ABSTRACT:

OBJECTIVE: To analyze the number of hospital permits for total knee arthroplasty (TKA) and total hip arthroplasty (THA) in Brazil between 2008 and 2015, and correlate them with regional, national, and international demographic and epidemiological aspects.
METHODS: Data on demographics, economic level, and TKA and THA were obtained from the website of the Ministry of Health/DATASUS, Brazilian Institute of Geography and Statistics, and the National Health Agency to assess the assistance provided by the Public Health Care System in arthroplasties for elderly Brazilian population without private health care.
RESULTS: The South and Southeast had the best care, with 8.07 and 6.07 TKAs/100,000 inhabitants, one TKA per 1811 and 2624 seniors, 17.3 and 10.99 THAs/100,000 inhabitants, and one THA per 923 and 1427 seniors, respectively. The worst rates were found in the North and Northeast, with 0.88 and 0.98 TKAs/100,000, one TKA per 6930 and 10,411 seniors, 0.96 and 3.25 THAs/100,000, and one THA per 6849 and 2634 seniors, respectively. The national average was 4.00 TKAs/100,000, one TKA per 3249 seniors, 8.01 THAs/100,000, and one THA per 1586 seniors. The international average was 142.8 TKAs/100,000 and 191.8 THAs/100,000.
CONCLUSION: The results expressed unsatisfactory results for TKA and THA in Brazil, with greater relevance in the North and Northeast.

Keywords: Arthroplasty; Knee; Hip.

RESUMO:

OBJETIVO: Analisar o número de autorizações de internação hospitalar para cirurgias de artroplastia total de joelho (ATJ) e quadril (ATQ) no Brasil entre 2008 e 2015 e correlacioná-lo com aspectos demográficos e epidemiológicos regionais, nacionais e internacionais.
MÉTODOS: Os dados sobre informativos demográficos, econômicos e sobre ATJ e ATQ foram obtidos no website do Instituto Brasileiro de Geografia e Estatística (IBGE), Agência Nacional de Saúde (ANS) e Ministério da Saúde/Datasus para avaliar o assistencialismo do Sistema Único de Saúde (SUS) em artroplastias para a população idosa brasileira sem planos de saúde privados.
RESULTADOS: As Regiões Sul e Sudeste apresentaram a melhor relação assistencial, com 8,07 e 6,07ATJ/100.000 habitantes e uma ATJ para 1.811 e 2.624 idosos e 17,3 e 10,99ATQ/100.000 habitantes e uma ATQ para 923 e 1.427 idosos, respectivamente. Os piores índices foram do Norte e Nordeste, com 0,88 e 0,98 ATJ/100.000 e uma ATJ para 6.930 e 10.411 idosos e 0,96 e 3,25 ATQ/100.000 e uma ATQ para 6.849 e 2.634 idosos, respectivamente. A média nacional foi de 4,00 ATJ/100.000 e uma ATJ para 3.249 idosos e 8,01 ATQ/100.000 e uma ATQ para 1.586 idosos. A média internacional foi de 142,8 ATJ/100.000 e 191,8 ATQ/100.000.
CONCLUSÃO: Os resultados indicaram resultados assistenciais insatisfatórios para ATJ e ATQ no Brasil, principalmente nas regiões Norte e Nordeste.

Palavras-chave: Artroplastia; Joelho; Quadril.

Citation: Ferreira MC, Oliveira JCP, Zidan FF, Franciozi CES, Luzo MVM, Abdalla RJ. Total knee and hip arthroplasty: the reality of assistance in Brazilian public health care☆. 53(4):432. doi:10.1016/j.rboe.2018.05.002
Note: ☆ Study conducted at the Hospital do Coração, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil.
Received: September 5 2016; Accepted: November 10 2016
 

INTRODUCTION

Osteoarthritis (OA) is the most prevalent musculoskeletal disease, affecting 4% of the Brazilian population; it is associated with morbidities such as falls, depression, and obesity.1-3 The mortality risk is 50% higher in patients with gait limitation due to knee and hip OA when compared with the general population.4

By 2050, the mean life expectancy in Brazil will be 81 years, and 30% of the Brazilian population will be represented by the elderly.5-9 In Brazil, a concerning fact regarding individuals over the age of 60 is that only 12% of the population in this age group had private health insurance in 2015.10

The increase in the number of total knee (TKA) and hip (TKA) arthroplasties has a relevant social and economic impact, and countries such as Australia, the United States, England, Canada, and South Korea are therefore conducting epidemiological and financial studies on these surgeries.11-14 In Brazil, information on such procedures is scarce. National data on such surgeries performed under the Brazilian Unified Health System (Sistema Nacional de Saúde [SUS]) are available through the Brazilian Ministry of Health website. However, these indicators do not represent the entire Brazilian population.15

The objective of this study was to analyze the data of the primary TKA and THA provided by the Brazilian Ministry of Health/DATASUS between 2008 and 2015 and to observe the extent to which the SUS assists the Brazilian population for these surgeries at a state, regional, and national level, and to compare these results with international indicators.

 

MATERIAL AND METHODS

The data for the study were obtained through PubMed and Google; as it did not involve any intervention or direct contact with patients, the study was not submitted to the ethics committee for approval.

