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Do Patients Live Longer After THA and Is the Relative Survival Diagnosis-specific?

Cnudde, Peter, MD; Rolfson, Ola, MD, PhD; Timperley, A. John, FRCS(Ortho), DPhil; Garland, Anne, MD, PhD; Kärrholm, Johan, MD, PhD; Garellick, Göran, MD, PhD; Nemes, Szilard, PhD

Clinical Orthopaedics and Related Research®: June 2018 - Volume 476 - Issue 6 - p 1166–1175
doi: 10.1007/s11999.0000000000000097

Background Hip replacements are successful in restoring mobility, reducing pain, and improving quality of life. However, the association between THA and the potential for increased life expectancy (as expressed by mortality rate) is less clear, and any such association could well be influenced by diagnosis and patient-related, socioeconomic, and surgical factors, which have not been well studied.

Questions/purposes (1) After controlling for birth year and sex, are Swedish patients who underwent THA likely to survive longer than individuals in the general population? (2) After controlling for relevant patient-related, socioeconomic/demographic factors and surgical factors, does relative survival differ across the various diagnoses for which THAs were performed in Sweden?

Methods Data from the Swedish Hip Arthroplasty Register, linked to administrative health databases, were used for this study. We identified 131,808 patients who underwent THA between January 1, 1999, and December 31, 2012. Of these, 21,755 had died by the end of followup. Patient- and surgery-specific data in combination with socioeconomic data were available for analysis. We compared patient survival (relative survival) with age- and sex-matched survival data in the entire Swedish population according to Statistics Sweden. We used multivariable modeling proceeded with a Cox proportional hazards model in transformed time.

Results Patients undergoing elective THA had a slightly improved survival rate compared with the general population for approximately 10 years after surgery. At 1 year after surgery, the survival in patients undergoing THA was 1% better than the expected survival (r = 1.01; 95% confidence interval [CI], 1.01-1.02; p < 0.001); at 5 years, this increased to 3% (r = 1.03; 95% CI, 1.03-1.03; p < 0.001); at 10 years, the difference was 2% (r = 1.02; 95% CI, 1.02-1.03; p < 0.001); and by 12 years, there was no difference between patients undergoing THA and the general population (r = 1.01; 95% CI, 0.99-1.02; p = 0.13). Using the diagnosis of primary osteoarthritis as a reference, hip arthroplasties performed for sequelae of childhood hip diseases had a similar survival rate (hazard ratio [HR], 1.02; 95% CI, 0.88-1.18; p = 0.77). Patients undergoing surgery for osteonecrosis of the femoral head (HR, 1.69; 95% CI, 1.60-1.79; p < 0.001), inflammatory arthritis (HR, 1.49; 95% CI, 1.38-1.61; p < 0.001), and secondary osteoarthritis (HR, 2.46; 95% CI, 2.03-2.99; p < 0.001) all had poorer relative survival. Comorbidities and the Elixhauser comorbidity index had a negative association with relative survival. Level of achieved education (middle level of education: HR, 0.90, 95% CI, 0.87-0.93, p < 0.001; high level: 0.76, 95% CI, 0.73-0.80, p < 0.001) and marital status (single status: HR, 1.33; 95% CI, 1.28-1.38; p < 0.001) were also negatively associated with survival.

Conclusions Whereas it has been known that in most patients, THA improves quality of life, this study demonstrates that it also is associated with a slightly increased life expectancy that lasts for approximately 10 years after surgery, especially among patients whose diagnosis was primary osteoarthritis. This adds further proof of a health-economic value for this surgical intervention. The reasons for the increase in relative survival are unknown but are probably multifactorial.

Level of Evidence Level III, therapeutic study.

P. Cnudde, O. Rolfson, A. Garland, J. Kärrholm, G. Garellick, S. Nemes, Swedish Hip Arthroplasty Register, Centre of Registers Västra Götaland, Gothenburg, Sweden

A. J. Timperley, Hip Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon & Exeter Hospital, Exeter, UK

P. Cnudde, O. Rolfson, J. Kärrholm, G. Garellick, S. Nemes, Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

A. Garland, Department of Orthopaedics, Institute of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden

P. Cnudde, Swedish Hip Arthroplasty Register, Centre of Registers Västra Götaland, Medicinargatan 18G, SE 413 45, Gothenburg, Sweden, email:

Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at the Swedish Hip Arthroplasty Register, Gothenburg, Sweden.

Received March 26, 2017

Received in revised form June 20, 2017

Accepted November 20, 2017

© 2018 Lippincott Williams & Wilkins LWW
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