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Mayo Clin Proc. Oct 2010; 85(10): 898–904.
PMCID: PMC2947961

A Population-Based Study of Trends in the Use of Total Hip and Total Knee Arthroplasty, 1969-2008

Abstract

OBJECTIVE: To study the rates of use of total hip arthroplasty (THA) and total knee arthroplasty (TKA) during the past 4 decades.

METHODS: The Rochester Epidemiology Project was used to identify all Olmsted County, Minnesota, residents who underwent THA or TKA from January 1, 1969, through December 31, 2008. We used a population-based approach because few data are available on long-term trends in the use of THA and TKA in the United States. Rates of use were determined by age- and sex-specific person-years at risk. Poisson regression was used to assess temporal trends by sex and age group.

RESULTS: The age- and sex-adjusted use of THA increased from 50.2 (95% confidence interval [CI], 40.5-59.8) per 100,000 person-years in 1969-1972 to 145.5 (95% CI, 134.2-156.9) in 2005-2008, whereas TKA increased markedly from 31.2 (95% CI, 25.3-37.1) per 100,000 person-years in 1971-1976 to 220.9 (95% CI, 206.7-235.0) in 2005-2008. For both procedures, use was greater among females, and the rate generally increased with age.

CONCLUSION: In this community, TKA and THA use rates have increased steadily since the introduction of the procedures and continue to increase for all age groups. On the basis of these population-based data, the probable need for TKA and THA exceeds current federal agency projections.

CI = confidence interval; NHDS = National Hospital Discharge Summary; NIS = National Inpatient Sample; THA = total hip arthroplasty; TKA = total knee arthroplasty

Although total hip arthroplasty (THA) and total knee arthroplasty (TKA) have been shown to lead to marked improvement in health outcomes1,2 and have been performed in the United States for nearly 40 years, little population-based research examining their use has been performed.3-6 Most recent information on the use of THA and TKA has come from examining particular subsets of the population, usually Medicare recipients or specific age groups.5-8 Nationally, the latest estimates indicate that 231,000 THA and 542,000 TKA procedures were performed in the United States in 2006, based on data from the National Hospital Discharge Summary (NHDS) published on July 30, 2008.9 This contrasts with data from the National Inpatient Sample (NIS), in which the same authors reported that 202,500 primary THAs and 402,100 primary TKAs were performed in the United States in 2003.10 The NHDS and NIS datasets have several strengths but also a number of important limitations, including diagnostic coding errors,11,12 counting hospital discharges rather than procedures (bilateral arthroplasty would be counted as a single procedure), and restriction to nonfederal facilities. Not only do these issues lead to underestimation of use when using these datasets, but also they do not account for health disparities in many parts of the United States, which may lead to underuse of these procedures by many who need the procedure the most.13,14

We previously described the use of THA in Olmsted County, Minnesota, from 1969 through 19903 and of TKA from 1971 through 1986.4 An update of these studies might identify trends in use and form the basis for a better estimation of the national need for these procedures. Indeed, a stated concern of a recent National Institutes of Health Consensus Conference report on TKA was the lack of population-based research on the procedure.15 It was noted that most of the available data are derived from the Medicare system and that comparable population data are not available in younger age groups. This is critically important given recent findings that one-third of all knee and hip arthroplasties in California were performed in adults younger than 65 years,16 which represents a substantial cost and disease burden.

The purpose of the current study was to determine secular trends in the use of primary THA and TKA in a single US county for which detailed demographic and use information has been available since the inception of both procedures. Our hypotheses were as follows: (1) we would observe increasing rates of use of THA and TKA over time; (2) use rates would vary substantially with respect to age and sex; (3) an underlying diagnosis of rheumatoid arthritis would decrease over time (ie, there would be a progressive decrease in the proportion of these procedures performed in patients with rheumatoid arthritis and an increase in those with osteoarthritis); and (4) previously reported use estimates for THA and TKA would differ from those obtained by studying the entire community.