The search terms used in both portals followed the PubMed Medical Subject Headings (MeSH) algorithm. The words used for the search were arthroplasty, replacement, knee, hip, cost, and epidemiology. The term AND was used between words as a Boolean operator.

A Google search was performed to obtain epidemiological, economic, and statistical data in Brazil through the search on the websites of the Brazilian Ministry of Health/DATASUS the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística [IBGE]), the National Agency of Supplementary Health (Agência Nacional de Saúde Suplementar [ANS]), and the World Health Organization (WHO). International statistical reports on arthroplasties were also obtained using the same MeSH terms.

Data on the authorization for hospital admission (AHA), mean length of hospitalization, and mortality rate in TKA and THA were collection from the website of the Brazilian Ministry of Health/DATASUS between 2008 and 2015.

The national and regional demographic indices in the study period were obtained from the IBGE website.16 Only the portion of the population that consisted of elderly individuals relying exclusively on the SUS for healthcare was used for the population calculations, excluding individuals over 60 years old who had private healthcare plans registered at ANS at the national, regional, and state levels.10 The classification of the elderly used in this study followed that presented in Art. 1 of Law 10,741, from October 1, 2003, known as the Statute of the Elderly, which establishes that this denomination applies for individuals over 60 years of age. The percentage of elderly individuals who underwent TKA and THA procedures at the national, regional, and state level was calculated by dividing the number of surgeries performed in that period by the relevant population in the study group.

The states were ranked according to the healthcare assistance they provided to their population regarding TKA and THA procedures, in which a higher proportion of surgeries in the elderly led to a better classification on the ranking.

Data on the number of TKA and THA procedures in European countries, the United States, and Australia were obtained from the epidemiological study published by Kurtz et al.11 in 2011, which collected data on these surgeries from 2000 to 2010. These results were compared with the data from Brazil, aiming to contrast the arthroplasty coverage between economically developed countries and Brazil. For these calculations, the ratio of surgeries per 100,000 elderly individuals was used.

The results obtained at the national and regional levels for TKA and THA were distributed in tables, according to the characteristics studied, between 2008 and 2015. A general table was elaborated with data referring to the results obtained in each state.

Statistical analysis

Data on TKA and THA in economically developed countries, as well as information about Brazil and its regions, were statistically described as mean, median, mode, and percentiles for a descriptive comparison of the obtained results.

The annual growth rates in the number of TKAs and THAs, both internationally and in Brazil, were obtained by dividing the number of procedures of one year by those from the previous year. The mean value was calculated by adding all growth rates and dividing by the number of years under evaluation.

The number of AHAs, the mean time of hospitalization, and the mortality rates were collected directly from the Brazilian Ministry of Health website.15

 

RESULTS

Number of TKAs and THAs performed in Brazil and its regions

Between 2008 and 2015, the Southeast region stood out, averaging 57% and 51.6% of the TKAs and THAs surgeries in the country. The South Region accounted for 29.1% and 28%, followed by the Northeast, with 7.8% and 12.9%; the Midwest accounted for 3.3% and 6.1%, and the North, for 2.6% and 1.2%, respectively (Tables 1 and 2).

Table 1. Number of AHAs for TKA and THA between 2008 and 2015 in Brazilian states and the proportion of arthroplasties per elderly individuals, mean length of hospitalization, mortality rate, and ranking.15
 Indexes states AHA/TKA AHA/THA RegionalpercentageTKA; THA Regionalpercentage of elderly Proportionelderly/TKA –yearly Proportionelderly/THA –yearly Period of hos-pitalizationTKA; THA(days) MortalityRate TKA;THA Nationalranking TKA;THA
  North                  
      Rondônia    98    150 7.8%; 13.0% 10.6% 7789 5193 3.4; 27.4 0.0; 4.0 21st; 22nd
      Acre    170    120 13.5%; 10.4% 4.5% 1953 2766 4.9; 5.2 0.0; 0.0 6th; 14th
      Amazonas    350    220 27.8%; 19.1% 18.9% 3939 6270 7.5; 12.5 0.0; 0.91 11th; 23rd
      Roraima    61    51 4.8%; 4.4% 2.3% 2780 3228 4.0; 5.1 0.0; 0.0 10th; 18th
      Para    468    402 37.2%; 34.9% 48.7% 7592 8842 5.8; 8.8 0.43; 1.0 19th; 25th
      Amapá    0    33 0%; 2.8% 3.3% 0 7494 0.0; 9.3 0.0; 1.0 27th; 24th
      Tocantins    109    175 8.6%; 15.2% 11.4% 7647 4774 4.3; 11.0 0.92; 1.71 20th; 20th
                   
