Abstract
Introduction
Hip hemiarthroplasty is a surgical procedure that requires the adhesion of the prosthetic implant by utilizing a fixation technique, either cemented or noncemented. The current literature does not provide a clear recommendation on a superior technique, although many countries outside the US have guidelines recommending cemented over noncemented procedures. Further, surgeon perceptions and beliefs related to the cemented and noncemented techniques in hip arthroplasty fractures are generally unknown.
Methods
Orthopedic surgeon leaders adopted a quality assurance initiative to increase the rate of cemented cases within their practice. A survey was developed to capture the surgeons’ perceptions related to fixation technique, affordability, and potential barriers and facilitators. Likert scale data were analyzed with descriptive statistics and chi-square tests.
Results
Sixty-one total joint surgeons throughout 13 locations were invited to participate in the study via email. A total of 38 of the 61 total joint surgeons completed the survey, representing a 62% response rate. Most responses were neutral or disagreed with the use of cement for femoral fixation in hemiarthroplasty.
Conclusion
Although some questions elicited strong opinions, many surgeons expressed hesitancy to change their current fixation technique and their desire for autonomy within their clinical practices. However, the large number of neutral responses suggests the potential to engage, educate, and shift the surgeons’ perception to adopt the quality assurance initiative and increase the rate of cemented cases.
Keywords: Total Joint Surgeons, Perceptions, Hip Arthroplasty, Quality Assurance Initiative
Introduction
Total hip arthroplasty (THA) is a common procedure for treating conditions like osteoarthritis, osteonecrosis, hip fractures, and tumors in the hip joint that are affected by aging, injury, or other conditions. In 2023, THA for femoral neck fractures accounted for 27.7% of procedures and remains the most common approach in displaced fractures. 1 Hip hemiarthroplasty, replacing only the femoral head component, is a further option, and a recent systematic review supports its effectiveness, though it suggests that THA may be a better option in patients < 80 years old who have a longer life expectancy (> 4 years). 2 In addition to the choice of THA or hemiarthroplasty, surgeons must consider a cemented or noncemented fixation technique in the planning stage. The noncemented approach relies on the metal stem naturally adhering and securing the prosthesis over time with the expansion of bony ingrowth, whereas the cemented procedure relies on a binding agent to secure the prosthesis when inserted into the femur.
According to multiple studies, 3–5 the noncemented procedure is considered to be more efficient related to operating room time and affordability. In contrast, other studies have found that the cemented technique has notable advantages, such as increased mobility immediately postoperatively and less pain, and it may be better suited for individuals who lead a low-demand active lifestyle. 3–6 Furthermore, the cemented technique is presumed to lengthen the prosthetic lifespan and enhance functionality, reducing potential mobility complications. 7,8
Health care system models and specific patient characteristics can directly influence the fixation technique performed during a hip arthroplasty. The United Kingdom, Sweden, Canada, Australia, and Japan have all adopted guidelines that suggest utilizing a cemented technique when performing hip arthroplasties. 1,9,10 Research studies from the United Kingdom, including England and Scotland’s health care systems, highlight the benefits and successful outcomes of the cemented technique. 11 The noncemented technique is frequently represented as a nonpreferred practice with higher costs due to higher complication rates, burdening the health care systems and patients. 12,13 Despite being linked to a higher risk of revision surgery, up to 93% of hip arthroplasties for osteoarthritis cases in the US utilize the noncemented fixation technique. 9,12,14,15 The preference is based on the presumption that the noncemented methodology reduces the risk of bone cement implantation syndrome (cement-induced cardiovascular events) and long-term complications associated with early bone-cement interface loosening. 12,16 However, for hip fractures, the use of cement is becoming more common in the US, with the 2023 American Joint Replacement Registry noting increases in the past 5 years, with > 20% of THA cases and > 50% of hemiarthroplasty cases now using cemented fixation. 1
The current literature does not identify a superior fixation technique, and as a result, health care systems are impacted by a lack of direction. Clinicians must approach this complex issue by making educated decisions based on experience, preference, and available resources. 17 Gender, age, and the potential onset of a secondary condition (ie, infections, fractures, chronic disease, revision surgery) should be considered when choosing a fixation technique. Cost-effectiveness adds to the burden of identifying a superior fixation method. Both the patient and the health care system may be impacted by the short- and long-term effects of cost.