METHODS

Olmsted County is situated in southeastern Minnesota and is composed of approximately 124,000 people (2000 US Census), of whom 86,000 reside in the county's urban center, Rochester; more than 80% of the county population resides within 5 miles of the city. In 2000, 89% of the population was white and not of Hispanic origin (vs 69% nationwide). Although 25% of the county residents are employed in health care services (vs 8% nationwide) and the level of education is correspondingly higher (30% having completed college vs 21% nationwide), the residents of Olmsted County are socioeconomically similar to the US non-Hispanic white population.17

Population-based epidemiological research can be conducted in this community because of the Rochester Epidemiology Project, a unique medical records linkage system developed in the 1960s that has been continuously supported by the National Institutes of Health since then.17 This is feasible because of 2 key features: (1) the local population is relatively isolated from other urban centers and receives its medical care from a small number of health care professionals, and (2) medical diagnoses and surgical procedures are identified in a computerized central index that covers essentially all sources of medical care used by county residents. The Rochester Epidemiology Project exploits the fact that virtually all the health care for Olmsted County residents is provided by the Mayo Medical Center, consisting of Mayo Clinic and its 2 affiliated hospitals (Rochester Methodist Hospital and Saint Marys Hospital), and the Olmsted Medical Center, consisting of a multispecialty clinic and its affiliated hospital. The closest competing medical centers are in Minneapolis, MN (139 km to the north), and LaCrosse, WI (114 km to the east). Although best known as a tertiary referral center, Mayo Clinic has always provided primary and secondary care to local residents. In any 3-year period, more than 90% of the county residents are examined at 1 of the 2 health care systems.17 A final important aspect of this setting is that, because of the presence of Mayo Clinic, THA and TKA have been readily available to this relatively stable population for several decades.3,4 Because a large and active orthopedic service exists to meet the needs not only of these local patients but also of national and international referrals to Mayo Clinic, surgical capacity was not a limiting factor in this study.

After approval of the institutional review boards of Mayo Clinic and the Olmsted Medical Center, we identified all Olmsted County residents who had a primary THA from January 1, 1969, through December 31, 2008, or a primary TKA from January 1, 1971, through December 31, 2008. Because the original medical records of all inpatient and outpatient medical care are readily available for review, along with data from the Mayo Clinic Total Joint Registry, it was possible to eliminate any patients who were improperly coded as having undergone a THA or TKA. Revision operations, as well as endoprosthetic and unicompartmental arthroplasty procedures, were excluded. Per a Minnesota statute, all patients must provide authorization for the use of their medical record for research purposes,18 but 184 patients coded as undergoing THA and 137 who underwent TKA had declined such authorization and could not be included in this study.

In calculating use rates, the entire population of Olmsted County was considered at risk. Denominator age- and sex-specific person-years were estimated from decennial census data.19 To obtain some sense of variability, it was assumed that, given a fixed number of person-years, the number of THA or TKA cases follows a Poisson distribution. This allowed for the estimation of standard errors and the calculation of 95% confidence intervals (CIs) for the rates. Overall use rates were directly age- and sex-adjusted to the population distribution of the United States in 2000. The standard errors and CIs for the adjusted rates were based on the same assumption as aforementioned. A Poisson regression model was used to assess temporal trends in the use of THA and TKA. Age and sex and their interactions with the calendar period were incorporated in these models to look for differential changes in the use rates by sex and age group. The change in the distribution of underlying diagnosis (eg, osteoarthritis, rheumatoid arthritis, and other diagnoses) among total joint arthroplasties and period was assessed using a Kruskal-Wallis test. All analyses were performed with SAS statistical software (SAS Institute, Cary, NC).

RESULTS

From 1969 (when THA was first introduced) through 2008, a total of 2742 primary THAs were performed on 2209 Olmsted County residents. From 1971 (when TKA was first introduced) through 2008, 3488 primary TKAs were performed on 2479 residents. No patient had simultaneous bilateral THA, but 533 patients had both hips replaced on different dates. Three hundred thirty-nine patients had simultaneous bilateral TKA, whereas 670 others had both knees replaced on different dates.

