The Impact of Surgeon Variability on Patient-Reported Outcome Measures, Length of Stay, Discharge Disposition, and 90-Day Readmission in TKA

Machine learning model outperforms the ACS Risk Calculator in predicting non-home discharge following primary total knee arthroplasty

PURPOSE

Despite the increase in outpatient total knee arthroplasty (TKA) procedures, many patients are still discharged to non-home locations following index surgery. The ability to accurately predict non-home discharge (NHD) following TKAs has the potential to promote a reduction in associated adverse events and excess healthcare costs. This study aimed to evaluate whether a machine learning (ML) model could outperform the American College of Surgeons (ACS) Risk Calculator in predicting NHD following TKA, using the same set of clinical variables. We hypothesised that the ML model would outperform the ACS Risk Calculator.

METHODS

Data from 365,240 patients who underwent a primary TKA between 2013 and 2020 were extracted from the ACS-National Surgical Quality Improvement Program database and used to develop an artificial neural network (ANN) to predict discharge disposition following primary TKA. The ANN and ACS calculator were assessed and compared using discrimination, calibration and decision curve analysis.

RESULTS

Age (>68 years), BMI (>35.5 kg/m2) and ASA Class (≥2) were found to be the most important variables in predicting NHD following TKA. When compared to the ACS calculator, the ANN model demonstrated a significantly superior ability to distinguish the area under the receiver operating characteristic curve (AUC) among NHD patients and provided probability predictions well aligned with the true outcomes (AUCANN = 0.69, AUCACS = 0.50, p = 0.002, slopeANN = 0.85, slopeACS = 4.46, interceptANN = 0.04, and interceptACS = 0.06).

CONCLUSION

Our findings support the hypothesis that machine learning models outperform the ACS Risk Calculator in predicting non-home discharge after TKA, even when constrained to the same clinical variables. Our findings underscore the potential benefits of integrating machine learning models into clinical practice for improving preoperative patient risk identification, optimisation, counselling and clinical decision-making.

LEVEL OF EVIDENCE

III.

Medicare's Post-Acute Care Reimbursement Models as of 2023: Past, Present, and Future

ABSTRACT

The Centers for Medicare & Medicaid Services is continually working to mitigate unnecessary expenditures, particularly in post-acute care (PAC). Medicare reimburses for orthopaedic surgeon services in varied models, including fee-for-service, bundled payments, and merit-based incentive payment systems. The goal of these models is to improve the quality of care, reduce health-care costs, and encourage providers to adopt innovative and efficient health-care practices.This article delves into the implications of each payment model for the field of orthopaedic surgery, highlighting their unique features, incentives, and potential impact in the PAC setting. By considering the historical, current, and future Medicare reimbursement models, we hope to provide an understanding of the optimal payment model based on the specific needs of patients and providers in the PAC setting.

Fellowship-Trained Surgeons Experience a Learning Curve Performing Revision Total Joint Arthroplasty

BACKGROUND

Revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) require considerable surgical proficiency, but are frequently delegated to the least experienced surgeons. This study examined the influence of surgeon experience on revision outcomes.

METHODS

Prospective data on confirmed aseptic rTHAs (n = 122) and rTKAs (n = 195) performed by 4 fellowship-trained surgeons in the same practice were retrospectively analyzed. Surgeons were grouped based on years in practice (inexperienced [IE] first 2 years, early experience [EE] 4 to 6 years, and senior experience [SE] 15 to 17 years). Procedure duration, estimated blood loss (EBL), and reoperation rates were compared, controlling for potential covariates.

RESULTS

Procedure durations varied based on surgeon experience for 3 of 4 rTHA diagnoses (P ≤ 0.001). Relative to the SE surgeon, procedure duration was 80.0 (95% confidence interval 61.7 to 98.4, P < 0.001) minutes longer for IE surgeons and 30.9 (95% confidence interval 17.5 to 44.3, P < 0.001) minutes longer for the EE surgeon. Procedure durations also varied based on surgeon experience for 3 of 4 rTKA diagnoses (P < 0.001), with the longest durations for IE surgeons. Procedure durations varied based on the interaction of surgeon experience, patient age, and body mass index. The EBL did not differ in rTHA based on surgeon experience (P = 0.978), but did differ for rTKA (P = 0.004). There were 25% of rTHAs performed by IE surgeons compared to 15.5% for the EE surgeon and 3.6% for the SE surgeon that underwent reoperation within a year of the index procedure (P = 0.064), with significantly more reoperations for the same indication among IE and EE surgeons (P = 0.046).

