Pathology Assessment of Femoral Head Resection Specimens: An Important Quality Assurance Procedure

Abstract

Context.— Decisions to perform hip arthroplasty rely on both radiographic and clinical findings. Radiologists estimate degree of osteoarthritis (OA) and document other findings. Arthroplasty specimens are sometimes evaluated by pathology. Objective.— To determine the frequency of pathologic changes not recognized clinically. Design.— Nine hundred fifty-three consecutive femoral head resections performed between January 2015 and June 2018, with recent radiologic and histologic study, were reviewed. We compared severity of OA reported by radiology and pathology. Findings unrecognized radiographically but recorded pathologically, and discrepancies between clinical diagnosis and pathology diagnosis, were tabulated. Results.— Twenty-one cases of osteomyelitis were diagnosed radiographically or pathologically. Eight discrepancies were present. Fourteen osteomyelitis cases were recognized clinically. Pathology recognized 2 neoplasms missed radiographically. Avascular necrosis was diagnosed on pathology but not radiology in 25 cases, and 35 cases of avascular necrosis were seen radiographically but not pathologically. Osteoarthritis was graded both radiographically and pathologically from 0 to 3. Five hundred ninety-one of 953 cases (62%) were grade 3. Pathologists and radiologists had perfect agreement in 696 of 953 cases (73%). When grade of OA seen at pathology was correlated with surgeon, 2 groups of surgeons were detected: one with a low threshold for performance of hip arthroplasty (23%–28% low-severity OA) and the second with a high threshold (2%–5% low-severity OA). Conclusions.— Correlation between radiology and pathology diagnoses is high. Degree of OA present varies significantly between surgeons. Pathology discloses findings not recognized clinically.

Routine Pathologic Examination of Femoral Head Specimens from Total Hip Arthroplasty May Not Be Indicated or Cost-effective: A Systematic Review

“…[ 10 ] 1999 Single center, retrospective US THA for any indication 562 0% $102.59 per specimen Against Layfield et al. [ 11 ] 2020 Single center, retrospective US THA for OA 953 0.52% None For Lin et al. [ 4 ] 2012 Single center, retrospective US Elective THA 457 0.22% $102.37 per specimen; no gain in QALY Against Liow et al.…”

“…Of the articles that commented on the need for routine pathologic examination of femoral heads retrieved during THA, 58% (7 of 12 articles) advised against this practice as it was not found to change patient management [ 4 , 5 , 8 , 10 , 12 , 13 , 15 ]. It is our opinion that the remaining 5 articles that favored routine pathologic examination did so after mischaracterizing many pathologic diagnoses that did not impact patients’ clinical course as discordant [ 6 , 7 , 9 , 11 , 17 ]. This resulted in an overvaluation of routine femoral head pathology, which skewed analyses of cost-effectiveness and ultimately these articles’ conclusions.…”

“…Article screening was performed using Covidence (Melbourne, Australia) systematic review management software. After full-text review, 14 of these articles were confirmed to meet study inclusion and exclusion criteria ( Table 1 ) and comprised our final cohort for data extraction [ [4] , [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] ]. Figure 1 , illustrating the aforementioned process, is the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram [ 18 ].…”

Routine Histopathologic Analysis of Hip and Knee Bone Specimens After Total Joint Arthroplasty

“…Among their sample, most discrepancy came in the form of unsuspected diagnosis of osteonecrosis of the femoral head, with a much smaller percentage secondary to osteomyelitis. 3 Conversely, studies from orthopaedic surgeons have called into question both the existence of a discrepancy and the clinical significance of these diagnostic discrepancies when present. In a review of 715 consecutive cases of total joint arthroplasty including 283 THAs and 432 TKAs by Campbell et al, in only 3 of the 283 THAs was the pathology report discordant with the preoperative clinical diagnosis.…”

Evaluation of the Cost Effectiveness of Routine Histopathologic Femoral Head Analysis in Hip Arthroplasty

“…The study by Besser 6) , which reported unsuspected tuberculosis detected during a total knee replacement, is often cited as justification for the practice, and additional studies such as a review of 1,794 femoral heads by DiCarlo et al 7) reported discrepancies between operative and pathological diagnosis in 5.4% of cases, as well as the discovery of seven morbid conditions not noted clinically. A recent study by Layfield et al 8) , which noted a significant percentage of patients undergoing hip arthroplasty where significant pathological changes were not recognized preoperatively by the orthopaedic surgeon, advocated for the continued use of pathology for diagnosis.…”