Journal of Arthroplasty

Journal of Arthroplasty

Does Patient Experience After a Total Knee Arthroplasty Predict Readmission?

10-06-2019 – Nipun Sodhi, Michael A. Mont, Cleveland Clinic Orthopaedic Arthroplasty

Journal Article

Background

To our knowledge, the relationship between patient Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and patient outcomes in total knee arthroplasty (TKA) has not yet been analyzed. Therefore, the purpose of this study is to determine whether readmissions within the 30 or 90 days postoperative window after TKA were predicted by patient satisfaction scores, as measured by the HCAHPS survey.

Methods

We analyzed HCAHPS survey scores from all patients who underwent primary or revision TKA at our institution between January 1, 2016 and September 1, 2016. Demographic readmission information, preoperative baseline health status measures, validated patient-reported pain and joint function measures, and HCAHPS survey scores were collected. To determine whether 30-day or 90-day readmissions were independently associated with HCAHPS scores, statistical analyses were conducted using chi-squared and Student’s t-tests for categorical and continuous variables. Multivariable regression analysis adjusted for patient-level risk factors.

Results

Patients readmitted within 30 days were significantly less likely to choose the highest rating on survey questions in several dimensions of patient satisfaction when compared to patients who were not readmitted. These dimensions included physician communication (P = .045), discharge information (P = .016), and transition of care (P = .044). Similarly, patients who were readmitted within 90 days were less likely to choose the highest rating in survey questions that pertained to physician communication (P = .046), medication information (P = .040), and quietness of the hospital environment (P = .048).

Conclusion

Our results show that readmission is predicted by lower patient satisfaction scores in several dimensions of patient care including physician communication, hospital environment, medication information, discharge information, and transition of care.

Response to Letter to the Editor on “Adductor Canal Block or Local Infiltrate Analgesia for Pain Control After Total Knee Arthroplasty? A Systematic Review and Meta-Analysis of Randomized Controlled Trials”

02-09-2019 – Vandit Sardana, Joanna M. Burzynski, Giles R. Scuderi

Letter

Letter to the Editor on “Adductor Canal Block or Local Infiltrate Analgesia for Pain Control After Total Knee Arthroplasty? A Systematic Review and Meta-Analysis of Randomized Controlled Trials”

27-08-2019 – Jian Zhou, Kun Wang, Guofeng Wu, Xiaoliang Sun

Letter

Total Knee Arthroplasty in Patients With Knee Osteoarthritis: Effects on Proprioception. A Systematic Review and Best Evidence Synthesis

10-07-2019 – Giorgio di Laura Frattura, Stefano Zaffagnini, Giuseppe Filardo, Iacopo Romandini, Augusto Fusco, Christian Candrian

Journal Article

Background

Impact of total knee arthroplasty (TKA) on proprioception remains to be determined. The aim of this systematic review is to analyze factors influencing proprioception in patients with knee osteoarthritis (OA) undergoing TKA.

Methods

A systematic literature search was conducted on 3 medical electronic databases: PubMed, Pe
DRO, and Cochrane Collaboration. The Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were used. Risk of bias analysis and best evidence synthesis were performed. Three main aspects were investigated: the presence of preoperative, surgical, and postoperative factors influencing proprioception in OA patients undergoing TKA.

Results

Search identified 1601 records. After screening, 19 papers were used for the analysis of 676 patients. Proprioception generally improved but often remained impaired after surgery. Strong evidence was found for no influence of prosthesis design on proprioception. Moderate evidence was found for patellar resurfacing not affecting proprioception, varus deformity negatively influencing proprioception, and time elapsed from surgery positively influencing proprioception. Limited evidence was found for valgus deformity, OA grade, intact anterior cruciate ligament, and anteroposterior joint laxity negatively affecting knee proprioception, and for muscle strength and sensorimotor training not affecting proprioception. Finally, conflicting evidence was found for better postoperative proprioception vs preoperative level.

Conclusion

Proprioception in OA patients undergoing TKA improves but remains impaired after surgery. The best evidence synthesis demonstrated no influence of prosthetic design, while the role of the treatment remains unclear. This warrants for further research efforts to study proprioceptive impairment to better manage OA patients undergoing TKA.

Comparison of the Efficacy Between Closed Incisional Negative-Pressure Wound Therapy and Conventional Wound Management After Total Hip and Knee Arthroplasties: Axa0Systematic Review and Meta-Analysis

11-07-2019 – Jun-Ho Kim, Hyun-Jung Kim, Dae-Hee Lee

Journal Article

Background

Wound-related problems after total hip arthroplasty (THA) and total knee arthroplasty (TKA) can cause periprosthetic joint infections. We sought to evaluate the effect of closed incisional negative-pressure wound therapy (ci
NPWT) on wound complications, skin blisters, surgical site infections (SSIs), reoperations, and length of hospitalization (LOH).

Methods

Studies comparing ci
NPWT with conventional dressings following THA and TKA were systematically searched on MEDLINE, Embase, and the Cochrane Library. Two reviewers performed the study selection, risk of bias assessment, and data extraction. Funnel plots were employed to evaluate publication bias and forest plots to analyze pooled data.

Results

Twelve studies were included herein. The odds ratios (ORs) for wound complications and SSIs indicated a lack of publication bias. ci
NPWT showed significantly lower risks of wound complication (OR, 0.44; 95% confidence interval CI, 0.22-0.9; P = .027) and SSI (OR, 0.39; 95% CI, 0.23-0.68; P < .001) than did conventional dressings. ci
NPWT also yielded a significantly lower reoperation rate (OR, 0.38; 95% CI, 0.21-0.69; P = .001) and shorter LOH (mean difference, 0.41 days; 95% CI, −0.51 to −0.32; P < .001). However, the rate of skin blisters was higher in ci
NPWT (OR, 4.44; 95% CI, 2.24-8.79; P < .001).

Conclusion

Although skin blisters were more likely to develop in ci
NPWT, the risks of wound complication, SSI, reoperation, and longer LOH decreased in ci
NPWT compared with those in conventional dressings. This finding could alleviate the potential concerns regarding wound-related problems after THA and TKA.

Accuracy of a New Robotically Assisted Technique for Total Knee Arthroplasty: A Cadaveric Study

16-07-2019 – Sébastien Parratte, Andrew J. Price, Lee M. Jeys, William F. Jackson, Henry D. Clarke

Journal Article

Background

Although the utility of robotic surgery has already been proven in cadaveric studies, it is our hypothesis that this newly designed robotically assisted system will achieve a high level of accuracy for bone resection. Therefore, we aimed to analyze in a cadaveric study the accuracy to achieve targeted angles and resection thickness.

Methods

For this study, 15 frozen cadaveric specimens (30 knees) were used. In this study, Zimmer Biomet (Warsaw, IN) knees, navigation system, and robot (ROSA Knee System; Zimmer Biomet) were used. Eight trained, board-certified orthopedic surgeons performed robotically assisted total knee arthroplasty implantation using the same robotic protocol with 3 different implant designs. The target angles obtained from the intraoperative planning were then compared to the angles of the bone cuts performed using the robotic system and measured with the computer-assisted system considered to be the gold standard. For each bone cut the resection thickness was measured 3 times by 2 different observers and compared to the values for the planned resections.

Results

All angle mean differences were below 1° and standard deviations below 1°. For all 6 angles, the mean differences between the target angle and the measured values were not significantly different from 0 except for the femoral flexion angle which had a mean difference of 0.95°. The mean hip-knee-ankle axis difference was −0.03° ± 0.87°. All resection mean differences were below 0.7 mm and standard deviations below 1.1mm.

Conclusion

Despite the fact that this study was funded by Zimmer Biomet and only used Zimmer Biomet implants, robot, and navigation tools, the results of our in vitro study demonstrated that surgeons using this new surgical robot in total knee arthroplasty can perform highly accurate bone cuts to achieve the planned angles and resection thickness as measured using conventional navigation.

High Rate of Early Intraprosthetic Dislocations of Dual Mobility Implants: A Single Surgeon Series of Primary and Revision Total Hip Replacements

14-08-2019 – Jacqueline L. Addona, Alex Gu, Ivan De Martino, Michael-Alexander Malahias, Thomas P. Sculco, Peter K. Sculco

Journal Article

Background

Dual mobility (DM) articulations have become an increasingly popular bearing choice in efforts to reduce dislocation rates in high risk primary and revision total hip arthroplasties (THA). However, DM dislocations can still occur. Intraprosthetic dislocation (IPD) is a unique failure mode for DM compared to standard femoral heads. Currently, the incidence of this phenomenon during attempted hip reduction is unknown.

Methods

A retrospective analysis of a consecutive series of all primary, revision, and conversion THA procedures performed by a single surgeon was collected. For all dislocations, patient demographics, location where reduction was performed, type of anesthetic used was recorded. For DM dislocations, the rate of successful closed reduction, reoperation due to failure of closed reduction, and incidence of IPD at time of reduction was recorded. Descriptive statistics were conducted on the data.

Results

In total, 527 cases were included for analysis. The overall rate of dislocation (with and without DM) was 2.85%. Among DMs, the dislocation rate was 4.55%. The rate of IPD after closed reduction was 5/7 (71%) with all five requiring revision surgery to either another DM bearing or constrained liner.

Conclusions

We report a high rate of early IPD after DM dislocation. This study supports alternative treatment protocols for these patients including regional or general anesthesia to be administered in the operating room and for the reduction to be performed under fluoroscopy. Dislocated DM components handled in this manner could reduce the high incidence of IPD reported.

Early Morbidity but Not Mortality Increases With Surgery Delayed Greater Than 24 Hours in Patients With a Periprosthetic Fracture of the Hip

08-07-2019 – Venkat Boddapati, Matthew J. Grosso, Nana O. Sarpong, Jeffrey A. Geller, H. John Cooper, Roshan P. Shah

Journal Article

Background

Studies have identified a possible morbidity and mortality benefit with expedited time to surgery after a native hip fracture. This association after hip periprosthetic fractures (PPF) has been less clearly delineated. The purpose of this study is to assess the effect of time to surgery on rates of 30-day complications.

Methods

The National Surgical Quality Improvement Program registry was used to identify all patients who underwent surgical intervention for hip PPF between 2005 and 2016. Patients were stratified into 2 cohorts based on time from hospital admission to surgery, either ≤24 hours (expedited) or >24 hours (non-expedited). Thirty-day outcome variables were assessed using bivariate and multivariate analyses.

Results

We identified 857 patients undergoing surgical intervention for hip PPF, of whom 402 (46.9%) underwent expedited surgery and 455 (53.1%) underwent non-expedited surgery. Patients with non-expedited surgery had an average time to surgery of 2.4 days (range, 1-14 days). Multivariate analysis adjusting for differences in baseline patient characteristics revealed that patients with a non-expedited procedure had higher rates of overall complications (odds ratio OR = 1.72; P = .014), respiratory complications (OR = 4.15; P = .0029), urinary tract infections (OR = 2.77; P = .020), nonhome discharge (OR = 2.22; P < .001), and blood transfusions (OR = 1.86; P < .001). There was no statistical difference in mortality (P = .093). Patients with non-expedited surgery also had longer total and postoperative (+2.7 days; P < .001) length of stay.

Conclusion

This study did not identify any statistical difference in mortality but found an association with increased postoperative complications and non-expedited surgery for PPF. Additional prospective studies may be warranted to identify the causative factors behind this association.

Clostridium difficile Colitis Following Revision Total Knee Arthroplasty: Incidence and Risk Factors

16-07-2019 – Gannon L. Curtis, Sanar S. Yokhana, Linsen T. Samuel, Jaiben George, Carlos A. Higuera-Rueda, Bryan E. Little, Hussein F. Darwiche

Journal Article

Background

Clostridium difficile–associated diarrhea (CDAD) is associated with adverse events and financial liability. As institutions continue to adopt CDAD rates as a quality control metric, it is important to identify patients at risk before surgery, including revision total knee arthroplasty (r
TKA). This study was conducted to (1) determine the incidence of CDAD within 30 days of r
TKA and (2) identify perioperative risk factors for CDAD following r
TKA.

Methods

The American College of Surgeons National Surgical Quality Improvement Program was queried to identify 6023 r
TKA procedures from 2015-2016. Preoperative and perioperative variables, including patient demographics, lab values, comorbidities, operative time, procedure type, presence of postoperative infections, and rates of CDAD were collected. Chi-square and Fisher’s exact tests were used to detect differences between categorical variables, and t-tests were used to compare continuous variables. A stepwise logistic regression model was used to identify the risk factors for CDAD.

Results

The rate of CDAD within 30 days of r
TKA was found to be 0.4% (24/6024). The CDAD rate following aseptic revision was 0.2% (12/4893), while the incidence of CDAD after septic revision was 1.1% (12/1130). Preoperative functional dependence (odds ratio OR = 5.14; P = .002), septic revision (OR = 2.77; P = .026), and cancer (OR = 14.26; P = .016) were statistically significant independent risk factors for CDAD after r
TKA.

Conclusion

The incidence of CDAD after r
TKA is approximately 0.4% in the United States. Independent risk factors for CDAD include septic revision, preoperative functional dependence, and cancer. Prevention of CDAD in these higher risk patients must be considered before surgery and antibiotic selection for other infections should be managed judiciously.

Gastrointestinal Complications Warranting Invasive Interventions Following Total Joint Arthroplasty

08-07-2019 – Abidemi S. Adenikinju, James E. Feng, Clementine A. Namba, Tyler A. Luthringer, Claudette M. Lajam

Journal Article

Background

Gastrointestinal (GI) complications following total joint arthroplasty (TJA) are uncommon but can be associated with substantial morbidity and mortality. The current literature on GI complications that warrant invasive procedures after TJA is lacking. This study reviews the incidence and outcomes of GI complications after TJA that went on to require invasive procedures.

Methods

All TJA patients at our institution between January 2012 and May 2018 who had GI complications requiring an invasive procedure within 30 days of TJA were identified and retrospectively chart reviewed. Descriptive statistics were used to evaluate these patients.

Results

Of 19,090 TJAs in a 6-year period, 34 patients (0.18%) required invasive procedures for GI complications within 30 days of the index surgery. Twenty-two (64%) of the required procedures were endoscopy for suspected GI bleeding. Within this cohort, aspirin was the most common thromboprophylaxis used (63.6% of patients) and smoking was more prevalent (9.1% current smokers) (P = .28). Of the remaining 12 GI procedures required, 75% were exploratory laparotomies, 44.4% of which were performed for obstruction. Three (33.3%) of the exploratory laparotomy patients died during the study period.

