Complication rates after direct anterior vs posterior approach for hip hemiarthroplasty in elderly individuals with femoral neck fractures

BACKGROUND Dislocation rates after hemiarthroplasty reportedly vary from 1%to 17%.This serious complication is associated with increased morbidity and mortality rates.Approaches to this surgery are still debated,with no consensus regarding the superiority of any single approach.AIM To compare early postoperative complications after implementing the direct anterior and posterior approaches(PL)for hip hemiarthroplasty after femoral neck fractures.METHODS This is a comparative,retrospective,single-center cohort study conducted at a university hospital.Between March 2008 and December 2018,273 patients(a total of 280 hips)underwent bipolar hemiarthroplasties(n=280)for displaced femoral neck fractures using either the PL(n=171)or the minimally invasive direct anterior approach(DAA)(n=109).The choice of approach was related to the surgeons’practices;the implant types were similar and unrelated to the approach.Dislocation rates and other complications were reviewed after a minimum followup of 6 mo.RESULTS Both treatment groups had similarly aged patients(mean age:82 years),sex ratios,patient body mass indexes,and patient comorbidities.Surgical data(surgery delay time,operative time,and blood loss volume)did not differ significantly between the groups.The 30 d mortality rate was higher in the PL group(9.9%)than in the DAA group(3.7%),but the difference was not statistically significant(P=0.052).Among the one-month survivors,a significantly higher rate of dislocation was observed in the PL group(14/154;9.1%)than in the DAA group(0/105;0%)(P=0.002).Of the 14 patients with dislocation,8 underwent revision surgery for recurrent instability(posterior group),and one of them had 2 additional procedures due to a deep infection.The rate of other complications(e.g.,perioperative and early postoperative periprosthetic fractures and infection-related complications)did not differ significantly between the groups.CONCLUSION These findings suggest that the DAA to bipolar hemiarthroplasty for patients with femoral neck fractures is associated with a lower dislocation rate(<1%)than the PL.

Direct anterior compared to posterior approach for hip hemiarthroplasty following femoral neck fractures

The differences in complication rates between the direct anterior and posterior approaches for hemiarthroplasty in elderly patients with femoral neck fractures are not yet fully understood.Dislocation,a severe complication associated with increased mortality and often requiring additional surgery,may occur less frequently with the direct anterior approach compared to the posterior approach.Careful consideration of patient demographics is essential when planning the surgical approach.Future research in this area should focus on robust randomized controlled trials involving elderly patients recovering from femoral neck fractures.

Hemiarthroplasty for irreparable distal radius fractures in the elderly:A comprehensive review

BACKGROUND Elderly patients maintaining functional independence can now be candidates for primary wrist hemiarthroplasty to manage acute irreparable distal radius fractures(DRFs).However,further investigation with long-term follow-up is required to validate these initial findings.AIM To review the literature on the outcomes of distal radius hemiarthroplasty with available implants to assess its viability as a treatment option.METHODS A comprehensive review of the literature was conducted using electronic databases,including PubMed,Medline,and Scopus.The search terms employed were"distal radius fracture","hemiarthroplasty","wrist arthroplasty",and related terminology.The search was restricted to articles published in English from 1980 until June 2023.Inclusion criteria encompassed cases or case series of DRF treated with hemiarthroplasty,providing clinical or radiographic outcomes,and published in peer-reviewed journals.RESULTS A total of 2508 articles from PubMed and 883 from Scopus were identified initially.Following screening and removal of duplicates,13 articles met the inclusion criteria.These articles,predominantly clinical retrospective studies,provided insights into hemiarthroplasty outcomes,including functional improvements and complications.Hemiarthroplasty was a treatment option for complex DRF,particularly those cases with severe comminution,intraarticular involvement,or severe osteoporosis.Functional outcomes demonstrated improvements in pain relief,wrist mobility,and grip strength,with variability across studies.Complications included implant loosening,infection,nerve injury,and stiffness,with varying incidence rates influenced by surgical techniques and implant choice.Long-term outcomes were inadequately documented,warranting further research.CONCLUSION Hemiarthroplasty is a promising treatment for irreparable DRF in the elderly.Long-term outcomes and complications require further study.