CONCLUSIONS

Complex procedures completed by less experienced surgeons may result in longer procedures, higher EBL, and more early reoperations. Study findings implicate a learning curve for revision arthroplasty that continues for several years, warranting consideration of existing patient allocation and referral patterns.

How to Raise the Bar in the Capture of Patient-Reported Outcome Measures in Total Joint Arthroplasty: Results from Active and Passive Follow-up Measures

BACKGROUND

With the upcoming U.S. Centers for Medicare & Medicaid Services 2027 policy for mandatory reporting of patient-reported outcome measures (PROMs) for total hip or knee arthroplasty (THA or TKA), it is important to evaluate the resources required to achieve adequate PROM collection and reporting at a clinically relevant rate of follow-up. This study aimed to (1) determine follow-up rates for 1-year PROMs when the follow-up was conducted with active methods (attempted contact by staff) and passive (automated) methods, and (2) evaluate factors associated with higher odds of requiring active follow-up or being lost to follow-up following THA or TKA.

METHODS

A prospective cohort of patients undergoing primary elective THA (n = 7,436) or TKA (n = 10,119) between January 2016 and December 2020 at a single institution were included. The primary outcome was the response rate achieved with active and passive follow-up methods at our institution. Patient characteristics, health-care utilization parameters, PROM values, and patient satisfaction were compared between follow-up methods.

RESULTS

Passive and active measures were successful for 38% (2,859) and 40% (3,004) of the THA cohort, respectively, while 21% (1,573) were lost to follow-up. Similarly, passive and active measures were successful for 40% (4,001) and 41% (4,161) of the TKA cohort, respectively, while 20% (2,037) were lost to follow-up. Younger age, male sex, Black or another non-White race, fewer years of education, smoking, Medicare or Medicaid insurance, and specific baseline PROM phenotypes (i.e., with scores in the lower half for pain, function, and/or mental health) were associated with loss to follow-up. Older age, male sex, Black race, and a residence with a higher Area Deprivation Index were associated with requiring active follow-up.

CONCLUSIONS

One of 5 patients were lost to follow-up despite active and passive measures following THA or TKA. These patients were more likely to be younger, be male, be of Black or another non-White race, have fewer years of education, be a smoker, have Medicaid insurance, and have specific baseline PROM phenotypes. Innovative strategies aimed at targeting individuals with these baseline characteristics may help raise the bar and increase follow-up while mitigating costs after total joint arthroplasty.

LEVEL OF EVIDENCE

Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Modern Hip Arthroscopy for FAIS May Delay the Natural History of Osteoarthritis in 25% of Patients: A 12-Year Follow-up Analysis

BACKGROUND

Little is known about the effect of modern hip arthroscopy on the natural history of femoroacetabular impingement syndrome (FAIS) with respect to joint preservation.

PURPOSE

To (1) characterize the natural history of FAIS and (2) understand the effect of modern hip arthroscopy by radiographically comparing the hips of patients who underwent only unilateral primary hip arthroscopy with a minimum follow-up of 10 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between 2010 and 2012, 619 consecutive patients were reviewed from the practice of a single fellowship-trained hip arthroscopic surgeon. Inclusion criteria were FAIS, bilateral radiographic findings of femoroacetabular impingement, primary unilateral hip arthroscopy (labral repair, femoroplasty, or capsular closure), and minimum 10-year follow-up. The preoperative and minimum 10-year postoperative radiographs of patients were evaluated at each time point. Both operative and nonoperative hips were graded using the Tönnis classification or the presence of hip arthroplasty by 2 independent reviewers. Subgroup analyses were performed.

RESULTS

A total of 200 hips from 100 patients were evaluated at a mean follow-up of 12.0 years. Preoperatively, 98% and 99% of operative and nonoperative hips were evaluated as Tönnis grades 0 and 1, respectively; 5% of nonoperative hips had worse Tönnis grades than operative hips. The nonoperative hip advanced to a worse Tönnis grade in 48% (48/100) of cases compared with 28% (28/100) among operative hips. At follow-up, Tönnis grades between hips were equal in 70% (70/100) of the cases, the operative hip had a better grade 25% (25/100) of the time, and the nonoperative hip had a better grade 5% (5/100) of the time. Modern hip arthroscopy was associated with a relative risk reduction of 42% in osteoarthritis progression. Impingement with borderline dysplasia, age, preoperative Tönnis grade, and alpha angle >65° were key risk factors in the radiographic progression of osteoarthritis.

