decides which services are
annual audits are conducted by the Notified Bodies. covered by statutory health insurance (SHI) as well
In addition, the Notified Bodies conduct spontane- as which quality assurance measures are employed
ous audits of the manufacturers and their major in patient care (G-BA 2015a).
suppliers (European Union 2013). External quality assurance within hospitals is
The certification procedure for endoprostheses regulated by § 137 Volume V of the German Social
is standardized and regulated by the Medical Device Security Code. The G-BA has commissioned the
Directive 93/42/EEC which is implemented in AQUA Institute for Applied Quality Improvement
Germany through the Medical Devices Act and oth- and Research in Health Care (AQUA-Institut für
er decrees. Endoprostheses that have been granted angewandte Qualitätsförderung und Forschung im
the CE mark according to the Medical Devices Act Gesundheitswesen GmbH) for the supervision and
are marketable across the 31 member states of the implementation of external inpatient quality assur-
European Economic Area. ance (Section 4.3.1). Annual publications on exter-
According to § 15 of the Medical Devices Act, nal quality assurance for the years from 2009 to
the Federal Ministry of Health (Bundesministerium 2015, which also exist for THA and TKA amongst
für Gesundheit (BMG)) must inform the Federal other procedures, are available on the AQUA Insti-
Ministry for Economic Affairs and Energy (Bunde- tute website (http://www.sqg.de, accessed: 24 Feb-
sministerium für Wirtschaft und Energie (BMWi)) ruary 2016). According to § 137a Volume V of the
of which bodies have been notified by the ZLG and German Social Security Code, the G-BA is respon-
what their assigned responsibilities are. Subse- sible for the founding of the Institute for Quality
quently, the BMWi informs the European Com- Assurance and Transparency in Healthcare (Institut
mission. Beyond this, the BMG has various respon- für Qualitätssicherung und Transparenz im Ge-
sibilities which directly and indirectly affect the sundheitswesen (IQTiG)) as an independent scien-
field of arthroplasty. These include establishing reg- tific institute. Since 2016, the IQTiG has assumed
ulations for medical rehabilitation and developing the role of the AQUA Institute’s quality assurance
frameworks for monitoring medical devices. tasks with regard to endoprosthetics (Section 4.3.2).
The Federal Institute for Drugs and Medical Since 2005, hospitals in Germany which have
Devices (Bundesinstitut für Arzneimittel und been approved to treat statutory health insurance
Medizinprodukte (BfArM)) is an independent fed- patients are obliged to publish structured quality re-
eral authority within the Federal Ministry of Health ports online. Amongst other details, these reports
portfolio and is both directly and indirectly involved include case numbers for individual indications and
in the field of arthroplasty. Responsibilities of the operations that a hospital has performed. In addi-
BfArM with regard to medical devices include cen- tion, the hospitals are obliged to publish some of the
tralizing recording, evaluating and assessing risks outcomes of the surveyed indicators for external in-
and coordinating relevant corrective measures that patient quality assurance purposes. Patients can
subsequently need to be taken (BfArM 2013). therefore obtain information about the procedures a
The BMG also assumes a supervisory role in the hospital is specialized in and check the measurable
healthcare system’s joint self-governing structure. quality outcomes (quality indicators) before under-
The Federal Joint Committee (Gemeinsamer Bun- going treatment. However, as these reports only con-
tain past outcomes, they can only give a reference had increased their case number to precisely the
and do not cover all potential quality indicators (G- threshold value (de Cruppé et al. 2014). According
BA 2014b). Since 2013, a G-BA reference database to the so-called »TKA transparency list of the feder-
provides access to overall German hospital quality al associations of the health insurance funds and the
reports. Information from these reports can be ac- Federation of Private Health Insurance Funds«, 808
cessed with hospital search engines providing fur- German hospitals met the minimum number re-
ther details on individual quality aspects that have quirement for TKA in 2011 (vdek 2011). This is
not been included in the above mentioned reports. markedly lower than the number of hospitals that
4 The database can be accessed through the following performed primary TKA in 2011.
website: http://www.g-ba-qualitaets-berichte.de/ It should be noted that the minimum volume
(accessed: 22/12/2015) (G-BA 2015b). The G-BA regulation applies to primary total arthroplasty.
introduced a regulation with regard to the annual Unicondylar prostheses replacement and revision
number of total knee arthroplasties which is set at a total arthroplasty which are technically more de-
minimum of 50 procedures per hospital (site) per manding are not governed by this regulation. This
year. This means that hospitals may only provide can lead to distortions in service provision as hospi-
these services on behalf of the SHI if they expect to tals increasingly perform total arthroplasty in order
perform at least 50 TKAs per year (G-BA 2014a). to meet the minimum number requirements. Con-
This regulation is based on study data for hip and sequently, fewer unicondylar sledge prostheses are
knee endoprosthetics which show a predominantly implanted, even though this procedure is less harsh
positive connection between case numbers and on the bones.
treatment outcomes (Haas et al. 2013, Lau et al. 2012,
Schräder and Ewerbeck 2007, Zenk et al. 2014).
The minimum volume regulation includes the 4.3 Quality Assurance Initiatives
following procedures (G-BA 2014a):
4 5-822.9** custom-made prosthesis, 4.3.1 AQUA Institute
4 5-822.g** bicondylar surface prosthesis,
4 5-822.h** femoral and tibial stem prosthesis, The AQUA Institute was commissioned to supervise
4 5-822.j** endoprosthesis with enhanced flexion, and implement external quality assurance for inpa-
4 5-822.k** bicompartmental partial joint tient care. For distinct medical procedures such as
prosthesis. THA and TKA (primary and revision surgery), treat-
ments in all hospitals in Germany are documented
However, there are exceptional budgets which allow according to certain quality indicators. The data are
a hospital to perform TKAs and be reimbursed by recorded, prepared and evaluated by quality offices at
the SHI even if it has not reached the limit of 50 state level (LQS) and by the AQUA Institute (up until
operations per year. An example of this is emergen- 2015). Comparative feedback on the outcomes is pro-
cy surgery (G-BA 2014a). An analysis of data from vided to the hospitals. If individual hospitals show
German hospital quality reports from 2004 to 2010 irregular outcomes, the LQS conduct a so-called
concluded that despite the introduction of mini- »structured dialogue« with the hospitals in order to
mum volumes, case numbers which were previous- initiate measures towards improving quality.
ly below the specified limit have not been in decline. The AQUA Institute has made comprehensive
This also applies to TKA. According to the evalua- and detailed quality reports available concerning
tion, this was the case for approximately 8 % of hos- the outcomes of patient care in hip and knee endo-
pitals performing primary TKA (n=81) and 1 % of prosthetics, which is an important aspect in the de-
all cases (n=2,048) in 2010. 19 hospitals did not in- bate regarding quality of care in this particular field
dicate any relevant exceptional budgets in their of healthcare.
quality reports. In contrast, the analysis shows a External hospital quality assurance publications
sharp increase in the number of hospitals that were for endoprosthetics are available on the internet at:
just below the minimum volume threshold and that www.sqg.de in the following areas:
4.3 · Quality Assurance Initiatives
95 4
4 primary total hip arthroplasty, and is continuously being updated. The data are
4 revision total hip arthroplasty and component stored for over a period of 30 years (EPRD 2015b).
revision, The aim of the registry is to enable tracking of
4 primary total knee arthroplasty, individual implant components, to determine typi-
4 revision total knee arthroplasty and compo- cal service lives of a product and to investigate rea-
nent revision. sons for undesired treatment outcomes which are
not always due to the implant. Patients can therefore
The web page lists the national evaluations and de- be kept informed if they are potentially affected by
scriptions of quality indicators for the period from outcome abnormalities. In addition, the registry en-
2009 to 2014. As of 2016, the newly founded IQTiG ables the analyses of data at a hospital level, taking
has assumed the AQUA Institute’s role in the field of into account not only information about the implant
endoprosthetics. itself but also aspects of inpatient care and patient-re-
lated factors. Physicians, hospitals, endoprosthesis
manufacturers and health insurance funds are in-
4.3.2 Institute for Quality Assurance formed of the results serving as a basis for the further
and Transparency in Healthcare development of quality assurance measures (EPRD
2015b, Hassenpflug and Liebs 2014).
The Institute for Quality Assurance and Transpar- Establishment of the registry was initiated by
ency in Healthcare (IQTiG) was founded in early the German Association for Orthopaedics and
2015 by partners in the joint self-governing struc- Orthopaedic Surgery (DGOOC), the AOK Federal
ture of the healthcare system and the BMG (IQTiG Association, the Association of Substitute Health
2015). On behalf of the G-BA, it is to develop meas- Insurance Funds (vdek), the BQS Institute for Qual-
ures for quality assurance and present quality of care ity and Patient Safety (BQS) and the prostheses
criteria in the healthcare system and take part in manufacturers represented by The German Medical
their implementation (IQTiG 2015). The IQTiG fo- Technology Association (BVMed) (EPRD 2015a, b).
cuses mainly on cross-sectoral quality assurance The registry is managed by »Deutsche Endoprothe-
and developing evaluation criteria for certificates senregister EPRD gGmbH«, a DGOOC subsidiary
and quality seals. The IQTiG evaluation results are (EPRD 2015a). It is financed by participating health
to be published transparently and presented in a insurance funds, hospitals and by the industry. Ac-
manner that is understandable by the general public cording to its own statements, the registry is exclu-
(IQTiG 2015). sively committed to scientific principles and guar-
antees the independent and neutral evaluation of
documented data (EPRD 2015b).
4.3.3 German Arthroplasty Registry The EPRD was initiated in Germany in 2011
»Endoprothesenregister and following a probation phase was introduced
Deutschland« nationally in 2013. Hospitals that perform arthro-
plasty can contribute to the EPRD (EPRD 2015b).
The German arthroplasty registry »Endoprothesen- Arthroplasty registries were introduced in other
register Deutschland (EPRD)« (EPRD 2015a) aims countries much earlier than in Germany. In Sweden,
to document quality outcomes of knee and hip ar- for instance, knee arthroplasty registries were intro-
throplasty across Germany (EPRD 2015b). To this duced in 1975 and hip arthroplasty registries in
end, routine hospital accounting data and pseu- 1979 (Kärrholm 2010, Knutson and Robertsson
donymized patient data from the health insurances 2010). Various studies have demonstrated signifi-
(for example, underlying diseases) are analyzed to- cant decreases in the rates of complications and in
gether with the manufacturers« data of the implant- the necessity of revision replacements following the
ed prosthesis components. A product database was introduction of these registries (Herberts and Mal-
established in order to identify prostheses compo- chau 2000, Malchau et al. 2005, Swedish Knee
nents. It currently lists approximately 45,000 items Arthroplasty Register (Hrsg.) 2014). Other arthro-
plasty registries exist in Norway, Finland, Denmark, 4.3.4 endoCert