Debate on direct-anterior vs posterior approach for hip hemiarthroplasty:The authors’insights

We read and discussed the study entitled“Complication rates after direct anterior vs posterior approach for Hip Hemiarthroplasty in elderly individuals with femoral neck fractures”with great interest.The authors have done justice to the topic of comparison of anterior and posterior surgical approaches for bipolar hemiarthroplasty which has been an everlasting debate in the existing literature.However,there are certain aspects of this study that need clarification from the authors.

Indications and Results of Hip Arthroplasty and Hemiarthroplasty at Treichville University Teaching Hospital

Objective: Hip arthroplasty has variable and codified indications. The interest of this study results from the need to adapt our practices to the socio-economic status of our patients. The aim of this study was to describe the epidemiological profile of patients, the indications and results of hip arthroplasties performed in our hospital. Methodology: A descriptive monocentric study was conducted from January 2010 to December 2019 at Treichville University Teaching Hospital. All patients, who underwent total hip arthroplasty or hemiarthroplasty with intermediate or cervico-cephalic prosthesis, were included in the study. Epidemiological, clinical, therapeutic and follow-up data were analysed. Results: We collected 95 patients with 97 hips operated. The mean age was 67 years. 56% of patients were male. Arthroplasty was performed after femoral neck fractures in 78% of cases, followed by osteonecrosis of the femoral head (15%). The left side was affected in 51% of cases. The Moore’s posterior approach was used in 79% of cases, followed by the Hardinge’s lateral approach (21%). Hemiarthroplasties were implanted in 78% of patients. We observed 4 dislocations and 3 post-operative infections at 48 months of follow-up. The mean Harris score was 75.2. Conclusion: Arthroplasty has improved the function of our patients. Most of young males undergo the arthroplasty. Intermediate prostheses are commonly used implants.

Bipolar hemiarthroplasty for femoral neck fracture using the direct anterior approach

AIM: To evaluate whether walking ability recovers early after bipolar hemiarthroplasty(BHA) using a direct anterior approach.METHODS: Between 2008 and 2010, 81 patients with femoral neck fracture underwent BHA using the direct anterior approach(DAA) or the posterior approach(PA). The mean observation period was 36 mo. The age, sex, body mass index(BMI), time from admission to surgery, length of hospitalization, outcome after discharge, walking ability, duration of surgery, blood loss and complications were compared. RESULTS: There was no significant difference in the age, sex, BMI, time from admission to surgery, length of hospitalization, outcome after discharge, duration of surgery and blood loss between the two groups. Two weeks after the operation, assistance was not necessary for walking in the hospital in 65.0% of the patients in the DAA group and in 33.3% in the PA group(P < 0.05). As for complications, fracture of the femoral greater trochanter developed in 1 patient in the DAA group and calcar crack and dislocation in 1 patient each in the PA group.CONCLUSION: DAA is an approach more useful for BHA for femoral neck fracture in elderly patients than total hip arthroplasty in terms of the early acquisition of walking ability.

Periprosthetic joint infections in femoral neck fracture patients treated with hemiarthroplasty–should we use antibiotic-loaded bone cement?

BACKGROUND Hemiarthroplasty is the most common treatment in elderly patients with displaced intra-capsular femoral neck fracture(FNF).Prosthetic joint infection(PJI)is one of the most feared and frequent complications post-surgery because of the frail health status of these patients and the need for fast track surgery.Therefore,priorities should lie in effective preventive strategies to mitigate this burden.AIM To determine how much the implementation of the routine use of antibioticloaded bone cement(ALBC)as a relatively easy-to-apply amendment to the surgical practice reduces the infection rate in our hemiarthroplasty cohort.METHODS We retrospectively assessed all demographic,health status and treatment-related data of our FNF patients undergoing cemented hemiarthroplasty in the period from 2011 to 2017;241 patients were further analyzed after exclusion of patients with cancer-related sequelae and those who died before the end of the 1-year observation period.The PJI rate as diagnosed on basis of the Musculoskeletal Infection Society(MSIS)criteria 2011 was determined for each included patient and compared in function of the bone cement used for hip stem fixation.Patients were split into a group receiving a plain bone cement in the period from January 2011 to June 2013(non-ALBC group)and into a group receiving an ALBC in the period July 2013 to December 2017(ALBC group).Data analysis was performed with statistical software.We further calculated the cost-efficacy of the implementation of routine use of ALBC in the second group balancing the inhospital infection related treatment costs with the extra costs of use of ALBC.RESULTS In total 241 FNF patients who received cemented hemiarthroplasty in the period from January 2011 to January 2017 were eligible for inclusion in this retrospective study.There were 8 PJI cases identified in the ALBC group among n=94 patients,whereas 28 PJI cases were observed in the non-ALBC group among n=147 patients.The statistical analysis showed an infection risk reduction of 55.3%(in particular due to the avoidance of chronic delayed infections)in the ALBC group(95%CI:6.2%-78.7%;P=0.0025).The cost-evaluation analysis demonstrated a considerable cost saving of 3.500€per patient,related to the implementation of routine use of ALBC in this group.CONCLUSION Use of ALBC is a potent infection preventive factor in FNF patients receiving cemented hemiarthroplasties.It was further found to be highly cost-effective.