  Northeast                  
      Maranhão    139    318 3.7%; 2.6% 10.6% 27,617 12,071 5.3; 10.5 0.72; 10.5 26th; 27th
      Piauí    315    619 8.4%; 5.0% 6.1% 6981 3552 6.2; 8.7 0.0; 8.7 17th; 19th
      Ceara    221    2306 5.9%; 18.8% 16.1% 26,309 2521 6.8; 8.9 0.0; 8.9 25th; 13th
      Rio Grande Norte    415    1623 11.1%; 13.3% 6.3% 5470 1397 4.9; 7.5 0.0; 7.5 15th; 9th
      Paraíba    252    908 6.7%; 7.4% 7.9% 11,318 3141 5.2; 11.8 0.40; 11.8 24th; 17th
      Pernambuco    872    2780 23.3%; 22.7% 16.9% 7004 2197 4.4; 9.8 0.34; 9.8 18th; 11th
      Alagoas    362    208 9.6%; 1.7% 5.1% 5102 8879 5.8; 6.1 0.0; 6.1 13th; 26th
      Sergipe    248    254 6.6%; 2.0% 4.0% 4932 4816 4.2; 4.4 0.40; 4.4 12th; 21st
      Bahia    910    3188 24.3%; 26.1% 27.2% 10,784 3078 3.7; 9.1 0.11; 9.1 23rd; 16th
                   
  Southeast                  
      Minas Gerais    6581    11,920 24.4%; 24,% 26.3% 2120 1170 3.7; 5.9 0.14; 1.83 8th; 6th
      Espirito Santo    1884    1173 6.9%; 2.4% 3.7% 1060 1707 3.3; 5.1 0.21; 0.60 1st; 10th
      Rio de Janeiro    5709    9420 21.1%; 19.2% 20.9% 2502 1176 6.3; 9.8 0.16; 1.60 9th; 7th
      São Paulo    12,793    26,300 47.4%; 53.8% 49.0% 2030 987 4.5; 6.7 0.24; 2.62 7th; 5th
                   
  South                  
      Paraná    4760    8649 34.5%; 32.5% 35.3% 1544 850 4.0; 5.2 0.25; 1.75 3rd; 3rd
      Santa Catarina    3277    4846 23.7%; 18.2% 20.1% 1278 864 4.7; 5.9 0.21; 1.09 2nd; 4th
      Rio Grande Sul    5739    13,078 41.6%; 49.2% 44.5% 1614 709 4.8; 6.7 0.09; 1.06 4th; 2nd
                   
  Midwest                  
      Mato Grosso    159    703 10.2; 12.0% 17.6% 10,459 2831 5.0; 6.1 0.90; 1.14 22th; 15th
      Mato Grosso Sul    223    509 14.3 (8.7%) 20.3% 6463 2365 5.1; 8.4 0.63; 3.14 16th; 12th
      Goiás    503    2908 32.3%; 49.9% 47.8% 5380 1343 4.9; 6.0 0.40; 2.85 14th; 8th
      Distrito Federal    671    1706 43.1%; 29.2% 14.4% 1719 676 8.4; 13.5 0.15; 0.94 5th; 1st
Table 1. Number of AHAs for TKA and THA between 2008 and 2015 in Brazilian states and the proportion of arthroplasties per elderly individuals, mean length of hospitalization, mortality rate, and ranking.15
Table 2. Number of authorizations for hospital admission for total knee (TKA) and hip (THA) arthroplasties in Brazil and regions.15
   Region Year North TKA; THA Northeast TKA; THA   Southeast TKA; THA South TKA; THA Midwest TKA; THA Brazil TKA; THA
   2008 49; 126 268; 1500   2269; 4939 1307; 3279 135; 538 4028; 10,382
   2009 191; 100 342; 1511   2864; 5507 1303; 3252 194; 622 4894; 10,992
   2010 146; 114 476; 1600   3147; 5817 1421; 3187 160; 742 5350; 11,460
   2011 144; 113 519; 1632   3339; 6118 1728; 3176 167; 655 5898; 11,694
   2012 143; 113 490; 1472   3368; 6254 1651; 3041 176; 641 5828; 11,521
   2013 188; 164 625; 1529   3813; 6817 2090; 3357 254; 819 6970; 12,686
   2014 177; 208 564; 1519   4082; 6735 2195; 3510 277; 845 7245; 12,817
   2015 218; 213 450; 1443   4085; 6626 2080; 3771 243; 964 7076; 13,017
    Mean 157; 143 466; 1525   3370; 6101 1721; 3321 200.7; 728.2 5911; 11,821
    Total 1256; 1151 3734; 12,206   26,967; 48,813 13,775; 26,573 1606; 5826 47,289; 94,569
Table 2. Number of authorizations for hospital admission for total knee (TKA) and hip (THA) arthroplasties in Brazil and regions.15

The state of São Paulo, which has 49% of the elderly population of the Southeast, accounted for 47.4% and 53.8% of the TKAs and THAs, respectively. Espírito Santo, with 3.7% of the regional population, accounted for 6.9% of the TKAs in the Southeast region, and obtained the best ratio of knee prostheses per elderly individuals in Brazil. Through the same evaluation method, Distrito Federal presented the best THA coverage, accounting for 29.2% of regional surgeries and 14.4% of the elderly population (Table 1).

In Brazil, TKA presented an annual growth oscillation, with a decreasing number of procedures between 2011/2012 and 2014/2015 (−1.1% and −2.3%, respectively). However, the mean annual growth between 2008 and 2015 was 8.7%. The only region that presented continuous growth in this surgery was the Southeast (Tables 2 and 3).