England, Canada, Australia and New Zealand (Has-
senpflug and Liebs 2014). endoCert is an initiative and a certification system
The EPRD’s 2015 status report largely presents for centers that perform knee and hip arthroplasty.
descriptive data on primary hip and knee arthro- The initiative was started by the DGOOC with the
plasty and revision arthroplasty according to patient support of the German association for arthroplasty
age and gender. The most common reason for revi- »Deutsche Gesellschaft für Endoprothetik (AE)« of
sion total hip and knee replacement is implant loos- the German Society for Orthopaedics and Trauma
4 ening (hip: 46.7 %, knee: 39.4 %) followed by infec- (DGOU) and the Professional Association of Or-
tions (hip: 10 %, knee: 13.9 %). Implant component thopaedic Surgeons (BVOU) (7 Section 4.4).
failure accounted for of 3.3 % of all revision total hip endoCert aims to develop and assure quality of
arthroplasties and 2.9 % of revision total knee ar- treatment through the certification of medical
throplasties. Determining implant service life based centers based on up-to-date scientific insights and
on the data is not yet possible as the majority of on its experience through the establishment of med-
patients undergoing revisions underwent primary ical centers in other fields. At present, this certifica-
surgery before they were recorded in the EPRD tion concept is limited to elective arthroplasty (Haas
(EPRD 2015b). et al. 2013). General criteria for the certification
Significant and reliable results can only be process are presented in . Fig. 4.1.
achieved through high rates of participation in the Medical centers are required to provide docu-
registry (Hassenpflug and Liebs 2014). According to mentation that cover structural quality (e.g. equip-
February 2016 figures, 684 out of 1,200 hospitals ment, staff qualification), process quality (e.g.
that performed arthroplasty participated in the reg- standardized treatment pathways) and outcome
istry. In 2015, over 140,000 endoprosthetic hip and quality (patient-reported results, e.g. satisfaction
knee replacements were documented (EPRD 2016). and objective outcomes).
Participation in the registry and the quantity of
data submitted therein is voluntary. Data on im-
plants and surgery are only recorded after a patient
Providing patient
has given his/her consent in writing following which Interdisciplinary and support throughout the
participating hospitals can decide whether they cross-sectoral entire treatment process
document the data for all affected patients or not organization of (collaborative and
(EPRD 2015b). Given that the recording of such treatment processes involving all professional
groups concerned)
data is not mandatory, there is the risk of consider-
able data loss or having only partially documented
data in the registry. This may lead to data biases in Qualified training and
Participation in external
that the actual quality of treatment may not be fully quality assurance
continuing education for
measures with bench-
depicted through the registry. When interpreting physicians and health
marking and regular
the registry evaluations, one must take into account professionals
certification
the fact that the represented population consists of
patients insured by the statutory health insurance
AOK and the Association of Substitute Health In- Coordinated treatment
surance Funds »vdek« (EPRD 2015b). The source settings in which infor- Willingness to conduct
mation and advice are or support qualified
population consequently represents approximately actively provided to research (particularly
two thirds of the insurees from statutory and private patients; active involve- health services
health insurances in Germany (BMG 2015). Poten- ment of patients in research)
tial differences amongst those insured by the health treatment decisions
insurance funds and insurance companies can in-
fluence the validity of the outcomes of the analysis . Fig. 4.1 General criteria for the endoCert certification
of the registry. process. (Source: IGES – Haas et al. 2013)
4.3 · Quality Assurance Initiatives
97 4
The minimum case volume thresholds for ar- However, at present it is expected that the long-
throplasty for different centers are listed below. term effects of endoCert on treatment outcomes
However, the initiative emphasizes that these are not (complications, service lives) can only be evaluated
recommendations for legal minimum volume regu- in combination with the EPRD (Section 4.3.3). Hos-
lations: pitals that participate in endoCert are also obliged
4 Arthroplasty center: At least two main sur- to participate in the EPRD (Haas u. Mittelmeier
geons who each perform at least 50 THAs and/ 2014).
or TKAs per year (on their own or as responsi-
ble assistants)
4 Arthroplasty center providing comprehensive 4.3.5 Project on Quality Assurance of
care: At least two main senior surgeons who Inpatient Care using Routine Data
each perform at least 100 THAs and/or TKAs
per year, including revision total arthroplasty In 2002, the quality assurance initiative for inpatient
surgery care using routine data »Qualitätssicherung der sta-
tionären Versorgung mit Routinedaten (QSR)« was
This results in a link between minimum case num- started as a joint research project between the AOK
bers for surgeons and minimum case numbers for Federal Association, HELIOS Kliniken, the research
arthroplasty centers (at least 100 per year) and ar- and development institute for social affairs and the
throplasty centers providing comprehensive care (at healthcare system in Saxony-Anhalt »Forschungs-
least 200 per year). und Entwicklungsinstitut für das Sozial- und Ge-
Centers that would like to attain certification sundheitswesen Sachsen-Anhalt (FEISA)« and the
must provide evidence showing that they conform to AOK Research Institute (Wissenschaftliches Insti-
the quality requirements at all levels (establishment, tut der AOK (WidO)). The project aimed to »review
structures, processes, outcomes). After an application the possibilities of measuring quality on the basis of
has been submitted, assessed and any further ques- SHI routine data« and specific quality indicators
tions and outstanding issues have been clarified an were developed to this end (WiDO 2007).
on-site audit is conducted. The center is subsequent- Information on hospital stays is obtained from
ly granted a period of time in order to rectify any routine data, in the same way as for statutory exter-
shortfalls. Certifications are limited to a duration of nal hospital quality assurance data collection. The
3.5 years. Besides the initial audit, additional super- main difference with regard to statutory quality as-
visory audits are conducted and the center is audited surance measures and an advantage of the project is
again once the certification has expired. If the center that several episodes within the chain of a patient’s
no longer fulfills the given requirements at this time, treatment can be combined to obtain longer-term
the certification can be suspended or, in the worst treatment outcomes. This is made possible through
case, revoked (Haas et al. 2013). data from AOK insurees. The major limitations of
The endoCert website (www.endocert.de) lists this approach are that the data pool is restricted to
471 certified treatment centers in Germany (as de- AOK insuree data only, the characteristics of which
termined on 24 February 2016). Some endopros- differ to those of the general population, in addition
thetics centers (comprehensive care) have reported to the fact that the data used for the quality analysis
a reduction in complication rates and improve- were collected for other purposes and hence only
ments in quality of outcomes after implementation permit limited observations concerning the quality
of the certification (Lewinski et al. 2015). Attaining of treatment (Jeschke et al. 2013).
certification works as an incentive for the centers as
they can demonstrate a high level of quality of care
to the general public and their (potential) patients
and also improve treatment outcomes allowing
them to attain good benchmarking levels and exter-
nal inpatient quality assurance results.
4.3.6 Quality Assurance Measures obtain patient evaluations on the success of

in Rehabilitation treatment,
4 assessments of individual rehabilitation pro-
Quality assurance measures are also conducted for cesses by experienced rehabilitation staff,
rehabilitation treatment. Ambulatory and inpatient 4 documentation of the range of therapeutic
rehabilitation institutions with care contracts (ac- services provided by the rehabilitation insti-
cording to § 111, 111a or 111c section 1 Volume V tutions,
of the German Social Security Code) are to conduct 4 developing rehabilitation guidelines for the
4 external quality assurance measures according to § structuring of rehabilitation measures.
137d Volume V of the German Social Security
Code. In addition, legal regulations exist for estab- These measures also cover THA and TKA. Rehabil-
lishing internal quality measures within the institu- itation establishments are issued so-called »Reports
tions according to § 135a section 2 Volume V of the on the quality assurance of rehabilitation« which
German Social Security Code. The Federal Associ- provide feedback about how they conform to the
ation of the Statutory Health Insurance Funds above-mentioned rehabilitation therapy standards
(GKV-Spitzenverband) agrees upon the external and to enable comparisons with other institutions.
quality measures with »the major care provider or- Therapy standards are divided into modules that
ganizations« according to § 137d Volume V of the enable targeted improvements if any shortfalls are
German Social Security Code. The agreement spec- identified (Deutsche Rentenversicherung Bund
ifies that the QSReha® procedure be the measure 2011). Systematic publications of quality assurance
(GKV Spitzenverband (Hrsg.) 2008). outcomes do not exist but overall results, for exam-
QS-Reha® takes into account structural quality, ple with regard to patient satisfaction, may be in-
process and outcome qualities as well as patient sat- cluded in other publications (Deutsche Rentenver-
isfaction. According to data currently available, ap- sicherung Bund 2013). In addition, assessments of
proximately 300 specialist institutions participate in patient discharge reports are conducted by experi-
QS-Reha®. They are listed on the website (http:// enced physicians in so-called peer reviews. Check-
www.qs-reha.de/; accessed: 24 February 2016). The lists for rehabilitation procedures, processes and
group of »musculoskeletal diseases« is included as indication-specific requirements are used for these
an indicator. In 2011, the BQS Institute won the ten- reviews (Baumgarten and Klosterhuis 2007).
der to evaluate quality assurance measures. Out-
comes from individual institutions are compared
with those in the same indication area in order to 4.3.7 Review of Orthopedics
obtain comparative quality outcomes and average and Trauma Surgery Research
outcomes. The procedure has not yet been fully es-
tablished. Ambulatory rehabilitation facilities for Diseases of the musculoskeletal system are amongst
musculoskeletal diseases (and other areas) have the most common diseases in Germany. In 2013,
only been included in the procedure during the cur- these diseases accounted for 313 days of incapacity
rently ongoing three-year data collection period to work per 100 insuree years with which diseases of
from 2015 to 2017 (QS-Reha 2015). the musculoskeletal system were more frequent
The German Statutory Pension Insurance also than any other type of disease (DAK 2014). Osteo-
conducts comprehensive quality assurance meas- arthritis is one of the most common joint diseases in
ures in the fields of structural quality as well as pro- adults worldwide. It is characterized by degenerative
cess and outcome quality. The procedures include diseases of the joints caused by wear and tear of the
(Deutsche Rentenversicherung 2015): articular cartilage. Large joints such as the hip (os-
4 surveys of the structural quality of rehabilita- teoarthritis of the hip) and knees (osteoarthritis of
tion institutions, the knee) are most commonly affected. In Germany,
4 patient interviews to determine patient satis- arthrosis of the hip or knee joint affects approxi-
faction with rehabilitation measures and to mately 28 % of women and approximately 20 % of
4.4 · Medical Societies and Professional Associations
99 4
men (lifetime prevalence) (7 Chapter 1). Arthro- modern computer simulations and robot tests be-
plasty has become an established procedure for fore they are approved (Mittelmeier et al. 2012).
treating these joint diseases (Mittelmeier et al. Further research in the future is to focus on
2012). physiological, biological, biomechanical mecha-
The DGOU surveyed the increasing prevalence nisms of action and their interactions with the aim
of musculoskeletal diseases in relation to demo- of developing new materials and bioactive coatings.
graphic trends, current therapeutic measures and Past research has contributed to developing specific
the need for further research. The results of this sur- types of synthetic materials that reduce implant
vey were published in a 2012 White Paper: »Research abrasion and consequently improve patient care
in Orthopedics and Trauma Surgery – Review and (Ewerbeck et al. 2012).
Outlook (Weißbuch »Forschung in Orthopädie und
Unfallchirurgie – Bestandsaufnahme und Aus-
blick«)«. The White Paper contains detailed infor- 4.4 Medical Societies and Professio-
mation about fundamental research, current renal Associations
search activities and future perspectives with regard
to musculoskeletal research (Mittelmeier et al. The German Society of Orthopedics and Orthope-
2012). dic Surgery (DGOOC, Deutsche Gesellschaft für
Due to demographic trends and the increasing Orthopädie und Orthopädische Chirurgie) is de-
number of younger patients being treated, it can be dicated to promoting orthopedics and represents
expected that the numbers of hip and knee arthro- the interests of approximately 3,000 members
plasties will rise in the future (Ewerbeck et al. 2012). (DGOU 2013). Besides providing continuing edu-
External quality assurance in the field of endopros- cation and specialty training programs in orthope-
thetics in Germany focuses on short-term outcome dics, the DGOOC is involved in developing evi-
quality documented up to the point of patient dis- dence-based guidelines in collaboration with other
charge (Liebs and Hassenpflug 2012). Long-term medical societies. Various DGOOC divisions are
outcome quality is currently not being systematical- responsible for the improvement in different ortho-
ly measured and the effects of different determi- pedic sub-specialties. Each division may found its
nants on outcome quality are unknown. It is still own non-profit association as, for example, the
currently unclear how long-term outcome quality rheumatic orthopedics division has done with the
could be measured precisely (service life, health-re- creation of the association »Deutsche Gesellschaft
lated quality of life, patient satisfaction) and how it für orthopädische Rheumatologie e.V« (DGORh
is affected by surgical procedures, implants, fol- 2015, DGOU 2013). Working groups within the
low-up care and individual patient characteristics DGOOC deal with specific scientific subject areas.
(Liebs and Hassenpflug 2012). According to the au- Currently, there are 17 working groups, including
thors of the White Paper, maintaining an endopros- the German joint registry (EPRD) working group
theses registry could be one way of measuring and (DGOOC 2015). The DGOOC established the
evaluating patient data with regard to long-term EPRD (Section 4.3.3) as a non-profit limited liabili-
quality as this has been shown to contribute to ty company under German law as a wholly-owned
significant improvements in the quality of care in subsidiary.
other countries (Liebs and Hassenpflug 2012). Such The German Society for Trauma Surgery (DGU,
a registry was introduced into German hospitals in Deutsche Gesellschaft für Unfallchirurgie) was
2013 (Section 4.3.3). founded in 1922 and includes approximately 4,600
Comparative sustainability testing for safe and members. The DGU is committed to providing ba-
low-risk medical devices is another objective that sic and specialty training as well as continuing edu-
has been identified for future research (Mittelmeier cation in orthopedics and trauma surgery. It pub-
et al. 2012). Simulations are to play a greater role in lishes guidelines for trauma surgery diagnostics and
the testing of implants in the future. New implants therapy and plays a major role in quality assurance
are to undergo endurance testing by means of and improvement of treatment for severely injured
patients (DGU 2015b). The DGU trauma registry training in orthopedics, trauma surgery and related
»TraumaRegister DGU« is an organization made up subjects in collaboration with the orthopedic acad-
of trauma surgery specialist hospitals which aims to emy »Akademie Deutscher Orthopäden« (BVOU
assess the quality of care and evaluate medical treat- 2015b).
ment methods with regard to their effectiveness. Together with the AE and the BVOU, the
Over 100,000 datasets from severely injured pa- DGOOC has developed an initiative for certifying
tients are currently documented in the Trauma medical institutions that offer joint replacement
Register DGU (DGU 2015a). The DGU trauma net- services (endoCert, section 4.3.4).
4 work »TraumaNetzwerk DGU« aims to establish
nationwide networks for interdisciplinary care of
severely injured patients and consequently optimize 4.5 Patient Support and Advice
treatment (DGU 2015a).
The German Society for Orthopaedics and The German association for osteoarthritis support
Trauma (DGOU, Deutsche Gesellschaft für Or- »Deutsche Arthrose-Hilfe e.V.« is a registered
thopädie und Unfallchirurgie) represents the inter- non-profit association which aims to inform people
ests of its two funding bodies, the DGOOC and suffering from osteoarthritis about the causes, pre-
DGU in orthopedics and trauma surgery. The vention and treatment of osteoarthritis. It also pro-
DGOU was founded in 2008 as a non-profit associ- vides support and counseling in individual cases.
ation and currently includes approximately 10,000 The association regularly publishes the »Ar-
members. Responsibilities of the DGOU include throse-Info« magazine which provides information
basic and specialty training, continuing education, about the different types of osteoarthritis, their
promotion of research in orthopedics and trauma diagnoses and treatment as well as prevention and
surgery, making networks and platforms available early detection methods (DAH 2015c).
for scientific exchange and enabling the communi- A further goal is to support scientific and clinical
cation of research results through different scientific osteoarthritis research (DAH 2015b) for example, by
journals (DGU 2015b). funding research projects and providing grants to
The German arthroplasty association »Deutsche young scientists. The association funded the estab-
Gesellschaft für Endoprothetik e. V. (AE)« is a divi- lishment of the EPRD, for example (Section 4.3.3), in
sion of the DGOU dealing with endoprosthetics addition to a study to measure patient preferences
(DGOU 2015). It was founded in 1996 as a non-pro- with regard to TKA as well as the in-vivo evaluation
fit association with the aim of improving the quality of hip implant fixation in THA (DAH 2015a).
of life of patients with joint diseases and injuries The German league against rheumatism
(Deutsche Gesellschaft für Endoprothetik 2014). »Deutsche Rheuma-Liga« includes 290,000 mem-
The AE’s main responsibilities include quality as- bers and describes itself as the largest self-help or-
surance and quality control of endoprosthetic care ganization in the field of healthcare. Its responsibil-
as well as the further development of existing and ities include offering support and self-help services
novel technologies for movement recovery. To this to patients, representing the interests of those suf-
end, the association works closely together with the fering from rheumatism in politics, healthcare and
medical technology industry (Deutsche Gesellschaft the public as well as promoting research (Deutsche
für Endoprothetik 2014). Rheuma-Liga 2015a). To this end, the Rheuma-Liga
The Professional Association of Orthopaedic collaborates closely with other associations and or-
Surgeons (BVOU, Berufsverband für Orthopädie ganizations such as the DGOOC (Deutsche Rheu-
und Unfallchirurgie) represents the professional ma-Liga 2015b). It makes comprehensive informa-
interests of orthopedic and trauma surgery special- tion available regarding endoprosthetics and facili-
ists in medical associations and political institu- tates decision-making processes with regard to re-
tions. The association currently includes approxi- placement surgery. Amongst other things, it
mately 7,000 members (BVOU 2015a). In addition, provides reports on patient experiences, a fact sheet
the BVOU organizes certified advanced and further on arthroplasty and information about treatment
4.7 · Training and Further Education of Healthcare Staff
101 4
options if an implant is defective (Deutsche Rheu- patient and accompanying diseases but also to med-
ma-Liga 2015c). ical staff involved in the operation. Studies on hip
The pain forum »Forum Schmerz« is a division and knee replacements demonstrate that a surgeon’s
of the German Green Cross (Deutsches Grünes professional capabilities can influence the rate of
Kreuz e. V.) which keeps patients informed on pain complications (Lau et al. 2012, Zenk et al. 2014).
therapy options and makes recommendations for
various approaches to treatment in collaboration
with a scientific advisory board. The forum pro- 4.7.1 Basic and Specialty Training
vides information online (http://www. fo- of physicians
rum-schmerz.de/schmerz-infos/arthrose.html, last
accessed: 22 December 2015) regarding osteoarthri- As registered organizations under public law in
tis, its causes, diagnosis, therapies and self-help op- Germany, all State Chambers of Physicians
tions (Forum Schmerz 2015). (Landesärztekammer) are responsible for offering
further specialist training. The German Medical As-
sociation (Bundesärztekammer) develops (model)
4.6 The German Medical Technology regulations on specialty training which serve as a
Association (BVMed) recommendation for the State Chambers of Physi-
cians (BÄK 2015). In addition to (model) specialty
As a trade association, The German Medical training regulations, (model) guidelines are also
Technology Association (BVMed) promotes and given for further training. These guidelines are
represents the interests of the medical technology developed in collaboration with the State Chambers
industry and trade companies in public and informs of Physicians and are also based on feedback from
political decisions (BVMed 2014b). The BVMed medical societies and professional associations. The
currently includes 227 member companies (BVMed (model) guidelines stipulate requirements for train-
2015a). ing in terms of the number of examinations and
The BVMed represents the interests of its mem- treatments that must be performed to attain a spe-
bers with regard to hip, knee, shoulder and spinal cific qualification. They also take into account aver-
implants, heart valves and defibrillators as well as age performance of hospitals and medical practices
medical dressings, incontinence products, synthetic (BÄK 2011).
disposable items such as catheters and cannulas, Specialty training for orthopedics and the
homecare services and nanotechnology applica- sub-specialty trauma surgery were merged in 2005
tions (BVMed 2014a). (BÄK 2015). The goal upon completion of this six-
The BVMed provides its members with infor- year specialty training for orthopedics and trauma
mation and advice on legal matters and regulations surgery is for physicians to attain basic and subse-
and establishes platforms for dialogue and exchange quent specialist competence in orthopedics and
through project groups, working groups and sector trauma surgery upon completion of the required
interest groups. The »Endoprosthetics – Implants« training period.
sector interest group is involved in public discus- According to the German Medical Association’s
sions and works towards informing political deci- 2013 model code of continuing professional devel-
sion-makers about the benefits of endoprosthetic opment, physicians must undergo continuing edu-
care (BVMed 2015a). cation in order to maintain and develop their profes-
sional expertise. Physicians are required to attain a
minimum of 250 additional training credit points
4.7 Training and Further Education within a period of five years. According to Volume V
of Healthcare Staff of the German Social Security Code, statutory health
insurance physicians and consultants in working in
The outcome of joint replacement surgery is not hospitals are required to provide further evidence of
only determined by factors relating to an individual participation in continuing medical education.
Professional associations (e.g. DGOOC, 4.7.2 Training and Continuing