Long-Term Clinical and Radiological Outcome in Primary Hemiarthroplasty for Comminuted Humeral Head Fractures in the Elderly: A 5 - 10 Years Follow-Up Prospective Study

Objective: In the constantly growing population of people beyond the age of 60 years, the incidence of complex comminuted humeral head fractures increases, thus increasing the need for prosthetic replacement. The purpose of this study was to determine the long-term results after primary hemiarthroplasty in patients older than 60 years. Methods: From 08/2010 to 12/2015 a prospective study of 54 patients (mean age 75 years) with complex humeral head fracture was performed at the University Hospital Rostock. 24 patients were available for follow-up after 5 - 10 years. Pain, the Karnofsky-index, and the range of motion were obtained as well as radiographs in two planes. The Constant-Murley score and the UCLA rating system were evaluated for functional assessment. Results: 15 patients were painfree. The Karnofsky index deteriorated from 94 preoperatively to 70. The Constant-Murley score of the operated extremity reached 47 points out of possible 100, the uninjured side scored 82 points. The age-specific Constant-Murley score showed more favorable results. The UCLA rating system values leveled up to 22 out of 35 points for the replaced shoulder and 33 points for the other arm. Radiologically, more than 50% of the implants were classified as non-centered and the acromio-humeral space diminished significantly. Conclusions: Primary hemiarthroplasty helps to restore a situation of little or no pain whereas functional and radiological outcome remains limited. Revision surgery or conversion to reverse shoulder arthroplasty was not indicated in any case supporting the clinical value of hemiarthroplasty.

Comparison of Reverse Shoulder Arthroplasty and Hemiarthroplasty for Proximal Humeral Fractures: What about Functional Outcome? Reverse versus Hemiarthroplasty in Shoulder Fractures

Purpose: Shoulder replacement becomes more indicated in complex fractures of the humeral head. Indications depend on some factors especially age and fracture’s pattern. The aim of our study is to compare the functional results of both reverse shoulder arthroplasty (RSA) and hemi-arthroplasty (HA) in complex proximal humerus fractures. Materials and Methods: Fifty-two shoulder arthroplasties (20 reverse shoulder arthroplasties, 38 hemiarthroplasties), were reviewed retrospectively, between January 2010, and December, 2015. Preoperative, operative, and postoperative evaluations were achieved based on medical observations. At last follow-up, functional outcomes were established according Constant-Murley Score and American Shoulder and Elbow Surgeons (ASES) score. Complications rates were well-defined and compared between the study groups. Results: The mean of follow-up was 41.5 months. Comparing the study groups, reverse shoulder arthrosplasties were significantly older (mean age: 76.3 versus 66). These fractures occur more in women (70% versus 57%). At last follow-up, functional outcomes were better in reverse shoulder arthroplasty group (Constant-Murley Score 76 versus 59;ASES score 56 versus 41). The mean anterior elevation and external rotation were better in reverse shoulder arthroplasty respectively (110&deg;versus 88°;28° versus 19°). Revision was more required in hemiarthroplasty group than reverse shoulder arthroplasty group. Conclusion: Reverse shoulder arthroplasty seems to improve functional outcome at intermediate and long-term of follow-up of proximal complex humeral fractures on comparison to hemiarthroplasty.

