Patient Frailty is Correlated With Increased Adverse Events and Costs After Revision Total Hip Arthroplasty

BACKGROUND

Frailty has been associated with poor outcomes and higher costs after primary total hip arthroplasty. However, frailty has not been studied in relation to outcomes after revision total hip arthroplasty (rTHA). This study examined the relationship between the Hospital Frailty Risk Score (HFRS), postoperative outcomes, and cost profiles following rTHA.

METHODS

In this retrospective cohort study, we identified patients who underwent rTHA from January 2017 to November 2019 in the Nationwide Readmission Database. The 3 most frequently reported diagnosis codes for rTHA were then selected: dislocation; mechanical loosening; and infection. We calculated the HFRS for each patient to determine frailty status. We compared 30-day readmission rate, length of stay, and hospitalization cost between frail and nonfrail patients, using multivariate logistic and negative binomial regressions to adjust for covariates. We identified 36,243 total patients who underwent rTHA. Overall, 15,448 patients had a revision for dislocation, 11,062 for mechanical loosening, and 9,733 for infection.

RESULTS

Compared to nonfrail patients, frail patients had higher rates of 30-day readmission, longer length of stay, and higher hospitalization cost. Frail patients had significantly higher rates of 30-day complication and 30-day reoperation.

CONCLUSIONS

Frailty, measured using HFRS, is associated with increased postoperative complications and costs after rTHA. The HFRS has the ability to efficiently identify frail patients at-risk for perioperative complications enabling care teams to better focus optimization interventions on this patient cohort.

Treating Hepatitis C Before Total Knee Arthroplasty is Cost-Effective: A Markov Analysis

BACKGROUND

Patients who have the hepatitis C virus (HCV) have increased mortality and complication rates following total knee arthroplasty (TKA). Recent advances in HCV therapy have enabled clinicians to eradicate the disease using direct-acting antivirals (DAAs); however, its cost-effectiveness before TKA remains to be demonstrated. The aim of this study was to perform a cost-effectiveness analysis comparing no therapy to DAAs before TKA.

METHODS

A Markov model using input values from the published literature was performed to evaluate the cost-effectiveness of DAA treatment before TKA. Input values included event probabilities, mortality, cost, and health state quality-adjusted life-year (QALY) values for patients who have and do not have HCV. Patients who have HCV were modeled to have an increased rate of periprosthetic joint infection (PJI) infection (9.9 to 0.7%). The incremental cost-effectiveness ratio (ICER) of no therapy versus DAA was compared to a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses were performed to investigate the effects of uncertainty associated with input variables.

RESULTS

Total knee arthroplasty in the setting of no therapy and DAA added 8.1 and 13.5 QALYs at a cost of $25,000 and $114,900. The ICER associated with DAA in comparison to no therapy was $16,800/QALY, below the willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses demonstrated that the ICER was affected by patient age, inflation rate, DAA cost and effectiveness, HCV-associated mortality, and DAA-induced reduction in PJI rate.

CONCLUSION

Direct-acting antiviral treatment before TKA reduces risk of PJI and is cost-effective. Strong consideration should be given to treating patients who have HCV before elective TKA.

LEVEL OF EVIDENCE

Cost-effectiveness Analysis; Level III.

A 7-year perspective on femoral neck fracture management in New York State-Do Level 1 trauma centers provide better care?

INTRODUCTION

Patients with femoral neck fractures are at a substantial risk for medical complications and all-cause mortality. Given this trend, our study aims to evaluate postoperative outcomes and the economic profile associated with femoral neck fractures managed at level-1 (L1TC) and non-level-1-trauma centers (nL1TC).

METHODS

The SPARCS database was queried for all geriatric patients sustaining atraumatic femoral neck fractures within New York State between 2011 and 2017. Patients were then divided into two cohorts depending on the treating facility's trauma center designation: L1TC versus nL1TC. Patient samples were evaluated for trends and relationships using descriptive analysis, Student's t-tests, and Chi-squared. Multivariable linear-regressions were utilized to assess the effect of trauma center designation and potential confounders on patient mortality and inpatient healthcare expenses.

RESULTS

In total, 44,085 femoral neck fractures operatively managed at 161 medical centers throughout New York during a 7-year period. 4,974 fractures were managed at L1TC while 39,111 were treated at nL1TC. Following multivariate regression analysis, management at L1TC was the most significant cost driver, resulting in an average increased cost of $6,330.74 per fracture.

CONCLUSION

Our results suggest that femoral neck fractures treated at L1TC have more comorbidities, higher in-hospital mortality, longer LOS, and greater hospital costs.