Table 3. Growth of TKA and THA procedures in Brazil and its regions between 2008 and 2015.
   Region Period North TKA/THA Northeast TKA/THA Southeast TKA/THA   South TKA/THA Midwest TKA/THA Brazil TKA/THA
   2008/2009 289%; −20.6% 27.6%; 0.7% 26.2%; 11.5%   −0.3%; −0.8% 43.7%; 15.6%    21.4%; 5.8%
   2009/2010 −23.5%; 14% 39.1%; 5.8% 9.8%; 5.6%   9.0%; −1.9% −17.5%; 19.2%    9.3%; 4.2%
   2010/2011 −1.3%; −0.8% 9.0%; 2.0% 6.1%; 5.1%   21.6%; −0.3% 4.3%; −11.7%    10.2%; 2.0%
   2011/2012 −0.6%; 0% −5.5%; −9.8% 0.8%; 2.2%   −4.4%; −4.6% 5.3%; −2.1%    −1.1%; −1.4%
   2012/2013 31.4%; 45.1% 27.5%; 3.8% 13.2%; 9.0%   26.5%; 10.3% 44.3%; 27.7%    19.5%; 10.1%
   2013/2014 −5.8%; 26.8% −9.7%; −0.6% 7.0%; −1.2%   5.0%; 4.5% 9.0%; 3.1%    3.9%; 1.0%
   2014/2015 23.1%; 2.4% −20.2%; −5.0% 0%; −1.6%   −5.2%; 7.4% −12.2%; 14.0%    −2.3%; 1.5%
    Mean 44.8%; 9.5% 9.6%; −0.4% 9.0%; 4.3%   7.4%; 2.0% 10.9%; 10%    8.7%; 3.3%
Table 3. Growth of TKA and THA procedures in Brazil and its regions between 2008 and 2015.

THA presented periods of decrease in all regions studied. The negative highlight was for the Northeast, which presented a negative annual growth of −0.4% for the studied period. In turn, the Midwest region showed the highest mean growth (10%), followed by the North region (9.5%). At the national level, the rate of THA decreased by −1.4% in 2011/2012. However, the mean growth in the entire study period was 3.3% (Tables 2 and 3).

Elderly population who relied exclusively on SUS in Brazil and its regions

A discrepancy in the demographic distribution among the five regions of Brazil was observed. The Northeast is the second most populous region, accounting for 24.9% of the total number of elderly people who rely exclusively on SUS, second only to the Southeast, which accounted for 47.2% of the total population in this age group. The South, Midwest, and North regions accounted for 16.5%, 6.1%, and 5.0%, respectively (Table 4).

Table 4. Total number and percentage of elderly in Brazil and its regions who rely exclusively on the Brazilian Unified Health System (SUS).10,16
   Region Year North (Total ± %) Northeast (Total ± %) Southeast (Total ± %) SUL (Total ± %) Midwest (Total ± %) Brazil (Total ± %)
   2008 792,063 ± 5.6% 4,127,256 ± 9.0% 7,509,158 ± 14.0% 2,622,132 ± 12.6% 939,127 ± 9.7% 15,989,738 ± 11.0%
   2009 824,484 ± 5.7% 4,247,855 ± 9.2% 7,811,180 ± 14.4% 2,731,930 ± 13.0% 985,703 ± 10.0% 16,601,153 ± 11.3%
   2010 860,179 ± 5.9% 4,373,937 ± 9.4% 8,131,829 ± 14.8% 2,848,241 ± 13.5% 1,035,443 ± 10.3% 17,249,631 ± 11.6%
   2011 899,102 ± 6.1% 4,505,972 ± 9.6% 8,471,984 ± 15.2% 2,971,283 ± 13.9% 1,088,442 ± 10.7% 17,936,783 ± 12.0%
   2012 941,292 ± 6.3% 4,644,148 ± 9.8% 8,831,956 ± 15.9% 3,101,156 ± 14.3% 1,144,769 ± 11.1% 18,663,323 ± 12.4%
   2013 986,504 ± 6.5% 4,788,886 ± 10.0% 9,211,035 ± 16.4% 3,237,311 ± 14.9% 1,204,304 ± 11.4% 19,428,039 ± 12.9%
   2014 1,034,299 ± 6.7% 4,940,945 ± 10.2% 9,608,665 ± 17.0% 3,379,149 ± 15.5% 1,266,933 ± 11.9% 20,229,983 ± 13.2%
   2015 1,084,402 ± 6.9% 5,100,897 ± 10.4% 10,023,944 ± 17.6% 3,520,041 ± 16.0% 1,332,533 ± 12.3% 21,067,978 ± 13.6%
    Mean 928,290 ± 6.2% 4,591,237 ± 9.7% 8,699,968 ± 15.6% 3,051,405 ± 14.2% 1,124,656 ± 10.9% 18,395,828 ± 12.2%
Table 4. Total number and percentage of elderly in Brazil and its regions who rely exclusively on the Brazilian Unified Health System (SUS).10,16

The North and Northeast regions presented the lowest proportion of elderly people, i.e., they had greater asymmetries between the base and apex of the age pyramid. In turn, the South and Southeast regions presented the highest proportion of individuals aged over 60 years. All regions presented growth of the elderly age range above that of the population (Table 4).