Orthopedic leaders in a large California health care network introduced a quality assurance (QA) initiative following discussion and analysis of the literature. The group decided to prioritize increasing the number of cemented hip hemiarthroplasty procedures when treating hip fractures as a key quality measure. Their decision was based on current research supporting the long-term reduction of revision risk for cemented hip hemiarthroplasty procedures. 18 A new strategy for change was implemented that modified existing workflows and began routine collecting and reviewing of data to monitor the QA initiative. Initial trends demonstrated a mixed utilization of both fixation techniques and the opportunity to effectively identify potential facilitators and barriers that influence changes in practice. This study aimed to explore how total joint surgeons within an integrated health care system perceive a QA initiative. Bridging this knowledge gap can potentially assist other health care systems improve the quality of care by gaining insights into how surgeons view the adoption of quality processes within integrated health care systems.
Methods
Study design
A survey instrument was developed to capture the surgeons’ perceptions related to fixation technique, affordability, and preferences. A total of 61 joint surgeons were invited to participate via an introductory email sharing the aim of the study, survey link, and informed consent. By accessing the survey via the Research Electronic Data Capture (REDCap) link, the respondents consented to participate. Two follow-up emails were sent to remind the cohort that there was still time to complete the survey. Study data were collected and managed using REDCap electronic data capture tools hosted at The George Washington University. REDCap is a “secure, web-based software platform designed to support data capture for research studies, providing 1) an intuitive interface for validated data capture; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for data integration and interoperability with external sources.” 19,20
The George Washington University Institutional Review Board (IRB) determined the study was exempt from IRB review (IRB#NCR224648).
Survey development
The brief 16-question survey included questions adapted from reference articles, as well as newly formulated questions. 21–25 The instrument was divided into three sections: 1) demographics, 2) perceptions (Likert scale questions), and 3) a free-text section to record additional comments. The demographic questions collected information related to practice location, experience, residency and fellowship training, and an estimate of annual procedure volume. The Likert scale questions were related to perceptions of fixation procedures, affordability, resources, and potential facilitators and barriers. The 5-point Likert scale ranged from strongly disagree, disagree, neutral, agree, to strongly agree. The survey was sent to 3 subject matter experts for content evaluation. Additionally, it was piloted by 7 volunteers to ensure operability. The study instrument is included in the Supplemental Appendix.
Study population/Participants
A convenience sample of all 61 total joint surgeons throughout 13 locations was invited to participate in the study via email. Surgeons of all races and genders were invited to participate; however, the majority of potential respondents were men of different ethnicities between the ages of 40 and 65 years.
Data analysis
The survey data was recorded by The George Washington University REDCap repository, and all statistical analyses were performed on IBM SPSS Statistics for Windows, version 28. 26 Descriptive statistics were utilized to analyze both frequencies and crosstabulations of nominal and ordinal data. To identify statistical significance between survey questions related to fixation techniques, affordability, and preferences, chi-square (χ2) tests were performed to determine if any relationships existed. An alpha (α) value of 0.05 was used as the benchmark of statistical significance throughout the study. Last, a qualitative analysis of the free-text responses on completed surveys helped to identify and highlight recurring themes to better understand the surgeons’ perceptions related to fixation techniques.
Results
Participants
A total of 38 of the 61 total joint surgeons completed the survey, averaging 3 participants per location and representing a 62% response rate. Only 1 of the 13 locations had no participants.
Table 1 reflects information on location, experience, residency and fellowship training, and an estimate of annual procedure volume. A large proportion (39%) of the surgeons reported having > 20 years of experience. The second-highest group, at 21%, reported 6–10 years of experience. The large majority of the respondents, n = 28 (74%), noted the noncemented technique for hip arthroplasty was the preferred method in their residency, with n = 9 (24%) preferring the cemented technique and 1 participant indicating “not applicable.” During fellowship, 82% noted the noncemented technique was the preferred approach, and 18% indicated this did not apply to them. Half of the surgeons indicated an annual volume of ≥ 100 hip arthroplasty cases.