Conclusion

GI complications necessitating surgical intervention after TJA are rare. Suspected GI bleeding is the most common indication for intervention and is typically managed endoscopically. Other complications, such as GI obstruction, often require more extensive intervention and open procedures. Though rare, GI complications following TJA can lead to detrimental outcomes, significant patient morbidity, and occasionally mortality; therefore, a heightened awareness of these complications is warranted.

Venous Thromboembolism Rates Did Not Decrease in Lower Extremity Revision Total Joint Arthroplasty From 2008 to 2016

04-06-2019 – Jared A. Warren, Kavin Sundaram, Atul F. Kamath, Robert M. Molloy, Viktor E. Krebs, Michael A. Mont, Nicolas S. Piuzzi

Journal Article

Background

In revision total knee arthroplasty (r
TKA) and revision total hip arthroplasty (r
THA), venous thromboembolism (VTE) has been reported to be a relatively common and potentially serious complication. To mitigate this risk, strategies such as rapid recovery programs and thromboprophylaxis guidelines have been utilized. This study sought to identify the annual incidence and recent trends of VTE (defined as the presence of deep vein thrombosis DVT and/or pulmonary embolism PE in the same patient), DVT, PE, and mortality in the 30-day period after r
TKA and r
THA.

Methods

We identified 30,406 r
TKA and r
THA patients from 2008 to 2016 using the National Surgical Quality Improvement Program database. Thirty-day incidences for VTE, DVT, PE, and mortality for each year and the overall study period were calculated. Bivariate and multivariate regressions were performed using patient demographics and comorbidities to assess trends in the outcomes of interest.

Results

The overall incidences of 30-day VTE, DVT, PE, and mortality for r
TKA were 1.2%, 0.9%, 0.4%, and 0.5%. Bivariate analysis revealed no significant change over the study period for VTE (P = .137), DVT (P = .406), PE (P = .121; 99% confidence interval 0.112-0.129), and mortality (P = .463). The incidences over the study period of VTE, DVT, PE, and mortality in r
THA were 1.0%, 0.7%, 0.4%, and 0.7%. Bivariate analysis revealed no changes in VTE (P = .393), DVT (P = .376), and PE (P = .602). However, bivariate analysis revealed significant decrease in mortality (P = .010) over the study period.

Conclusion

Within 30 days of surgery, approximately 1 in 83 r
TKA patients and 1 in 100 r
THA patients experienced a VTE. Furthermore, the rates of VTE remained largely unchanged from 2008 to 2016. Further research regarding the optimal individualized prophylaxis algorithm in r
TKA and r
THA is warranted to prevent this complication. This study represents the first investigation of thromboembolic events in r
THA and r
TKA.

Partial Component–Retained 2-Stage Reconstruction in the Treatment of Infected Hip Arthroplasty

17-07-2019 – Jian Zhou, Shuo Jie, Xiadong Du, Yihan Li, Wanchun Wang, Tang Liu

Journal Article

Background

It is considered the gold standard treatment for infected hip arthroplasty to remove and reimplant the corresponding whole set of implant components before and after infection control, but it usually causes substantial bone loss to remove the well-fixed cup or stem, which may increase the difficulty in reconstruction. We would like to determine whether infected hip arthroplasty can be treated without removal of a well-fixed cup or stem.

Methods

Patients with infected hip arthroplasty and a radiographically well-fixed, cementless cup or stem were selected. During the first surgical stage, we retained the stem or cup if these cannot be removed using a stem or cup extractor. We performed the reimplantation surgery after control of infection.

Results

From January 2008 to December 2016, 26 patients underwent partial component–retained 2-stage reconstruction. All the patients were free of infection with a mean follow-up time of 43.85 months.

Conclusion

Partial component–retained 2-stage reconstruction may be a treatment option for infected total hip arthroplasty with a well-fixed component in patients.

Improved Patient-Reported Quality of Life and Hip Function After Cementless 1-Stage Revision of Chronic Periprosthetic Hip Joint Infection

04-07-2019 – Ninna Rysholt Poulsen, Inger Mechlenburg, Kjeld Søballe, Anders Troelsen, Jeppe Lange, Anders Troelsen, Andre Zawadski, Anne Grete Kjersgaard, Christian Heine, Jeppe Lange, Jess Riis, Kjeld Søballe, Kristian Otte, Martin Lamm, Mohammad Hossein Dehghani, Niels Krarup, Per Kjærsgaard-Andersen, Poul Torben Nielsen, Søren S. Mikkelsen, Søren Solgaard

Journal Article

Background

Limited information is available on health-related quality of life (HRQoL) and patient-reported hip function following treatment for a chronic periprosthetic hip joint infection. The purpose of this study is to evaluate changes in HRQoL and patient-reported hip function 2 years following a cementless 1-stage revision for chronic periprosthetic hip joint infection.

Methods

Patients (n = 52) enrolled in a previously published clinical study on cementless 1-stage revision in chronic periprosthetic hip joint infection prospectively answered the Euro
Qol-5D, Short-Form Health Survey 36 (SF-36), and Oxford Hip Score preoperatively and at 3, 6, 12, and 24 months follow-up. Results were compared to age-matched and gender-matched population norm.

Results

A significant improvement in HRQoL and patient-reported hip function appeared in the first 3 months after surgery and reached a plateau after 6 months. The patients statistically reached age-matched and gender-matched population norm after 3 to 12 months follow-up on most items, except for Physical Functioning and Social Functioning on the SF-36. The largest effect sizes were found for Oxford Hip Score at 1.8 and for Role Limitation, Physical and Bodily Pain on the SF-36 at 1.5 and 1.6, respectively.

Conclusion

Patients treated with a cementless 1-stage revision for chronic periprosthetic hip joint infection experienced a marked increase in HRQoL and patient-reported hip function, and matched population norms on many parameters.

Do Culture Negative Periprosthetic Joint Infections Remain Culturexa0Negative?

23-07-2019 – Beverly L. Hersh, Neel B. Shah, Scott D. Rothenberger, Jason P. Zlotnicki, Brian A. Klatt, Kenneth L. Urish

Journal Article

Background

Diagnosis and treatment of culture negative total knee arthroplasty (TKA) periprosthetic joint infection (PJI) is challenging. There is debate over whether culture negative PJI confers increased risk of failure and which organisms are responsible. It is also unclear as to what factors predict conversion from culture negative to culture positivity. To address these issues, we performed an observational study to detect factors associated with transition from culture negative to culture positive TKA PJI in those patients that failed irrigation and debridement (I&D), determine the incidence of this transition, and identify those organisms that were associated with treatment failure.

Methods

A multicenter observational cohort study was performed on patients with TKA PJI as defined by Musculoskeletal Infection Society criteria without cultured organisms and treated with I&D. Primary outcome was failure defined as any subsequent surgical procedure. Secondary outcome included cultured organism within 2 years of initial I&D.

Results

Two hundred sixteen TKA I&D procedures were performed for PJI, and 36 met inclusion criteria. The observed treatment failure rate for culture negative PJI treated with I&D was 41.67%. Of those culture negative I&Ds that failed, 53.33% became culture positive after failure. Of those that converted to culture positive, 62.5% were Staphylococcus species. The odds ratio associated with becoming culture positive following culture negative treatment failure in the setting of antibiotic administration prior to the initial I&D procedure was 0.69 (95% confidence interval 0.14-3.47, P = .65).

Conclusion

Many cases of culture negative TKA PJI treated with I&D eventually fail and become culture positive. Staphylococci are common organisms identified after culture negative PJI.

Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection: The Rate and Reason for the Attrition After the First Stage

10-07-2019 – Qiaojie Wang, Karan Goswami, Feng-Chih Kuo, Chi Xu, Timothy L. Tan, Javad Parvizi

Journal Article

Background

Two-stage exchange arthroplasty remains a popular surgical treatment for patients with chronic periprosthetic joint infection (PJI). Patients who do not receive reimplantation were largely overlooked in the current literature. We aimed at investigating the clinical outcomes of these patients.

Methods

Our institutional PJI database was retrospectively reviewed to identify 616 patients (237 hips, 379 knees) who were treated with an intended 2-stage exchange. Of them, 111 (18%) did not receive reimplantation within a minimum follow-up of 1 year. Chart review and targeted interviews were performed to elucidate the cause of attrition. Patients were considered to have failed treatment in the absence of reimplantation if they remained medically unfit for reimplantation, underwent a salvage procedure, or died during the study period.

Results

Of the 111 patients without reimplantation, 29 (26.1%) did well with their retained spacer and were unwilling to proceed with reimplantation, 23 (20.7%) underwent salvage procedures, and the remaining 59 (53.2%) were considered medically unfit for reimplantation, with 34 of them dying within 1 year of initial spacer insertion. The overall success rate for 2-stage exchange cohort at 2 years was 65.7% when treatment failure without reimplantation was taken into account. Several factors associated with increased risk of treatment failure without reimplantation were identified using a multivariate regression model.

Conclusion

Almost 1 in 5 patients may never receive the intended reimplantation. Among many reasons for attrition, mortality appears to be a relatively common event. The current definition of treatment success does not take into account the attrition group and thus inflates the relative success of 2-stage exchange arthroplasty.

Reevaluating Current Cutoffs for Acute Periprosthetic Joint Infection: Current Thresholds Are Insensitive

17-07-2019 – Chi Xu, Timothy L. Tan, Feng-Chih Kuo, Karan Goswami, Qiaojie Wang, Javad Parvizi

Journal Article

Background

Diagnosing acute periprosthetic joint infection remains a challenge. Several studies have proposed different acute cutoffs resulting in the International Consensus Meeting recommending a cutoff of 100 mg/L, 10,000 cell/μL and 90% for serum C-reactive protein (CRP), synovial white blood cell count (WBC), and polymorphonuclear percentage (PMN%), respectively. However, establishing cutoffs are difficult as the control group is limited to rare early aseptic revisions, and performing aspiration in asymptomatic patients is difficult because of a fear of seeding a well-functioning joint arthroplasty. This study (1) assessed the sensitivity of current thresholds for acute periprosthetic joint infection (PJI) and (2) identified associated factors for false negatives.

Methods

We retrospectively reviewed patients with acute PJIs (n = 218), defined as less than 6 weeks from index arthroplasty, treated between 2000 and 2017. Diagnosis of PJI was based on 2 positive cultures of the same pathogen from the periprosthetic tissue or synovial fluid samples. Sensitivities of International Consensus Meeting cutoff values of CRP, synovial WBC, and PMN% were evaluated according to organism type. Multiple logistic regression analysis was performed to determine associated factors for false negatives.

Results

Overall, the sensitivity of CRP, synovial WBC, and PMN% for acute PJI was 55.3%, 59.6%, and 50.5%, respectively. Coagulase-negative Staphylococcus (CNS) demonstrated the lowest sensitivity for both CRP (37.5%) and WBC (55.6%). CNS infection was identified as an independent risk factor for false-negative CRP.

Conclusions

Current thresholds for acute PJI may be missing approximately half of PJIs. Low virulent organisms, such as CNS, may be responsible for these false negatives. Current thresholds for acute PJI must be reexamined.

The Quality of Diagnostic Studies in Periprosthetic Joint Infections: Can We Do Better?

22-07-2019 – Anas Saleh, Jaiben George, Assem A. Sultan, Linsen T. Samuel, Michael A. Mont, Carlos A. Higuera-Rueda

Journal Article, Review

Background

The diagnosis of periprosthetic joint infections (PJIs) continues to be a subject of extensive debate. This is in part due to the lack of a single “gold standard” test, and the marked heterogeneity in the design of studies evaluating the accuracy of different diagnostic modalities. The goal of this review is to critically analyze the evidence cited by the proceedings of the 2013 International Consensus Meeting (ICM) on PJI with regards to the diagnosis of PJI.

Methods

References from the Proceedings of the ICM on PJI related to PJI minor criteria were retrieved and manually reviewed. A total of 25 studies were analyzed using a Validated Quality Assessment of Diagnostic Accuracy Studies tool.

Results

A large number of studies were determined to have a high risk of bias for flow and timing domains due to the large numbers of exclusions. Studies of synovial white blood cells count and polymorphonuclear neutrophils percentage suffered from threshold optimization and lack of internal validity. Furthermore, due to the lack of homogeneity across studies, index test and reference standard domains showed high risk of bias for white blood cell/polymorphonuclear neutrophil percentage and the utility histological analysis, respectively. Leukocyte esterase testing lacked standardization with regard to the strip reagent used, and the exclusion of bloody samples limited sample sizes.

Conclusion

The 2013 ICM minor criteria were based on studies with a low quality of evidence. As the committee continues to adjust these guidelines, they should encourage future studies with sound clinical design, patient selection, and testing procedures.

Development and Validation of an Evidence-Based Algorithm for Diagnosing Periprosthetic Joint Infection

08-07-2019 – Noam Shohat, Timothy L. Tan, Craig J. Della Valle, Tyler E. Calkins, Jaiben George, Carlos Higuera, Javad Parvizi

Journal Article

Background

The guidelines for diagnosis of periprosthetic joint infection (PJI) introduced by the American Academy of Orthopaedic Surgeons served the orthopedic community well. However, they have never been validated and do not account for newer diagnostic modalities. Our aim was to update current guidelines and develop an evidence-based and validated diagnostic algorithm.

Methods

This multi-institutional study examined total joint arthroplasty patients from 3 institutions. Patients fulfilling major criteria for infection as defined by Musculoskeletal Infection Society were considered infected (n = 684). Patients undergoing aseptic revision for a noninfective indication and did not show evidence of PJI or undergo reoperation within 2 years served as a noninfected control group (n = 820). The algorithm was validated on a separate cohort of 422 cases.

Results

The first step in evaluating PJI should include a physical examination, followed by serum C-reactive protein, erythrocyte sedimentation rate, and D-dimer. If at least one of these tests are elevated, or if high clinical suspicion exists, joint aspiration should be performed, sending the fluid for a white blood cell count, leukocyte esterase, polymorphonuclear percentage, and culture. Alpha defensin did not show added benefit as a routine diagnostic test. In inconclusive cases, intraoperative findings including gross purulence, histology, and next-generation sequencing or a single positive culture can aid in making the diagnosis. The proposed algorithm demonstrated a high sensitivity (96.9%) and specificity (99.5%).