TKA and THA per 100,000 inhabitants - International, Brazil, and its regions

A growth in the number of THA and TKA procedures has been observed in Brazil. Nonetheless, the surgical coverage in the public healthcare system presented absolutely unsatisfactory results when compared with those of economically developed countries (Tables 2 and 5).

Table 5. Total knee (TKA) and hip (TKA) arthroplasties per 100,000 elderly individuals, mean annual growth of surgeries in several countries, and mean population estimate with percentage of elderly subjects. 10,11,14–16
   Indexes   Countries TKA/100,000 (year) TKA annual growth THA/100,000 (year) THA annual growth Population (2010)
   Germany 213.1 (2010) 4.8% (2005–2010) 295 (2010) 2.3% (2005–2010) 81,780,000 ± 21%
   Australia 200.6 (2010) 5.8% (2002–2010) 249.1 (2010) 2.4% (2002–2010) 22,030,000 ± 14%
   Brazil (SUS) 3.9 (2010) 8.7% (2008–2015) 7.8 (2010) 3.3% (2008–2015) 147,600,836 ± 10%a
   Denmark 174.7 (2010) 13.7% (2000–2010) 225.4 (2010) 4.9% (2000–2010) 5,548,000 ± 17%
   Spain 104.4 (2010) 8.1% (2000–2010) 97 (2010) 3.2% (2000–2010) 47,020,000 ± 17%
   United States 213.3 (2010) 9.2% (2000–2010) 257 (2010) 8.0% (2000–2010) 309,000,000 ± 13%
   Finland 187 (2010) 7.6% (2000–2010) 199.1 (2010) 4.2% (2000–2010) 5,363,000 ± 18%
   France 124 (2010) 4.7% (2000–2010) 224.7 (2010) 1.0% (2000–2010) 65,020,000 ± 17%
   Netherlands 127.6 (2009) 10.7% (2000–2009) 213.3 (2009) 2.7% (2000–2009) 16,620,000 ± 16%
   Italy 97.7 (2009) 9.7% (2000–2009) 146.9 (2009) 2.3% (2000–2009) 59,280,000 ± 21%
   Luxembourg 155.4 (2010) 3.7% (2000–2010) 207.6 (2010) 0.8% (2000–2010) 92,441 ± 14%
   Portugal: 61.7 (2009) 19.1% (2000–2009) 87.8 (2009) 2.5% (2000–2009) 10,570,000 ± 19%
   Sweden 125.3 (2009) 6.1% (2000–2010) 210.4 (2010) 2.4% (2000–2009) 9,378,000 ± 18%
   Switzerland 211.9 (2010) 8.1% (2002–2010) 265.5 (2010) 1.7% (2002–2010) 7,825,000 ± 17%
    Mean          142.8    8.5%        191.8    2.9% 56,223,376 ± 16.5%

a The classification considers individuals over 60 years of age, according to the law in force in the country for the classification of the elderly.

The other countries used the cut-off 65 years to define the elderly.

Table 5. Total knee (TKA) and hip (TKA) arthroplasties per 100,000 elderly individuals, mean annual growth of surgeries in several countries, and mean population estimate with percentage of elderly subjects. 10,11,14–16

SUS showed a care deficit of approximately 36 times (3.9/100,000 vs. 142.8/100,000) when compared with the assistance provided in developed countries in 2010. Regarding THA, the result was 24 times lower than the mean of the European countries, United States, and Australia (7.8/100,000 vs. 191.8/100,000; Table 5).

In Brazil, the mean number of THAs was twice as high (2.04) as the number of TKAs performed by SUS. In the Northeast and Midwest regions, the disproportion between the procedures was more evident, with a superiority of THA over TKA of 231% and 265%, respectively. In the South and Southeast regions, these rates were 115% and 81%, respectively. In the North region, the number of THAs was only 9% higher than that of TKAs, and some years showed an inversion in this predominance (Table 6).

Table 6. Proportion of knee (TKA) and hip (TKA) arthroplasties performed by 100,000 people who rely exclusively on SUS in Brazil and regions.10,15,16
   Region Year North TKA; THA Northeast TKA; THA Southeast TKA; THA   South TKA; ATQ Midwest TKA; THA Brazil TKA; THA
   2008 0.35; 0.90 0.58; 3.29 4.23; 9.21   6.31; 15.83 1.40; 5.58 2.78; 7.92
   2009 1.34; 0.70 0.74; 3.28 5.29; 10.10   6.23; 15.56 1.97; 6.34 3.63; 7.76
   2010 1.00; 0.78 1.02; 3.45 5.76; 10.65   6.74; 15.12 1.60; 7.44 3.94; 7.80
   2011 0.97; 0.76 1.11; 3.49 6.06; 11.11   8.13; 14.94 1.64; 6.46 3.95; 7.84
   2012 0.95; 0.75 1.04; 3.12 6.06; 11.26   7.70; 14.19 1.70; 6.22 3.87; 7.65
   2013 1.23; 1.08 1.31; 3.22 6.81; 12.0   9.67; 15.54 2.42; 7.83 4.59; 8.35
   2014 1.15; 1.35 1.18; 3.18 7.23; 11.94   10.08; 16.12 2.60; 7.95 4.73; 8.37
   2015 1.41; 1.38 0.93; 3.00 7.19; 11.66   9.48; 17.20 2.25; 8.94 4.58; 8.43
    Mean 0.88; 0.96 0.98; 3.25 6,07; 10,99   8.04; 17.3 1.94; 7.09 4.00; 8.01
Table 6. Proportion of knee (TKA) and hip (TKA) arthroplasties performed by 100,000 people who rely exclusively on SUS in Brazil and regions.10,15,16

