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Arthroplasty is defined as the surgical replacement of a joint with artificially produced material. Total arthroplasty refers to the replacement of all joint surfaces concerned, while partial replacement involves the replacement of only one or some of the surfaces but not the entire joint. Hip and knee joints are those that are most frequently replaced. The most common indications for hip or knee arthroplasty are symptomatic osteoarthritis and femoral neck fractures (hip). When patients undergo hip or knee replacement for the first time (due to osteoarthritis) they are usually between 60 and 70 years of age. More than two thirds of patients who undergo arthroplasty due to femoral neck fractures are over 85 years of age. Primary arthroplasty refers to the first hip or knee replacement and revision arthroplasty refers to follow-up surgery on the same joint. The period of time (without complications) between primary arthroplasty and revision arthroplasty is termed as »service life«. In symptomatic osteoarthritis, arthroplasty is performed after all conservative and joint preserving therapy options have been exhausted. With regard to femoral neck fractures, joint replacement is usually the primary treatment option. Surgery aims to improve the quality of life, to restore the greatest possible functionality, mobility and freedom from pain, to assure a long service life with good weight-bearing capacity and to avoid secondary complications. These constitute important prerequisites for leading an independent life in old age.

The annual rate of primary hip and knee arthroplasty has not increased since 2007. In the 70 years plus age group, the rate of primary hip arthroplasty was 1.1 % (in both 2007 and 2014) and the rate of primary knee arthroplasty was 0.7 % in 2007 and 0.6 % in 2014. In 2014, the prevalence of surgery in relation to the entire population was 0.26 % for the hip and 0.19 % for the knee. Approximately 219,000 primary hip replacements and 149,000 primary knee replacements were documented in Germany in 2014. The most common procedure performed on a joint was total replacement. Approximately 40 % of all primary hip or knee replacements are performed in patients in the 70 to 79 year age group; women are more frequently affected than men (ratio 2:1). In 2014, the absolute number of revisions (including revisions without replacements) amounted to approximately 30,000 for the hip and 20,000 for the knee. The number of revisions performed in any given year is not necessarily directly related to the number of primary replacements performed in the same year. Instead, the number of revisions should be considered in relation to the cumulative number of primary replacements performed over the past years and decades. As with primary arthroplasty, approximately 40 % of the revisions are performed on patients in the 70 to 79 years age group. However, the difference between men and women is less pronounced.

Between 2007 and 2014, the rate of hip and knee revision replacements (including revision without replacements) also remained stable. In 2014, in the 70 years plus age group, the rate of revision replacements (including revision without replacements) was 0.19 % for the hip and 0.10 % for the knee. The annual utilization rate of primary hip and knee arthroplasty varies internationally. Regional differences also exist within Germany itself, as evaluations conducted by the statutory health insurances for the period from 2005 to 2011 have shown. A comparatively low utilization rate was associated in particular with low incidences of osteoarthritis, low social status, a high number of regional specialist physicians (orthopedists) and patients living in urban areas.

Approximately half of all hospitals in Germany perform primary hip and knee arthroplasty. Symptomatic osteoarthritis is the cause of 80 % of primary hip replacements and 96 % of primary knee replacements. In accordance with mandatory external quality assurance measures for hospitals, an increase in the documentation of appropriate indications has been observed for a growing proportion of patients over the last few years and reached 96 % for both types of surgery in 2014. A limiting factor, however, is that some of the relevant indication criteria do not yet exist in a standardized or evidence-based format. Hip and knee replacements are amongst the most commonly performed inpatient procedures. Patients who undergo primary hip or knee replacement account for approximately 2 % of all full-time inpatients. Over the past years, the length of hospital stay for arthroplasty patients has been declining continuously with a greater decline relative to the average length of stay for all other types of hospital treatments. In 2014, the average length of stay was approximately 11.8 days and 10.6 days for total hip and for total knee arthroplasty respectively. Surgical complications during inpatient stays for primary arthroplasty have been declining for years and are now in the lower single-digit percentage range. Routine statutory health insurance data between 2005 and 2006 show that that 3.5 % of primary hip arthroplasty patients and 3.8 % of primary knee arthroplasty patients underwent premature revision total replacement within the first 2 years after surgery. The risk of complications from endoprosthetic surgery depends on numerous factors. Influencing factors include the implant itself and the type surgery performed (including the surgeon's experience, surgical techniques, the duration of surgery, etc.), the patient's medical characteristics (concomitant diseases, compliance, etc.) as well as the type of rehabilitation care and ambulatory follow-up care. To date, no relevant data on service lives and influencing factors have been systematically collected in Germany. However, this is expected to change thanks to the German arthroplasty registry »Endoprothesenregister Deutschland« which was established in 2011. Rehabilitation treatment should start soon after surgery and in the majority of cases this is commenced a few days after discharge from hospital. However, due to shorter lengths of hospital stays, patients in rehabilitation clinics have greater care requirements. Older multimorbid patients in particular, require targeted geriatric, interdisciplinary care. Surveys carried out on statutory health insurees have indicated that most patients show a significant reduction in symptoms after surgery and that this is still the case even 5 years after surgery. In addition, a large majority of patients are satisfied with the procedure. These effects are more pronounced in hip surgery patients than in patients who have undergone knee replacements. The vast majority of patients return to work following the procedure.