DGOU) and institutional centers provide part of the Education for Nursing Staff
further training required. In addition, workshops
and seminars held by manufacturers of medical de- Nursing training is regulated by the Nursing Act
vices also constitute part of the further training (Krankenpflegegesetz). Surgical nursing staff firstly
(BVMed 2015b). Further training programs have work in a surgical unit for at least six months and
not been systematically evaluated. subsequently complete a two-year vocational train-
Further training and continuing education for ing program. Surgical technicians (Operationstech-
4 physicians and nursing staff plays an important role nischer Assistent (OTA)) undergo a three-year
in establishing integrated comprehensive risk and training program. OTAs support the surgical team
quality management under endoCert (Haas et al. and the patient before, during and after surgery
2013). (DOSV 2016). Training content and examination
regulations for nursing staff are developed in paral-
lel to those of physicians. Further training events,
workshops and seminars held by manufacturers of
medical devices manufacturers also constitute part
of the training and continuing education for nurses.
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105 5
Health Economic Aspects

Michael Weißer, Hubertus Rosery, Tonio Schönfelder
5.1 Costs – 106

5.1.1 Direct Costs – 106
5.1.2 Indirect Costs – 112
5.1.3 Intangible Costs and Health Burden – 112
5.2 Financing, Remuneration and Regulations – 114
References – 118

DOI 10.1007/978-3-662-55918-5_5
106 Chapter 5 · Health Economic Aspects
Summary possible arthroplasty case fees selected according to

The costs incurred for knee and hip arthroplasty de- the specific service provided and the circumstances
pend on the different type of treatments provided of each case. The case fees are based on the average
within the chain of medical care. Indirect costs of the costs of a given treatment. The case fee figures in
disease, such as the incapacity to work resulting from 2015, which were based on certain benchmarks,
the underlying diseases and intangible costs which ranged between approximately 6,400 euros and
cannot be evaluated in monetary terms, must also be 17,300 euros. However, case fees do not always seem
taken into account. Patient care is financed through to cover the hospital costs, particularly in the treat-
established remuneration systems. According to dif- ment of more complicated cases.
ferent publications, data extrapolations have shown
5 that German statutory health insurances spent ap-
proximately 1.4 to 1.6 billion euros per year on hospi- 5.1 Costs
tal treatments for hip arthroplasty between 2003 and
2009. With regard to knee arthroplasty, expenditure 5.1.1 Direct Costs
for the same period was estimated at 1.0 to 1.3 billion
euros per year. The direct costs for the associated in- Direct costs of treatment for patients who undergo
patient stays are financed through case-based fees, knee or hip arthroplasty include those incurred
which are in turn based on the actual average hospi- prior to surgery, during inpatient stay and over the
tal costs. The most commonly remunerated case fees course of postoperative treatment.
(hip arthroplasty/knee arthroplasty) have shown cost The typical ideal treatment pathway for patients
increases of a few percentage points over the last few with osteoarthritis of the knee and the hip starts in
years which are mainly due to the rising costs of an ambulatory setting with a consultation with a
personnel. In the two case-fee groups, implant costs primary-care physician and continues with the
constitute 21 % of the total cost for hip treatments referral to a practice-based specialist who subse-
and 25 % of the total cost for knee treatments. Par- quently refers the patient to hospital for surgery.
ticularly complicated cases such as infected hip en- After surgery, the patients undergo (subsequent)
doprostheses are relatively more costly. With regard rehabilitation procedures and, if necessary, follow-
to indirect costs, the diagnosis »Osteoarthritis of hip« up ambulatory care by the specialist physician
(ICD-10 M16) resulted in 2,585,157 days of incapacity (AQUA-Institut 2012).
to work amongst compulsory statutory health insu- Therefore, healthcare providers who are directly
rees (excluding pensioners) in 2011. For »Osteo- involved in the patient treatment, i.e. primary-care
arthritis of knee« (ICD-10 M17) the figure was almost physicians, practice-based specialists, hospitals and
double at 4,971,052. Some patients who are in rehabilitation establishments consequently incur
employment are unable to return to work despite healthcare expenses. Beyond this, physicians pre-
having undergone a joint replacement and either scribing medication, therapeutic products or medi-
have to change profession or accept a loss of income cal technical aids also add to further healthcare ex-
that includes social security contributions. Osteoar- penditure as do prescriptions for other care provid-
thritis, which is the most common reason for hip or ers (for example, physiotherapists) in addition to
knee replacements, is associated with a significant, material costs for equipment and consumables.
increasing and in part immeasurable disease burden. In 2008, the disease costs cited for the entire
International studies have demonstrated that the dis- spectrum of osteoarthritis (ICD-10 M15M16) in
ease is accompanied by a high degree of suffering on Germany amounted to 7.62 billion euros. This total
the part of the patient as the large majority (70 % or cost is distributed across various establishments
more) would be personally willing to finance the hip within the chain of care (Rabenberg 2013) as pre-
or knee arthroplasty at their own cost if the proce- sented in . Tab. 5.1.
dures were not included amongst those reimbursed Malzahn (2014) made various observations
by health insurance systems. Hospitals in Germany from an economic perspective with regard to the
finance the costs of arthroplasty with one of several conservative and surgical treatment of patients who
5.1 · Costs
107 5
treatment. The data shows that the group of older
. Tab. 5.1 Osteoarthritis-related disease costs in
Germany in 2008, by type of medical institution
patients constitutes the absolute majority of patients
observed, but that individual patient expenditures
Type of institution Total expenditure are lower for the older age group than for the young-
in million € er age group. This applies to both conservative and
surgical treatment (Malzahn 2014).
Ambulatory institutions 2,547
The largest single expenditure item for individ-
Doctors’ practices 978 ual patients, outside of expenses incurred in hospi-
Pharmacies 939 tal, was expenditure on therapeutic products. It re-
mains the largest single expenditure as long as the
Ambulatory care 515
expenditure for medication is divided into costs that
Others 660 are strictly related to osteoarthritis only and costs
Inpatient/day-care facilities 4,284 that are potentially connected to osteoarthritis in a
Hospitals 2,705 broader sense, as was done in the publication. These
expenditures are presented in . Tab. 5.3.
Preventive/rehabilitation facilities 873
. Tab. 5.4 presents expenditures for hospital ser-
Inpatient care/day-care 706 vices provided to the patient cohort observed. The
Other institutions 790 implantation of the actual prosthesis is included in
the 12 months after surgery expenditure period
Institutions in total 7,620
which is why preoperative hospital expenditure is
Source: IGES – Destatis (2015) the same for both considerations (with/without en-
doprosthetic replacement).
Endoprosthetic surgery costs have been estimat-
are of working age (20–59 years) who were suffering ed at 7,105.50 euros. This accounts for the difference
from osteoarthritis of the knee. His observations observed between hospital expenditure with and
were based on the individual one-year periods be- without endoprosthetic replacements (costs per pa-
fore and after arthroplasty to treat osteoarthritis of tient 12 months after surgery). The costs for the re-
the knee«. The data were obtained from services placement itself are to be considered as an estimate
provided to male AOK insurees who were of work- based on the lowest determined value. This value is
ing age. . Tab. 5.2 presents total expenditures for higher than the average expenditure for knee arthro-
individual patients in the periods 12 months before plasty as it includes treatment costs related to osteo-
to 12 months after surgery, divided into two age arthritis of the knee (main diagnosis M17) over a
groups and according to conservative or surgical period of three months after surgery (Malzahn 2014).
. Tab. 5.2 Total individual patient expenditures for total knee arthroplasty (TKA) due to osteoarthritis of the knee
Patient age (years) Case number Expenditure (€)
12 months before surgery 12 months after surgery
Conservative treatment Surgery
Including TKA Excluding TKA

expenditure expenditure
20-49 452 1,249.34 9,638.71 2,533.21
50-59 3,895 988.26 8,145.07 1,039.57
Source: IGES – Mahlzahn (2014)

. Tab. 5.3 Expenditures for therapeutic products, contractual physician care and drugs for patients with osteo-
arthritis of the knee who undergo total knee arthroplasty (TKA)
Patient age (years) Expenditure 12 months before surgery (€) Expenditure 12 months after surgery (€)
Expenditure for therapeutic products
20–49 125.25 378.97
50-59 133.38 395.57
Expenditure for contractual physician care
20-49 75.19 87.55

5
50-59 95.55 106.81
Expenditure for drugs I: strictly for osteoarthritis only
20-49 55.13 58.19
50-59 65.91 65.09
Expenditure for drugs II: potentially related to osteoarthritis
20-49 196.52 313.14
50-59 114.39 100.45
. Tab. 5.4 Hospital expenditure for patients with osteoarthritis of the knee who undergo total knee arthroplasty
(TKA)
Patient age (years) Expenditure 12 months before surgery (€) Expenditure 12 months after surgery (€)
per patient per patient
Hospital expenditure
20-49 797.28 8,800.86
50-59 579.03 7,477.15
Hospital expenditure excluding endoprosthetic replacement
20-49 797.28 1,695.36
50-59 579.03 371.65
According to the SHI Barmer GEK (2010), ex- The remuneration that a hospital receives for
trapolations from the period between 2003 and inpatient treatment cases constitutes the direct
2009 showed that statutory health insurance funds health insurance fund costs for the treatment case.
in Germany spent approximately 1.4 to 1.6 billion The hospitals receive fees on a case-per-case basis
euros per year on hospital treatment for hip arthro- (case fees) for individual inpatient stays for primary
plasty. For knee arthroplasty, the amounts for the total arthroplasty and revision total arthroplasty/
same period were estimated at 1.0 to 1.3 billion eu- revisions (the case fees are also labelled Diagnosis
ros per year (Barmer GEK 2010). Related Groups (DRGs)). The case fees reflect the
5.1 · Costs
109 5
average costs of treatment during a patient’s stay in
hospital.
6,291.7
6,164.7
6,097.8
5,947.4
5,966.3
Total
The most commonly remunerated endopros-
thetic procedure on the hip is DRG I47B (revision
or replacement of a hip joint without complicating
infrastructure
Non-medical
diagnosis/without complicating surgery). With re-
Personnel/material costs
gard to knee arthroplasty, the most common DRG
1,191.1
1,147.8
1,151.4
1,127.4
1,132.8
is I44B (implantation of a bicondylar endoprosthe-
8
sis or other endoprosthesis implantation/revision
on the knee joint) (InEK 2009), cf. . Tab. 5.5 and
frastructure
Medical in-
. Tab. 5.6.
As can be seen from the terms used to describe
430.2
419.4
411.2
395.5
385.4
the DRGs, the fees usually cover several different
7
types of interventions. Consequently, calculating
the average costs of primary arthroplasty, revisions
158.0
166.9
159.9
145.4
140.0
Other medical
6b*
requirements
and/or revision hip or knee replacements separately
is not possible. This is because the DRG system re-
305.1
297.1
305.2
303.5
326.5
munerates similar cases and treatments based on
6a*
. Tab. 5.5 Simplified calculation matrix, exemplified with G-DRG I47B (revision or replacement of a hip joint)
the average costs of different interventions.