Proportion of TKA and THA in relation to the elderly population in Brazil and regions

Among all Brazilian regions, the Northeast presented the greatest care deficit for TKA, with a mean of one prosthesis made per 10,411 elderly individuals. The North region presented the worst THA coverage, with a mean of one surgery per 6849 elderly individuals (Table 7).

Table 7. Number of elderly in Brazil and regions for each total knee arthroplasty (TKA) and hip (TKA) performed.10,15,16
   Region Year North TKA; THA Northeast TKA; THA Southeast TKA; THA   South TKA; ATQ Midwest TKA; THA Brazil TKA; THA
   2008 16,164; 6286 15,400; 2751 3309; 1520   2006; 799 6956; 1745 3969; 1540
   2009 4503; 8601 12,789; 2894 2727; 1418   2096; 840 5080; 1584 3392; 1510
   2010 5891; 7545 9188; 2733 2583; 1397   2090; 932 6471; 1395 3252; 1565
   2011 6243; 7956 8682; 2761 2537; 1384   1719; 935 6517; 1661 3041; 1533
   2012 6582; 8330 9477; 3154 2622; 1412   1878; 1019 6504; 1785 3202; 1619
   2013 5247; 6015 7662; 3132 2415; 1351   1474; 964 4.741; 1.470 3333; 1686
   2014 5843; 4972 8760; 3252 2353; 1428   1539; 962 4573; 1499 2902; 1594
   2015 4974; 5091 11,335; 3534 2453; 1512   1692; 933 5483; 1382 2907; 1643
    Mean 6930; 6849 10,411; 2634 2624; 1427   1811; 923 5790; 1565 3249; 1586
Table 7. Number of elderly in Brazil and regions for each total knee arthroplasty (TKA) and hip (TKA) performed.10,15,16

The South region presented the best ratio of knee and hip surgeries for the elderly population who relied exclusively on SUS: one THA and one TKA were performed per 1811 and 923 elderly individuals, respectively (Table 7).

The Southeast presented a THA rate similar to that observed in the Midwest. However, TKA presented disparate results among these regions, since the Southeast performed twice the number of surgeries as the Midwest (Table 7).

The states with the worst results were Maranhão, which was ranked last for THA care (one surgery per 12,071 elderly individuals) and second to last for TKA (one surgery per 27,617 elderly individuals), and Amapá, which was ranked last for TKA (no surgeries in a population of 30,914 elderly individuals) and 24th for THA (one surgery per 7494 elderly individuals).

The state of Espírito Santo was ranked first for TKA, with one surgery per 1060 elderly individuals; Distrito Federal was the first for THA, with one surgery per 676 elderly individuals. In the South, Paraná was ranked third for both arthroplasties; Santa Catarina was ranked second and fourth place for TKA and THA, respectively; and Rio Grande do Sul was ranked fourth for TKA and second for THA (Table 1).

Hospitalization for TKA and THA in Brazil and regions

The hospitalization duration for TKA showed regional disparities, since the North, Northeast, and Midwest regions presented a hospitalization time of approximately one day greater than the Southeast and South regions.

The length of hospital stay for THA also presented heterogeneous results in Brazil. Contrary to the tendency in the studied period, the North and Northeast regions presented an increase in the hospitalization time - five and three days more than the South region for THA. The Southeast region presented a discrete oscillation of this index, ranging from 6.9 to 7.5 days. In the Midwest region, the mean hospitalization time increased by 2.2 days between 2008 and 2012, followed by a mean decrease of 2.7 days between 2012 and 2015. The South was the only region that showed a progressive decrease in the length of hospital stay for THA (Table 8).

Table 8. Mean length of hospital stay for knee (TKA) and hip (TKA) arthroplasties in Brazil and regions.15
   Region Year North TKA; THA Northeast TKA; THA Southeast TKA; THA   South TKA; ATQ Midwest TKA; THA Brazil TKA; THA
   2008 6.3; 8.0 6.7; 8.7 5.1; 6.9   5.3; 6.7 8.5; 7.7 5.4; 7.2
   2009 6.8; 8.7 6.2; 8.5 4.7; 7.5   4.9; 6.3 6.4; 8.5 5.0; 7.3
   2010 5.4; 8.8 6.1; 8.9 4.5; 6.9   4.7; 6.1 7.2; 8.6 4.8; 7.1
   2011 5.9; 11.5 5.0; 8.9 4.5; 7.2   4.4; 6.0 7.4; 9.5 4.6; 7.3
   2012 5.9; 11.6 5.2; 9.1 4.7; 7.2   4.6; 5.9 7.7; 9.9 4.8; 7.3
   2013 5.2; 12.3 4.7; 9.5 4.7; 7.0   4.3; 5.9 5.8; 8.7 4.6; 7.2
   2014 5.4; 15.4 4.7; 9.2 4.3; 6.9   4.3; 5.8 5.4; 7.6 4.4; 7.1
   2015 5.6; 13.2 4.6; 9.7 4.6; 6.9   4.1; 5.5 5.0; 7.2 4.5; 7.0
    Mean 5.8; 11.1 5.4; 9.0 4.6; 7.0   4.5; 6.0 6.6; 8.4 4.7; 7.1
Table 8. Mean length of hospital stay for knee (TKA) and hip (TKA) arthroplasties in Brazil and regions.15