In order for a medical device to be marketable in Europe it must bear the CE mark. CE certification is granted if the device conforms to specific safety and performance requirements. Monitoring is conducted by so-called »Notified Bodies«. Manufacturers can select any one of these certification bodies to certify a medical device. In Germany, the certification procedure for endoprostheses is regulated in the Medical Device Directive 93/42/EEC and is implemented through the Medical Devices Act and further decrees. Up to now, the AQUA Institute for Quality Improvement and Research in the Healthcare System (AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen) has been responsible for external inpatient quality assurance which is mandatory in Germany. The institute publishes detailed reports concerning the quality outcomes of patient care, which both hospitals and patients can use for comparisons with other establishments. As of 2016, the Institute for Quality Assurance and Transparency in the Healthcare System (Institut für Qualitätssicherung und Transparenz im Gesundheitswesen (IQTiG)), which was founded by the Federal Joint Committee, has assumed this responsibility. The German arthroplasty registry »Endoprosthenregister Deutschland« was initiated in 2013 and aims to document quality outcomes of knee and hip arthroplasty across Germany. The purpose of the registry is to enable the tracking of typical service lives of implants used and to investigate reasons for undesired treatment outcomes. The validity of the registry is still limited as about only half of the hospitals that perform arthroplasty currently contribute to it and only a limited number of primary hip and knee arthroplasties are recorded.

EndoCert is a certification system that was established by the German Society of Orthopedics and Orthopedic Surgery (Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC)) and the German arthroplasty association »Deutsche Gesellschaft für Endoprothetik (AE)« and the Professional Association of Orthopaedic Surgeons (Berufsverband der Fachärzte für Orthopädie und Unfallchirurgie e. V. (BVOU)).

Initial results show a decline in complication rates and an improvement in outcome quality amongst a few certified institutions.

Alongside representing the interests of their members and offering basic and specialty training, medical societies also assume an important role with regard to research and towards improving the quality of healthcare. The trauma registry »TraumaRegister of the German Society for Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie (DGU))« is affiliated with hospitals specializing in trauma surgery and aims to evaluate the effectiveness of methods used in medical treatment. The German arthroplasty association »Deutsche Gesellschaft für Endoprothetik (AE)« is a division of the German Society for Orthopaedics and Trauma (Deutsche Gesellschaft für Orthopädie und Unfallchirurgie (DGOU)) and is involved in quality assurance of endoprosthetic care and in the development of new technologies.

The costs incurred for knee and hip arthroplasty depend on the different type of treatments provided within the chain of medical care. Indirect costs of the disease, such as the incapacity to work resulting from the underlying diseases and intangible costs which cannot be evaluated in monetary terms, must also be taken into account. Patient care is financed through established remuneration systems. According to different publications, data extrapolations have shown that German statutory health insurances spent approximately 1.4 to 1.6 billion euros per year on hospital treatments for hip arthroplasty between 2003 and 2009. With regard to knee arthroplasty, expenditure for the same period was estimated at 1.0 to 1.3 billion euros per year. The direct costs for the associated inpatient stays are financed through case-based fees, which are in turn based on the actual average hospital costs. The most commonly remunerated case fees (hip arthroplasty/knee arthroplasty) have shown cost increases of a few percentage points over the last few years which are mainly due to the rising costs of personnel. In the two case-fee groups, implant costs constitute 21 % of the total cost for hip treatments and 25 % of the total cost for knee treatments. Particularly complicated cases such as infected hip endoprostheses are relatively more costly. With regard to indirect costs, the diagnosis »Osteoarthritis of hip« (ICD-10 M16) resulted in 2,585,157 days of incapacity to work amongst compulsory statutory health insurees (excluding pensioners) in 2011. For »Osteoarthritis of knee« (ICD-10 M17) the figure was almost double at 4,971,052. Some patients who are in employment are unable to return to work despite having undergone a joint replacement and either have to change profession or accept a loss of income that includes social security contributions. Osteoarthritis, which is the most common reason for hip or knee replacements, is associated with a significant, increasing and in part immeasurable disease burden. International studies have demonstrated that the disease is accompanied by a high degree of suffering on the part of the patient as the large majority (70 % or more) would be personally willing to finance the hip or knee arthroplasty at their own cost if the procedures were not included amongst those reimbursed by health insurance systems. Hospitals in Germany finance the costs of arthroplasty with one of several possible arthroplasty case fees selected according to the specific service provided and the circumstances of each case. The case fees are based on the average costs of a given treatment. The case fee figures in 2015, which were based on certain benchmarks, ranged between approximately 6,400 euros and 17,300 euros. However, case fees do not always seem to cover the hospital costs, particularly in the treatment of more complicated cases.

The previous chapters reviewed the status of knee and hip arthroplasty care based on existing literature. This chapter assesses the current situation from an expert perspective through the examination and analysis of available data. In August 2015, a workshop was conducted in preparation for this chapter, which was attended by a renowned panel of experts and stakeholders who play an important role in shaping the provision of healthcare services in Germany. This chapter presents the results following this workshop, the content of which has been approved by the relevant participants.