The cost composition of an individual DRG is Implants
1,329.9
1,303.4
1,320.9
1,331.8
1,360.3
presented in . Tab. 5.5 and . Tab. 5.6 using DRG
I47B (endoprosthetics hip joint) and DRG I44B (en- 5*
doprosthetics knee joint) as examples. The German
Material costs [€]
institute for hospital reimbursement »Institut für 42.7
50.8
57.0
52.3
45.9
4b*
das Entgeltsystem im Krankenhaus (InEK)« collects

Medication
the relevant cost data from several hundred German

hospitals on an annual basis (§17b German Hospital
100.4
108.5
84.3
88.2
90.6
4a
Remuneration Act KHG (InEK 2014)). The calcula-
Note: *Individual costs/actual expenditures; source: IGES – InEK (2015c)

tions are defined by actual average cost data for spe-
Medical techno-
cific cases in a particular year. The tables contain

logical service
data from 2008 to 2013 illustrating changes in pro-

portions of the different costs.
659.3
639.3
610.5
587.1
602.1
. Tab. 5.5 shows that medical personnel (cost

3
type 1–3) account for the largest proportion of costs

Nursing/train-
related to DRG I47B cases, i.e. the average hip re-

ing service
placement or revision case (2,750.33 euros in 2013,

or just under 44 % of the total amount). In contrast,
Personnel costs [€]
938.6
938.5
920.4
884.0
891.3
implants show lower proportions of medical per-

2
sonnel costs at 1,329.94 euros or approximately

1,152.4
1,113.4
1,070.7
1,020.0
973.6
21 % of the total amount. From 2009 to 2013, the

Medical
service
costs for an average treatment case rose by approxi-

1
mately 325 euros, which was due to increasing staff

costs in particular. Implant costs, however, have
material costs,
Personnel and
hardly changed.
data for the
A similar trend is presented in . Tab. 5.6. In

2013, the staff costs related to hospital treatment
2013
2012
2011
2010
2009
year
cases under DRG I44B (implantation of a bicondy-

lar endoprosthesis or other endoprosthesis implan-
. Tab. 5.7 Costs of infected hip endoprostheses in
6,749.1
6,571.0
6,389.0
6,316.9
6,436.6
. Tab. 5.6 Simplified calculation matrix based on G-DRG I44B (implantation of a bicondylar endoprosthesis or other endoprosthesis implantation/revision on the knee joint)
the DRG system

Total
Group Patient Costs per

number patient (€)
infrastructure
Non-medical
Infected hip 49 29,331.36

Personnel/material costs
1,263.4
1,203.3
187.4
1,163.9
1,189.9
endoprosthesis
8
Primary THA 21 6,263.59

frastructure
Source: IGES – Haenle et al. (2012)

Medical in-
5
446.4
429.3
420.9
410.4
401.6
7
tation/revision on the knee joint) amounted to

2,887.37 euros (cost types 1-3), approximately 43 %
214.7
211.9
187.7
163.1
164.9
Other medical
6b*
requirements
of the total amount. Implant costs amounted to

1,504.78 euros or approximately 22 % of the total
313.8
309.4
316.4
320.0
344.1
amount. In these DRG cases, the costs also increased

6a*
by approximately 315 euros from 2009 to 2013. Al-

though implant costs decreased during this period,
Implants
1,504.8
1,527.4
1,508.4
1,566.1
1,632.0
staff costs in particular increased, as was the case for

DRG I47B. Haenle et al. (2012) conducted a retro-
5*
spective study on the costs of revision surgery due

Material costs [€]
to periprosthetic infection after primary total hip

30.9
36.9
40.2
43.1
37.9
4b*
arthroplasty. The study assessed a group of 49 pa-

Medication
tients who underwent revision (with different kinds

of revision procedures) the different costs of which
103.9
112.8
87.4
91.4
93.5
4a
were compared to the costs and remuneration for 21

Note: *Individual costs/actual expenditures; source: IGES – InEK (2015c)
patients with primary total hip arthroplasty. All the

Medical techno-
patients were treated in the Rostock University

logical service
Medical Center. The 49 patients with infected endo-

prostheses had an average length of stay of 52.7
748.3
711.3
662.2
644.6
666.3
days, of which 4.4 days were in intensive care. The

3
average costs for both groups are shown in . Tab. 5.7

Nursing/train-
(Haenle et al. 2012).

ing service
This shows that revision total replacements with

periprosthetic infection lead to costs that are sever-
Personnel costs [€]
935.6
916.2
912.2
869.1
892.1
al times higher than primary arthroplasty costs. The

2
highest cost items of the surgery are presented in

1,203.6
1,133.8
1,060.2
1,032.6
995.0
. Tab. 5.8 (Haenle et al. 2012).

Medical
service
The analysis is not representative for Germany

1
as it was based on a small group of patients who

were treated in a single center. However, the calcula-
material costs,
Personnel and
tion does demonstrate the additional expenses for

data for the
treating infected endoprostheses.

An additional German study including 114 pa-
2013
2012
2011
2010
2009
year
tients assessed the surgery costs of hip revisions due

to aseptic loosening of the endoprosthesis (one of
5.1 · Costs
111 5
. Tab. 5.8 Costs of primary THA and infected hip prosthesis
Costs of Primary THA Infected hip prosthesis
Implant €2,111.66 (33.7 %) €5,133.12 (17.5 %)
Medical requirements €1,165.27 (18.6 %) €6,254.99 (21.3 %)
Normal hospital ward €1,713.76 (27.4 %) €7,134.91 (27.4 %)
Anesthesia €710.27 (11.3 %) €5,395.61 (18.4 %)
the most common reasons for revisions, 7 Chapter to (additional) costs presents the following results
3.3) (Assmann et al. 2014). The study focused on the (Tuominen et al. 2010). Over 400 osteoarthritis pa-
direct costs of the intervention and compared these tients were randomly allocated either to a waiting
with the respective DRG calculations. DRG calcula- list for surgery to take place within three months or,
tions are maintained by the German Institute for as is common in normal hospital routine, to a wait-
Hospital Reimbursement »Institut für das Entgelt- ing list with a waiting period of longer than three
system im Krankenhaus (InEK)« using cost data months. The average waiting times were 94 days in
from several hundred German hospitals (7 Chapter one group and 239 days in the other. Statistically
5.2). An analysis published by Assmann et al. (2014) significant differences between the groups were
grouped the cost components into two cost items: identified for two aspects. In the group that had to
the hospital ward costs and the actual surgery costs. wait longer for surgery, the health-related quality of
. Tab. 5.9 illustrates a comparison between the aver- life one year post-surgery was higher than in the
age treatment costs of the study population and the other group. In contrast, the weekly cost of medica-
calculated costs of the most common DRGs. It tion at the time of hospital admission was higher in
should be noted that the DRG characteristics and the group that had shorter waiting periods. The au-
calculations are based on 2011 figures and specifica- thors discuss that the latter result could be due to the
tions (Assmann et al. 2014). fact that patients within the shorter waiting period
The majority of revision replacements (98 of a group had more severe pain at the time of inclusion
total of 114 patients) were allocated to DRGs I46A in the study. No statistically significant differences
(referred to in 2011 as »Change of prosthesis of the with regard to the weekly cost of medication could
hip joint with very severe CC or with allogenic bone be found at the time of the three month follow-up
transplant« ) and I46B (referred to in 2011 as and one year after surgery (Tuominen et al. 2010).
»Change of prosthesis of the hip joint without very In most cases of hip and knee arthroplasty pa-
severe CC, without allogenic bone transplant«). The tients undergo subsequent rehabilitation treatment
direct average costs in the study population were (AHB) and some patients even receive medical re-
4,380 euros which were below the calculated costs habilitation care prior to surgery (7 Chapter 3.4).
for the corresponding DRGs. The authors attribute The direct costs of rehabilitation should be added to
this difference to indirect hospital costs (adminis- the costs of additional ambulatory care and inpa-
trative costs, buildings, energy, etc.) (Assmann et al. tient stays. However, as mentioned in Section 3.4.,
2014). As this study solely illustrates the cost struc- the data regarding rehabilitation are fragmented
ture of one individual hospital it cannot be consid- and limited.
ered representative for Germany as a whole.
A randomized controlled study conducted in
Finland of patients who underwent TKA to deter-
mine whether delayed or untimely treatment leads
5.1.2 Indirect Costs
All patients included in

From a societal perspective, indirect costs arise as
. Tab. 5.9 Average costs of patient cases in a study population and average costs of respective DRG calculations for hip joint revisions due to aseptic loosening of the
the study (n=114)

patients with osteoarthritis of the knee or hip arise
are unable to work and hence lose years of employ-
ment.
1,655.1
2,724.9
4,380.0
In 2011, the diagnosis »Osteoarthritis of the
hip« (ICD-10 M16) resulted in 2,585,157 days of
incapacity to work amongst the compulsory statu-
Other DRGs (n=16)
tory health insurees (excluding pensioners). For

5 »Osteoarthritis of the knee« (ICD-10 M17), the
number of days of incapacity to work was almost
double at 4,971,052 days. In the same year, approxi-
1,811.8
3,609.6
5,421.4
Study
mately 1,600 working people went into retirement

due to a reduced capacity to work as a result of os-
teoarthritis of the hip and approximately 3,100 due
-546.8 (71.2 %)
-125.3 (95.3 %)
-672.1 (85.2 %)
to osteoarthritis of the knee. In 2011, these account-

Difference
ed for almost 80 % of all people going into retire-

ment because of osteoarthritis. The average age at
the time of retirement was approximately 55 years
for women and 56 years for men. The diseases os-
DRG calculation
teoarthritis of the knee and osteoarthritis of the hip

are therefore of great economic importance with
1,897.8
2,645.4
4,543.2
regard to indirect costs (Rabenberg 2013).

This is further highlighted by an analysis of rou-
I46B (n=43)
tine data by the German Statutory Pension Insur-

1,351.0
2,520.1
3,871.1
ance. Even if patients can be reintegrated back into

Study
work after undergoing a joint replacement, it may

result in their having to change profession or in a
-1,597.2 (73.7 %)
loss of income that includes social security contri-

-707.5 (72.3 %)
-889.7 (74.7 %)
butions. The analysis shows that this is the case in

Difference
36.5 % of all patients following total hip arthroplas-

ty (Krischak et al. 2013).
DRG calculation
5.1.3 Intangible Costs and

Health Burden
2,554.8
3,517.4
6,072.2
Besides direct and indirect costs, patients are also

Source: IGES – Assmann (2014)
I46A (n=55)
subject to intangible costs.

1,847.3
2,627.7
4,475.0
Study
» Intangible costs arise from incidents such pain

and anxiety and cannot be directly calculated
endoprosthesis
in terms of resource requirements or evaluated

Surgery costs
Ward costs
in monetary terms (IQWiG 2015).