Time Trends in Overall Incidence

A significant association was found between more recent period and an increased incidence of THA (P<.001). The age- and sex-adjusted rate of primary THA use in Olmsted County has increased from 50.2 (95% CI, 40.5-59.8) per 100,000 person-years in 1969-1972 to 145.5 (95% CI, 134.2-156.9) per 100,000 in 2005-2008 (Table 1). Although the overall use rate has increased steadily, there was a notable increase in use more recently, with a 20% increase in 2001-2004 and a 43% increase in 2005-2008 (Figure 1, left).

TABLE 1.
Use of Total Hip Arthroplasty Among Olmsted County, MN, Residents by Period, 1969-2008
FIGURE 1.
Use rates of total hip arthroplasty among Olmsted County, MN, residents from 1969 to 2008, overall by sex (left) and age (right).

A significant association was also found between more recent period and an increased incidence of TKA (P<.001). The age- and sex-adjusted use of primary TKA in Olmsted County has increased from 31.2 (95% CI, 25.3-37.1) per 100,000 person-years in 1971-1976 to 220.9 (95% CI, 206.7-235.0) per 100,000 in 2005-2008 (Table 2). Similarly, the overall use rate has continued to increase steadily, but an increased use of 32% and 24%, respectively, was noted in 2001-2004 and 2005-2008 (Figure 2, left).

TABLE 2.
Use of Total Knee Arthroplasty Among Olmsted County, MN, Residents by Period, 1971-2008
FIGURE 2.
Use rates of total knee arthroplasty among Olmsted County, MN, residents from 1971 to 2008, by age group (left) and age-adjusted rates for women, men, and all patients (right).

Trends by Age

Increasing patient age was associated with a significant increase in the incidence of THA (P<.001; Figure 1, right). Use was highest in patients aged 70 through 79 years, with a decrease seen in patients 80 years or older. For the 0- through 49-, 50- through 59-, and 60- through 69-year age groups, the use rate gradually increased during the entire study period, with peaks in 2005-2008. Among the older age groups, after a decrease from a peak rate in the late 1970s and early 1980s, the use rate of THA has increased rapidly in recent years. The absolute magnitude of THA use in the 0- through 49-year age group was small in relation to others; however, the use rate increased more than 7-fold during the study period, with almost a doubling between 1997-2000 and 2005-2008.

A significant association was also found between older age and an increased incidence of TKA use during the study period (P<.001; Figure 2, right). As with hips, TKA use peaked among 70- through 79-year-olds and decreased in those 80 years or older. However, the use rate for the oldest age group was greater than that for the 0- through 49-year and 50- through 59-year age groups. In all age groups, except the 0- through 49-year-olds and the oldest age group, use peaked during 2005-2008. The oldest age group had an initial peak rate in 1985-1988, but similar to THA, the rates in this age group have increased notably in recent years. The absolute magnitude of TKA use for the 0- through 49-year age group was relatively small, but it increased by greater than 2-fold between 1997-2000 and 2005-2008.

Trends by Sex

During the 39-year study period, no significant association was found between sex and the incidence of THA (P=.79; Figure 1, left). The age-adjusted, sex-specific rates for females and males were 91.0 (95% CI, 86.6-95.5) per 100,000 person-years and 81.6 (95% CI, 76.7-86.5) per 100,000 person-years, respectively (Table 1). In the most recent period (2005-2008), the use of THA in females was numerically greater (ie, more actual procedures) than that in males for every age group except the youngest age group of those younger than 50 years (data not shown).

During a similar 37-year period, there was a significantly higher incidence of TKA among females (P<.001; Figure 2, left). Overall age-adjusted, sex-specific rates for females and males were 129.3 (95% CI, 123.9-134.8) per 100,000 person-years and 104.0 (95% CI, 98.2-109.8) per 100,000 person-years (Table 2 and Figure 2, left). In the most recent period (2005-2008), the use of TKA in females was numerically greater than males for every age group except the oldest one (data not shown).

Trends by Underlying Cause

Osteoarthritis was the primary underlying diagnosis leading to THA and TKA (Table 3). Among the Olmsted County residents undergoing THA, the proportion with an underlying diagnosis of rheumatoid arthritis decreased significantly during the study period (P<.001), from 3.7% and 4.1% in the first 2 periods to 1.9% and 0.9% in the last 2 periods. Likewise, among the Olmsted County residents undergoing TKA, the proportion of patients with an underlying diagnosis of rheumatoid arthritis decreased significantly (P<.001), from 39.1% and 23.4% in the first 2 periods to 2.0% and 2.4% in the last 2 periods.