Conclusion

This validated, evidence-based algorithm for diagnosing PJI should guide clinicians in the workup of patients undergoing revision arthroplasty and improve clinical practice. It also has the potential to reduce cost.

Extended Antibiotic Prophylaxis Confers No Benefit Following Aseptic Revision Total Hip Arthroplasty: A Matched Case-Controlled Study

04-07-2019 – Feng-Chih Kuo, Arash Aalirezaie, Karan Goswami, Noam Shohat, Kier Blevins, Javad Parvizi

Journal Article

Background

Administration of perioperative antibiotic prophylaxis is one of the most important practices for prevention of periprosthetic joint infection (PJI) in patients undergoing total hip arthroplasty (THA). It is common to continue perioperative antibiotic prophylaxis for 48 hours or longer in patients undergoing revision arthroplasty, until results of intraoperative culture samples become available. However, the utility of this practice remains unclear. We examined whether extended antibiotic prophylaxis following aseptic revision THA reduces the risk of subsequent PJI.

Methods

We retrospectively reviewed records of patients undergoing aseptic revision THA between January 2000 and December 2015. At our institution, some surgeons administer prophylactic antibiotics to revision patients for only 24 hours while others prefer to extend until intraoperative culture results become available. We matched 209 patients undergoing revision THA who received extended antibiotic prophylaxis (>24 hours) in a 1:1 ratio with 209 patients receiving standard antibiotic prophylaxis (≤24 hours). The matching criteria were age, sex, body mass index, Charlson comorbidity index, and operative time.

Results

The incidence of subsequent PJI was 4.8% in patients receiving extended antibiotic prophylaxis vs 2.4% in patients receiving standard. After adjusting for all cofounders and using multivariate logistic regression, the administration of extended prophylactic antibiotics did not reduce the incidence of subsequent infection. When stratified by postoperative antibiotic regimens, the 2 groups had similar infection-free implant survival rate (95.2% in extended and 97.6% in standard).

Conclusion

It appears that extending perioperative prophylactic antibiotics until intraoperative culture results become available in patients undergoing revision THA for aseptic failures does not provide any additional benefit in terms of reducing the risk of subsequent PJI.

Does Trochanteric Osteotomy Length Affect the Amount of Proximal Trochanteric Migration During Revision Total Hip Arthroplasty?

30-07-2019 – Sebastián A. León, Xin Y. Mei, Ethan B. Sanders, Oleg A. Safir, Allan E. Gross, Paul R.T. Kuzyk

Journal Article

Background

Nonunion and proximal trochanteric migration is a known complication of trochanteric osteotomy. This study examines the effect of osteotomy length on proximal greater trochanter (GT) migration.

Methods

We analyzed 113 modified trochanteric slide osteotomies and 73 extended trochanteric osteotomies performed between 2008 and 2016. All osteotomies were fixed using cerclage wires and had minimum 6-month radiographic follow-up. Spearman correlations were used to assess association between osteotomy length and GT migration distance. Chi-squared test and logistic regression were used to assess association between patient and surgical factors and GT migration >1 cm. Receiver operating characteristic curves were constructed to determine the optimal cutoff osteotomy length for predicting GT migration >1cm.

Results

Mean osteotomy length was 6.1 cm (range 3-12) for modified trochanteric slide osteotomies and 14.8 cm (range 8-23) for extended trochanteric osteotomies. Osteotomy length was negatively correlated (r = −0.340, P < .001) with GT migration distance. Longer osteotomy length was protective against GT migration >1 cm (odds ratio 0.67, P = .002). Receiver operating characteristic curve analysis demonstrated an optimal cutoff osteotomy length of 9.8 cm for predicting GT migration >1 cm (sensitivity 0.971, specificity 0.461). Among osteotomies <10 cm, those fixed using at least one distal wire below the lesser trochanter and vastus ridge demonstrated less mean GT migration (3.86 vs 7.12 mm, P = .009) and higher mean union rate (68.8% vs 31.2%, P < .001).

Conclusion

Osteotomies shorter than 10 cm are at higher risk of developing proximal GT migration >1 cm. A distal cerclage wire below the lesser trochanter and vastus ridge may help decrease the amount of GT migration.

Level of Evidence

Prognostic Level IV.

Hybrid Fixation for Total Hip Arthroplasty Showed Improved Survival Over Cemented and Uncemented Fixation: A Single-Center Survival Analysis of 2156 Hips at 12-18 Years

16-07-2019 – Anna-Kate Fowler, Andrew R. Gray, David P. Gwynne-Jones

Journal Article

Background

Despite increased use of uncemented and hybrid fixation, there is little evidence of their superiority over cemented implants. The aim of this study is to compare the long-term survivorship of cemented, hybrid and uncemented total hip arthroplasty (THA) at varying ages.

Methods

A total of 2156 hips (1315 cemented, 324 uncemented, and 517 hybrid) were performed in a single center between 1999 and 2005 with follow-up through to 2017. Registry and local databases were used to determine revision rates and cause. Unadjusted and adjusted competing risk survival analysis was performed.

Results

The cumulative incidence of all-cause revision at 18 years was cemented 10.9%, uncemented 8.9%, and hybrid 6.5%. Cemented fixation had a statistically significant higher risk of all-cause revision than hybrid in the adjusted model for all ages to 65 years (subhazard ratios SHRs, 2.28-4.67) and a higher risk of revision for loosening, wear, or osteolysis at all ages (SHRs, 3.25-6.07). Uncemented fixation showed no advantage over hybrid fixation at any age, but did show advantages over cemented at younger ages (≤60 years) for all-cause revision (SHRs, 2.3-4.3).

Conclusion

Hybrid fixation with conventional polyethylene shows an advantage over cemented hips at all ages. Uncemented THA showed improved survival over cemented only at younger ages and no advantage over hybrid THA.

Ten- to 16-Year Results of a Modern Cementless Dual-Mobility Acetabular Implant in Primary Total Hip Arthroplasty

30-07-2019 – Romain Gaillard, Raymond Kenney, Jean-Luc Delalande, Cécile Batailler, Sébastien Lustig

Journal Article

Background

The purpose of this study is to assess the radiographic results, clinical outcomes, and survivorship of a modern cementless dual-mobility cup (DMC) implant as a primary THA with a minimum of 10 years follow-up.

Methods

This study retrospectively assessed a series of 310 primary THAs using a modern-generation cementless DMC (Saturne acetabular cup) between April 2001 and December 2005 at a single center. Patients were followed prospectively clinically and radiographically after surgery. Hips with follow-up less than 120 months were excluded from the study (5 lost to follow-up and 167 deceased). In total, a cohort of 138 hips were included for preoperative and postoperative analysis with an average follow-up of 152.4 months. All complications were collected, and a Kaplan-Meier survival analysis was performed.

Results

There was a significant increase in the mean Harris and Postel-Merle d’Aubigne scores between preoperative and postoperative cohorts (P < .001). No loosening of the cup and no acetabular osteolysis were found at final follow-up. No prosthetic dislocation, no intraprosthetic dislocation, and no infections were reported. The survival curve of THA in the total cohort (N = 310) was about 98% at 10 years with 3 stem revisions for femoral fracture. One psoas impingement was also described.

Conclusion

This study showed no acetabular component failure and no reported cases of acetabular osteolysis with this DMC acetabular component retention at 10 years. No prosthetic or intraprosthetic dislocation was reported.

Short-Term Morbidity and Mortality After Hemiarthroplasty and Total Hip Arthroplasty for Pathologic Proximal Femur Fractures

08-07-2019 – Nathan H. Varady, Bishoy T. Ameen, Brett L. Hayden, Caleb M. Yeung, Pierre-Emmanuel Schwab, Antonia F. Chen

Journal Article

Background

As oncology patients have increasing life expectancies, total hip arthroplasty (THA) may become an important treatment option for pathologic proximal femur fractures (PPFFs). Although THA and hemiarthroplasty (HA) have been compared for native hip fracture treatment, no data on short-term morbidity and mortality are available in the pathologic setting. The purpose of this study is to compare short-term morbidity and mortality of HA vs THA for PPFFs.

Methods

The National Surgical Quality Improvement Program database was queried from 2007 to 2017 for patients with PPFFs treated with HA or THA. Propensity-adjusted logistic regressions were implemented to compare 30-day morbidity and mortality between procedures. Backwards stepwise regression was then used to determine independent predictors of treatment with HA compared to THA.

Results

In adjusted analysis, THA was associated with longer operative times (120.3 ± 5.6 vs 98.7 ± 4.9 minutes, P < .001); however, there were no differences between THA and HA with regard to 30-day rates of major complications (P = .3), minor complications (P = .77), reoperations (P = .99), readmissions (P = .35), or deaths (P = .63). Older age (P < .001), dependent functional status (P = .02), and the presence of disseminated cancer (P = .049) were predictive of undergoing HA compared to THA.

Conclusion

As patients with metastatic cancer continue to live longer with their disease, the durability of surgical reconstruction to treat PPFFs is becoming increasingly important. This study demonstrated no significant differences in 30-day complications between PPFF patients treated with THA or HA after controlling for underlying confounders. These results suggest that THA can be utilized to treat certain patients with PPFFs, and future work is warranted to examine long-term functional outcomes.

Acetabular Erosion After Bipolar Hemiarthroplasty in Proximal Femoral Replacement for Malignant Bone Tumors

08-07-2019 – Christoph Theil, Burkhard Möllenbeck, Georg Gosheger, Tom Schmidt-Bräkling, Dimosthenis Andreou, Marcel-Philipp Henrichs, Ralf Dieckmann

Journal Article

Background

Hemiarthroplasty megaprosthetic proximal femur reconstruction after tumor resection is a widespread procedure in orthopedic oncology. One potential complication is acetabular wear requiring secondary acetabular revision. The study’s purpose is to investigate prevalence of acetabular erosion, secondary revisions, and potential risk factors.

Methods

We retrospectively identified 112 patients who underwent proximal femur replacement after resection of a malignant bone tumor and had radiological follow-up longer than 12 months. Patient demographic, surgical, and oncologic factors were recorded, acetabular wear was measured using the classification proposed by Baker, and prosthetic failure was classified using the International Society on Limb Salvage classification. Functional assessment was performed using the Musculoskeletal Tumor Society Score and Harris Hip Score.

Results

Prevalence of acetabular wear was 28.6%. Secondary conversion to total hip arthroplasty was required in 5 patients (4.6%), all treated for primary bone tumors. No patient treated for metastatic tumor had higher grade acetabular wear or required revision. Significant risk factors for the development of acetabular wear were age under 40 (P = .035) and longer follow-up (63 vs 43 months, P = .004). Other patient, surgical, or adjuvant treatment-related factors were not associated with acetabular revision or acetabular wear. The dislocation rate in the patient cohort was 0.9%.

Conclusion

Bipolar hemiarthroplasty proximal femoral replacement represents a durable reconstruction after tumor resection. Hip instability is rare. Acetabular erosion is rare and can be successfully treated with conversion to total hip arthroplasty. Young patients with long-term survival over 10 years are at risk. In reconstruction for metastases, instability and acetabular wear are rare.

The Accuracy of the Computed Tomography-Based Navigation System in Total Hip Arthroplasty Is Comparable With Crowe Type IV and Crowe Type I Dysplasia: A Case-Control Study

02-07-2019 – Ken Ueoka, Tamon Kabata, Yoshitomo Kajino, Junya Yoshitani, Takuro Ueno, Hiroyuki Tsuchiya

Journal Article

Background

Clinical outcomes of total hip arthroplasty (THA) for Crowe type IV are poorer than for Crowe type I, because it is more difficult to accurately position the acetabular components. This study aimed to examine the accuracy of the computed tomography (CT)-based navigation system for acetabular component positioning in primary THA for Crowe type IV.

Methods

From 2006 to 2018, 29 patients who underwent 34 primary THAs for Crowe type IV were enrolled in the “Type IV” group and 32 patients who underwent 34 THAs for Crowe type I were enrolled in the “Type I” group, formed by matching patients in the Type IV group on age, gender, body mass index, and surgical approach. We investigated (1) the accuracy of the cup size between that at preoperative planning and that actually implanted and (2) the mean deviation of the cup angle and 3-dimensional position of acetabular components between preoperative plan and postoperative records.

Results

The accuracy of the cup size was 79.4% and 94.1% in the Type IV and Type I groups, respectively, without a statistically significant change detected (P = .075). The mean deviations of the cup angle and 3-dimensional position were comparable in both groups.

Conclusion

Using the CT-based navigation system, it was possible to accurately implant the acetabular component for Crowe type IV, and the accuracy was comparable to that for Crowe type I. The CT-based navigation system is a useful intraoperative tool to accurately implant the acetabular component, especially with severe pelvic deformities such as Crowe type IV.

Thirty-Day Major and Minor Complications Following Total Hip Arthroplasty—A Comparison of the Direct Anterior, Lateral, and Posterior Approaches

31-07-2019 – Adam Hart, Cody C. Wyles, Matthew P. Abdel, Kevin I. Perry, Mark W. Pagnano, Michael J. Taunton

Journal Article

Background

The choice of surgical approach during total hip arthroplasty (THA) remains highly controversial. The aim of the present study was to compare 30-day major and minor complications, following primary THA between the direct anterior, lateral, and posterior approaches.

Methods

Our hospital performs primary THAs using all 3 aforementioned approaches based on surgeon preference. Patients who underwent primary THA from August 2010 to August 2017 were identified using our institution’s total joint registry, and their data were combined with prospectively collected data from the National Surgical Quality Improvement Program database (which evaluates a random sample of approximately 20% of all surgical patients in our hospital). Baseline characteristics, operative variables, and postoperative complications were then compared between the three groups.

Results

The analysis comprised 1967 primary THAs (1913 patients), whereby 56%, 29%, and 15% were performed through a posterior, lateral, and direct anterior approach, respectively. Thirty-day major and minor complications occurred in 3.9% and 9.4% of surgeries, respectively. After adjusting for baseline patient characteristics, there was no significant difference in major or minor perioperative complications between the 3 approaches.