Total costs
Intangible costs are difficult to quantify and hence

only very few studies on the subject exist. With re-
gard to the underlying diagnosis (7 Chapter 2) high
5.1 · Costs
113 5
intangible costs due to pain and anxiety before sur- ment status but also on their general condition. A
gery can be expected on the part of patients. A num- higher perceived state of health led to a lower will-
ber of international studies based on data collected ingness to pay (Xie et al. 2008).
on a patient’s willingness to pay for treatment have Health-related factors that have a significant in-
been conducted. However, their validity for Germa- fluence on the (hypothetical) willingness to pay for
ny is limited. Approaches that use the willingness to treatment of osteoarthritis of the knee, or for THA
pay aim to assess intangible costs for avoiding dis- and TKA as alternative intangible cost variables,
ease, pain and anxiety in monetary measures. seem in particular to be pain and the patients’ gen-
An Australian study surveyed patients who had eral state of health. In addition, (socio)economic
to undergo THA or TKA and their willingness to factors also seem to play a role in the amount pa-
pay for treatment two to three years after the sur- tients were willing to pay.
gery. The patients were asked how much and wheth- The quality-adjusted life year (QALY) concept is
er they were willing to pay out of their own pocket an approach that takes into account a patient’s qual-
for arthroplasty if the procedure was not included in ity of life for cost evaluations. It measures the ben-
the services provided by the healthcare system. 71 % efit of medical interventions or surgery in relation
of THA patients were prepared to pay for the opera- to the resulting prolongation of life and the quality
tion but 11 % reported that they were not willing to of life gained by the patient (Schulenburg and
do so. 25 % of the patients stated they were willing Greiner 2007). To calculate this, the effect of surgery
to pay more than 15,000 Australian dollars, which on the quality of life as well as on the prolongation
was equivalent to the hospital costs for joint replace- of life must be identifiable. In this concept, one year
ments at the time. With regard to TKA patients, of full health corresponds to a value of 1 (= opti-
70 % reported that they were willing to pay for the mum state of health) and death corresponds to a
surgery, but 16 % said they were not. 18 % of the value of 0 (= worst state of health) (Phillips and
patients said they were willing to pay over 15,000 Thompson 2009, Schulenburg and Greiner 2007).
Australian dollars. Amongst the patients who were For example, surgery that prolongs the remaining
willing to pay for surgery in both groups (THA and lifetime of a patient by 10 years with impaired health
TKA), the relative majority in each group were will- of 0.75 would result in 7.5 (10 x 0.75) quality-adjust-
ing to pay up to 4,999 Australian dollars. The au- ed life years or QUALYs.
thor’s calculations illustrated that those patients A study carried out from the perspective of the
who were more willing to pay achieved better out- German SHI system by Mujica-Mota et al., analyzed
comes after surgery with regard to both their gen- both the average and incremental costs per QALY of
eral and disease-specific conditions (including pain, patients who were either treated conservatively
joint stiffness and physical function). According to (without surgery) or who underwent THA (Mujica-
the authors, other aspects besides the state of health Mota et al. 2015). The analysis demonstrated that
also played a role in the willingness to pay for treat- the costs for both forms of treatment were compa-
ment. For TKA patients, the most important aspects rable. For 55-year-old patients, non-surgical treat-
included the patients« willingness to recommend ment leads to costs of approximately 27,300 euros
the treatment, having private health insurance and for their remaining lifetime. With regard to THA,
lower WOMAC pain scores. For THA patients, the timely and delayed surgeries were analyzed sepa-
strongest predictor for the willingness to pay was rately. The median period between both operations
income, followed by the pain classification in the was 11 years. Delayed THA resulted in costs of
WOMAC score (Cross et al. 2000). 26,800 euros and timely THA resulted in costs of
A study of 105 patients with osteoarthritis of the 28,600 euros. However, marked differences were
knee conducted in a center in Singapore investigat- found between the treatment procedures with re-
ed the amounts participants were willing to pay for gard to QALYs. Non-surgical treatment amounted
a hypothetical, complete cure of osteoarthritis with- to 10.3 QALYs, and significantly higher values of
out any side effects. The willingness to pay depend- 18.8 QALYs were established for delayed THA and
ed not only on the patients« income and employ- 20.7 QALYs for timely THA. When the incremental
costs per QALY (discounted at 5 %) were investi- members of statutory health insurance physicians«
gated for both types of surgical treatment, timely associations. These services are remunerated based
THA was shown to be more cost-effective than de- on the uniform value scale »Einheitlicher Bewer-
layed THA by approximately 1,000 euros for women tungsmaßstab (EBM)«. The physician is remunerat-
treated at the age of 55 and 1,250 euros for women ed directly for services that are listed in the EBM
treated at the age of 65 and 1,100 euros or 1,900 without the patient having to pay for the services
euros respectively for men (Mujica-Mota et al. themselves.
2015). Regarding private health insurance, the physi-
Chronic joint diseases are considered to be the cian invoices the patient based on the physicians’ fee
most frequent cause of disability in the USA. Ac- catalog »Gebührenordnung für Ärzte (GOÄ)«. The
5 cording to WHO calculations, they are the fourth patient pays for the service and the costs are subse-
most common cause of years lived with a disability quently reimbursed by the private health insurance
(YLD) worldwide (Merx et al. 2007). fund.
The Global Burden of Disease study compared The costs of medication, therapeutic products
291 diseases based on the causes of disabilities mea- and medical technical aids prescribed by the physi-
sured in YLD and ranked hip and knee osteoarthri- cian are covered by the payers, provided they are
tis 11th amongst diseases assessed worldwide in approved for reimbursement.
2010. Following diabetes and falls, hip and knee For both statutory and private health insurances
osteoarthritis are therefore amongst the most com- there may be services that have not been approved
mon diseases that lead to disability. In 1990, osteo- by the payers and which patients consequently have
arthritis was ranked 15th amongst diseases assessed. to cover themselves without being reimbursed.
According to calculations in this study, the YLDs for Under the statutory health insurance system, indi-
osteoarthritis of the hip and knee have risen glob- vidual health services that are paid for privately by
ally from 10.5 million in 1990 to 17.1 million in the patient are termed »Individuelle Gesundheits-
2010 (Cross et al. 2014). leistungen (IGeL)«.
For the entire disease burden, calculated as dis- Immediate and running costs of medically re-
ability-adjusted life years (DALY), osteoarthritis of quired hospital services are covered by statutory and
the hip and the knee ranked 38th in 2010, following private health insurances and remunerated accord-
cardiovascular diseases and epilepsy, amongst ing to the German case-based payment system
others. Since 1990, the number of DALYs has been »German Diagnosis Related Groups, (G-DRG)«. The
increasing with osteoarthritis of the hip and the G-DRG system is developed further every year by
knee ranking 48th, resulting in an increase in their the InEK. Chapter 5.1.1 presents typical DRGs for
disease burden as was also observed for YALYs. In hip and knee replacements and the corresponding
1990, they accounted for 0.42 % of the total DALYs benchmarks for 2015. It also illustrates how a DRG
calculated. In 2010, this proportion rose to 0.69 % is calculated. The most common case rates related
(Cross et al. 2014). to hip arthroplasty, according to the available rele-
Joint diseases, particularly osteoarthritis which vant data (data publication according to § 21 Hospi-
is the most common reason for requiring a joint re- tal Remuneration Act), are listed in . Tab. 5.10 and
placement, are therefore accompanied by a signifi- those related to knee arthroplasty are listed in . Tab.
cant, increasing and sometimes immeasurable dis- 5.11. The tables illustrate the levels of remuneration
ease burden. for each flat rate as a monetary benchmark for pa-
tients with normal lengths of stays in 2015. They also
show the case numbers of patients with normal
5.2 Financing, Remuneration lengths of stay recorded in 2013. In some federal
and Regulations states, the amount reimbursed may deviate from the
benchmarks presented.
Statutory health insurance funds in Germany cover An additional DRG which is not listed in the
ambulatory services provided by physicians who are tables as it is attributable to both hip and knee ar-
5.2 · Financing, Remuneration and Regulations
115 5
. Tab. 5.10 Hospital case fees for hip arthroplasty, main department (2015)
DRG Text Case fee Registered patients with

(benchmark, normal lengths of stay
€)* main department 2013
I03A Revision or replacement of the hip joint with complicating 17,280.46 1,835
diagnosis or arthrodesis or age < 16 years or bilateral surgery
or several major procedures on the joints of the lower extrem-
ities with complicated procedure, with major CC or multi-
stage replacement or surgery in several regions
I03B Revision or replacement of the hip joint with complicating 12,049.15 4,919
diagnosis or arthrodesis or age < 16 years or bilateral surgery
or several major procedures on the joints of the lower extrem-
ities with complicated procedure, without major CC, without
multi-stage replacement, without surgery in several regions
I05A Revision or replacement of the hip joint without complicating 10,129.81 6,773
diagnosis, without arthrodesis, without complex surgery, with
major CC
I46A Revision replacement hip joint prosthesis with major CC or 17,089.82 1,247
surgery in several regions
I46B Revision replacement hip joint prosthesis without major CC, 9,105.52 14,188
without surgery in several regions
I47A Revision or replacement of the hip joint without complicating 7,861.51 10,317
diagnosis, without arthrodesis, without major CC, age > 15
years, with complicating surgery or implantation/revision
replacement of a radial head prosthesis or change of inlay of
the hip
I47B Revision or replacement of the hip joint without complicating 7,237.9 147,861
diagnosis, without arthrodesis, without major CC, age > 15
years, without complicating surgery
* Assuming a nationwide base rate of 3231.20 euros in 2015; abbreviation: CC = complications or comorbidities,
source: IGES calculations based on InEK data (2015a)
throplasty is DRG I36Z (bilateral implantation or defined by the InEK, as are the case rates them-
revision hip or knee replacement). In 2013, approx- selves.
imately 800 patients with normal lengths of stay in Additional funding for innovations is available
Germany were allocated to this DRG. Similar to the under new examination and treatment methods
calculations in . Tab. 5.10 and . Tab. 5.11, the »Neue Untersuchungs- und Behandlungsmethoden
benchmark value for this was 11,978.06 euros in (NUB)’. Hospitals can submit NUB applications to
2015 (InEK 2015a). the InEK DRG institute once a year. The InEK sub-
Usually, the hospitals are required to cover their sequently determines whether the prerequisites for
own costs based on these case rates. For the health temporary additional remuneration (NUB) for the
insurance funds these constitute the direct costs of individual hospital are fulfilled. If the NUB applica-
the relevant treatment cases. tion is approved, the hospital enters into negotia-
Two main further remuneration pathways exist tions with the payers during the course of its overall
for costly treatments, which can be applied in addi- budget negotiations. Negotiations are based on the
tion to the relevant DRG case rate. Both options are number of treatments and the remuneration
. Tab. 5.11 Hospital case fees for knee arthroplasty, main department (2015). IGES calculations based on InEK data
(2015a)
DRG Text Case rate Registered patients with

(benchmark, normal lengths of stay
€)* main department 2013
I04Z Implantation, replacement or removal of a knee endopros- 11,451.37 4,111

thesis with complicating diagnosis or arthrodesis
I43A Implantation or replacement of specific knee or elbow endo- 15,836.11 1,014

prostheses or replacement of shoulder or ankle prostheses,
with major CC
5
I43B Implantation or replacement of specific knee or elbow endo- 10,297.83 11,075
prostheses or replacement of shoulder or ankle prostheses
without major CC
I44A Implantation of a bicondylar endoprosthesis or other endo- 11,121.79 1,314

prosthesis implantation/revision on the knee joint, with
major CC or correction of a rib cage deformity
I44B Implantation of a bicondylar endoprosthesis or other endo- 7,764.57 103,628

prosthesis implantation/revision on the knee joint, without
major CC or without correction of a rib cage deformity
I44C Various types of endoprosthesic surgery on the knee joint 6,407.47 17,875
* Assuming a nationwide base rate of 3231.20 euros in 2015; abbreviation: CC = complications or comorbidities,
source: IGES calculations according to InEK data (2015a)
amounts (§ 6 Section 2 Hospital Remuneration Act was higher than the calculated costs for all countries
(SVR Gesundheit 2014)). Individual hospital nego- except for Poland. The remuneration for Spain
tiations regarding implantable endoprostheses for could not be determined due to the specifics of the
»(total) temporomandibular joint replacements« healthcare system. It can also be observed that the
and »expandable endoprostheses« were granted by level of remuneration in Germany was not the high-
the InEK for the year 2015 (InEK 2015b). est amongst the countries listed (Stargardt 2008).
Besides the NUB process, there is also the option Although the analysis for Germany indicates a
of negotiating so-called additional remunerations financial gain for hospitals performing the surgery,
(Zusatzentgelte (ZE)) in addition to the DRG case the actual situation can differ significantly depend-
rate (cf. § 7 Hospital Remuneration Act (KHG)). ing on the treatment case.
These additional remunerations are not restricted to Haenle et al. 2012 reviewed not only the costs of
innovations (SVR Gesundheit 2014). In 2015, there revision procedures in comparison to primary THA
were a total of 170 additional remunerations which but also the corresponding excesses or shortfalls in
are partly negotiable by individual hospitals. Re- payments in the DRG remuneration system. The
garding replacement surgery, additional remunera- average costs, DRG remuneration and the excess or
tions for modular endoprostheses (ZE 2015-25, shortfalls in payments for both groups are presented
OPS 5-829.k, OPS 5-829.m) for individual hospitals in . Tab. 5.12 (Haenle et al. 2012).
can be agreed upon between the hospitals and the It becomes apparent that the treatment of in-
health insurance funds (InEK 2015a). fected hip endoprostheses resulted in costs of al-
Figure 5.1 illustrates a total cost comparison of most 30,000 euros and a deficit of approximately
unilateral primary hip replacement in nine Euro- 12,700 euros. Consequently, cases in treating hospi-
pean countries and shows that the remuneration tals were underfinanced. This demonstrates the
5.2 · Financing, Remuneration and Regulations
117 5
10,000 €
9,000 €
8,000 €
7,000 €
6,000 €
5,000 €
4,000 €
3,000 €
2,000 €
1,000 €
0€
Denmark England France Germany Hungary Italy Netherlands Poland Spain
Total costs Total costs, adjusted for purchasing power parity of the countries Remuneration
. Fig. 5.1 Costs and remuneration of primary hip arthroplasty in nine European countries in 2005. (Source: IGES –
Stargardt 2008)
. Tab. 5.12 Deficit/surplus in the DRG system with regard to infected hip endoprostheses
Group Number of Costs per DRG Excess payment

patients patient (€) remuneration (€) or shortfalls (€)
Infected hip prosthesis 49 29,331.36 16,645.76 –12,685.60
Primary total hip arthroplasty 21 6,263.59 7,045.00 781.41
economic challenge hospitals are faced with in such versicherungsamt) which also covers osteoarthritis
treatment cases, and they have to compensate the of the knee and the hip (Bundesversicherungsamt
losses through gains made via other types of treat- 2014).
ment. Through the Morbi-RSA, health insurance
A distinctive situation exists related to SHI fi- funds that include older and more sickly insurees
nancing. The so-called health fund »Gesundheits- receive higher funds than those that include many
fonds« was introduced on 1 January, 2009. Statutory healthier or young insurees. This assures compensa-
health insurance funds receive the same amount tion in accordance with the SHI’s solidarity code,
(basic rate) for every insuree and additional or re- and consequently health insurance funds do not
duced amounts adjusted according to age, sex and have the economic incentive to specifically acquire
risk (KV Berlin 2007). The morbidity oriented risk young and healthy patients as members (Bundes-
structure adjustment scheme (Morbi-RSA) takes versicherungsamt 2008). As a result, standardized
into account the health status of insurees with re- additional remunerations can be claimed for every
gard to funding (Jahn et al. 2012). The additional insuree suffering from one of the 80 diseases. If dur-
remuneration for morbidity is based on 80 costly, ing a patient’s stay in hospital any of the relevant
chronic and severe diseases. »Osteoarthritis of the diseases are diagnosed, the additional remuneration
large joints« is included amongst the diseases listed is immediately paid to the patient’s health insurance
by the German Federal Insurance Office (Bundes- fund. If the diagnosis is made during ambulatory
treatment, the additional remuneration is only paid surance. The degrees of severity of the cases are not
in the following quarter once the diagnosis has been differentiated in the case rates. Consequently, the
confirmed (DIMDI 2015). financial risk of treating patients with severe cases
Remuneration for rehabilitation services, which lies with the care providers and not the payers. The
play a particular role following acute-care in hospi- case fees cover all costs, including investment costs.
tal, is paid based on a per diem rate or case fee rate. There is »hardly any representative data« with re-
Per diem rates tend to be applied for remuneration gard to the case rate amounts (SVR Gesundheit
by the German Statutory Pension Insurance fund- 2014).
ing bodies and case rates by the statutory health in-
5
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121 6
Requirements for
Adequate Arthroplasty Care
(Expert Opinions)
Hans-Holger Bleß
6.1 Prevalence of Hip and Knee Arthroplasty – 122