Intraoperative Periprosthetic Femoral Fractures Related to Austin Moore Hemiarthroplasty—A Retrospective Review of 365 Patients

Intraoperative periprosthetic femoral fractures (IPFF) have been studied extensively for total hip arthroplasties, but not for hemiarthroplasties. Recent series in the literature show an IPFF rate for hemiarthroplasties ranging from 0% to 14%. The present study was designed to determine the prevalence and outcome after IPFF during non-cemented hemiarthroplasty. In addition, the surgical step at higher risk to produce these fractures was evaluated in an attempt to identify strategies that could minimize the prevalence of this complication. We performed an observational study of 365 consecutive patients undergoing and Austin-Moore hemiarthroplasty from 2005 to 2006 at our institution. The institutional IPFF rate was 6.8% (twenty-five out of 365). The moment at which the fracture was detected was collected: 1) intraoperatively and 2) in the postoperative radiological control. The surgical step in which the fracture occurred was collected: 1) neck osteotomy, 2) broaching, 3) prosthesis introduction, and 4) reduction. Results were compared to a control group according to blood transfusion rate, mortality rate and revision surgery rate. The fractures were detected during the surgery in twenty cases (80%);for the five remaining cases the fracture was only detected in the postoperative radiology. For those detected during the surgery, the two most common manouvers in which the fracture occurred was hip reduction (10 cases) and prosthesis introduction (7 cases). The blood transfusion rate, first-month mortality rate and revision surgery rate showed no statistical difference between the two groups (p = 0.3). In the present series, most of IPFF during Austin-Moore hemiarthroplasty implantation, occurred during arthroplasty reduction. Difficulties during this step should lead the surgeon to reconsider if technical mistakes are present and can be solved. However, if fracture occurs, adequate treatment of IPFF should provide satisfactory results without increasing blood transfusion needs, mortality or revision surgery.

Intermediate Hip Arthroplasty in Gabon: Blood Loss and Risk Factor for Transfusion

Background: Hip arthroplasty is a surgery with a high risk of bleeding. The main objective of this study was to research risk factors for bleeding and transfusion in patients undergoing hip hemiarthroplasty in Gabon. Method: It was a retrospective, monocentric, descriptive and analytical study carried out from June 2011 to June 2021 at the Omar Bongo Ondimba army training hospital. The variables studied were demographic characteristics, biological variables, transfusion and intraoperative data. The primary outcome was intraoperative transfusion. A univariate and multivariate analysis was conducted to identify the factors associated with the occurrence of a transfusion. Results: Of the 97 patients included, the average age was 74.2 years ± 10, male predominance was 73.2%, the average ASA score was 1.9 ± 0.5, and transfusion incidence was 38.1%. The average number of RBCs transfused was 1.2 ± 0.6. Tranexamic acid was used in 11.3% of patients. The average bleeding was 450 ± 453 ml. Preoperative anemia was predictor of transfusion to be significant. Conclusion: The incidence of transfusion is law compared to total hip arthroplasty. The implementation of a patient blood management protocol is difficult given the urgency of bone repair. However, a better use of tranexamic acid could reduce this transfusion incidence.

Does total hip arthroplasty provide better outcomes than hemiarthroplasty for the femoral neck fracture? A systematic review and meta-analysis

Purpose By comparing the outcomes of total hip arthroplasty with hemiarthroplasty in elderly patients with a femoral neck fracture to investigate the one-year mortality,dislocation,infection,reoperation rate,and thromboembolic event.Methods The PubMed,EMBASE databases,and Cochrane library were systematically searched from the inception dates to April 1,2020 for relevant randomized controlled trials in English language using the keywords:“total hip arthroplasty”,“hemiarthroplasty”and“femoral neck fracture”to identify systematic reviews and meta-analyses.Two reviewers independently selected articles,extracted data,assessed the quality evidence and risk bias of included trials using the Cochrane Collaboration’stools,and discussed any disagreements.The third reviewer was consulted for any doubts or uncertainty.We derived risk ratios and 95%confidence intervals.Mortality was defined as the primary outcome.Secondary outcomes were other complications,dislocation,infection,reoperation rate,and thromboembolic event.Results This meta-analysis included 10 studies with 1419 patients,which indicated that there were no significant differences between hemiarthroplasty and total hip arthroplasty in reoperation,infection rate,and thromboembolic event.However,there was a lower mortality and dislocation rate association with total hip arthroplasty at the one-year follow-up.Conclusion Based on our results,we found that total hip arthroplasty was better than hemiarthroplasty for a hip fracture at one-year follow-up.