Conclusions

This study compared perioperative complications between the 3 most commonly used approaches for THA utilizing a synthesis of our institutional total joint registry and high-quality National Surgical Quality Improvement Program data. Thirty-day major and minor complications were similar regardless of the surgical approach employed, which may help surgeons and patients simplify the multiple considerations taken into account when deciding on surgical approach for primary THA.

Level of Evidence

Therapeutic, Level III.

Postoperative Opioid Consumption After Total Hip Arthroplasty: Axa0Comparison of Three Surgical Approaches

18-07-2019 – Sebastian Seah, Mark Quinn, Oren Tirosh, Phong Tran

Journal Article

Background

The surgical approach for total hip arthroplasty (THA) has the potential to affect the immediate postoperative recovery; however, there is limited published data comparing the 3 most common surgical approaches. The purpose of the study was to investigate postoperative pain and subsequent opioid consumption between surgical approaches (anterior—AA, lateral—LA, and posterior—PA) in those undergoing primary elective THA.

Methods

A retrospective cohort study assessed patient demographics (age, sex, and body mass index), American Society of Anesthesiologists grade, opioid naivety, operative details (anesthetic method, fixation method, and local infiltration analgesia), pain scores, and length of stay. Statistical analysis was performed with a 1-way analysis of variance 3 × 1 table with a P value < .05.

Results

A total of 560 patients were included in the analysis (335 females and 225 males). The cohort consisted of 179 AA, 178 LA, and 203 PA patients. The average postoperative opioid usage was 63.05 (standard deviation SD = 42.97), 79.81 (SD = 56.10), and 77.50 (SD = 54.52) oral morphine equivalent daily dose (o
MEDD) for the AA, LA, and PA, respectively. The mean difference was 16.8 o
MEDD lower in the AA compared with the LA (P < .01) and 14.5 o
MEDD lower in the AA compared with the PA (P = .02).

Conclusion

The direct anterior approach was associated with lower daily opioid usage and pain scores after elective THA in the early postoperative period. This represents a potential 21% reduction in daily opioid dosage when compared with LA patients and 18.7% reduction in PA patients.

A Novel Opioid-Sparing Pain Management Protocol Following Total Hip Arthroplasty: Effects on Opioid Consumption, Pain Severity, and Patient-Reported Outcomes

18-07-2019 – Jorge A. Padilla, Jonathan A. Gabor, Ran Schwarzkopf, Roy I. Davidovitch

Journal Article

Background

Opioid prescriptions and subsequent opioid-related deaths have increased substantially in the past several decades. Orthopedic surgery ranks among the highest of all specialties with respect to the amount of opioids prescribed. We present here the outcomes of our opioid-sparing pain management pilot protocol for total hip arthroplasty (THA).

Methods

A retrospective study was conducted to assess outcomes before and after the implementation of an opioid-sparing pain management protocol for THA. Patients were divided into 2 cohorts for comparison: (1) traditional pain management protocol and (2) opioid-sparing pain management protocol. The Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, pain severity using a Visual Analog Scale, and inpatient morphine milligram equivalents (MMEs) per day were compared between the 2 cohorts.

Results

No statistically significant difference was observed in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement between the 2 cohorts at any time point (P > .05). Although there was a significant decrease in pain scores over time (P < .01), there was no statistically significant difference in the rates of change between the 2 pain management protocols at any time point (P = .463). Inpatient opioid consumption was significantly lower for the opioid-sparing cohort in comparison to the traditional cohort (14.6 ± 16.7 vs 25.7 ± 18.8 MME/d, P < .001). Similarly, the opioid-sparing cohort received significantly less opioids than the traditional cohort during the post discharge period (13.9 ± 24.2 vs 80.1 ± 55.9 MME, P < .001).

Conclusion

The results of this study suggest that an opioid-sparing protocol reduces opioid consumption and provides equivalent pain management and patient-reported outcomes during the 90-day THA episode of care relative to a traditional opioid-based regimen. These findings may help decrease the risk of adverse events associated with postoperative opioid use and provide a means of decreasing the opioid footprint in clinical practice.

Effects of Sagittal Spinal Alignment on Postural Pelvic Mobility in Total Hip Arthroplasty Candidates

16-07-2019 – Aaron J. Buckland, Laviel Fernandez, Andrew J. Shimmin, Jonathan V. Bare, Stephen J. McMahon, Jonathan M. Vigdorchik

Journal Article

Background

Recent research has demonstrated that patients with reduced pelvic mobility from standing to sitting have higher rates of dislocation after total hip arthroplasty (THA). This study evaluates the effect of sagittal spinal deformity, defined by pelvic incidence–lumbar lordosis mismatch (PI-LL), on postural changes in pelvic tilt (PT).

Methods

A multicenter database of 1100 preoperative THA patients was queried. Anterior-pelvic-plane tilt (APPt), spinopelvic tilt (SPT), and LL were measured from radiographs of patients in supine, standing, flexed-seated, and stepping-up postures; PI was measured from computed tomography. Patients were separated into 3 groups based on PI-LL (<−10°, −10° to 10°, >10°) and propensity-score matched by PI. Lumbar flatback-deformity was defined as PI-LL > 10°, hyperlordosis: PI-LL < −10°. SPT/APPt, including changes between each posture were compared across PI-LL groups using analysis of variance, with post-hoc Tukey tests. Pearson correlations were reported when testing associations between SPT/APPt change and PI-LL.

Results

After propensity-score matching, 288 patients were analyzed (mean 65 y; 49% F). SPT and APPt change differed across all PI-LL categories from standing to seated, supine, and stepping-up with less SPT/APPt recruitment among hyperlordotic vs flatback patients (all P < .001). Greater PI-LL correlated with greater SPT recruitment from standing to seated (R = 0.294), supine (R = 0.292), and stepping-up (R = 0.207) (all P < .001). Smaller LL changes from standing to seated were associated with greater SPT recruitment (R = 0.372, P < .001).

Conclusions

Postural changes in SPT/APPt are associated with spinopelvic measures in THA candidates. Hyperlordotic patients tend to utilize their spines more compared with flatback patients who were more likely to recruit PT. Increased focus on patients with lumbar flatback and hyperlordosis may help in reducing prosthetic dislocation prevalence following THA.

Does It Matter: Total Hip Arthroplasty or Lumbar Spinal Fusion First? Preoperative Sagittal Spinopelvic Measurements Guide Patient-Specific Surgical Strategies in Patients Requiring Both

20-07-2019 – Frank W. Parilla, Ritesh R. Shah, Alexander C. Gordon, Steven M. Mardjetko, Nancy E. Cipparrone, Wayne M. Goldstein, Jeffrey M. Goldstein

Journal Article

Background

In patients requiring both total hip arthroplasty (THA) and lumbar spinal fusion (LSF), consideration of preoperative sagittal spinopelvic measurements can aid in the prediction of postfusion compensatory changes in pelvic tilt (PT) and inform adjustments to traditional THA cup anteversion. This study aims to identify relationships between spinopelvic measurements and post-THA hip instability and to determine if procedure order reveals a difference in hip dislocation rate.

Methods

Patients at a single practice site who received both THA and LSF between 2005 and 2015 (292: 158 = LSF prior to THA, 134 = THA prior to LSF) were retrospectively reviewed for incidents of THA instability. Those with complete radiograph series (89) had their sagittal (standing) spinopelvic profiles measured preoperatively, immediately postoperatively, and 3 months, 6 months, 1 year, 1.5 years, and 2 years postoperatively. Measured parameters included lumbar lordosis (LL), pelvic incidence (PI), PT, and sacral slope (SS).

Results

No significant differences in dislocation rates between operative order groups were elicited (7/73 LSF first, 4/62 THA first; Z = 0.664, P = .509). Compared to nondislocators, dislocators had lower LL (−10.9) and SS (−7.8), and higher PT (+4.3) and PI-LL (+7.3). Additional risk factors for dislocation included sacral fusion (relative risk RR = 3.0) and revision fusion (RR = 2.7) . Predictive power of the model generated through multiple regression to characterize individual profiles of post-LSF PT compensation based on perioperative measurements was most significant at 1 year (R2 = 0.565, F = 0.000456, P = .028) and 2 years (R2 = 0.741, F = 0.031, P = .001) postoperatively.

Conclusion

In performing THA after LSF, it is theoretically ideal to proceed with THA at a postfusion interval of at least 1 year, beyond which further compensatory PT change is minimal. However, the order of surgical procedure revealed no statistical difference in hip instability rates. In cases characterized by large PI-LL mismatch (larger or less predictable compensation profiles) or large SS or LL loss (considerably atypical muscle recruitment), consideration of full functional anteversion range between sitting and standing positions to account for abnormalities not appreciated with standing radiographic assessment alone may be warranted.

Same-Day Surgery Does Not Increase the Manipulation Under Anesthesia and Reoperation Rates for Stiffness Following Bilateral Total Knee Arthroplasty

06-07-2019 – Lazaros A. Poultsides, Georgios K. Triantafyllopoulos, Florian Wanivenhaus, Matthias Pumberger, Stavros G. Memtsoudis, Thomas P. Sculco

Journal Article

Background

There is a paucity of data on the incidence of stiffness and need for subsequent manipulation under anesthesia (MUA) and reoperation following same-day bilateral total knee arthroplasty (BTKA). We compared the rates of at least 1 MUA, bilateral knee involvement, single and multiple MUA rates, and stiffness-related reoperation rates between patients undergoing same-day, same-admission staged, and staged within 1 year BTKA in a tertiary institution.

Methods

We analyzed institutional data for 3175 same-day (group A), 153 same-admission staged (group B), and 1226 staged within 1 year BTKA patients (group C) from 1998 to 2009. Several variables, including patient demographics, comorbidity profile, Charlson-Deyo index, and range of motion at different time points, were tabulated. Follow-up was minimum 1 year after first MUA. Univariate analyses were performed using the Wilcoxon rank-sum or Kruskal-Wallis test, and Fisher exact or the chi-square test for continuous and categorical variables, respectively. The Cochran-Armitage trend test was used to check the bilateral knee involvement rate across groups.

Results

Overall, 2.2% (98/4554) of BTKA patients required MUA. The rate of at least 1 MUA was similar across groups but the percentage of bilateral knee involvement was higher in group A. The single MUA rate was comparable among groups. Both no revision and revision reoperation rates were similar among the manipulated groups.

Conclusion

Same-day BTKA was not associated with increased incidence of single or multiple MUA and stiffness-related reoperation rates. These findings may facilitate preoperative counseling in patients with symptomatic bilateral knee disease, eligible for same-day BTKA.

Activity Impairment and Work Productivity Loss After Total Knee Arthroplasty: A Prospective Study

07-07-2019 – Tjerk H. Hylkema, Martin Stevens, Faith Selzer, Ben A. Amick, Jeffrey N. Katz, Sandra Brouwer

Journal Article

Background

Total knee arthroplasty (TKA) is increasingly performed among working-aged individuals, highlighting the importance of work-related outcomes. Therefore, the aim is to examine the extent of both activity impairment outside work and work productivity (absenteeism, presenteeism, at-work productivity loss) at 6 and 24 months post-TKA surgery. Additionally, associated risk factors with these outcomes were evaluated.

Methods

This analysis included 183 patients <70 years undergoing TKA who completed questionnaires pre-operatively and during follow-up. Outcomes were derived from the Work Productivity and Activity Impairment questionnaire and included activity impairment, absenteeism (sick leave), presenteeism (reduced work performance), and at-work productivity loss (overall work productivity loss). All outcomes were scaled 0%-100%, with higher percentages indicating higher impairments. Covariates included age, gender, education, pain catastrophizing, pain, function, psychological distress, and knee-related and health-related quality of life. Linear and logistic regression was used to assess associations between covariates and Work Productivity and Activity Impairment scores at follow-up.

Results

At 6 months, the mean activity impairment was 22.8% (standard deviation SD 23.5) dropping to 17.1% (23.1) by 24 months. Among workers, presenteeism was 18.4% (24.6) and at-work productivity loss was 20.8% (26.1). Both dropped significantly by 24 months to 14.2% (22.4) and 12.9% (20.9), respectively. Absenteeism levels were low at both time points. Pain catastrophizing was associated with all outcomes.

Conclusion

This study showed that activity impairment and work productivity loss are common following TKA, decreased significantly over time, but still existed 2 years post-operatively. Those reporting high levels of pain catastrophizing may benefit from targeted rehabilitation guidance to reduce and possibly prevent activity impairment and work productivity loss.

Incidence, Causes, and Timing of 30-Day Readmission Following Total Knee Arthroplasty

03-07-2019 – Gannon L. Curtis, Michael Jawad, Linsen T. Samuel, Jaiben George, Carlos A. Higuera-Rueda, Bryan E. Little, Hussein F. Darwiche

Journal Article

Background

It is important to study the incidence and causes of readmissions in order to understand why they occur and how to reduce them. This study looks at a national sample of patients following total knee arthroplasty (TKA) to identify incidences, trends, causes, and timing of 30-day readmissions.

Methods

Patients undergoing primary TKA from 2012 to 2016 in the American College of Surgeons National Surgical Quality Improvement Program database were identified (n = 197,192). Patients with fractures (n = 177), nonelective surgery (n = 2234), bilateral TKA (n = 5483), and cases with unknown readmission status (n = 1047) were excluded, leaving a total of 188,251 cases. Linear regression analysis was used to determine trends over time.

Results

The incidence of overall 30-day readmission following primary TKA from 2012 to 2016 was 3.19% (6014/188,251), with significant decreases in readmission rates during this time (β = −0.001, P < .001). The top 5 causes of readmission included superficial surgical site infection (SSI; 9.7%), non-SSI infection (9.5%), cardiovascular complications (CV; 9.3%), gastrointestinal complications (8.8%), and venous thromboembolisms (8.8%). The most common cause of readmission during postoperative week 1 was CV complications (12.2%), week 2 was superficial SSI (11.6%), week 3 was deep SSI (11.4%), and week 4 was deep SSI (12.4%).

Conclusion

Overall, 30-day readmissions following TKA were found to significantly decline from 2012 to 2016. The most common causes of overall readmission included superficial SSI, non-SSI infection, CV complications, gastrointestinal complications, and venous thromboembolisms. However, the most common causes of readmission changed from week to week postoperatively. This data may help institutions develop policies to prevent unplanned readmissions following TKA.