6.1.1 Fixation Techniques and Revision Total Replacement – 124
6.1.2 Regional Distribution and International Comparison – 125
6.2 Status of Hip and Knee Arthroplasty Care – 126

6.2.1 Medical Rehabilitation – 127
6.2.2 Service Lives and Revision – 128
6.2.3 Adherence to Indication Criteria – 129
6.2.4 Minimum Volume Regulations and Increasing Case Numbers – 130
6.3 Health Economic Aspects of Arthroplasty – 131

DOI 10.1007/978-3-662-55918-5_6
122 Chapter 6 · Requirements for Adequate Arthroplasty Care (Expert Opinions)
Summary years age group constitute the largest proportion of

The previous chapters reviewed the status of knee all hip and knee arthroplasty cases (hip: 41.8 %,
and hip arthroplasty care based on existing literature. knee: 41.0 %). The average patient age for primary
This chapter assesses the current situation from an total hip arthroplasty (THA) was 69.7 years in
expert perspective through the examination and 2013 and for primary total knee arthroplasty (TKA)
analysis of available data. In August 2015, a work- 69.2 years.
shop was conducted in preparation for this chapter, Primary hip arthroplasty case numbers record-
which was attended by a renowned panel of experts ed by the Federal Statistical Office for the period
and stakeholders who play an important role in shap- from 2008 to 2013 show a plateau from 2009 to 2011
ing the provision of healthcare services in Germany. with approximately 213,000 operations each year.
This chapter presents the results following this work- After a peak in 2011 at 213,935 cases, the case num-
shop, the content of which has been approved by bers decreased slightly in 2012 and 2013 (7 Chapter
the relevant participants. 2). A similar trend is observed in primary knee
6 arthroplasty: A plateau phase can be observed from
The panel of experts (. Tab. 6.1) represented the 2009 and 2011 with a subsequent marked decline in
following areas of care: case numbers in 2012 and 2013. While approxi-
4 Research and Training mately 159,000 cases of knee arthroplasty were re-
4 Specialized Clinical Care corded in 2009, approximately 143,000 cases of pri-
4 Medical Rehabilitation mary knee arthroplasty were recorded in 2013
4 Professional Medical Societies (7 Chapter 2).
4 Registry According to the panel of experts, data pub-
4 Statutory Health Insurances lished by the Federal Statistical Office was origi-
4 Medical Technology nally collected solely for accounting purposes and is
consequently only of limited use in making reliable
Relevant statements regarding hip and knee arthro- evaluations in relation to hip and knee arthroplasty
plasty in the following areas were selected: case number progressions. Consequently, the data
4 Prevalence of primary and revision arthro- do not permit evaluations of the degree to which
plasty government policy or patient-related causes, for ex-
4 Healthcare situation for primary and revision ample, influence the rate of joint replacements. For
arthroplasty reliable assessments of both the prevalence of ar-
4 Health economics throplasty and potential influencing factors, further
data should be used in the future (for example, from
The experts were requested to give their interpreta- the German joint replacement registry »Endopro-
tion of the data and discuss the requirements, aims thesenregister« or the EndoCert initiative). This
and challenges of joint replacement care as well as would enable a comprehensive, quality-assured and
potential solutions and future needs for action. cross-sectoral collation of data which would allow
reliable and verifiable interpretations.
In previous years, frequent comparisons have
6.1 Prevalence of Hip and Knee been made to international data (for example,
Arthroplasty OECD comparisons) to evaluate case number de-
velopment trends for hip and knee arthroplasty.
According to the German Federal Statistical Office, These trends confirmed Germany’s alleged top
approximately 210,000 primary hip arthroplasty ranking position in this field. However, according to
(partial or total replacement) inpatient cases were the panel of experts, these comparisons are un-
registered in Germany in 2013. In the same year, founded owing to several factors such as different
approximately 143,000 primary knee arthroplasty patient cohorts, the means by which surveys were
(partial or total replacement) inpatient cases carried out, inclusion criteria and, in part, a lack of
(7 Chapter 2) were recorded. Patients in the 70 to 80 age standardization. Meanwhile, however, this has
6.1 · Prevalence of Hip and Knee Arthroplasty
123 6
. Tab. 6.1 Expert panel workshop participants
Name Occupation
Univ.-Prof. Dr. Professor of Musculoskeletal Rehabilitation, Prevention and Health Services Research at the
Karsten Dreinhöfer center for musculoskeletal surgery »Centrum für Muskuloskeletale Chirurgie (CMSC)«, Charité
– Universitätsmedizin Berlin
Medical Director and Head of the Department for Orthopaedics and Traumatology Medical
Park Berlin Humboldtmühle
Vice-President of the Professional Association of Orthopaedic Surgeons (Berufsverband der
Fachärzte für Orthopädie und Unfallchirurgie e. V. (BVOU))
Prof. Dr. med. Executive Director of the University Center of Orthopedics and Traumatology at the Univer-
Klaus-Peter Günther sity Hospital Carl Gustav Carus of the Technical University Dresden (Universitätsklinikum Carl
Gustav Carus an der Technischen Universität Dresden)
Past President of the German endoprosthetics society »Deutsche Gesellschaft für Endopro-
thetik (AE)«
Past President of the German Society of Orthopedics and Orthopedic Surgery (Deutsche
Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC))
Dr. med. Dipl.-Ing. Publicly appointed expert in medical technology

Hans Haindl
Prof. Dr. Head of the Orthopedic Department Herzogin Elisabeth Hospital Braunschweig
Karl-Dieter Heller Secretary General of the German arthroplasty association »Deutsche Gesellschaft für Endo-
prothetik (AE)«
First Chairman of the German association of senior orthopedists and trauma surgeons
»Verband leitender Orthopäden und Unfallchirurgen (VLOU)«
Vice-President of the Professional Association of Orthopaedic Surgeons (Berufsverband für
Orthopädie und Unfallchirurgie e. V. (BVOU)
Board member of the German Society of Orthopedics and Orthopedic Surgery (Deutsche
Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC))
Vice President of the German hip society »Deutsche Hüftgesellschaft (DHG)«
Dr. med. Managing Director of the German arthroplasty registry »Deutsche Endoprothesenregister
Andreas Hey gGmbH (EPRD)«
Prof. Dr. Dr. Medical Director of the BG Hospital Frankfurt am Main (Unfallklinik Frankfurt am Main
Reinhard Hoffmann gGmbH)
Secretary General of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie
(DGU))
Secretary General of the German Society for Trauma Surgery (Deutsche Gesellschaft für
Orthopädie und Unfallchirurgie (DGOU))
Univ.-Prof. Dr. med. Director of the Department of Orthopaedics Düsseldorf University Hospital
Rüdiger Krauspe President of the German Society of Orthopedics and Orthopedic Surgery (Deutsche Gesell-
schaft für Orthopädie und Orthopädische Chirurgie (DGOOC))
N. N. Statutory health insurance representative
Univ.-Prof. Dr. med. Professor of Orthopedics at the Jena University Hospital, Campus Eisenberg, Department of
Georg Matziolis Orthopaedics and Trauma Surgery
Medical Director of the Clinic for Orthopaedics and Accident Surgery at the Waldkrankenhaus
Eisenberg (Waldkrankenhaus »Rudolf Elle« GmbH)
Univ.-Prof. Dr. med. Medical Director of the Orthopaedic Clinic of the Hannover Medical School in the DIAKOVERE
Henning Windhagen Annastift Hospital
Past President of the German Society of Orthopedics and Orthopedic Surgery (Deutsche
Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC)), and the German Society
for Orthopaedics and Trauma (Deutsche Gesellschaft für Orthopädie und Unfallchirurgie
(DGOU))
also been amended in relevant publications (7 Sec- 6.1.1 Fixation Techniques and
tion 2.6). Revision Total Replacement
Nonetheless, despite limitations in the reliability
and validity of the data available so far, the panel of Federal Statistical Office data on the types of im-
experts has observed some obvious connections. In planted prostheses and the fixation techniques used
the period from 2009 to 2011, during which a pla- show that the majority of hip procedures (51 % in
teau in the number of arthroplasty cases was ob- 2013) are total hip arthroplasties (THA) without the
served, the necessity of arthroplasty was being criti- use of bone cement (7 Section 2.2). In contrast, for
cally discussed in the media which consequently led the knee, total knee arthroplasty (TKA) with the use
to uncertainty amongst patients. The incorrect as- of bone cement for fixation constitutes the largest
sessment, consequently rectified, that Germany was proportion of surgery cases (66 % in 2013) (7 Sec-
ranked in the top position with regards to arthro- tion 2.2).
plasty rates, led to verifiable confusion and mistrust Revisions and revision total replacements over
6 towards treating doctors. The panel of experts the past few years (2008 to 2013, also based on Fed-
deemed knee arthroplasty to have been affected in eral Statistical Office data) show a marked increase
an over proportionate manner by these discussions. following primary uncemented THA. In addition,
At the same time, however, the panel of experts in- there was also a distinct decrease in the number of
dicated that before having to resort to surgery, more revision procedures following cemented primary
conservative treatment alternatives were available THAs in the period from 2008 to 2013 (7 Section
for the knee than for the hip and consequently, knee 2.3). With regard to knee arthroplasty, the rates of
patients have a broader range of treatments to revision total replacement and revision remained
choose from. Additionally, fractures constitute a predominantly stable. Solely bicondylar surface re-
more frequent indication for hip arthroplasty which placements showed an increase in rates up until
could explain the greater decline in knee arthro- 2011 and a subsequent decrease in revision replace-
plasty. In addition, the decline in arthroplasty rates ments over time.
could also be related to an improvement in conser- According to the panel of experts, interpreting
vative treatment over the past few years. the data published for case number trends for revi-
However, the panel of experts expects a re- sion and revision total replacements is also limited
newed increase in the number of hip and knee re- as it involves raw data that were reported to the Fed-
placements in the future based on current demo- eral Statistical Office by the payer institutions. The
graphic trends and the related increases in degen- data included numerous different types of revision
erative joint diseases. Another factor that could and revision total replacement procedures, includ-
lead to a rise in knee arthroplasty is the fact that ing surgery without or with only partial replace-
joint preserving arthroscopic surgery for osteoar- ments of prosthetic components through to revision
thritis of the knee has been subject to criticism and total replacements. It is unclear to what extent the
may no longer be reimbursed as it is not considered current documentation, information transfer and
a curative procedure. Consequently, joint preserv- analysis routines in hospitals and external institu-
ing surgery may be performed less frequently in the tions (payers, AQUA, Statistical Office) correctly
future. Softer criteria such as access to care, who depict the numbers and types of operations actually
makes the indication and the institution in which it performed. This could result in misleading estima-
is made (primary care physician, specialist physi- tions of the number of operations performed.
cian, hospital) as well as changes in the public per- Determining correlations between primary im-
ception of joint replacements will influence the plantation and replacement and/or revision is not
development. However the impacts cannot be pre- possible as existing data do not link cases. Develop-
dicted at present. ment trends in replacement and revision surgery
rates are typically characterized by two peaks.
Shortly after primary replacement, renewed surgery
may become necessary mainly due to infections and
6.1 · Prevalence of Hip and Knee Arthroplasty
125 6
complications and in rarer cases due to implant-re- Regional variations in remuneration for surgery
lated issues. A second peak occurs after ten years or performed by fee-based surgeons could be deduced
more and is due in particular to the loosening of the from this observation. Conversely, surprisingly
implant. These two peaks overlap in the Federal higher rates of surgery were observed particularly in
Statistical Office’s cumulative presentation hence areas with lower numbers of specialist physicians.
making a connection between primary surgery and This might suggest more intensive conservative
the need for revision total replacement or revision treatment being performed as an alternative to sur-
indeterminable. This will only be possible through gery in regions with higher numbers of practice-
future evaluations of data from the German joint based orthopedists. However, from the panel of
replacement registry »Endoprothesenregister«. experts« point of view, regional differences in Ger-
many cannot be conclusively assessed as numerous
concurrent influencing factors with largely unclear
6.1.2 Regional Distribution and causal relationships are still a matter of ongoing
International Comparison discussion. Therefore, more funding towards im-
proving healthcare research is necessary.
Analyses of AOK insuree data show that there are Contradictory data exist when comparing inter-
regional differences in the rates of primary hip and national surgery rates to those in Germany based on
knee arthroplasty per 100,000 inhabitants (7 Sec- publications using data from other OECD coun-
tion 2.4). When observing data within an area from tries. Two years ago, a comparison of endoprosthet-
the southeast to the northwest of Germany, it can be ic procedures conducted in five EU countries (UK,
seen that in 2013, there was an upward trend in the France, Germany, Italy, Spain) and the USA, based
number of surgeries performed. on raw, non-age-standardized data was published
The panel of experts considers that the regional and showed there were similar increases in surgery
distribution shown by AOK insuree data is not en- rates in both hip and knee replacements per 100,000
tirely representative as varying patients in the co- inhabitants in the period from 2000 to 2012. The
horts may potentially differ from the patients of original database which was published by the OECD
other payer institutions. Moreover, in order to make at the time, ranked the OECD countries according
conclusive assessments, other factors that could po- to surgery rates. In this case, Germany had the high-
tentially have an impact on the regional rates must est rate of hip arthroplasty (287 procedures per
also be taken into consideration. These include po- 100,000 inhabitants in 2012) (7 Section 2.6) and
tential differences in patient demands and socio- ranked third for knee arthroplasty following Austria
economic factors (for example, lifestyle habits) as (highest rate) and Finland (second highest rate)
well as differences between urban and rural areas. (7 Section 2.6).
International statistics also show that social depri- However, when age-standardized data are used
vation considerably influences the rate of knee and for the OECD country ranking, which take into ac-
hip arthroplasty. Lower rates of surgery in areas with count specific demographic factors per country,
high social deprivation can also be observed in Ger- Germany’s ranking shifts from a top position to 5th
many. Some of the experts also consider that supply- for hip arthroplasty. For knee arthroplasty, Ger-
driven or economic reasons may play a role: Prac- many drops from 3rd to 8th position (7 Section 2.6).
tice-based physicians are also permitted to perform The panel of experts emphasize that there are
endoprosthetic surgery as visiting consultants with serious methodological shortfalls in the OECD’s
admission privileges or through other contractual ranking of international surgery rates. The data used
agreements with hospitals (for example, as so-called are derived from data sources that differ in so many
fee-based physicians). According to the panel of ex- ways that making comparisons is questionable.
perts, an indication of potentially influencing mon- International coding systems differ, which
etary factors could be the considerable differences therefore do not allow for any direct comparability.
in the rates of care observed at administrative levels, The case numbers in the OECD database, for ex-
particularly at the individual federal state borders. ample, are based on ICD codes and do not permit
clear differentiations to be made between elective 6.2 Status of Hip and