The comparison of the length of stay rates between the TKA and THA procedures indicated that hospitalization was 51.0% longer in the former when compared with the latter. The same regional analysis indicated a higher mean length of stay when compared with TKA in 91.3% of the cases in the North region, 66.6% in the Northeast, 52.1% in the Southeast, 33.3% in the South, and 27.2% in the Midwest (Table 8).

Regarding the states, Distrito Federal and Amazonas presented higher length of stay: 8.4 and 7.5 days for TKA and 13.5 and 12.5 days for THA, respectively. Rondônia presented the discrepant result of 27.4 days of hospitalization in THA.

The positive highlights for length of stay in TKA were Espírito Santo, with 3.3 days, and Bahia and Minas Gerais with 3.7 days. For THA, Sergipe presented 4.4 days and Espírito Santo, 5.1 days (Table 1).

Mortality rate in TKA and THA in Brazil and regions

The mortality rate for arthroplasties in Brazil indicates that the risk of death in THA is nine times higher than in TKA. In the Southeast, hip surgeries presented a 13-fold higher rate of mortality than knee surgeries. The region that presented the smallest difference between the mortality rates for the two procedures was the North, where the mortality rate of THA was three times that of TKA (Table 9).

Table 9. Mortality rate in total knee (TKA) and hip (TKA) arthroplasties in Brazil and regions.15
   Region Year North TKA; THA Northeast TKA; THA   Southeast TKA; THA South TKA; ATQ Midwest TKA; THA Brazil TKA; THA
   2008 2.0; 0.0 0.3; 1.6   0.2; 2.6 0.1; 1.2 0.0; 2.6 0.5; 2.0
   2009 0.0; 1.0 0.3; 2.8   0.3; 2.2 0.1; 1.5 0.5; 2.2 0.3; 2.1
   2010 0.7; 0.0 0.2; 1.6   0.1; 2.2 0.1; 1.3 0.6; 2.9 0.1; 1.9
   2011 0.0; 1.7 0.2; 2.3   0.1; 2.6 0.1; 1.3 0.6; 2.4 0.1; 2.2
   2012 0.0; 0.9 0.0; 2.8   0.1; 2.5 0.3; 1.2 1.1; 1.4 0.2; 2.1
   2013 0.0; 1.8 0.0; 2.9   0.1; 2.0 0.1; 1.4 0.4; 1.0 0.1; 1.8
   2014 0.0; 2.9 0.5; 1.6   0.3; 1.8 0.2; 1.4 0.0; 2.5 0.3; 1.7
   2015 0.4; 0.9 0.0; 2.1   0.1; 1.6 0.1; 1.0 0.0; 1.9 0.1; 1.5
    Mean 0.38; 1.15 0.18; 2.21   0.16; 2.18 0.13; 1.28 0.4; 2.11 0.21; 1.91
Table 9. Mortality rate in total knee (TKA) and hip (TKA) arthroplasties in Brazil and regions.15

The state of Paraíba presented a worrysome 11.8% mortality rate for TKA. The highest mortality rates for TKA were observed in Tocantins (0.92%) and Mato Grosso (0.9%; Table 1).

 

DISCUSSION

In Brazil, the data related to public assistance for procedures of primary THA and TKA showed worrisome results, which highlights the immediate and future need for planning and management for surgical treatment for gonarthrosis and coxarthrosis.

Worldwide, TKA and THA are in rapid expansion, particularly the former, which present a more marked increase in the number of procedures than the latter.12 This trend stems from the aging of the global population, as well as from an increase in the sequelae from trauma and obesity.17 Sports injuries also contribute to the need for these surgeries, which are responsible for the growth in arthroplasties in ever younger patients.18

Socioeconomic studies on arthroplasties are increasingly frequent. In 2005, in the United States, approximately 500,000 knee replacements accounted for $11 billion in expenses19; while in Australia, one billion Australian dollars were spent on the same procedure in 2015.20 According to the data available in DATASUS, 189,457 hip and knee surgeries of partial arthroplasties, primary total arthroplasties, revisions, unconventional implants, and post-arthroplastic hip dislocation surgeries were performed in Brazil between 2008 and 2015, generating a cost of R$ 705,793,263.15.15