Clinical and Statistical Validation of a Probabilistic Prediction Tool of Total Knee Arthroplasty Outcome

03-07-2019 – Joshua G. Twiggs, Edgar A. Wakelin, Brett A. Fritsch, David W. Liu, Michael I. Solomon, David A. Parker, Antonio Klasan, Brad P. Miles

Journal Article

Background

Predicting patients at risk of a poor outcome would be useful in patient selection for total knee arthroplasty (TKA). Existing models to predict outcome have seen limited functional implementation. This study aims to validate a model and shared decision-making tool for both clinical utility and predictive accuracy.

Methods

A Bayesian belief network statistical model was developed using data from the Osteoarthritis Initiative. A consecutive series of consultations for osteoarthritis before and after introduction of the tool was used to evaluate the clinical impact of the tool. A data audit of postoperative outcomes of TKA patients exposed to the tool was used to evaluate the accuracy of predictions.

Results

The tool changed consultation outcomes and identified patients at risk of limited improvement. After introduction of the tool, patients booked for surgery reported worse Knee Osteoarthritis and Injury Outcome Score pain scores (difference, 15.2; P < .001) than those not booked, with no significant difference prior. There was a 27% chance of not improving if predicted at risk, and a 1.4% chance if predicted to improve. This gives a risk ratio of 19× (P < .001) for patients not improving if predicted at risk.

Conclusion

For a prediction tool to be clinically useful, it needs to provide a better understanding of the likely clinical outcome of an intervention than existed without its use when the clinical decisions are made. The tool presented here has the potential to direct patients to surgical or nonsurgical pathways on a patient-specific basis, ensuring patients who will benefit most from TKA surgery are selected.

Impact of Resilience on Outcomes of Total Knee Arthroplasty

07-07-2019 – Robert J. Magaldi, Ilene Staff, Ashly E. Stovall, Sherry A. Stohler, Courtland G. Lewis

Journal Article

Background

Resilience, defined as the ability to bounce back from stress, has been suggested as a predictor of surgical outcomes. The purpose of this study is to examine the relationship between resilience and patient-reported outcomes following primary elective total knee arthroplasty (TKA). We hypothesized that patients exhibiting greater preoperative resilience would report better outcome scores.

Methods

A prospective cohort of 153 patients (74 male, 79 female) undergoing primary elective TKA completed questionnaires preoperatively and at 3 and 12 months following their index procedure. The validated Brief Resilience Scale was used to evaluate resilience. Hierarchical multiple linear regression was used to analyze the effect of resilience on KOOS-JR (Knee Injury and Osteoarthritis Outcome Score JR) and PROMIS-10 (Patient-Reported Outcomes Measurement Information System) outcome scores.

Results

At 12 months, the change in the coefficient of determination (R2) attributable to preoperative resilience was 0.101 (P < .001) and 0.204 (P < .001) for physical and mental health, respectively. Although there was expected improvement in KOOS-JR scores following TKA, the effect of baseline resilience for this outcome was not significant. When evaluating resilience measured concurrently, there was significant correlation with both 3-month and 12-month KOOS-JR and PROMIS-10 outcome scores.

Conclusion

Preoperative resilience is a significant predictor of overall physical and mental health outcomes at both 3 and 12 months. Greater concurrent resilience predicted better scores across all outcomes. These findings suggest that major elective surgery, like other traumatic events, can cause a change in resilience. Although functional improvements after TKA are expected, those patients who exhibit greater resilience at baseline are more likely to report an improved quality of life.

The Combination of Inlay Patellofemoral Arthroplasty and Medial Unicompartmental Knee Arthroplasty Versus Total Knee Arthroplasty for Mediopatellofemoral Osteoarthritis: A Comparison of Mid-Term Outcomes

20-07-2019 – Enes Uluyardimci, Cetin Isik, Mesut Tahta, Fahri Emre, Sahin Cepni, Ismail Oltulu

Journal Article

Background

To the best of our knowledge, there have been no studies in the literature related to the use of second-generation inlay patellofemoral arthroplasty and unicompartmental knee arthroplasty combination (inlay PFA/UKA) in the treatment of mediopatellofemoral osteoarthritis (MPFOA). The aim of this study is to evaluate the efficacy of inlay PFA/UKA in MPFOA.

Methods

The study included 49 patients applied with inlay PFA/UKA because of MPFOA and 49 patients applied with TKA, matched one-to-one according to age, gender, body mass index, follow-up period, preoperative Knee Society Score, and range of motion. All the patients were evaluated clinically using the Knee Society Score, Knee Injury Osteoarthritis Outcome Score, and range of motion, and were also evaluated radiologically. Complication rates and length of hospital stay were compared.

Results

The mean follow-up period was 54 ± 4 and 54.4 ± 3.9 months in inlay PFA/UKA and TKA groups, respectively. (P = .841). No statistically significant difference was determined between the 2 groups in respect of the mean clinical scores at the final follow-up examination (P ≥ .129). Total complications were fewer and length of hospital stay was shorter in the inlay PFA/UKA group than in the TKA group (P = .037 and P = .002). There was no radiographic evidence of progression of lateral compartment osteoarthritis according to Kellgren-Lawrence in any patient in the inlay PFA/UKA group.

Conclusion

In selected patient groups, inlay PFA/UKA is an alternative to TKA, with lower complication rates, shorter length of hospital stay, and clinical and functional results similar to those of TKA without osteoarthritis progression in the unresurfaced lateral compartment in the mid-term.

Level of Evidence

III.

Adequate Positioning of the Tibial Component Is Key to Avoiding Bearing Impingement in Oxford Unicompartmental Knee Arthroplasty

27-06-2019 – Tomoyuki Kamenaga, Takafumi Hiranaka, Koji Takayama, Masanori Tsubosaka, Ryosuke Kuroda, Tomoyuki Matsumoto

Journal Article

Background

Bearing dislocation is a serious complication of unicompartmental knee arthroplasty (UKA) with the Oxford knee prosthesis equipped with a mobile bearing. We aimed to clarify the extent of intraoperative movement of the mobile bearing and its relationship with the positioning of prosthesis components in patients undergoing Oxford UKA.

Methods

This retrospective study included 50 patients (50 knees) who underwent Oxford UKA for anteromedial osteoarthritis or osteonecrosis of the knee. Intraoperative bearing movement was assessed at various angles of knee flexion (0°, 30°, 60°, 90°, and 120°). We stratified patients according to the extent of bearing movement posteriorly during intraoperative knee flexion, with or without contacting the lateral wall of the tibial component (with contact, 20 knees; without contact, 30 knees). Postoperative radiographic evaluations were conducted at 1 week postoperatively to assess the positional parameters of the tibial and femoral components (varus/valgus alignment, rotation, mediolateral position). Clinical evaluations were conducted at 1 year postoperatively (maximum flexion angle, Oxford Knee Score).

Results

Abnormal intraoperative movement of the mobile bearing resulting in contact with the lateral wall of the tibial component was associated with a significantly more medial position and external rotation of the tibial component, as well as poorer improvement in knee flexion angle at 1 year postoperatively.

Conclusion

In Oxford UKA recipients, the bearing may impinge on the lateral wall of the tibial component during flexion above 60° if the tibial component is placed too medially or exhibits pronounced external rotation, which may limit knee function improvement postoperatively.

Preoperative C-Reactive Protein/Albumin Ratio, a Risk Factor for Postoperative Delirium in Elderly Patients After Total Joint Arthroplasty

22-07-2019 – Jie Peng, Guorong Wu, Junping Chen, Hui Chen

Journal Article

Background

Postoperative delirium (POD), as an acute brain failure, is widely reported as a very common postoperative complication, and it is closely associated with increased morbidity and mortality. This study aimed to investigate potential risk factors including C-reactive protein/albumin ratio (CAR) for POD in elderly subjects after total joint arthroplasty (TJA).

Methods

A total of 272 elderly patients (aged 65∼85 years) who were scheduled to undergo elective TJA with epidural anesthesia were consecutively recruited. The data of baseline characteristics, operation-associated indexes, and preoperative laboratory tests were collected. POD assessment was performed daily within postoperative 7 days. Receiver operating characteristic curve analysis was utilized for evaluating the predictive and cut-off value of CAR for POD. Risk factors for POD were evaluated by the binary univariate and multivariate logistic regression analyses.

Results

Within postoperative 7 days, there were 55 patients who had suffered POD with an incidence of 20.2% (55/272). The area under the curve of CAR for POD was 0.804, with the cut-off value of 2.35, a sensitivity of 66.82%, and a specificity of 80.00%, respectively (95% confidence interval CI: 0.737-0.872, P < .001). Age (odds ratio: 2.02, 95% CI: 1.03-3.96, P = .038) and preoperative CAR level (odds ratio: 3.04, 95% CI: 1.23-7.23, P = .016) were 2 independent risk factors for POD in elderly subjects undergoing TJA.

Conclusions

Preoperative CAR level may be a promising predictor for POD in elderly subjects following TJA.

The Role of Malnutrition in Ninety-Day Outcomes After Total Joint Arthroplasty

27-06-2019 – Collin S. Black, Daniel E. Goltz, Sean P. Ryan, Amanda N. Fletcher, Samuel S. Wellman, Michael P. Bolognesi, Thorsten M. Seyler

Journal Article

Background

Research has linked malnutrition to more complications in total joint arthroplasty (TJA) patients. The role of preoperative albumin in predicting length of stay (LOS) and 90-day outcomes remains understudied. Often, an albumin cut-off ≤3.5 g/d
L is used as proxy for malnutrition, although this value remains understudied. This preoperative level may be missing some patients at risk for adverse events post TJA.

Methods

TJA patients at a single institution from 2013 to 2018 were reviewed for preoperative albumin level. In total, 4047 cases (total knee arthroplasty: 2058; total hip arthroplasty: 1989) had available data, including 90-day readmissions, 90-day emergency department (ED) visits, and postoperative LOS.

Results

About 5.6% experienced a readmission and 9.6% had at least one ED visit within 90 days. Overall prevalence of malnutrition was 3.6%, and this cohort experienced a longer average LOS (3.5 vs 2.2 days, P < .0001) and was more likely to experience a readmission (16% vs 5%, P < .0001) or ED visit (18% vs 9%, P = .0005). Additionally, albumin ≤3.5 g/d
L was correlated with more frequent discharge to skilled nursing facility/rehab (30.8% vs 14.7%, P < .0001), increased risk for 90-day readmission with univariable (odds ratio OR 1.79, P < .0001) and multivariable logistic regression (OR 1.55, P < .0001), and increased risk for 90-day ED visits with univariable (OR 1.62, P < .0001) and multivariable regression (OR 1.35, P < .0001). The optimal albumin cut-off was 3.94 g/d
L in a univariable model for 90-day readmission.

Conclusion

Screening for malnutrition may serve a role in preoperative evaluation. An albumin cutoff value of 3.5 g/d
L may miss some at-risk patients.

Discharge Home is Associated With Decreased Early Complications Following Primary Total Joint Arthroplasty

30-07-2019 – Michael A. Mayer, Kevin Pirruccio, Matthew Sloan, Neil P. Sheth

Journal Article

Background

Primary total hip (THA) and total knee arthroplasty (TKA) volume has increased over the past decade. Patients discharged home (HD) have demonstrated improved postoperative outcomes compared with non-home discharge (NHD) patients. We reviewed trends in HD over the past decade and compared complication rates between HD and NHD primary total joint arthroplasty (TJA) patients.

Methods

Retrospective analysis of the National Surgical Quality Improvement Program was performed on TJA cases and patients were grouped by discharge type. Trends in the prevalence of HD were compared by chi-square test, from 2011 to 2016. Univariate and bivariate statistics were performed. Multivariate logistic and propensity score–matched analyses were used to control for confounding variables.

Results

During the 6-year review, HD increased significantly for THA (71.2% to 83.6%) and TKA (65.6% to 80.7%). Overall HD was 75.4% of THA and 71.0% of TKA patients. Propensity matching identified 16,580 THA pairs and 34,952 TKA pairs. Compared with NHD patients, HD patients had shorter operative times, were younger, and had shorter lengths of stay. Controlling for confounders, the HD patients had lower risk of death within 30 days, lower risk of major medical morbidity, decreased risk of reoperation, and decreased risk of readmission compared with NDH patients. Multivariate models demonstrated similar findings.

Conclusion

HD in both THA and TKA independently predicts decreased early (30-day) postoperative complications after controlling for confounding variables. Given the improved outcomes, we advocate for continued emphasis on HD rather than NHD when clinically appropriate.

Hospital Consumer Assessment of Healthcare Providers and Systems: Do Patient Demographics Affect Outcomes in Total Hip Arthroplasty?

04-07-2019 – Nima Eftekhary, James E. Feng, Afshin A. Anoushiravani, Ran Schwarzkopf, Jonathan M. Vigdorchik, William J. Long

Journal Article

Background

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score is a nationally standardized measure of a patient’s hospital experience. This study aims to assess whether HCAHPS scores vary by demographic or surgical factors in patients undergoing primary total hip arthroplasty.

Methods

Patients who completed an HCAHPS survey after a primary total hip arthroplasty between October 2011 and November 2016 were included in this study. Patient demographics and surgical factors were evaluated for correlations with individual HCAHPS questions.

Results

One thousand three hundred eighty-three HCAHPS questionnaires were reviewed for this study. Patients with a submitted HCAHPS response had an average age of 63.83 ± 10.17 years. Gender distribution was biased toward females at 57.27% (792 females) versus 42.73% (591 males). The average body mass index (BMI) was 28.68 ± 5.86 kg/m2. Race distribution was predominantly Caucasian at 81.49% (1127 patients), followed by “unknown” at 8.60% (119 patients) and African-American at 8.46% (117 patients). Home discharge occurred for 93.06% (1287 patients) versus 6.94% for facility discharge (96 patients). Mean length of stay was 2.41 ± 1.17 days. Each 1-year increase in age was positively correlated with a 0.16% increase in top-box response rate (β = 0.0016 ± 0.0008; P < .05). Male gender was correlated with a 4.61% increase in top-box response rate when compared to female gender (β = 0.0461 ± 0.0118; P < .01). BMI was found to be correlated with a 0.20% increase in HCAHPS response rates for each 1 kg/m2 increase (β = 0.0020 ± 0.0010; P < .05). For each day increase in length of stay, HCAHPS top-box response rates decrease by 3.41% (β = −0.0341 ± 0.0051; P < .0001). Race, marital status, smoking status, insurance type, and discharge disposition were not found to be significantly correlated with HCAHPS top-box response rate (P > .05).