CONCLUSION

Although the majority of patients (70%) undergoing hip arthroscopy for FAIS did not experience differences between operative and nonoperative hips in terms of the radiographic progression of osteoarthritis, the natural history may be favorably altered for 25% of patients whose Tönnis grade was better after undergoing arthroscopic correction. Modern hip arthroscopy indications and techniques represent a valid joint-preservation procedure conferring a relative risk reduction of 42% in the progression of osteoarthritis. Arthroscopy for mixed patterns of impingement and instability were the fastest to degenerate.

Associations of parecoxib and other variables with recovery and safety outcomes in total knee arthroplasty: insights from a retrospective cohort study

Background

Early mobilization post-total knee arthroplasty (TKA) significantly affects patient outcomes. While parecoxib is known to reduce postoperative pain and morphine use with a favorable safety profile, its impact on mobilization timing post-TKA remains uncertain. This retrospective study aims to assess parecoxib's influence on postoperative mobilization timing in TKA patients without compromising safety.

Methods

This study included unilateral TKA patients treated for primary knee osteoarthritis under general anesthesia. We divided the study period into two intervals, 2007-2012 and 2013-2018, to evaluate temporal differences. Both the control group and parecoxib group received standard postoperative oral analgesics and as-needed intramuscular morphine. The control group did not receive parecoxib, while the parecoxib group did. Primary outcomes compared postoperative complications and mobilization timing between groups, with secondary outcomes including length of hospital stay (LOS), Visual Analog Scale (VAS) scores for pain, as-needed morphine use, and postoperative nausea/vomiting.

Results

Parecoxib did not increase postoperative complications. Unmatched comparison with patients in controlled group found that patients in parecoxib group had significantly shortened mobilization time (2.2 ± 1.1 vs. 2.7 ± 1.6 days, P < 0.001) and LOS (6.7 ± 2.5 vs. 7.2 ± 2.1 days, P = 0.01). Multivariate analysis linked parecoxib use with faster mobilization (β = -0.365, P < 0.001) but not LOS. Males showed increased mobilization time and LOS compared to females during the period of 2007-2018, but gender had no significant association with LOS during the period of 2013-2018. The 2013-2018 period saw significant reductions in both mobilization time and LOS. Use of a tourniquet and local infiltration analgesia showed no significant impact. ASA classification 1-2 was positively associated with faster mobilization but not LOS. Longer operation times were linked to delayed mobilization and increased LOS.

Conclusion

In this study, intravenous parecoxib injection, female gender, and shorter OP time had consistent positive association with shorter time to mobilization after individual multivariate analysis in 2 different period. The use of parecoxib had consistent no significant association with LOS. Only shorter OP time was consistent positive associated with shorter LOS.

Intersurgeon Variability of Minimal Clinically Important Difference for Worsening Achievement Rates After Total Joint Arthroplasty

BACKGROUND

Using the Patient-Reported Outcome Measurement Information System, we sought to evaluate surgeon performance variability via minimal clinically important difference for worsening (MCID-W) achievement rates in primary and revision total knee and hip arthroplasty.

METHODS

This retrospective study analyzed 3,496 primary total hip arthroplasty (THA), 4,622 primary total knee arthroplasty (TKA), 592 revision THA, and 569 revision TKA patients. Patient factors collected included demographics, comorbidities, and Patient-Reported Outcome Measurement Information System physical function short form 10a scores. Surgeon factors collected included caseload, years of experience, and fellowship training. The MCID-W rate was calculated as the percent of patients in each surgeon's cohort who achieved MCID-W. Distribution was presented via a histogram with associated average, standard deviation, range, and interquartile range (IQR). Linear regressions were performed to evaluate the potential correlation between surgeon- and patient-level factors with MCID-W rate.