TABLE 3.
Underlying Diagnosis Leading to Total Hip Arthroplasty and Total Knee Arthroplasty Among Olmsted County, MN, Residents by Period, 1969-2008

Potential National Use of Arthroplasty

For the purposes of estimating the current potential national need for THA and TKA, we selected the annual age- and sex-adjusted rates from the final 4 years (2005-2008) of the Olmsted County experience (ie, 145.5 per 100,000 for THA and 220.9 per 100,000 for TKA). When these rates are applied to the 2007 US population (the midpoint of the 2005-2008 period; 300 million), we obtained projected figures of 436,000 primary THAs and 662,700 primary TKAs for that year.

DISCUSSION

This population-based study provides detailed data on trends in the use of THA and TKA among all age groups during a period exceeding 35 years in the United States. The age- and sex-adjusted primary THA use rate increased almost 2-fold between 1969-1972 and 2005-2008. Likewise, the age- and sex-adjusted use of primary TKA among Olmsted County residents increased markedly from 31.2 per 100,000 person-years in 1971-1976 to 220.9 per 100,000 person-years in 2005-2008, a more than 7-fold increase. During this period, the use of THA and TKA increased for both sexes and all age groups. These data are consistent with other reports suggesting that THA and TKA use rates are increasing in the United States.5,9 Katz et al5 noted an annual 18% increase in TKA use rates in the US Medicare population from 1985 to 1990, whereas Kurtz et al9 reported a 50% increase in THA and a 3-fold increase in TKA use between 1991 and 2002 based on NHDS data. A much higher increase in TKA compared with THA rates in our study and others is likely due to increasing prevalence of obesity, which has a much stronger association with risk of knee osteoarthritis and weak or no association with hip osteoarthritis.20,21

Patients 80 years and older had an early peak of THA and TKA use in the late 1970s and early 1980s, followed by a decrease in use; a second notable increase in use was seen in the most recent years of the study. We hypothesize that earlier peak rates for this age group may have been related to a backlog of unmet demand for THA and TKA that was filled as the technology was more widely used. The increasing use in the most recent years is likely due to more willingness of patients to consider and surgeons to offer these procedures to elderly patients.

We also noted a decrease in the proportion of THA and TKA for patients with rheumatoid arthritis. We hypothesize that this may be due to initial treatment of a backlog of patients with rheumatoid arthritis as hip and knee arthroplasty became available, combined with earlier diagnosis and more effective medical treatment options now available for rheumatoid arthritis. Another possibility is that the incidence of rheumatoid arthritis may be decreasing. Two studies from Olmsted County have suggested a decreasing incidence of rheumatoid arthritis in a 40-year period from 1955 to 199422 and a slight increase in incidence from 1995 to 2007, especially in females.23 Our observation is consistent with a recent finding of substantial decreases in knee and hip arthroplasty rates in patients 40 years or older with rheumatoid arthritis from California.24

On the basis of our THA (96.0 per 100,000) and TKA (157.3 per 100,000) use rates for 2001-2004, we obtained projected figures of 276,424 primary THAs and 452,932 primary TKAs nationally for 2002. This compares to the estimates of 193,000 primary THAs and 381,000 primary TKAs performed in the United States in 2002 using the NHDS data.9 The discrepancies may represent an unmet need for THA and TKA services in the United States. The differences may also be due to exclusion of federal, military, and Veterans Affairs from the NHDS and/or the counting of bilateral procedures as one procedure because NHDS counts discharges, not procedures. Coding errors have been reported for similar national databases, such as the NIS.11,12