Conclusion

The HCAHPS quality measurement metric affects physician reimbursement and may be biased by a number of variables including sex, length of stay, and BMI, rather than a true reflection of the quality of their hospital experience. Further research is warranted to determine whether HCAHPS scores are an appropriate measure of the quality of care received.

Letter to the Editor on “Prognostic Role of Serum Albumin, Total Lymphocyte Count, and Mini Nutritional Assessment on Outcomes After Geriatric Hip Fracture Surgery: A Meta-Analysis and Systematic Review”

21-08-2019 – Mohammad Eghbal Heidari, Zohre Madadi

Letter

Surgeon Mean Operative Times in Total Knee Arthroplasty in a Variety of Settings in a Health System

16-07-2019 – Harpal S. Khanuja, Mitchell A. Solano, Robert S. Sterling, Julius K. Oni, Yash P. Chaudhry, Lynne C. Jones

Journal Article

Background

High-quality care is essential in total joint arthroplasty. Multiple initiatives such as centers of excellence, patient optimization, and alternative payment models have demonstrated improved outcomes and decreased cost. Many studies have shown that longer operative times (OTs) are associated with increased frequency of postoperative complications. These findings often come from large data sets and may not accurately represent the average OT of individual surgeons. The purpose of this study was to determine the hospital and patient-related factors that influence OT.

Methods

This retrospective study reviewed OT of 6003 total knee arthroplasty cases performed by 41 surgeons at 4 hospitals in a single health-care system. Mean OT was calculated for each surgeon. The effect of surgeon, hospital-, and patient-related factors on OT was assessed.

Results

Among the 41 surgeons, the mean OT was 105 ± 25 minutes. Two community hospitals had significantly faster OT compared with the tertiary care academic hospital. Surgeons’ OT for morbidly obese patients was significantly longer compared with normal, overweight, and obese patients. Surgeon volume, surgeon experience, trainee presence, and American Society of Anesthesiologists status did not significantly affect surgical time.

Conclusions

Operative time was influenced by hospital-related (tertiary, community) and patient-related (morbid obesity vs lower body mass index groups) factors. However, specific surgeon factors (surgical volume, experience), surgical team factors (presence or absence of trainee), and patient factors (American Society of Anesthesiologists status) did not significantly alter the OT. Additional studies of larger health systems are needed to examine additional patient, surgeon, and hospital factors which may influence the OT.

Effects of a Total Knee Arthroplasty Care Pathway on Cost, Quality, and Patient Experience: Toward Measuring the Triple Aim

07-07-2019 – Joseph Featherall, David P. Brigati, Andrea N. Arney, Mhamad Faour, Daniel V. Bokar, Trevor G. Murray, Robert M. Molloy, Carlos A. Higuera Rueda

Journal Article

Background

Care pathways are increasingly important as the shift toward value-based care continues; however, there is an inconsistent literature regarding their efficacy. The authors hypothesized that a total knee arthroplasty (TKA) care pathway, at a multihospital health system, would decrease cost, length of stay (LOS), discharges to inpatient facilities, postoperative complications at 90 days, and improve patient experience.

Methods

A historical control study with multivariable regression was used to determine the association of an evidence-based care pathway with episode of care cost, LOS, discharge disposition, 90-day postoperative complications, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.

Results

In total, 6760 primary TKA surgeries were analyzed. Multivariable regression demonstrated that the full protocol period was associated with a decrease in episode of care costs (−8.501%, 95% confidence interval CI −9.639 to −7.350), a decrease in LOS (−26.966%, 95% CI −28.516 to −25.382), and an increase in discharges to home (odds ratio OR 3.838, 95% CI 3.318-4.446). The full protocol was not associated with a change in 90-day complications (OR 1.067, 95% CI 0.905-1.258) or patient willingness to recommend (OR 1.06, 95% CI 0.72-1.55). Adjusted episode of care cost savings, normalized to average national Medicare reimbursement, were $2360 per patient.

Conclusion

TKA care pathways are an effective tool for standardizing care and reducing costs across a large health system. Further investigations are needed to develop interventions to consistently reduce complications. National scale implementation of care pathways in TKA could lead to estimated cost reductions of approximately $1.6 billion annually.

The Role of Social Support and Psychological Distress in Predicting Discharge: A Pilot Study for Hip and Knee Arthroplasty Patients

23-07-2019 – Kathryn E. Zeppieri, Katie A. Butera, Dane Iams, Hari K. Parvataneni, Steven Z. George

Journal Article

Background

Bundled payment initiatives for joint replacement have prompted re-evaluation of the continuum of care with emphasis on anticipating disposition needs. The purpose of this study is to investigate the role of social support and psychological distress in patient optimization after lower joint replacement.

Methods

Two hundred thirty-one patients undergoing elective joint replacement completed the Risk Assessment and Predictive Tool (RAPT) (social support assessment) and modified STar
T Back Tool (m
SBT) (assessment of pain-related psychological distress). Outcomes of interest were length of stay (LOS) and discharge location (home vs facility).

Results

No significant differences in m
SBT scores were observed across RAPT levels when comparing individuals by discharge location (P > .05). There was significant indirect effect (0.07; P < .001) between m
SBT and LOS. Therefore, the m
SBT does not predict discharge location as a standalone metric for this sample. Mediation analysis for LOS indicates that higher psychological distress was predictive of longer LOS. Higher psychological distress and lower social support are associated with longer LOS. Despite higher psychological distress scores, higher social support scores are associated with shorter LOS.

Conclusion

Analysis of this cohort suggests that pre-operative assessments of social and psychological constructs may provide preparatory information for patient discharge status. The RAPT is important for predicting LOS and discharge location. The m
SBT may be important for predicting LOS for individuals with low to moderate social support.

Arthroplasty Care Redesign Impacts the Predictive Accuracy of the Risk Assessment and Prediction Tool

23-07-2019 – Florian F. Dibra, Arnold J. Silverberg, Terri Vasilopoulos, Chancellor F. Gray, Hari K. Parvataneni, Hernan A. Prieto

Journal Article

Background

The Risk Assessment and Prediction Tool (RAPT) is used to predict patient discharge disposition after total joint arthroplasty. Following a comprehensive, multidisciplinary redesign, our institution noticed a trend toward home discharge in patients with RAPT scores that historically predicted discharge to acute care facilities, presenting an opportunity to redefine the predictive ranges for RAPT.

Methods

Retrospectively collected data were analyzed from a single institution in patients undergoing elective primary total joint arthroplasty from January 2016 to April 2017. Predictive accuracy (PA) was calculated for each RAPT score (1-12), RAPT score risk ranges (low, intermediate, and high), as well as overall. Other factors evaluated included patient-reported discharge expectation, body mass index, and American Society of Anesthesiologists scores as related to discharge disposition and the PA of RAPT.

Results

Overall PA of RAPT was 88% (n = 1024 patients). Patients were high risk for acute care facility with a RAPT score of 1 to 3 (PA ≥ 83%), intermediate risk 4 to 7 (PA, 52%-79%), and low risk 8 to 12 (PA ≥ 89%). In multivariable analysis, RAPT score and patient-reported discharge expectation had the strongest correlation with actual discharge disposition.

Conclusion

Our multidisciplinary redesign has impacted the PA of RAPT. The original predictive ranges should be modified to reflect the increasing proportion of patients being discharged home following elective arthroplasty procedures. We have identified patient-expected discharge destination as a powerful modulator of the RAPT score and suggest that it be taken into consideration for discharge planning.

Improving Orthopedic Patient Outcomes: A Model to Predict 30-Day and 90-Day Readmission Rates Following Total Joint Arthroplasty

06-07-2019 – Raymond M. Greiwe, Jonathon M. Spanyer, Joseph R. Nolan, Renée N. Rodgers, Misti A. Hill, Richard G. Harm

Journal Article

Background

Over the next 10-15 years, there is expected to be an exponential increase in the number of total joint arthroplasties in the American population. This, combined with rising costs of total joint arthroplasty and more recent changes to the reimbursement payment models, increases the demand to perform quality, cost-effective total joint arthroplasties. The purpose of this study is to build models that could be used to estimate the 30-day and 90-day readmission rates for patients undergoing total joint arthroplasty.

Methods

A retrospective review of patients admitted to a single hospital, over the course of 56 months, for total joint arthroplasty was performed. The goal is to identify patients with readmission in a 30-day or 90-day period following discharge from the hospital. Binary logistic regression was used to build predictive models that estimate the likelihood of readmission based on a patient’s risk factors.

Results

Of 5732 patients identified for this study, 237 were readmitted within 30 days, while 547 were readmitted within 90 days. Age, body mass index, gender, discharge disposition, occurrence of cardiac dysrhythmias and heart failure, emergency department visits, psychiatric diagnoses, and medication counts were all found to be associated with 30-day admission rates. Similar associations were found at 90 days, with the exclusion of age and psychiatric drug use, and the inclusion of intravenous drug abuse, narcotic medications, and total joint arthroplasty within 12 months.

Conclusion

There are patient variables, or risk factors, that serve to predict the likelihood of readmission following total joint arthroplasty.

Press Ganey Administration of Hospital Consumer Assessment of Healthcare Providers and Systems Survey Result in a Biased Responder Sample for Hip and Knee Arthroplasties

25-07-2019 – Anton Khlopas, Morad Chughtai, Wael K. Barsoum, Michael R. Bloomfield, Isaac N. Briskin, Peter J. Brooks, Peter J. Evans, Gregory J. Gilot, Carlos A. Higuera, Michael J. Joyce, Michael W. Kattan, Viktor E. Krebs, Nathan W. Mesko, Anthony A. Miniaci, Robert M. Molloy, Trevor G. Murray, Preetesh D. Patel, Eric T. Ricchetti, Jonathan L. Schaffer, William H. Seitz

Journal Article

Background

Press Ganey administration of Hospital Consumer Assessment of Healthcare Providers and Systems Survey after discharge is sometimes used to monitor hospital performance and adjust reimbursements. Hypothesis: significant differences exist between responders and nonresponders. We assessed baseline characteristic differences between responders and nonresponders; sampling bias; responding predictability in total joint arthroplasty patients; and differences in sampling and response rates among different hospitals.

Methods

A prospective database of arthroplasty patients from January 1, 2016 to September 30, 2016 was used to compare responders’ and nonresponders’ baseline characteristics at 4 hospitals. A univariate analysis between groups was performed. A multiple logistic regression model was used to assess whether Press Ganey sampling was predictable. We identified receiving and responding predictors.

Results

We captured 96.6% (3255 of 3369) of hip and knee arthroplasties. Hospital Consumer Assessment of Healthcare Providers and Systems Survey sampling rate was 60% and response rate was 36% (1157). Responders were more likely Caucasians, nonsmokers, discharged home, have shorter hospital stays, have higher baseline joint pain and physical composite scores, and have better mental health composite scores. Concordance indices suggest reasonable-to-very-strong model predictability for those sampled (range 0.56-0.91) and those responding (range 0.61-0.78). Completion predictors were Caucasian race (P < .0001), younger ages (P < .0001), discharged home (P < .0001), negative smoking status (P = .02), quit smoking (P = .0026), higher baseline mental health composite scores (P = .0096), and diagnoses of femoroacetabular impingement (P = .0056), osteoarthritis (P = .0111), or prosthesis failure (P = .0036).

Conclusion

Responders/nonresponders were significantly different in several characteristics. It can be predicted who will likely be sampled and who will complete. Responders were not representative of arthroplasty population. Research is needed for more representative sampling methods.

Level of Evidence

Level III.

The Joint Utilization Management Program—Implementation of a Bundle Payment Model and Comparison Between Year 1 and 2 Results

04-08-2019 – Mouhanad M. El-Othmani, Zain Sayeed, Jnise A. Ramsey, Leila Abaab, Bryan E. Little, Khaled J. Saleh

Journal Article

Background

Health care spending is projected to increase throughout the next decade alongside the number of total joint arthroplasties (TJAs) performed. Such growth places significant financial burden on the economic system. To address these concerns, Bundled Payments for Care Improvement (BPCI) is becoming a favorable reimbursement model. The aim of this study is to present the outcomes with BPCI model focused on the post–acute care (PAC) phase and compare the outcomes between years 1 and 2 of implementation.

Methods

The Joint Utilization Management Program (JUMP) was implemented in January 2014. Inclusion criteria were Medicare patients undergoing primary unilateral in-patient TJA procedures, outpatient procedures that resulted in an in-hospital admission, and trauma episodes that required TJA. Scorecards monitoring surgeons performance and tracking length of stay (LOS) in the PAC setting were established. The data generated from these scorecards guided percentage sum-allocation from the total gain-shared sum among the participating providers.

Results

A total of 683 JUMP patients were assessed over two years. PAC utilization decreased between 2014 and 2015. The average LOS was longer in year 1 than year 2 (4.50 vs 3.19 days). In-patient rehabilitation (IPR) decreased from 6.45% to 3.22%, with a decrease in IPR average LOS of 1.47 days. The rate of 30-day readmission was lower for JUMP patients in 2015 than 2014 (8.77% vs 10.56%), with day of readmission being earlier (11.91 days vs 13.71 days) in 2014.

Conclusion

Under the BPCI program, our experience with the JUMP model demonstrates higher efficiency of care in the PAC setting through reduced LOS, IPR admission rates, and 30-day readmission rate.

Quantifying the Perioperative Work Associated With Total Hip and Knee Arthroplasty: The Burden Has Increased With Contemporary Care Pathways

16-07-2019 – Amy S. Wasterlain, P. Maxwell Courtney, Michael F. Yayac, David G. Nazarian, Matthew S. Austin

Journal Article

Background

Recently, the Centers for Medicare and Medicaid Services (CMS) has labeled the procedural codes for total hip arthroplasty (THA) and total knee arthroplasty (TKA) as potentially misvalued and has asked the American Medical Association (AMA) and its Relative Value Scale Update Committee (RUC) to review this. To assess the validity of this claim, we aimed to catalog the specific service tasks and duration of time required for each task associated with the perioperative care of the patient who underwent primary THA and TKA.