(osteoarthritis-related) arthroplasty and emergency Knee Arthroplasty Care
arthroplasty which is performed to treat fractures.
They also partly contain both primary and revision Germany seems to offer arthroplasty care nation-
procedures. The lack of age-adjusted data, in at least wide (7 Chapter 3). This is the case for both knee
the first publications, has already been pointed out. and hip arthroplasty as indicated by the fact that
This is an important point as absolute numbers more than half of all German hospitals perform
without appropriate adjustments for demographic these procedures, amongst other things (7 Section
criteria lead to significant biases, particularly with 3.3). Primary hip arthroplasty is performed due to
regard to the increasing rates of osteoarthritis in osteoarthritis of the hip in 80 % of cases (7 Section
older age groups. According to the panel of experts, 3.3) and in approximately 12,5 % of cases due to
these biases lead to surgery rates in regions with femoral neck fractures. With regard to knee arthro-
older populations being over estimated as has been plasty, approximately 96 % of primary surgery is
6 the case in Germany, for example. Finally, virtually performed due to osteoarthritis of the knee (7 Sec-
no further information exists regarding population tion 3.3). Approximately one third of the patients
groups used for the OECD assessment, i.e. whether who undergo either THA or TKA also suffer from
the total population or only inpatient cohorts were serious systemic diseases and substantial functional
taken into account or whether the data included in- limitations (ASA score 3) (7 Section 3.3).
formation from private payer institutions or not. For THA patients, the length of stay in hospital
Major differences in the healthcare systems also do is about 4.5 days longer than the average length of
not favor the comparison of figures. Individual stay in a German hospital. Shorter lengths of stay
countries, for example, may have long waiting lists have been observed in the past few years. While the
for the surgical procedures in question. length of stay was in the region of 14 days in 2012, it
According to the panel of experts, if all the influ- decreased to 12 days in 2014. A similar trend can be
encing factors discussed were taken into account, observed for TKA patients.
the actual ranking of the rates of care would be con- Treatment begins with the treatment plan before
siderably different. In addition, there are clear indi- the actual surgery. This includes preliminary ex-
cations to suggest that case numbers correlate with aminations, surgery planning and follow-up treat-
individual gross national products. Consequently, ment planning. Numerous aspects therefore have an
the panel of experts agrees that it can be assumed influence on the treatment and its outcome.
that financially weaker countries do not meet their According to external inpatient quality assur-
care needs. ance data, nearly all THA and TKA patients are able
to walk independently and perform a daily hygiene
routine themselves upon discharge from hospital.
Need for action and solution approaches The panel of experts confirms that nationwide
5 Fact-based open discussions about the care coverage exists for hip and knee arthroplasty in
benefits and risks of arthroplasty, drawing Germany. Consequently, travel times for patients
on comprehensive quality-assured and are not problematic. In the opinion of some of the
cross-sectoral data. experts, there is even a surplus of hospitals provid-
5 Revision and harmonization of definitions ing arthroplasty services which, however, cannot be
and coding guidelines for revision total confirmed merely based on the number of hospitals
replacement and revision surgery in order offering joint replacement services. Instead, the
to achieve reliable coding for the services panel of experts suggests that status of care evalua-
provided in hospitals. tions should be based on differentiated analyses of
5 Improving healthcare research in order to certified arthroplasty centers. Only in this way
gain reliable insights into care needs and would it be possible to qualitatively evaluate the
care provision at regional and national levels. number of hospitals performing endoprosthetic
surgery based on defined quality criteria.
6.2 · Status of Hip and Knee Arthroplasty Care
127 6
The panel of experts pointed out that patient 6.2.1 Medical Rehabilitation
demands with regard to arthroplasty have notice-
ably changed in recent years. Patients demand faster Usually, patients undergo subsequent rehabilitation
recovery for early weight-bearing and mobility as (AHB) after the acute inpatient stay for the replace-
well as being able to resume sporting activities more ment surgery. This rehabilitation aims to generally
rapidly. This does not imply that more surgery is strengthen and mobilize patients while taking into
being performed but that the expectations of the account their personal and individual rehabilitation
surgery itself and the outcomes have increased. At goals particularly with regard to the required activ-
the same time, changes in patient expectations have ities of daily living (ADL) (7 Section 3.4).
also led to behavioral changes with regard to activi- These rehabilitation procedures are financed by
ties of daily life after joint replacement. This has different payer institutions which include the Ger-
resulted in implants being subjected to more stress man Statutory Pension Insurance (Deutsche Ren-
and strain. tenversicherung, DRV), statutory and private health
The panel of experts has observed marked im- insurances as well as the German employers’ liabil-
provements in the quality of devices used over the ity insurance associations. To date, only limited and
past few years. For example, they considered the unstructured data are available on subsequent reha-
developments in so-called tribological pairing posi- bilitation (AHB) treatment and a general overview
tive, especially with regard to the different technolo- of all the measures provided does not exist.
gies used in the manufacturing of ultra-highly Furthermore, the depth and quality of the data
cross-linked polyethylene and new ceramic mate- in most fields is so restricted that only limited dif-
rials with significantly reduced risks of breakage. ferentiated evaluations and interpretations are pos-
These implants are more expensive than implants sible.
using conventional materials, but they lead to sig- According to the panel of experts, the data pub-
nificantly reduced wear and therefore fewer late lished by the German Statutory Pension Insurance
stage complications. Other aspects, such as the im- (DRV) on the number and types of procedures con-
pact of different implant stem lengths on the treat- ducted during subsequent rehabilitation (AHB) for
ment outcomes cannot be fully evaluated at present. TKA and THA is limited in terms of representation
On the whole, the panel of experts considers the as it predominantly refers to rehabilitation patients
overall situation confusing due to the wide range of in general and not in particular to total arthroplasty
devices being used and the data situation unclear patients. In addition, data publications by some
with regard to surgery outcomes for the different health insurance funds are only very rudimentary
types of prostheses. and of limited applicability.
In addition, the panel of experts believes that The Advisory Council on the Assessment of
any modifications in a hospital’s administration Developments in the Healthcare System (Sachver-
with regards to purchasing processes could be pro- ständigenrat zur Begutachtung der Entwicklung im
blematic in practice in that they can lead to changes Gesundheitswesen (SVR)) found that »Even though
in implant procurement. For hospital administra- hardly any evidence pertaining to the effectiveness
tions economic factors play a more important role of rehabilitation under controlled conditions can be
than quality. Repeated changes in the type of implant confirmed, it may still be assumed that benefits do
being used necessitate regular training on behalf of exist«.
both surgeons and the surgical teams which could The panel of experts agrees that rehabilitation
increase the risk of complications. According to the subsequent to acute inpatient care is necessary for
panel of experts, it would make more sense if a hos- the large majority of patients. Younger and other-
pital agreed on a defined set of products containing wise healthy patients in particular may benefit from
a few high-quality devices that are quality-assured ambulatory rehabilitation close to their domiciles
based on scientific data and for which relevant and for the growing number of older patients treat-
know-how exists within the hospital. ment in a rehabilitation clinic is appropriate in most
cases.
The panel of experts stated that over the last few 6.2.2 Service Lives and Revision
years, significantly shorter lengths of stay in acute
care hospitals together with the higher number of To date, the service lives of hip and knee endopros-
older people undergoing surgery and the number of theses in Germany have not been investigated or any
patients with concomitant diseases have led to pa- reports on the subject published outside of studies.
tients being more unwell and in greater need of care The German joint replacement registry »Endopro-
when they are transferred to rehabilitation estab- thesenregister Deutschland (EPRD)« is still in the
lishments. These patients have considerably higher process of being established and it is therefore not
nursing care needs and medical requirements, yet possible to analyze any registry data. Interna-
which, however, are currently not reflected in the tional registries such as the National Joint Registry
remuneration for subsequent rehabilitation (AHB) for England, Wales, Northern Ireland and the Isle of
in orthopedics. Consequently, patients who require Man, the Scandinavian registries and the Australian
higher nursing care are often transferred into geri- National Joint Replacement Registry have been col-
6 atric care which does not always warrant specialist lecting comprehensive data on endoprosthesis ser-
rehabilitation care. vice lives for several years (7 Section 4.3). However,
The panel of experts sees a need for closer col- particularly in the field of hip arthroplasty, insights
laboration across all sectors and medical institu- from these data cannot be directly applied to Ger-
tions including payers. There is also a need for a many due to the differing healthcare systems,
graded remuneration system in order to maintain amongst other things. For example, Scandinavia
adequate care for the patients. and England have higher rates of cemented hip ar-
According to the panel of experts, the fact that throplasty.
subsequent rehabilitation (AHB) does not always Conversely, uncemented hip arthroplasty is
take place immediately after discharge from hospi- relatively common in Norway, Finland and Austra-
tal does not imply a lack of care. Many patients re- lia, as is the case in Germany, while the implants and
quest to be discharged to return home to be in their surgical techniques differ to those used in other
familiar environment after their inpatient stay. In countries.
addition, the German Statutory Pension Insurance In addition, the different international registries
recommendation stating that that subsequent reha- are very heterogeneous with regard to their data col-
bilitation (AHB) should start within 14 days after lection. Also, specific outcomes are defined differ-
discharge from hospital is not evidence-based. Dif- ently, in the case of revision, for example (7 Section
ferent regulations for this exist when making com- 4.3). For this reason, considerable efforts are being
parisons at an international level. For example, made in support of standardizing arthroplasty re-
some countries provide home care without subse- gistries worldwide while the German joint replace-
quent rehabilitation or provide subsequent rehabili- ment registry (EPRD) is being established.
tation at home. Nevertheless, subsequent rehabilita- According to the panel of experts, different rea-
tion (AHB) should take place as soon as possible sons for revision exist, the most common currently
after treatment in hospital. Advantages of this would being revision and revision total replacement due to
be that patients recover sooner and gain their ability infection. The prevalences of knee and hip arthro-
to work quicker while avoiding complications. plasty differ and are influenced considerably by risk
Avoidable delays include procedures such as com- factors such as body weight, diabetes mellitus and
plicated application processes for different payer other diseases with impaired immune systems.
institutions or arduous transfer processes and ar- Other reasons for revision and revision total re-
ranging for subsequent rehabilitation (AHB). placements, particularly during early postoperative
Speeding up these processes would be advanta- stages, are luxation and/or instability. In the long
geous. term, conditions such as aseptic loosening and par-
ticulate wear of a stable fixated prosthesis may deem
revision and replacement surgery necessary. Con-
trary to public perception, revision due to prosthesis
6.2 · Status of Hip and Knee Arthroplasty Care
129 6
fractures owing to material failure is very rare. In- From the panel of experts« point of view, adher-
vestigations into these occasional ceramic prosthe- ence to indications is generally poorly documented.
ses fractures (less than 0.01 % of all implantations) At present, there are no guidelines on the time
have shown that they could not be solely attributed points for when arthroplasty should be performed
to material failure but that the implantation tech- and the data collected for external quality assurance
nique may also play a role. For this reason, medical (stage of osteoarthritis visible in x-ray, pain and mo-
societies collaborate with the manufacturers to con- bility indicators) is only questionably suitable for
duct intensive training, for example. Prosthesis fail- determining »appropriate indications«. According
ure can also be provoked by strain due to excess to the panel of experts, some indications cannot be
weight or activity. As is often the case, according to portrayed on the basis of the AQUA data as they do
the panel of experts, not enough data exist to con- not necessarily correlate with arthritic changes as
clusively evaluate the situation. observed in x-rays (for example, aseptic necrosis or
Revision total hip or knee replacement or com- tumor near the joint). Particularly necrosis of the
ponent replacements lead to longer average lengths femoral head which is relatively common account-
of hospital stay than primary arthroplasty (7 Sec- ing for approximately 3 % of endoprosthetic surgery
tion 3.3). THA patients who undergo revision total is generally assessed incorrectly as it is not coded
replacement have inpatient stays of almost nine days separately With regard to this indication and others,
longer compared to primary surgery. The length of the data generated do not correspond to the actual
stay for revision total knee replacement patients is healthcare situation and incorrectly suggest that in-
four days longer on average than for primary TKA dications are not being adequately adhered to. In
patients. In general, replacement surgery is consid- addition, current data collection procedures do not
ered to be technically more demanding and more include other factors that have been shown to influ-
challenging to perform. ence indications, such as prior treatment, comor-
bidity, problems with other joints, quality of life and
expectations prior to surgery. Consequently, a group
6.2.3 Adherence to Indication Criteria of experts is currently working together with profes-
sional associations to develop indication guidelines
In Germany, the rates of adherence to medical indi- for joint replacements. Regardless of these conten-
cation criteria for both primary and revision THA tual issues, service providers« reliability with regard
and TKA are recorded during external inpatient to the use of the actual coding has also not been
quality assurance procedures. The indication crite- assessed, therefore indicating that data quality on
ria are defined by a federal expert group (7 Section the whole is not reliable.
3.5). From this quality assurance data, the adher- However, the panel of experts say, it should not
ence to indication criteria for primary THA showed be assumed that regional differences in the preva-
an increasing trend nationally over the past few lence of the provision of care are generally due to the
years with 95.8 % in 2014. For individual federal issue of documentation of »appropriate indica-
states, the data published showed significant differ- tions«.
ences in adherence to indication criteria. Revision Registry data would provide a suitable approach
total replacements had an adherence to indication for improving quality assurance. Registries contrib-
criteria of 93.1 % on a national level in 2014. At fed- ute to the collection of information and data accord-
eral state levels, the differences observed are similar ing to standardized criteria. A prerequisite for this
to those observed for primary arthroplasty. is that all patients are recorded in the registry. This
The results are comparable for TKA. In 2014, is why the panel of experts believes that private
the adherence to indication criteria at a national payer institutions should also submit their patient
level was 96.9 % for primary TKA and 92.3 % for data to the registry. Private payer institutions are
revision TKA. Here again, federal state levels show currently not participating in the reporting process.
marked differences between individual states In addition, reporting should not only be made
(7 Section 3.5). mandatory but should also be remunerated. Making
reporting mandatory would be a prerequisite for the increasing experience of the surgeons. On the
improving care especially for multimorbid patients. other hand, no reliable data-based thresholds exist
In addition, sufficient funding should be made for individual surgeons or for hospitals in which
available to subsequently enable evaluations of the several surgeons perform arthroplasty. Conse-
registry data. quently, the thresholds which were determined in
the Endocert© procedure are subject to further
modification. Some experts consider the current
6.2.4 Minimum Volume Regulations threshold of 50 arthroplasties per year per surgeon
and Increasing Case Numbers to be too low. The panel of experts state that there
is no danger of the minimum volume regulation
Minimum volume regulations for primary TKA jeopardizing nationwide coverage of endoprosthetic
were introduced at a hospital level in 2006. Accord- care. However, the aim of healthcare policies to pro-
ing to this regulation, a hospital may only be reim- vide care close to patients’ domiciles will always be
6 bursed for TKAs by the SHI if it performs at least 50 in conflict with the desire to establish specialized
TKAs per year. Analyses conducted by the Institute treatment centers that are located further apart.
for Quality and Efficiency in Health Care (Institut
für Qualität und Wirtschaftlichkeit im Gesund-
heitswesen (IQWiG)) show that the introduction of Need for action and potential solutions
minimum volumes has led to increases in case num- 5 Optimizing cross-sectoral care concepts.
bers (7 Section 3.5). 5 Systematic establishment and development
According to the panel of experts, the minimum of a relevant database, i.e. the German
volume regulation could lead to an increase in case joint replacement registry »EPRD«, which
numbers during the transition period as some of the includes all patients. This entails mandatory
care providers operating below the thresholds may registry participation including patients
still perhaps attempt to meet the requirements. with private health insurance. At the same
However, after the introduction of the regulation, time adequate funding for data collection
no further increase in case numbers can be expected and evaluation is required.
for to this reason as larger centers with higher case 5 Developing appropriate indication criteria
numbers are not affected and hospitals that had had and improving data collection in order
case numbers below the threshold are subsequently to gain reliable information for developing
no longer included. relevant needs-based care.
However, other factors may also play a role in 5 Developing suitable criteria for determining
increasing case numbers. For example, when the ambulatory and inpatient rehabilitation
minimum volume regulation was introduced, the needs. Correlating these criteria to future
remuneration for conservative therapies was simul- new phases in orthopedic rehabilitation
taneously reduced, which may have influenced the to determine the degree of comorbidity
decision for joint replacement therapy. and nursing care assistance required.
Meanwhile a positive correlation between case 5 Emphasis on requirements for and the
numbers and the quality of service provision has importance of specialist rehabilitation
been shown in many fields, for which reason the for older patients.
panel of experts consider the minimum volume 5 Accelerated application processes and
regulation to be a positive step on the whole. How- arrangements for subsequent rehabilitation
ever, there are certain issues with regard to the ac- (AHB).
tual implementation of such regulations in endo- 5 Developing and recording suitable quality
prosthetic care. On the one hand, there is sufficient criteria to appropriately depict the complex
evidence to show that hospitals operating as centers influence that physicians, patients and the
have low rates of morbidity and/or mortality in ad- implants have on quality.
dition to a decline in complication rates alongside
6.3 · Health Economic Aspects of Arthroplasty
131 6
the most common DRGs are more than double than
5 Improving knowledge regarding patient those in Germany (7 Section 5.2).
preferences and expectations paired The overall costs have risen over the past few
with higher patient involvement in the years as becomes apparent when considering the
decision-making process. most common DRG case fee calculations for hip
5 Concentrating on providing care through and knee arthroplasty. Costs for physician treat-
experienced surgeons in certified arthro- ment make up the largest proportion. The average
plasty care centers. costs for implants have either remained the same
5 Intensifying care research to gain reliable (hip) or decreased (knee).
information about care requirements at Meanwhile, the relative proportion of overall
regional and national levels. costs per case is markedly below 25 %.
5 Supporting rehabilitation research inde- Treatment of infected hip endoprostheses in par-
pendent of care providers in order to deve- ticular presents an economic challenge for hospitals.
lop needs-oriented and optimized care. According to certain publications, deficits (higher
costs versus remuneration) caused by this are on av-
erage over 12,000 euros per case per hospital.
Osteoarthritis is of particular economic impor-
6.3 Health Economic Aspects tance. In 2011, osteoarthritis of the hip or knee re-
of Arthroplasty sulted in approximately 7.6 million days of incapacity
to work (osteoarthritis of the knee: approximately 5
From a health economic perspective, the direct million days, osteoarthritis of the hip: approximately
costs arising from endoprosthetic care need to be 2.6 million days) (7 Section 5.1). In addition, in 2011,
taken into particular consideration. Results from almost 80 % of all retirements due to osteoarthritis
AOK data were published with regard to patients were due to osteoarthritis of the hip or knee.
suffering from osteoarthritis of the knee who un- The panel of experts clarified that the higher
derwent TKA in Germany. Not taking into account costs for younger patients can be explained by the
the costs for the TKA surgery itself, the data analysis different indications related to this age group. »Nor-
showed that the costs for the period of 12 months mal« patients within this age group with osteo-
after surgery (for example, for therapeutic products, arthritis of the knee are unusual. Instead, patients
drugs, contract physician care) are higher than usually suffer from more complex and cost-inten-
those for the period of 12 months prior to surgery. sive general diseases (for example, joint damage due
The costs for younger patients were considerably to hemophilia).
higher than for older patients (7 Chapter 5). None-
theless, several studies have demonstrated the de-
finitive cost efficiency of endoprosthetic care and of Need for action and potential solutions
different rehabilitation procedures in Germany 5 Fact-based discussions on the costs of
(7 Chapter 5). diseases from a social perspective, irrespec-
A cost and remuneration comparison of inpa- tive of payers, type of service or individual
tient primary THA cases (i. e. hospital cases) in nine aspects of care provision.
EU countries conducted in 2005 showed that even 5 Potentially involving patients financially, for
after adjustments for purchasing power parity, Italy example with fixed, diagnosis-dependent
has the highest costs followed by Germany. Cost additional surcharges that guarantee basic
comparisons become difficult when an individual care. This issue should be the subject of
country’s« purchasing-power parity has not been further open and straightforward discus-
adjusted for. This can be demonstrated by using sions. This would also necessitate impro-
non-adjusted average costs of hip and knee joint re- ving patient information and getting
placements in Switzerland as an example. In this patients more involved in their treatment.
case, after simple currency conversion, the costs of
6
133
Servicepart
Subject Index – 134