Note, however, that the Olmsted County population has a larger percentage of white residents compared with the national population as a whole, and they have good access to care. The use of THA and TKA is less for black and Hispanic Americans than that for white Americans in the United States5,6,13,14,25-27 despite a greater prevalence of osteoarthritis of the knee among blacks.26 Geographic and socioeconomic barriers have been shown to contribute to this racial disparity in THA and TKA rates.26,28-30 This may also explain some differences between our and previous national estimates. According to the Dartmouth Atlas, the THA rate in the Rochester region was 4.6 per 1000 Medicare enrollees in 1996-1997 compared with 3.0 per 1000 nationally. Likewise, the TKA rate in Rochester was 7.3 per 1000 compared with 5.7 per 1000 nationally,8 consistent with our observation. However, the excess cannot simply be explained by the relatively large number of orthopedic surgeons in Rochester because 89% and 86% of THAs and TKAs, respectively, at Mayo Clinic are performed on patients referred from outside the local region.

We are able to make this estimate because all major surgical procedures performed on Olmsted County residents were indexed for review; thus, the surgical experience of an entire population could be determined without the distortions inherent in a referral series. Our estimates reflect indications and contraindications for THA and TKA that are typical of currently acceptable surgical practice (substantial preoperative pain, functional limitations, and advanced arthritis or joint destruction on radiographs), and results at Mayo Clinic are comparable to those at other large centers.4,8,31 Studies of similar design have been conducted in this community to determine population-based trends in the use of procedures such as silicone breast implants,32 orchiectomy,33 and breast biopsy.34

Data regarding the need and use based solely on the Medicare population are likely to underestimate the use rates8 because 40% of THAs and 37% of TKAs in the United States are performed in patients younger than 65 years.16 In our cohort, patients younger than 65 years accounted for 42% of the THAs and 38% of the TKAs performed in 2005-2008. With the expansion of indications and age range for knee and hip arthroplasty in the past few years, a greater number of patients younger than 65 years are undergoing both TKA35,36 and THA37,38 with great success. Thus, national estimates of use rates need to take into account the patients younger than 65 years.

The strengths of the current study include data based on a defined geographic population for which detailed medical records are available. We can account for nearly every THA and TKA performed on the residents of this county during a period that begins with the introductions of THA (1969) and TKA (1971) in the United States. Although we may have missed some cases of THA and TKA in residents who underwent arthroplasty outside Olmsted County, any THA and TKA performed in the county would come to our attention because all orthopedic clinicians in Olmsted County participate in the Rochester Epidemiology Project. We also have information on the total underlying population at risk.

The current study has several limitations. A particular weakness is that we do not know the “correct” use of THA and TKA. As previously noted by other authors, it is difficult to determine the appropriate use of THA and TKA; in particular, it is not necessarily correct to assume that a high use rate is excessive.6,39 Our study was not designed to assess the appropriateness of hip and knee arthroplasty; however, previous studies have found little evidence of inappropriateness in patients undergoing arthroplasty. In a US study of 676 patients with knee or hip osteoarthritis, clinical appropriateness predicted referral to orthopedic surgery for total joint arthroplasty (hazard ratio, 1.95; 95% CI, 1.150-3.32; P=.01).40 Using explicit criteria based on the RAND method, a Spanish study found that indications for THA were appropriate in 59%, uncertain in 32%, and inappropriate in 8%41 and appropriateness improved over time.42 A small number of patients (321/4688) did not provide authorization to review their records, which could potentially bias our estimates toward a slightly lower use rate in the later years of the study. However, the bias is likely to be small and conservative in any event. As we discussed earlier, health care access in Olmsted County may be slightly better than that in the rest of the United States, indicating that these use rates may represent rates nationally with the assumption that patients in the rest of the United States do not have barriers to health care access.

CONCLUSION

Our study demonstrates that, in a single US county where access to THA and TKA has been widely available, use rates have increased steadily since the introduction of the procedures, and they continue to increase in all age groups. Use has decreased for patients with rheumatoid arthritis and increased for patients with osteoarthritis. On the basis of these data, the probable need for THA and TKA in the United States exceeds national projections based on the NIS.10

Supplementary Material

Author Interview:

Footnotes

This study was supported in part by research grant AR30582 from the National Institutes of Health, US Public Health Service, and a National Institutes of Health CTSA Award 1 KL2 RR024151-01 (Mayo Clinic Center for Clinical and Translational Research).

An earlier version of this article appeared Online First.

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