Postoperative infection caused by Acinetobacter baumannii misdiagnosed as a free-living amoeba species in a humeral head hemiarthroplasty patient:a case report

Background:Acinetobacter baumannii is ubiquitous,facultative intracellular,and opportunistic bacterial pathogen.Its unique abilities allow it to survive in a diverse range of environments,including health care settings,leading to nosocomial infections.And its exceptional ability to develop resistance to multiple antibiotics leaves few drug options for treatment.It has been recognized as a leading cause of nosocomial pneumonia and bacteremia over the world.Case presentation:In this case,a 73-year-old woman presented with a Neer Group VI proximal humeral fracture.Six hours after a successfully performed hemiarthroplasty,she developed continuous fever.Clinical examination revealed that the vitals were regular.Laboratory and radiographic examinations revealed only elevated procalcitonin levels.Blood culture revealed no bacterial or fungal growth.Cooling treatment and empirical broad-spectrum antibiotic therapy showed no apparent effect.Conclusions:We report a postoperative infection caused by Acinetobacter baumannii.The infectious pathogen was identified via molecular DNA sequencing and was initially misidentified as a free-living amoeba species upon microscopic examinations.The patient was mistreated with antiamebic combination therapy.Her symptoms persisted for over 4 months and were eventually followed by her death.

Hip dislocation and femoral component disassembly after bipolar hemiarthroplasty: a report of four cases and introduction of new reduction maneuvers

To the Editor: Bipolar hemiarthroplasty is one of the treatment options for unstable femoral neck fracture in the elderly. Hip dislocation after hip replacement is a common complication but dissociation of a bipolar prosthesis is rare and more serious complication, which always requires open reduction and revision. Some authors have reported dissociation after bipolar hemiarthroplasty of the hip. The present study reported four cases of disassembly after the primary bipolar hemiarthroplasty due to different causes and explained the mechanism. It will beneficial for surgeons who encounter the same situation.

Metallic resurfacing hemiarthroplasty of the first metatarsophalangeal joint combined with first metatarsal osteotomy for the treatment of hallux rigidus with hallux valgus in China

Hallux rigidus occurs mainly at the first metatarsophalangeal （MTP） joint,causing localized pain and degenerative arthritis.1 This condition frequently occurs together with hallux valgus and is difficult to treat.For hallux rigidus affecting only one joint,the treatment choices include articular debridement,resection arthroplasty,prosthetic arthroplasty,and arthrodesis,depending on the degree of arthritis.

半髋关节置换治疗高龄股骨颈骨折(英文)

Objective:To appraise the clinic effect of hemiarthroplasty for treating the femoral neck fracture.Methods: 65 elderly cases of femoral neck fracture were operated on with hemiarthroplasty from January, 1988 to May,2000. Results: 61 patients were followed up for an average period of about 2 years and 5 months. According to Harris evaluation method, the excellent or good results of unipolar hemiarthroplasty appeared in 88% of the patients, that of bipolar hemiarthoplasty in 94.4 % of the patients. By x2 test, there was no significant difference between the two operative results. ( P ＞ 0.05). Conclusion: The method is a fairly good one for the treatment of elderly patients with femoral neck fracture, in which early operation is important.

Management of proximal humerus fractures in adults

The majority of proximal humerus fractures are lowenergy osteoporotic injuries in the elderly and their incidence is increasing in the light of an ageing population. The diversity of fracture patterns encountered renders objective classification of prognostic value challenging. Non-operative management has been associated with good functional outcomes in stable, minimally displaced and certain types of displaced fractures.Absolute indications for surgery are infrequent and comprise compound, pathological, multi-fragmentary head-splitting fractures and fracture dislocations, as well as those associated with neurovascular injury. A constantly expanding range of reconstructive and replacement options however has been extending the indications for surgical management of complex proximal humerus fractures. As a result, management decisions are becoming increasingly complicated, in an attempt to provide the best possible treatment for each indi-vidual patient, that will successfully address their specific fracture configuration, comorbidities and functional expectations. Our aim was to review the management options available for the full range of proximal humerus fractures in adults, along with their specific advantages, disadvantages and outcomes.