Table 1:
Participant demographic information
| Demographic Item | Frequency | Percentage (%) |
|---|---|---|
| Location | ||
| Antelope Valley | 1 | 2.6 |
| Baldwin Park | 0 | 0.0 |
| Downey | 4 | 10.5 |
| Kern County | 2 | 5.3 |
| Los Angeles | 2 | 5.3 |
| Orange County | 6 | 15.8 |
| Panorama City | 2 | 5.3 |
| Riverside | 2 | 5.3 |
| South Bay | 3 | 7.9 |
| San Bernardino County | 4 | 10.5 |
| San Diego | 5 | 13.2 |
| Woodland Hills | 3 | 7.9 |
| West Los Angeles | 4 | 10.5 |
| Years of experience | ||
| 0–5 | 4 | 10.5 |
| 6–10 | 8 | 21.1 |
| 11–14 | 4 | 10.5 |
| 15–19 | 7 | 18.4 |
| ≥ 20 | 15 | 39.5 |
| Preferred fixation technique: Residency | ||
| Cemented | 9 | 23.7 |
| Noncemented | 28 | 73.7 |
| Unknown | 0 | 0.0 |
| Not applicable | 1 | 2.6 |
| Preferred fixation technique: Fellowship | ||
| Cemented | 0 | 0.0 |
| Noncemented | 31 | 81.6 |
| Unknown | 0 | 0.0 |
| Not applicable | 7 | 18.4 |
| Annual total number of hip arthroplasties performed | ||
| 0–24 | 4 | 10.5 |
| 25–49 | 0 | 0.0 |
| 50–74 | 4 | 10.5 |
| 75–99 | 11 | 28.9 |
| ≥ 100 | 19 | 50.0 |
| Awareness of an organizational initiative to increase cemented cases | ||
| Yes | 5 | 13.2 |
| No | 33 | 86.8 |
Total joint surgeons’ perceptions
Fixation Technique Preference
The surgeons’ perceptions related to fixation techniques within their practice are reflected in Table 2. The majority (87%) reported they were not aware of an organizational initiative to increase the percentage of cemented procedures. The majority of the study participants did not see the transition to more cemented cases as an important QA measure: a collective 42% affirmed disagreement (strongly disagree and disagree), 34% remained neutral, and a collective 23% selected strongly agree and agree.
Table 2:
Total joint surgeons’ perceptions of fix techniques and affordability
| Survey item | Yes, n (%) | No, n (%) | |||
|---|---|---|---|---|---|
| I am aware of the chiefs’ goal initiative to increase cemented cases. | 5 (13.2) | 33 (86.8) | |||
| Strongly disagree, n (%) | Disagree, n (%) | Neutral, n (%) | Agree, n (%) | Strongly agree, n (%) | |
|---|---|---|---|---|---|
| I believe that evidence-based medicine supports the significant benefits of the cemented technique over the noncemented technique. | 3 (7.9) | 6 (15.8) | 19 (50.0) a | 6 (15.8) | 4 (10.5) |
| Based on my practice or observations, I believe that increasing the amount of cemented cases over noncemented cases is an important quality assurance initiative. | 4 (10.5) | 12 (31.6) | 13 (34.2) a | 8 (21.1) | 1 (2.6) |
| Based on my practice or observations, I believe that cemented implants fail at a higher rate than noncemented implants. | 5 (13.2) | 10 (26.3) | 16 (42.1) a | 4 (10.5) | 3 (7.9) |
| Based on my practice or observations, I believe that patients strongly prefer the cemented technique over the noncemented technique. | 9 (23.7) | 13 (34.2) | 15 (39.5) a | 0 (0.0) | 1 (2.6) |
| Based on my practice or observations, I believe additional staff and resources are required for cemented cases. | 6 (15.8) | 11 (29.0) | 6 (15.8) | 13 (34.2) a | 2 (5.3) |
| Based on my observations, I believe my practice is impacted by the additional operating room time needed for cemented cases. | 5 (13.2) | 11 (29.0) | 7 (18.4) | 13 (34.2) a | 2 (5.3) |
| Based on my practice or observations, I believe cemented implants are less expensive than noncemented implants. | 1 (2.6) | 4 (10.5) | 16 (42.0) a | 13 (34.2) | 4 (10.5) |
| Based on my practice or observations, I believe the cementing technique is more cost-effective than the noncemented in the short term (less than a year). | 4 (10.5) | 11 (29.0) | 10 (26.3) | 12 (31.6) a | 1 (2.6) |
| Based on my practice or observations, I believe the cementing technique is more cost-effective than the noncemented in the long term (more than a year). | 7 (18.4) | 15 (39.5) a | 10 (26.3) | 4 (10.5) | 2 (5.3) |
The survey’s outcomes and comparison results are reflected in the table above.