Methods

We prospectively timed preservice and immediate postservice activities performed outside of the operating room (OR) by 7 arthroplasty surgeons over a four-week period. Specific timing data for preservice activities performed in the OR were obtained retrospectively from our institutional electronic medical record for 500 patients undergoing THA and 500 undergoing TKA. Results were compared with the current approved values reviewed by the RUC in 2013 and converted to work relative value units (w
RVUs) based on the intensity coefficients used by the RUC.

Results

The average total preservice evaluation time was 42.2 minutes. The average time from the patient entering the OR to incision was 40.8 ± 25.4 minute. Immediate postservice tasks took 30.0 minutes. Compared with the 2013 RUC weighted w
RVU value of 1.394 for preservice and 0.560 for immediate postservice activities, we found that surgeons actually perform 1.567 w
RVUs of preservice and 0.672 of immediate postservice activities.

Conclusion

Policymakers should consider these findings when reviewing the time and intensity spent on perioperative care for patients undergoing THA and TKA.

No Evidence to Support Lowering Surgeon Reimbursement for Total Joint Arthroplasty Based on Operative Time: An Institutional Review of 12,567 Cases

10-07-2019 – Morad Chughtai, Atul F. Kamath, the Cleveland Clinic Arthroplasty Group

Journal Article

Background

The Centers for Medicare and Medicaid Services has recently added primary total joint arthroplasty (TJA) codes to the 2019 Potentially Misvalued Codes List. The American Association of Hip and Knee Surgeons and the American Medical Association have called for contemporary data that would assess operative time to inform the decision on reimbursement valuation. Therefore, the purpose of this study was to report total hip arthroplasty (THA) and total knee arthroplasty (TKA) operative times within a large multihospital and physician organizational enterprise to assess stability over time.

Methods

The study was a retrospective review (2015-2019) of a prospectively maintained multihospital health system database. A total of 12,567 consecutive TJAs were included (5742 THAs by 16 surgeons; 6825 TKAs by 20 surgeons). Operative time was between incision and completion of wound closure. Descriptive statistics were performed for categorical/continuous variables, and trend analysis was performed to assess if there was a change in time over the study period.

Results

For THA, 43.1% were male, with a mean age of 64.1 ± 11.8 years and a mean BMI of 30.1 ± 6.6. The mean operative time was 96.4 ± 36.8 minutes. For TKA, 39.4% were male, with a mean age of 66.2 ± 9.4 years and a mean BMI of 32.7 ± 6.8. The mean operative time was 103.6 ± 29.9 minutes. Trend analysis demonstrated no significant difference in operative time across the study period.

Conclusion

Our analysis demonstrated that operative time has remained stable, with mean time for THA and TKA consistently within 3.6 minutes of the historical benchmark of 100 minutes. Given these findings in a large institutional cohort, there is no definitive evidence to support changing current procedural valuation for TJA based on operative time.

Corrigendum to ‘Opioid Prescribers to Total Joint Arthroplasty Patients Before and After Surgery: The Majority Are Not Orthopedists’ The Journal of Arthroplasty 33 (2018) 3118-3124

20-08-2019 – Robert S. Namba, Elizabeth W. Paxton, Maria C. Inacio

Published Erratum

Effects of Total Hip Arthroplasty on Axial Alignment of the Lower Limb in Patients with Unilateral Developmental Hip Dysplasia (Crowe type IV)

20-05-2019 – Hai-Yan Zhao, Peng-De Kang, Xiao-Jun Shi, Zong-ke Zhou, Jing Yang, Bing Shen, Fu-Xing Pei

Journal Article

Background

The aim of this study was to evaluate the influence of total hip arthroplasty on axial alignment of the lower limb in adults with unilateral developmental hip dysplasia (Crowe type IV).

Methods

We retrospectively reviewed medical records of 50 adults who underwent total hip arthroplasty, in which the acetabular cup was placed in the anatomical position. The following parameters were measured before surgery, immediately after surgery, and two years later: mechanical axis deviation (MAD), tibiofemoral angle (TFA), femoral offset, hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (LDFA), mechanical medial proximal tibial angle, height of medial femoral condyle, height of lateral femoral condyle, and leg lengthening. Length of the resected femoral segment was also recorded from medical records.

Results

Preoperative MAD, TFA, HKA, and LDFA of the ipsilateral lower limb showed significant valgus deformity. MAD of the ipsilateral lower limb and valgus inclination were significantly smaller immediately after surgery than before, while TFA, HKA, femoral offset, and LDFA were significantly larger (P < 0.05). These parameters did not differ significantly between immediately after surgery and two years later (P > 0.05). Ipsilateral extremities were extended by a mean of 2.54 cm (range, 0 to 5.35 cm). The mean length of the femoral resected segment was 3.56 cm (range, 2.03 to 5.74 cm). The contralateral lower limb showed marginally smaller MAD and medial proximal tibial angle after surgery than before, but larger LDFA, TAF, and HKA.

Conclusions

In patients with developmental hip dysplasia who underwent total hip arthroplasty with placement of the acetabular component at the level of the anatomic hip center, axial alignment of the ipsilateral lower limb was immediately altered, and valgus inclination was significantly reduced. The procedure only slightly altered the axial alignment of the contralateral lower limb.

Preoperative Systemic Bone Quality Does Not Affect Tibial Component Migration in Knee Arthroplasty: A 2-Year Radiostereometric Analysis of a Hundred Consecutive Patients

17-06-2019 – Karina N. Linde, Frank Madsen, Katriina B. Puhakka, Bente L. Langdahl, Kjeld Søballe, Inger Krog-Mikkelsen, Maiken Stilling

Journal Article

Background

Bone quality and other preoperative predictive factors may affect implant migration and the survival of knee arthroplasty.

Methods

In a prospective cohort of 100 consecutive patients (65 women) at a mean age of 67.7 years (range 39-87 years), we investigated preoperative predictors of postoperative tibial component migration in cemented and cementless total knee arthroplasties or cemented unicompartmental knee arthroplasty. Predictors consisted of Knee Injury and Osteoarthritis Outcome Score (KOOS) and Oxford Knee Score, questionnaires, bone turnover markers of CTX and P1NP, systemic bone mineral density (BMD), and knee osteoarthritis (OA) grade. Tibial component migration was measured with radiostereometry postoperative, at 1 and 2 years of follow-up.

Results

Between 1 and 2 years, 19 tibial components migrated continuously (maximum total point motion MTPM > 0.2 mm). In general, there was no difference in age, body mass index, BMD, KOOSs, or OA grade between patients with continuous tibial migration compared to patients without continuous migration (P > .11). However, cementless tibial components with continuous migration had a lower KOOS pain score (more pain), lower vitamin D, and a higher bone turnover (CTX) value than patients without continuous migration. There was no association between the BMD and MTPM at 1-year follow-up regardless of prothesis type (P > .17). Patients with osteoporosis and normal BMD had similar mean tibial component MTPM at 2 years (3 prostheses combined; P = .34).

Conclusion

Migration of tibial components inserted with or without bone cement was not affected by the preoperative bone quality in terms of systemic BMD, bone turnover markers, and OA grade in the knee.

Depression and Anxiety Are Risk Factors for Postoperative Pain-Related Symptoms and Complications in Patients Undergoing Primary Total Knee Arthroplasty in the United States

24-06-2019 – Xin Pan, Jian Wang, Zeming Lin, Wenli Dai, Zhanjun Shi

Journal Article

Background

The study was designed to analyze the underlying relationship between psychiatric comorbidities and postoperative outcomes in patients undergoing primary total knee arthroplasty (TKA).

Methods

We used the National Inpatient Sample data from 2002 to 2014. On the basis of the International Classification of Disease, Ninth Revision, Clinical Modification, we divided TKA patients into 4 subgroups: those diagnosed with depression, those diagnosed with anxiety, those concomitantly diagnosed with both depression and anxiety, and those without depression or anxiety. The chi-squared test and analysis of variance were performed to measure differences among these 4 subgroups. Multiple logistic regression analysis was used to determine whether psychological comorbidities were independent risk factors for postoperative complications and surgery-related pain.

Results

A total of 7,153,750 patients in the United States were estimated to have undergone TKA between 2002 and 2014. The prevalence of depression, anxiety, or both diagnoses in TKA patients significantly increased over time. Patients with psychiatric disorders showed higher hospital costs but shorter periods of hospitalization, with higher odds ratios for most complications and all pain-related symptoms observed in this study.

Conclusion

The prevalence of depression and anxiety in TKA patients is increasing steadily each year. Psychiatric disorders were closely correlated with the outcomes of TKA. The mental health of patients undergoing TKA needs more attention to ensure adequate relief from postoperative pain-related symptoms as well as quality of life.

Does Hemophilia Increase Risk of Adverse Outcomes Following Total Hip and Knee Arthroplasty? A Propensity Score–Matched Analysis of a Nationwide, Population-Based Study

25-07-2019 – Sheng-Hao Wang, Chi-Hsiang Chung, Yeu-Chin Chen, Alexus M. Cooper, Wu-Chien Chien, Ru-Yu Pan

Journal Article

Background

End-stage hemophilic arthropathy is the result of recurrent joint hemarthrosis. Although total hip arthroplasty (THA) and total knee arthroplasty (TKA) can reduce severe joint pain and improve functional activity, controversy remains regarding outcomes after THA and TKA among patients with hemophilia. This study evaluated the risk of adverse outcomes of hemophilia patients who underwent THA and TKA.

Methods

This retrospective cohort study was conducted using data from the National Health Insurance Research Database. Patients who had hemophilia and underwent THA and TKA between 2000 and 2015 were identified. A total of 121 patients with hemophilia and 194,026 patients without hemophilia were included. Through propensity score matching, patients with hemophilia were matched at a 1:4 ratio to patients without hemophilia. Multivariable regression analysis was used to control for confounding variables and compare the risk of postoperative complications and mortality, differences in length of stay, and cost of care for the hospital.

Results

After propensity score matching and multivariate regression analysis, the adjusted hazard ratio of postoperative transfusion for hemophilia patients was 5.262 (95% confidence interval CI = 3.044-26.565, P < .001) in THA group and 6.279 (95% CI = 3.246-28.903, P < .001) in TKA group, when compared with the control group. Patients with hemophilia had longer length of hospital stay (THA group: 95% CI, 1.541-2.669, P < .001; TKA group: 95% CI, 1.568-2.786; P < .001) and higher total hospital charges (THA group: 95% CI, 3.518-8.293, P < .001; TKA group: 95% CI, 3.584-8.842; P < .001) compared to patients without hemophilia. Hemophiliacs had a higher yet nonsignificant 1-year infection rate (8.11% vs 3.38%, P = .206) in the THA group. There were no differences between the rates of 30-day and 90-day complications, 1-year infection, reoperation and mortality between the hemophilia and nonhemophilia groups.

Conclusion

Hemophilia patients have higher rates of postoperative transfusion, hospital costs, and increased length of stay. There is an appreciable clinical difference in 1-year infection rates following THA but our analysis was limited by the small sample size. Other postoperative complications and mortality rates were comparable. Patients with hemophilia should be counseled that infection rate maybe as high as 8% following THA. Further investigation is needed to develop prophylactic and effective methods to decrease the rates of transfusions and associated adverse outcomes in hemophilia patients undergoing THA and TKA.

Indwelling Urinary Catheter for Total Joint Arthroplasty Using Epidural Anesthesia

16-07-2019 – Oliver J. Scotting, Wayne T. North, Chaoyang Chen, Michael A. Charters

Journal Article

Background

The objective of this study was to evaluate if not placing an indwelling urinary catheter leads to a higher potential for adverse genitourinary (GU) issues after total joint arthroplasty (TJA) under epidural anesthesia.

Methods

Three hundred thirty-five consecutive patients who underwent primary TJA using epidural anesthesia were retrospectively reviewed. The initial 103 patients received a preoperative urinary catheter, which was maintained until the morning of postoperative day 1. The subsequent 232 patients did not receive a preoperative urinary catheter. Demographics, medical complications, GU complications, and length of stay were compared between groups.

Results

Compared between catheter and noncatheter groups, there were no differences in demographics including age, gender, or laterality of surgery. There was a difference in type of surgery (total knee arthroplasty vs total hip arthroplasty) (P = .008). There was no difference in American Society of Anesthesiologists score, but with a difference in body mass index (P = .01). There were no differences in GU complications among patients with benign prostatic hyperplasia or prostate cancer. However, among patients with a history of prostate disorders (benign prostatic hyperplasia or prostate cancer), urinary tract infection rate was higher in catheter group (P = .023). Postoperative GU complications were associated with increased median age in years and increased average length of stay in days.

Conclusion

Patients undergoing TJA under epidural anesthesia demonstrate no increased risk of postoperative urological complications without the placement of preoperative indwelling urinary catheter. The routine use of preoperative catheters can be reconsidered for this mode of anesthesia.

Level of Evidence

Level II, retrospective comparative study.

Chronic Prescription Opioid Use Before and After Total Hip and Knee Arthroplasty in Patients Younger Than 65 Years

01-07-2019 – Eric Y. Chen, Rachel Lasky, William A. Dotterweich, Ruijia Niu, David J. Tybor, Eric L. Smith

Journal Article

Background

Opioids are commonly prescribed to patients with painful and symptomatic degenerative joint disease preoperatively as a nonoperative intervention to reduce patients’ symptoms and pain. The goal of total joint arthroplasty (TJA) is to reduce or eliminate the painful symptoms of degenerative joint disease. Due to the addictive property of opioid medications, some patients may develop a pattern of chronic opioid use after TJA.

Methods

We used Market
Scan Commercial Claims and Encounters database to identify 125,019 patients (age <65 years) who underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA) between 2009 and 2012. During the study period, opioid use was analyzed 3 months before surgery and at 12 months after surgery. We defined chronic opioid use as having 2 or more opioid prescriptions filled within any 6-week period. Multivariate logistic regression was used.

Results

Of the 24,127 patients who were chronic prescription opioid users before surgery, 72% were no longer chronic users 1 year after surgery. Of the 100,892 patients who were nonusers before surgery, 4% became chronic users within 1 year after surgery. TKA and hospital stay longer than 3 days were significant risk factors of persisting chronic opioid use after surgery, while age played a mixed role in predicting change of opioid use.