In the studied period, Brazil presented annual vegetative growth of 1.24%,16 and the number of TKA and THA procedures increased by 7.7% and 2.3%, respectively, close to the average of the countries studied (Table 5). Inversion of growth was observed in the biennia of 2011/2012 (−1.8% TKA and −1.4% THA) and 2014/2015 (−2.3% TKA). In these periods, the gross domestic product (GDP) decreased by −2% and −4.2%, respectively, in relation to the previous year.21,22 This same economic trend was observed in the 2010/2011 and 2013/2014 biennia, with GDP reductions of −3.8% and −3.3%, respectively; nonetheless, in those years the number of TKA procedures grew by 10.2% and 3.9%, and of THA, by 2.0% and 1.0%.15,21,22

The SUS coverage rate for TKA and THA per 100,000 inhabitants was alarming when compared with those of European countries, the United States, and Australia. SUS performed 36 times less TKA and 24 times less THA than the mean of the developed countries. The countries used in the comparisons had a more aged population percentile, especially Germany and Italy, in which this index was 11% higher.23 Nonetheless, Australia and Luxembourg presented only 4% more elderly individuals than Brazil and performed 45 times more TKA and 29 times more THA procedures. These results indicate a relevant care deficit, which leads to a reppressed demand of patients awaiting treatment and an overburden to the National Social Security System.

Data obtained through the Access to Information Law indicated that, in the study period, 56,111 individuals received Social Security benefits due to coxarthrosis and gonarthrosis. The cost of these benefits provided by the INSS in May 2016 was R$46,695,407.44.24

Nunley et al.25 and Lombardi et al.26 have indicated that the surgical treatment of gonarthrosis and coxarthrosis with arthroplasties substantially decreases the disability indexes, and allows 90% and 98% of patients that undergo TKA and THA to return to their work activities. In 2009, it was estimated that the United States obtained direct and indirect financial benefits of $12 billion from TKA surgery, as these surgeries allowed savings of $19,000 per citizen operated throughout their life, due to a 15% reduction of economic inactivity and an increase of productivity in 85% of patients.27

In 2010, the mean age of the Brazilian population was 29 years; the projections for 2050 indicate that this mean age will be 44 years, 30% of whom will be elderly.28 This estimate reinforces the need for a national management plan for the treatment of joint degenerative diseases due to the high growth prospects of these morbidities.

Regarding length of stay in TKA and THA, the mean results observed in Brazil were comparable to those of European countries,29,30 but higher than those in the United States.31 This data presented discrepancies per regions of Brazil, since the North and Northeast presented, on average, one more day of hospitalization for TKA and three more days for THA than the South region. A national plan with management and conduct protocols for patients undergoing this surgery is essential for the improvement of care and reduction of costs.

The mortality rate for TKA in Brazil was similar to that described in the world literature31; however, for THA it was twice that of the United States.31 It is noteworthy that the Brazilian results expressed only public hospitals, places that usually have intern physicians, a fact that contributes to higher complication rates.32 The improvement of preoperative risk stratification, as well as protocols for thromboprophylaxis and antibiotic therapy, may contribute to the reduction of these indices.

In Brazil, the number of THA procedures was almost twice that of TKA. One possible explanation is that THA is performed in cases of fracture and joint degeneration, while TKA is almost entirely determined by gonarthrosis, which facilitates the onset of a repressed demand. This gives THA a spontaneous random demand, since deviated fractures require almost compulsory hospitalization for the surgical treatment, something that is not observed in TKA.

A great disparity in care was observed among the five national demographic regions. The South Region, with 16.5% of the elderly population and third in GDP per capita,33 accounted for 29.1% and 28% of the TKAs and THAs in Brazil, presenting the best arthroplasties per elderly ratio in the country. The Southeast, with 47.2% of the elderly population and the highest GDP per capita,33 accounted for 57% and 51.6% of TKAs and THAs, respectively, having the second best arthroplasty per elderly ratio. The Midwest region, with 6.1% of the elderly population and the second best GDP per capita,33 accounted for 3.3% of the TKAs and 6.1% of the THAs. It was observed that the South region, despite having only the third best GDP per capita, provided the best coverage for arthroplasties.

The negative highlights were the Northeast and North regions. The Northeast, which has the lowest GDP per capita33 and approximately one-quarter of the country's total elderly population, performed only 7.8% and 12.9% of the TKAs and THAs, respectively, showing the worst TKA/elderly ratio and the second worst THA/elderly ratio. In turn, the North, with 5% of the elderly and the fourth GDP per capita,33 performed 2.6% and 1.2% of the TKAs and THAs, respectively, showing the worst THA/elderly ratio and the second worst TKA/elderly ratio.

It is necessary to create national policies for the professional development and to elaborate protocols for conducting conservative and surgical treatment of coxarthrosis and gonarthrosis in Brazil, as well as to improve data capture for arthroplasties, so that financial resources can be better distributed to improve the healthcare services provided to the Brazilian population.

Study limitations

The information for this study was collected from data available on the websites of public bodies, such as IBGE, ANS, WHO, and the Brazilian Ministry of Health, which were largely based on estimates and may interfere with the accuracy of the results.

 

CONCLUSION

The assistance provided by SUS to the Brazilian population for TKA and THA showed unsatisfactory results when compared with the same international indicators, with greater disparity in the North, Northeast, and Midwest regions.

 

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