This value represents the highest outcome for this specific question.
A predominantly neutral response (50%) illustrated the surgeons’ perceptions when asked if they believe evidence-based medicine supports the significant benefits of the cemented technique over the noncemented technique. The remaining responses reflect an even distribution when collapsed across strongly disagree and disagree, reflecting 24%, and strongly agree and agree, at 26%.
A collective 19% (strongly agree and agree) of the surgeons perceived that cemented implants fail at a lower rate than noncemented implants. However, 39% disagreed (collapsed across strongly disagree and disagree), and a notable 42% responded neutrally.
Correlations
Descriptive statistics and χ2 tests were performed to identify significant differences. The significance level for all tests was set at α = 0.05. All questions except for #1 (location) demonstrated a distribution of answers on the chi-square goodness of fit tests with a P < .05, indicating that the answers were not distributed by chance. In regards to location, there was no correlation between the different sites and perceptions of the evidence supporting cementing over noncementing [χ2 = 49.68, degrees of freedom (df) = 44, P = .257].
Tests of independence were performed to explore the relationship between different variables. No association was identified between the fixation technique learned in residency or fellowship and the surgeons’ perceptions of evidence-based medicine supporting the superiority of the cemented technique over the noncemented technique (χ2 = 9.6, df = 8, P = .296 and χ2 = 6.1, df = 4, P = .190, respectively). There was a statistically significant correlation (χ2 = 59.53, df = 16, P < .001) between belief in the evidence-based medicine supporting the cemented over the noncemented technique and support for the QA initiative to increase the percentage of cemented cases, with a moderately strong positive relationship (Cramer’s V = 0.63). From a resourcing perspective related to affordability, there was a statistically significant association (χ2 = 49.2, df = 16, P < .001) between the perceived need for additional staff/resources and the need for more operating room time for cemented procedures with a moderately strong effect size (Cramer’s V = 0.57). Last, a perception that cemented procedures had a lower failure rate than uncemented procedures was not associated with the perception of the short-term cost-effectiveness of cemented over uncemented cases (χ2 = 17.13, df = 16, P = .377); however, this was significant when considering the long-term cost-effectiveness of the same (χ2 = 31.81, df = 16, P = .01), with the relationship showing a moderate positive correlation (Cramer’s V = 0.457).
In the open-text section of the survey, 24 participants responded, resulting in a response rate of 63% for the qualitative analysis. The prominent theme of autonomy and its importance in the surgeon’s clinical practice was identified in 13 responses, representing 54% of the total. Another recurring theme was the customization of care through the selection of the fixation method based on the patient’s comorbidities, gender, age, and bone quality, which was reflected in 11 responses, or 45%. The results underscore the importance of surgeons having the autonomy to make independent, well-informed decisions based on their education, training, experience, and the unique needs of each patient in their clinical practice.
Discussion
This study aimed to gain insight into the total joint surgeons’ perspectives on the adoption of a QA initiative, fixation techniques, and affordability, as well as resources associated with hip arthroplasty. This survey effectively yielded a 62% response rate, with 38 of 61 total joint surgeons participating. One of the 13 sites chose not to complete the survey, resulting in its absence from the study. The reason behind their decision was unknown. According to Wu et al, 27 a range of 44% to 48% is considered a reasonable response rate for an online survey.