DOI 10.1007/978-3-662-55918-5
134 Servicepart
Subject Index
A F I
ability to undergo rehabilitation 65 Federal Institute for Drugs and Medical implant costs 106, 109, 110
additional remuneration (NUB) 115 Devices 93 incapacity to work 98, 112, 131
adherence to indication criteria 129 femoral component 10 infection 7, 11
anesthetic procedure 11 femoral neck fracture, incidence 5 initial certification 93
anticoagulation, risk of bleeding 60 Financing 114 Institute for Quality Assurance
arthroplasty 2 follow-up rehabilitation 52 and Transparency in Healthcare
audit 93 further training 101 95
insuree data 97, 125
ischemia 5
B G
bursitis 12 general anesthesia 10
German arthroplasty association 100
J
German arthroplasty registry 95 joint replacement, elective 72
C German association for osteoarthritis
support 100
calcification 12
cartilage degeneration 3
German institute for hospital
reimbursement 18, 109
K
case-based payment system, German joint replacement registry knee arthroplasty 7, 10
German Diagnosis Related Groups 7, 18, 73, 122, 125 knee replacement 6, 10, 19, 21
(G-DRG) 114 German league against rheumatism
case fees 72 71
case number development 27
CE mark 92
German Medical Technology
Association 95
L
certificate 95 German procedure classification 16 length of stay 49, 50, 51, 56
chronic joint diseases 114 German Society for Orthopaedics long-term quality 99
compliance 11 and Trauma 23, 96, 100
concomitant disease 10, 47 German Society for Trauma Surgery
conformity assessment procedure 92
continuing education 99
99
German Society of Orthopedics
M
costs and Orthopedic Surgery 99 material costs 106, 109, 110
– hospital 111 German Statutory Pension Insurance mechanisms of action
– surgery 107 65, 66, 69 – physiological 99
– arthroplasty 106 – biological 99
– Intangible 112 – biomechanical 99
H Medical Devices Act 93
minimum case number 97
D healthcare expenditure 106
healthcare provider 93, 106
minimum volume regulation 94, 130
musculoskeletal disease 4
days of incapacity to work 112 health fund 117
disabilities 114 health insurance data 42
hemiendoprosthesis 8
high-energy trauma 5
N
E hip arthroplasty 9, 19, 33
hip replacement 26, 35, 54
necrosis of the femoral head 129
nerve damage 11, 62
embolism 59 hospital service 107, 114 new examination and treatment
endoCert 96 hybrid fixation 8, 10 methods 115
endoprosthesis 4
endoprosthetic treatment 72
exceptional budget 94
expenditure, per patient 107
135 A–W
Subject Index
O T
osteoarthritis 2, 3 The German Medical Technology
osteonecrosis 5, 47 Association 101
osteophytes 3 therapeutic product 44, 65, 106, 114,
osteoporosis 3, 5, 78 131
outcome quality 67, 70, 96, 98 thromboprophylaxis 59, 61
thrombosis 11, 60
tibial component 10, 31, 55
P total arthroplasty 9
total hip arthroplasty 6, 35, 45
pathological bone disease 7 total hip replacement 21, 29
periprosthetic infection 11, 110 total knee arthroplasty 7, 45, 122
primary replacement 7, 12, 19, 23, total replacement 2, 9, 23, 29, 124
25, 26 trauma network 100
primary surgery 21, 126 trauma registry 100
private health insurance 96, 113, 114, treatment pathway 74, 96
127
process quality 96
product database 95
Professional Association of Ortho-
U
paedic Surgeons 100 unicondylar sledge prosthesis 29
uniform value scale, Einheitlicher
Bewertungsmaßstab (EBM) 114
Q
quality assurance 94, 95, 97
quality indicator 54, 81, 93
V
quality of care 73, 95, 100 visiting consultant system 44
quality seals 95
W
R willingness to pay 113
regional anesthesia 10, 12, 74
rehabilitation 42, 50, 52
revision arthroplasty 7
revision surgery 10, 12, 21
routine data 6, 97
S
service lives 128
statutory health insurance 23, 44, 47,
67
Statutory health insurance 65, 70
statutory product requirement 8
structural quality 96, 98
subsequent rehabilitation 65, 66
sustainability 99

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Hans-Holger Bleß

Miriam Kip Eds.

Dr. med. Miriam Kip

ISBN 978-3-662-55917-8 978-3-662-55918-5 (eBook)

Cover Design: deblik Berlin

Printed on acid-free paper

This Springer imprint is published by Springer Nature

Dr. Miriam Kip, Hans-Holger Bleß

1 Introduction to the Indications and Procedures . . . . . . . . . . . . . . . . . . . . 1

2 Prevalence of Hip and Knee Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . 15

3.5 Quality Aspects of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

4 Healthcare System Stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

5 Health Economic Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

6 Requirements for Adequate Arthroplasty Care (Expert Opinions) . . . . . . . 121

6.2.3 Adherence to Indication Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

List of Authors and Participants of the Expert

Authors Expert workshop participants

IV Integrated care (Integrierte Versorgung) VKA Vitamin K antagonist

Introduction to the Indications

1.2 Etiology, Indications and Treatment Goals –2

1.3 Materials, Surgical Procedures and Risks –8

© The Editor(s) (if applicable) and The Author(s) 2018

Summary The most common reason for joint replace-

. Tab. 1.1 Osteoarthritis classification and risk factors (selection)

Classification Risk factors Description

Primary localized (hip, knee) or generalized (polyosteoarthritis, more than

endocrine diseases e.g. diabetes mellitus

metabolic disorders e.g. hemochromatosis, hypercholesterolemia, hyperuricemia

other causes e.g. sepsis, inflammatory rheumatic disease, circulatory disorders

Source: IGES – Günther et al. 2013

jOsteoarthritis Osteoarthritis is characterized by an imbalance

1 Case numbers per 100,000 persons (2013) 900

Preliminary Follow-up treatment

(Digital) planning of the bio-

Selection of the implant (type, size,

Selection of the surgical access

Functionality and disability Perioperative and postoperative measures

References BVMed (2014): Hohe Anforderungen an Medizinprodukte.

Prevalence of Hip and Knee

2.2 Utilization of Primary Arthroplasty – 19

2.3 Utilization of Revision Total Arthroplasty and Revision

2.4 Regional Distribution – 23

2.5 Case Number Developments – 26

2.6 International Comparison – 31

© The Editor(s) (if applicable) and The Author(s) 2018

Summary destruction or pain which can no longer be treated

. Tab. 2.1 OPS classification

OPS description OPS description

Hip: Primary arthroplasty

5-820.0 Total arthroplasty 5-820.2 Total arthroplasty, custom-made prosthesis

5-820.3 Femoral head prosthesis 5-820.4 Dual head prosthesis

5-820.5 Acetabular support cup 5-820.7 Acetabular liner locking cup

5-820.8 Surface replacement 5-820.9 Short-stem femoral head prosthesis

5-820.x Other 5-820.y Unspecified

Hip: Revision total arthroplasty and revision