Selective pathological examination following hip arthroplasty: A retrospective cohort study

Background: Pathological examination of the femoral head after hip arthroplasty is often performed routinely. The cost-effectiveness of the examination with regard to identifying clinically relevant diagnoses has been a point of discussion. To date, recommendations on performing pathological examination based on patient characteristics, disease history or radiographic findings are scarce. The aim of this study was to gain insight in when to select a patient for pathological examination of the femoral head by means of the following research questions: "How many clinically relevant diagnoses does selective pathological examination identify?" "Which factors contribute to selection of the femoral head for conducting pathological examination?" "What are the costs of selective pathological examination for identifying clinically relevant diagnoses?"Hypothesis: Selective pathological examination of the femoral head results in higher ratios of identified clinically relevant diagnoses against substantially lower costs.Methods: A retrospective cohort study was performed over the period of 2010-2015. All pathological reports were collected from our hospital and screened for resected femoral heads after primary total hip arthroplasty (THA) or primary hemiarthroplasty (HA). The coherence between preoperative diagnosis and postoperative pathological diagnosis was defined as concordant, discrepant or discordant. The aim was to perform logistic regression analysis. Results: In total, 164 patients were included of 3998 hip arthroplasties performed during the study period with a mean age of 74 +/- 12.3 years including 54 (33%) male and 110 (67%) female of whom 112 (68%) underwent THA and 52 (32%) HA. A discrepancy in diagnosis was found in nine patients (6%) and discordance in three patients (2%). The most frequently reported reasons to perform pathological examination were malignancy in medical history n = 86 (53%), avascular necrosis n = 22 (13%), bone abnormality perioperatively n = 19 (11%) and pathological fracture n = 13 (8%). The factors that identified the unexpected clinically relevant diagnoses were pathological fracture (3 cases out of 13), bone abnormality perioperatively (2 out of 19), abnormalities on preoperative radiographs (1 out of 9) and to a lesser extent malignancy in history (2 out of 86). With costs of pathological examination of approximately euro 163 per femoral head, performed in 164 patients, the total costs of pathological examination resulted in euro 26,732. The cost per discrepant case (n = 9) was euro 2970 and the cost per discordant case (n = 3) was euro 8910.Conclusion: Selective pathological examination of the femoral head following hip arthroplasty results in higher ratios of discrepant and discordant cases against substantially lower costs. Factors that identify clinically relevant diagnoses are pathological fracture, perioperative bone abnormality, abnormalities on preoperative radiographs and to a lesser extent malignancy in history.Level of evidence: III; retrospective cohort study.(c) 2021 Elsevier Masson SAS. All rights reserved.