The survey captured two significant outcomes: 1) a high proportion of neutral responses, and 2) the majority of participants being unaware of a QA initiative associated with increasing cementation in hip hemiarthroplasty for fractures. The outcomes represent a prime opportunity to educate and engage the surgeons on the benefits of the QA initiative, which may facilitate improvement in the rates of adopting the cemented fixation technique. Additionally, the study demonstrated some apprehension from the surgeons to change their preferred fixation methodology within their clinical practice. This finding reaffirms the recurring themes in the free-text responses, where the surgeons emphasized the importance of autonomy and subject matter experts’ opinions in decision-making processes that impact patient outcomes, affordability and resources, and health care systems. Survey results inferred that the surgeons have differing perceptions of the superiority of one fixation technique over the other and short- and long-term affordability and resources.
This theme underscores the significance of involving subject matter experts in decision-making processes that impact the health care system. Furthermore, it emphasizes the value that orthopedic surgeons place on professional autonomy in their clinical practices.
A study 28 with a similar design and methodology surveyed Turkish orthopedic and traumatology residents through face-to-face interviews, aiming to gather information on basic demographic data, level of seniority, equipment competence, and theoretical and practical training. The residents were also asked about their beliefs regarding the types of surgical procedures they could perform after their specialization, taking into consideration follow-up and potential complications. Despite the similar approach, including a high response rate, the study did not capture information from experienced surgeons overseeing their practice and focusing on quality elements, such as fixation technique and affordability. This is an area of research that still requires further exploration to address current gaps and practical challenges that would contribute to advancing knowledge.
The study has strengths and limitations. A strength is the high response rate, including the free-text responses, which enhances the study’s data volume and quality content. The study’s scope did not account for external factors that may have influenced the results, contributing to its limitations. Notably, the data had a considerable neutral response rate. According to Kusmaryono et al, 29 a central tendency bias phenomenon occurs when the participant consciously selects a neutral response. This characteristic is recognized in scenarios such as when a participant avoids taking strong stances and instead chooses a “safe” option or attitude, shows indecisiveness in responding to a question, does not care to answer honestly or about the topic, and ultimately has no opinion. The generalizability of the study is somewhat limited based on the sample size, the specific health care model, the preferred or mandated fixation techniques, and the local work culture. Furthermore, it should be noted that although an internal validation process was utilized for the survey, there was a lack of formal instrument validation.
To make informed decisions regarding the utilization of cemented and noncemented fixation techniques, further research should take into account important factors. These factors encompass patient satisfaction, clinical outcomes, and financial cost gap analysis, which considers both affordability and cost-effectiveness. Additionally, it is essential to consider potential complications that could lead to revision surgical procedures and readmissions, as well as the workforce resources required by each technique. Last, both the short-term and long-term effects must be carefully evaluated to gain a comprehensive understanding of the benefits and disadvantages of each approach.
Conclusion
Effective collaboration and communication are crucial for establishing a QA effort within an integrated health care system, such as the efforts to increase the cementation of hemiarthroplasty in the setting of femoral neck fracture, that allows orthopedic surgeons to have autonomy in their clinical practice. As surgeons hold varying perceptions, there is a great opportunity for constructive dialogue and education to increase awareness about the benefits of this QA initiative. This may lead to a potential rise in the rate of cemented cases. Ultimately, this study may help other health care systems by raising awareness of how surgeons perceive the incorporation of quality processes into integrated health care systems.
Supplementary Material
Online supplementary file 1:
Acknowledgments
The authors express their gratitude to all surgeon participants who completed the survey and took the time to provide valuable insights on this topic.
Footnotes
Author Contributions: Ivette T Curiel, DHSc, participated in the study design, data procurement and analysis, writing original draft, review, and editing of the manuscript. Ronald A Navarro, MD, FAAOS, FAOA, served as the subject matter expert in the critical review and participated in the drafting and submission of the final manuscript. Norman W Gill, PT, DSc, was the project administrator and participated in the study design, data analysis, drafting, and submission of the final manuscript. All authors have given final approval to the manuscript.
Conflicts of Interest: None declared
Funding: None declared
Data-Sharing Statement: Underlying data are not available.
Supplementary Materials: Supplemental material is available at: https://www.thepermanentejournal.org/doi/10.7812/TPP/24.140#supplementary-materials.
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Supplementary Materials
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