Conclusion

Using our definition of chronic use, overall chronic opioid use decreased from 19% to 9% after TJA. Patients were more likely to cease chronic opioid use after TJA (72%) than to become chronic users (4%).

Early Experience and Results Using Patient-Reported Outcomes Measurement Information System Scores in Primary Total Hip and Knee Arthroplasty

25-06-2019 – Kelly R. Stiegel, Jonathan G. Lash, Andrew J. Peace, Michelle M. Coleman, Melvyn A. Harrington, Catherine W. Cahill

Journal Article

Background

Our study determined if preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores could predict achieving minimum clinically important differences (MCIDs) in postoperative PROMIS scores after primary total hip and knee arthroplasty.

Methods

Ninety-three patients were administered the PROMIS Depression, Pain Interference, and Physical Function domains at their preoperative appointment and 6-week follow-up visit. MCIDs were drawn from existing literature for the PROMIS domains.

Results

The MCID was achieved in 74% of patients for Pain Interference, 34% for Physical Function, and 24% for Depression. Our model could predict with 90% specificity which patients would meet MCID if their preop PROMIS Pain score was above 38, Physical Function score less than 19, or Depression score above 22.

Conclusion

Preoperative PROMIS Pain Interference, Physical Function, and Depression scores can predict achieving MCID in postoperative PROMIS scores.

Conversion Total Knee Arthroplasty Needs Its Own Diagnosis-Related Group Code

25-06-2019 – Michael Yayac, Jonah Stein, Gregory K. Deirmengian, Javad Parvizi, P. Maxwell Courtney

Journal Article

Background

Conversion from a prior knee procedure has been demonstrated to require greater operative times and resources, but still lacks a separate procedural or facility code from primary total knee arthroplasty (TKA). The purpose of this study is to determine differences in facility costs between patients who underwent primary TKA and those who underwent conversion TKA.

Methods

We retrospectively reviewed a consecutive series of patients undergoing primary TKA at 2 hospitals from 2015 to 2017, comparing itemized facility costs between primary and conversion TKA patients. A multivariate regression analysis was performed to identify independent risk factors for increased facility costs, the need for additional implants, length of stay, and discharge disposition.

Results

Of 2447 TKA procedures, 678 (27.7%) underwent conversion TKA, which was associated with greater implant costs ($3931.47 vs $2864.67, P = .0120) and total facility costs in a multivariate regression ($94.30 increase, P = .0316). When controlling for confounding variables, patients with a prior ligament reconstruction ($402 increase, P = .0002) and prior open reduction and internal fixation ($847 increase, P = .0020) had higher costs and were more likely to require stemmed implants (P < .05). There was an increase in TKA implant cost by $538 in patients with implants from a prior procedure (P < .0001).

Conclusion

Conversion TKA is associated with greater implant and inpatient facility costs than primary TKA, particularly those who had a history of an open knee procedure. A separate diagnosis-related group should be created for conversion TKA given the increased cost and complexity of these procedures compared to primary TKA.

Patterns and Costs of 90-Day Readmission for Surgical and Medical Complications Following Total Hip and Knee Arthroplasty

08-07-2019 – Ran Schwarzkopf, Omar A. Behery, HuiHui Yu, Lisa G. Suter, Li Li, Leora I. Horwitz

Journal Article

Background

Unplanned readmissions following elective total hip (THA) and knee (TKA) arthroplasty as a result of surgical complications likely have different quality improvement targets and cost implications than those for nonsurgical readmissions. We compared payments, timing, and location of unplanned readmissions with Center for Medicare and Medicaid Services (CMS)-defined surgical complications to readmissions without such complications.

Methods

We performed a retrospective analysis on unplanned readmissions within 90 days of discharge following elective primary THA/TKA among Medicare patients discharged between April 2013 and March 2016. We categorized unplanned readmissions into groups with and without CMS-defined complications. We compared the location, timing, and payments for unplanned readmissions between both readmission categories.

Results

Among THA (N = 23,231) and TKA (N = 43,655) patients with unplanned 90-day readmissions, 27.1% (n = 6307) and 16.4% (n = 7173) had CMS-defined surgical complications, respectively. These readmissions with surgical complications were most commonly at the hospital of index procedure (THA: 84%; TKA: 80%) and within 30 days postdischarge (THA: 73%; TKA: 77%). In comparison, it was significantly less likely for patients without CMS-defined surgical complications to be rehospitalized at the index hospital (THA: 63%; TKA: 63%; P < .001) or within 30 days of discharge (THA: 58%; TKA: 59%; P < .001). Generally, payments associated with 90-day readmissions were higher for THA and TKA patients with CMS-defined complications than without (P < .001 for all).

Conclusion

Readmissions associated with surgical complications following THA and TKA are more likely to occur at the hospital of index surgery, within 30 days of discharge, and cost more than readmissions without CMS-defined surgical complications, yet they account for only 1 in 5 readmissions.

Use of Observation Status Versus Readmission in Elective Total Knee and Hip Arthroplasty Returns to Hospital: A Single-Institution Perspective

14-07-2019 – Adam E. Goode, Trevor M. Owen, Joseph T. Moskal, Thomas K. Miller

Journal Article

Background

The Affordable Care Act’s Readmission Reduction Program (RRP) and ongoing transparency efforts to promote consumer-driven competition place significant institutional focus on improving 30-day readmission rates. It remains unclear whether the reduction in readmission rates subsequent to the RRP occurred due to improved quality and/or partly due to increased use of observation status in conditions that may have been classified as readmissions prior to the RRP. We hypothesize that a significant percentage of our institution’s 30-day readmissions after elective total knee and hip arthroplasty (TKA/THA) overestimate the needs, duration, and complexity of the hospital-based intervention and inaccurately reflect the quality of service provided.

Methods

We performed a retrospective review of prospectively collected quality control data for 30-day returns to hospital after elective TKA/THA at our institution over a 2-year period. After stratification of the readmissions to under 48-hour and over 48-hour length of stay, we calculated the financial implications to our institution if the under 48-hour length of stay admissions were reclassified as an observation by applying discharge-weighted and payment-weighted analyses to the 2017 RRP report. We then calculated the out-of-pocket expenses for the under 48-hour Medicare subpopulation.

Results

We found that 16.7% of the 30-day readmissions after elective TKA/THA required a length of stay under 48 hours. If the short length of stay TKA/THA readmissions were reclassified as observations, our institution’s 2018 RRP penalty would have been reduced to 39% or $334,512.28. However, this reclassification would result in an increase in out-of-pocket expenses by $540.25 (range $291.56-$1105.08) per patient.

Conclusion

A subpopulation of 30-day readmissions does not require a level of care consistent with inpatient admission services. Classification of this short length of stay subpopulation as an observation vs an admission per Centers for Medicare and Medicaid Services guidelines would have removed our institution from the TKA/THA-specific RRP penalty. However, this would result in the unintended consequence of shifting costs, particularly self-administered drug costs, to patients.

Defining and Optimizing Value in Total Joint Arthroplasty From the Patient, Payer, and Provider Perspectives

18-06-2019 – Amy Ahn, Chris Ferrer, Chris Park, Daniel J. Snyder, Samuel Z. Maron, Christopher Mikhail, Aakash Keswani, Ilda B. Molloy, Michael J. Bronson, Wayne E. Moschetti, David S. Jevsevar, Jashvant Poeran, Leesa M. Galatz, Calin S. Moucha

Journal Article

Background

The purpose of this study is to define value in bundled total joint arthroplasty (TJA) from the differing perspectives of the patient, payer/employer, and hospital/provider.

Methods

Demographic, psychosocial, clinical, financial, and patient-reported outcomes (PROs) data from 2017 to 2018 elective TJA cases at a multihospital academic health system were queried. Value was defined as improvement in PROs (preoperatively to 1 year postoperatively) for patients, improvement in PROs per $1000 of bundle cost for payers, and the normalized sum of improvement in PROs and hospital bundle margin for providers. Bivariate analysis was used to compare high value vs low value (>50th percentile vs <50th percentile). Multivariate analysis was performed to identify predictors.

Results

A total of 280 patients had PRO data, of which 71 had Medicare claims data. Diabetes (odds ratio OR, 0.45; P = .02) predicted low value for patients; female gender (OR, 0.25), hypertension (OR, 0.17), pulmonary disease (OR, 0.12), and skilled nursing facility discharge (OR, 0.17) for payers (P ≤ .03 for all); and pulmonary disease (OR, 0.16) and skilled nursing facility discharge (OR, 0.19) for providers (P ≤ .04 for all).

Conclusion

This is the first article to define value in TJA under a bundle payment model from multiple perspectives, providing a foundation for future studies analyzing value-based TJA.

Bundled Payments for Care Improvement: Health System Experience With Lower Extremity Joint Replacement at Higher and Lower Volume Hospitals

10-06-2019 – Craig J. McAsey, Elisabeth M. Johnson, Robert H. Hopper, Charles A. Engh

Journal Article

Background

The Bundled Payments for Care Improvement (BPCI) initiative was introduced in 2013 to reduce Medicare healthcare costs while preserving or enhancing quality. We examined data from a metropolitan healthcare system comprised of 1 higher volume hospital and 4 lower volume hospitals that voluntarily elected to participate in the BPCI Major Joint Replacement of the Lower Extremity Model 2, beginning July 1, 2015. Stratifying the data by hospital volume, we determined how costs changed during the 16-month period when all 5 hospitals participated compared to the 1-year period preceding BPCI participation, where savings were achieved, and how the hospitals were rewarded.

Methods

The Medicare data included the 90-day target for each episode and actual part A and part B spending for the anchor hospitalization plus all post-acute payments including inpatient rehabilitation, skilled nursing, home health, outpatient physical therapy, and hospital readmissions.

Results

The mean episode of care cost decreased by 11.1% (from $21,324 to $18,953) at the higher volume hospitals and by 8.3% (from $25,724 to $23,584) at the lower volume hospitals during BPCI participation compared to the preceding year. The savings were achieved by reducing the use of inpatient rehabilitation, shortening the length of stay at skilled nursing facilities, and decreasing readmission rates. Although the higher volume hospital achieved an increased mean savings of $230 per episode compared to the lower volume hospitals ($2371 vs $2141), it was penalized $490 per episode after reconciling the actual Medicare expenditures with the BPCI targets while the lower volume hospitals received a mean reward of $315 per episode.

Conclusion

The BPCI initiative decreased costs and readmissions within our healthcare system. Despite substantial savings compared to the preceding year, the higher volume hospital’s low target derived from its 2009-2012 baseline costs was not achieved which resulted in a penalty and led it to withdraw from the BPCI initiative in October 2016.

Virtual Reality Simulation Facilitates Resident Training in Total Hip Arthroplasty: A Randomized Controlled Trial

06-05-2019 – Jessica Hooper, Eleftherios Tsiridis, James E. Feng, Ran Schwarzkopf, Daniel Waren, William J. Long, Lazaros Poultsides, William Macaulay, George Papagiannakis, Eustathios Kenanidis, Eduardo D. Rodriguez, James Slover, Kenneth A. Egol, Donna P. Phillips, Scott Friedlander, Michael Collins

Journal Article

Background

No study has yet assessed the efficacy of virtual reality (VR) simulation for teaching orthopedic surgery residents. In this blinded, randomized, and controlled trial, we asked if the use of VR simulation improved postgraduate year (PGY)-1 orthopedic residents’ performance in cadaver total hip arthroplasty and if the use of VR simulation had a preferentially beneficial effect on specific aspects of surgical skills or knowledge.

Methods

Fourteen PGY-1 orthopedic residents completed a written pretest and a single cadaver total hip arthroplasty (THA) to establish baseline levels of knowledge and surgical ability before 7 were randomized to VR-THA simulation. All participants then completed a second cadaver THA and retook the test to assess for score improvements. The primary outcomes were improvement in test and cadaver THA scores.

Results

There was no significant difference in the improvement in test scores between the VR and control groups (P = .078). In multivariate regression analysis, the VR cohort demonstrated a significant improvement in overall cadaver THA scores (P = .048). The VR cohort demonstrated greater improvement in each specific score category compared with the control group, but this trend was only statistically significant for technical performance (P = .009).

Conclusions

VR-simulation improves PGY-1 resident surgical skills but has no significant effect on medical knowledge. The most significant improvement was seen in technical skills. We anticipate that VR simulation will become an indispensable part of orthopedic surgical education, but further study is needed to determine how best to use VR simulation within a comprehensive curriculum.

Level of Evidence

Level 1.

Development of Machine Learning Algorithms for Prediction of Sustained Postoperative Opioid Prescriptions After Total Hip Arthroplasty

23-07-2019 – Aditya V. Karhade, Joseph H. Schwab, Hany S. Bedair

Journal Article

Background

Postoperative recovery after total hip arthroplasty (THA) can lead to the development of prolonged opioid use but there are few tools for predicting this adverse outcome. The purpose of this study is to develop machine learning algorithms for preoperative prediction of prolonged opioid prescriptions after THA.

Methods

A retrospective review of electronic health records was conducted at 2 academic medical centers and 3 community hospitals to identify adult patients who underwent THA for osteoarthritis between January 1, 2000 and August 1, 2018. Prolonged postoperative opioid prescriptions were defined as continuous opioid prescriptions after surgery to at least 90 days after surgery. Five machine learning algorithms were developed to predict this outcome and were assessed by discrimination, calibration, and decision curve analysis.

Results

Overall, 5507 patients underwent THA, of which 345 (6.3%) had prolonged postoperative opioid prescriptions. The factors determined for prediction of prolonged postoperative opioid prescriptions were age, duration of opioid exposure, preoperative hemoglobin, and preoperative medications (antidepressants, benzodiazepines, nonsteroidal anti-inflammatory drugs, and beta-2-agonists). The elastic-net penalized logistic regression model achieved the best performance across discrimination (c-statistic = 0.77), calibration, and decision curve analysis. This model was incorporated into a digital application able to provide both predictions and explanations (available at https://sorg-apps.shinyapps.io/thaopioid/).

Conclusion

If externally validated in independent populations, the algorithms developed in this study could improve preoperative screening and support for THA patients at high risk for prolonged postoperative opioid prescriptions. Early identification and intervention in high-risk cases may mitigate the long-term adverse consequence of opioid dependence.

Level of Evidence

III.