Primary Bipolar Arthroplasty in Unstable Intertrochanteric Fractures in Elderly

Unstable intertrochanteric fracture in elderly is a challenging surgical condition with a high risk of morbidity and mortality. The aim of this study is to evaluate the results of bipolar arthroplasty as an alternative to the standard treatment of internal fixation. Materials and methods: 41 patients (22 females and 19 males) who had bipolar arthroplasty for unstable intertrochanteric fractures were prospectively evaluated. Modified lateral approach was used in all patients. Clinical evaluation was done using Harris Hip Score (HHS) and radiological follow up was done using plain X-rays. All the patients were 65 years of age or above. Follow up period ranged from (12 - 24) months. Results: During the last follow up, the Harris Hip Score ranged from 93 to 51 with a mean value 78.19. Four cases (9.76%) were excellent (91 - 100), 16 cases (39.02%) good (81 - 90), 16 cases (39.02%) fair (71 - 80) and 5 cases (12.02%) poor (= or < 70). Six cases had complications;infection (1), dislocation (1), stem loosening and subsidence (2), bleeding peptic ulcer (1) and intra-operative crack of the femur while preparing the femoral canal for implant insertion (1). Five patients died within the first year (12.19%). Four patients had revision surgery. Conclusion: Bipolar hemiarthroplasty for the unstable intertrochanteric fractures of the femur in elderly has a reasonable clinical outcome at 2 years. It is to be considered as one of the treatment options for such injury speciality in case of fragility fractures.

Return to sports after shoulder arthroplasty

Many patients prioritize the ability to return to sports following shoulder replacement surgeries, including total shoulder arthroplasty(TSA), reverse total shoulder arthroplasty(RTSA), and hemiarthroplasty(HA). While activity levels after hip and knee replacements have been well-established in the literature, studies on this topic in the field of shoulder arthroplasty are relatively limited. A review of the literature regarding athletic activity after shoulder arthroplasty was performed using the PubMed database. All studies relevant to shoulder arthroplasty and return to sport were included. The majority of patients returned to their prior level of activity within six months following TSA, RTSA, and shoulder HA.Noncontact, low demand activities are permitted by most surgeons postoperatively and generally have higher return rates than contact sports or high-demand activities. In some series, patients reported an improvement in their ability to participate in sports following the arthroplasty procedure. The rates of return to sports following TSA(75%-100%) are slightly higher than those reported for HA(67%-76%) and RTSA(75%-85%). Patients undergoing TSA, RTSA, and shoulder HA should be counseled that there is a high probability that they will be able to return to their preoperative activity level within six months postoperatively. TSA has been associated with higher rates of return to sports than RTSA and HA,although this may reflect differences in patient population or surgical indication.

National trends in total hip arthroplasty for traumatic hip fractures:An analysis of a nationwide all-payer database

BACKGROUND Hemiarthroplasty(HA)has traditionally been the treatment of choice for elderly patients with displaced femoral neck fractures.Ideal treatment for younger,ambulatory patients is not as clear.Total hip arthroplasty(THA)has been increasingly utilized in this population however the factors associated with undergoing HA or THA have not been fully elucidated.AIM To examine what patient characteristics are associated with undergoing THA or HA.To determine if outcomes differ between the groups.METHODS We queried the Nationwide Inpatient Sample(NIS)for patients that underwent HA or THA for a femoral neck fracture between 2005 and 2014.The NIS comprises a large representative sample of inpatient hospitalizations in the United States.International Classifications of Disease,Ninth Edition(ICD-9)codes were used to identify patients in our sample.Demographic variables,hospital characteristics,payer status,medical comorbidities and mortality rates were compared between the two procedures.Multivariate logistic regression analysis was then performed to identify independent risk factors of treatment utilized.RESULTS Of the total 502060 patients who were treated for femoral neck fracture,51568(10.3%)underwent THA and the incidence of THA rose from 8.3%to 13.7%.Private insurance accounted for a higher percentage of THA than hemiarthroplasty.THA increased most in urban teaching hospitals relative to urban non-teaching hospitals.Mean length of stay(LOS)was longer for HA.The mean charges were less for HA,however charges decreased steadily for both groups.HA had a higher mortality rate,however,after adjusting for age and comorbidities HA was not an independent risk factor for mortality.Interestingly,private insurance was an independent predictor for treatment with THA.CONLUSION There has been an increase in the use of THA for the treatment of femoral neck fractures in the United States,most notably in urban hospitals.HA and THA are decreasing in total charges and LOS.