RESULTS

The average MCID-W rates of the surgeons represented in the primary THA and TKA cohorts were 12.7 ± 9.2% (range, 0 to 35.3%; IQR, 6.7 to 15.5%) and 18.0 ± 8.2% (range, 0 to 36%; IQR, 14.3 to 22.0%). The average MCID-W rates among the revision THA and TKA surgeons were 36.0 ± 22.2% (range, 9.1 to 90%; IQR, 25.0 to 41.4%) and 21.2 ± 7.7% (range, 8.1 to 37.0%; IQR, 16.6 to 25.4%). Strong correlations were not found between patient- or surgeon-level factors and MCID-W rate of the surgeon.

CONCLUSION

We demonstrated variance in MCID-W achievement rates across surgeons in both primary and revision joint arthroplasty, independent of patient- or surgeon-level factors.

The safety and effectiveness of enhanced recovery after surgery (ERAS) in older patients undergoing orthopedic surgery: a systematic review and meta-analysis

INTRODUCTION

To systematically review and analyze the safety and effectiveness of ERAS in older patients undergoing orthopedic surgeries.

MATERIALS AND METHODS

We searched PubMed, EMBASE, CINAHL, MEDLINE (Ovid), Web of Science, the Cochrane Library, and other databases to identify all randomized controlled studies and cohorts. We used the Cochrane Risk of Bias Assessment Tool and the Newcastle‒Ottawa Scale to assess the study quality. A meta-analysis was performed using the inverse variance weighting method.

RESULTS

This study included 15 studies involving a total of 2591 older patients undergoing orthopedic surgeries with 1480 in the ERAS group. The ERAS group had a lower incidence of postoperative complications than the control group (RR 0.52; 95% CI 0.42-0.65). Length of stay was 3.37 days lower in the ERAS group than in the control group (P < 0.01). And the ERAS protocol reduced the patient's postoperative VAS score (P < 0.01). Meanwhile, there was a lack of evidence of significant differences between the ERAS group and the control group in total bleeding and 30-day readmission rate.

CONCLUSIONS

The implementation of the ERAS program in older patients undergoing orthopedic surgeries is safe and effective. However, there is still a lack of standardization of protocols across institutions and centers for orthopedic surgery for older patients. Identifying ERAS components that are beneficial to older patients and developing ERAS protocols that are appropriate for older adults may further improve outcomes.

Homogeneity in Surgical Series: Image Reporting to Improve Evidence

Good clinical practice guidelines are based on randomized controlled trials or clinical series; however, technical performance bias among surgical trials is under-assessed. The heterogeneity of technical performance within different treatment groups diminishes the level of evidence. Surgeon variability with different levels of experience-technical performance levels even after certification-influences surgical outcomes, especially in complex procedures. Technical performance quality correlates with the outcomes and costs and should be measured by image or video-photographic documentation of the surgeon's view field during the procedures. Such consecutive, completely documented, unedited observational data-in the form of intra-operative images and a complete set of eventual radiological images-improve the surgical series' homogeneity. Thereby, they might reflect reality and contribute towards making necessary changes for evidence-based surgery.

Personalized alignment™ for total knee arthroplasty using the ROSA® Knee and Persona® knee systems: Surgical technique

Total knee arthroplasty (TKA) procedures are expected to increase up to 565% in the United States over the next 3 decades. TKAs were traditionally performed with neutral mechanical alignments that provided equal medial and lateral gaps in extension and flexion to reduce implant wear but were less successful at restoring native knee function and associated with high patient dissatisfaction. Kinematic alignment (KA) restores native anatomy and minimizes soft tissue release; however, KAs that recreate severe deformities and/or biomechanically inferior alignments result in significant increases in implant stress and risk of aseptic loosening. Restricted kinematic alignment (rKA) recreates pre-arthritic anatomy within a range of acceptable alignment boundaries, and improved patient clinical scores and faster recoveries have been reported with rKA techniques. Personalized Alignment™ is an evolution of rKA that relies heavily upon robotic assistance to reliably recreate patient anatomy, native soft tissue laxity, and accurate component placement to improve patients' clinical outcomes. The purpose of this surgical technique report is to describe the Personalized Alignment TKA method using the ROSA^® Knee System and Persona^® The Personalized Knee^® implants. Herein we provide specific procedures for pre-operative planning, anatomical landmarking and evaluation, intra-operative planning and adjustment of resections and cuts, cut validation and soft tissue evaluation with robotic-assisted personalized TKA.