Radiographic Outcomes of Titanium Augment vs Bone Graft in Lateral Column Lengthening for Adult-Acquired Flatfoot Deformity

Background

Lateral column lengthening (LCL) is a surgical procedure used to manage forefoot abduction and, in theory, also increases the longitudinal arch by plantarflexion of the first ray through tensioning the peroneus longus for patients with stage IIB adult acquired flatfoot deformity (AAFD). This procedure utilizes an opening wedge osteotomy of the calcaneus, which is then filled with autograft, allograft, or a porous metal wedge. The primary aim of this study was to compare the radiographic outcomes of these different bone substitutes following LCL for stage IIB AAFD.

Methods

We conducted a retrospective review of all patients who underwent LCL from October 2008 until October 2018. Preoperative weightbearing radiographs, initial postoperative radiographs, and 1-year weightbearing radiographs were reviewed. The following radiographic measurements were recorded: incongruency angle, talonavicular coverage angle (TNCA), talar-first metatarsal angle (T-1MT), and calcaneal pitch.

Results

A total of 44 patients were included in our study. The mean age of the cohort was 54 (range, 18-74). The study cohort was divided into 2 groups. There were 17 (38.7%) patients who received a titanium metal wedge and 27 (61.5%) that received autograft or allograft. Patients that underwent LCL with the autograft/allograft group were significantly older (59 vs 47 years old, P = .006). Patients who underwent LCL with a titanium wedge had a significantly higher preoperative talonavicular angle (32 vs 27 degrees, P = .013). There were no significant differences in postoperative TNCA, incongruency angle, or calcaneal pitch at 6 months or 1 year.

Conclusion

At 6 months and 1 year, no radiographic differences were found between autograft/allograft bone substitutes vs titanium wedge in LCL.

Level of Evidence

Level III, retrospective cohort study.

Measurement of the gluteal compartment pressures: A cadaveric study describing safety and reproducibility of two methods

INTRODUCTION

Gluteal compartment syndrome is an uncommon entity and physicians may use intracompartmental pressure measurements for confirmation of the clinical diagnosis, or in cases where the physical exam is indeterminate. However, there is a paucity of literature describing a safe and reproducible technique to measure gluteal intracompartmental pressures during the diagnosis of gluteal compartment syndrome. The purpose of this cadaveric study is to evaluate the sole previous technique described in the literature to measure gluteal intracompartmental pressures and provide a modified technique which can be safely and reliably utilized clinically.

METHODS

A cadaveric study with three phases was performed in 16 gluteal regions in 8 cadavers. In the first phase, the previously described technique was assessed. In the second phase, a modified set of techniques was created and evaluated. In the third phase, inter-user reliability of the modified set of techniques was assessed and calculated using Cohen's ĸ coefficient. In all three phases, methylene blue was injected through pressure monitoring needles into the gluteus maximus (GMax), gluteus medius/minimus (GMM), and the tensor fascia lata (TFL) compartments. Following dissection, rate of successful penetration into each targeted compartment and distance from the neurovascular structures was recorded.

RESULTS

The previously described set of techniques was found to be variable. The modified set of techniques was effective, successfully reaching the GMax, GMM, and TFL compartments in 100%, 100%, and 81% of attempts, respectively. Inter-user reliability was excellent (ĸ = 1) for the techniques to reach both the GMax and GMM compartments, and moderate (ĸ = 0.54) for the technique to reach the TFL compartment. Within the GMax, the pressure monitoring needle was at a mean of 5.4±0.6 cm, 4.1±0.7 cm, 6.4±0.5 cm from the sciatic nerve (SN), superior gluteal nerve (SGN), and inferior gluteal nerve (IGN), respectively. Within the GMM, the pressure monitoring needle was at a mean of 9.7±1.4 cm, 7.4±1.3 cm, 11.1±1.7 cm from the SN, SGN, and IGN, respectively.

CONCLUSION

The modified set of techniques presented allows the three gluteal compartments to be safely and reproducibly reached to measure intracompartmental pressures during the diagnosis of gluteal compartment syndrome.

Treating Hepatitis C Prior to Total Hip Arthroplasty is Cost Effective: A Markov Analysis

INTRODUCTION

Patients infected with the hepatitis C virus (HCV) have high complication rates following total hip arthroplasty (THA). Advances in HCV therapy now enable clinicians to eradicate the disease, however, its cost effectiveness from an orthopaedic perspective remains to be demonstrated. We sought to conduct a cost effectiveness analysis comparing no therapy to direct acting antiviral therapy (DAA) prior to THA among HCV positive patients.

METHODS

A Markov model was utilized to evaluate the cost-effectiveness of treating HCV with DAA prior to THA. The model was powered with event probabilities, mortality, cost and quality adjusted life-year values for patients with and without HCV that were obtained from the published literature. This included treatment costs, successes of HCV eradication, incidences of superficial or periprosthetic joint infection (PJI), probabilities of utilizing various PJI treatment modalities, PJI treatment success/failures, and mortality rates. The incremental cost-effectiveness ratio (ICER) was compared to a willingness-to-pay threshold of $50,000/QALY.

RESULTS

Our Markov model indicates that in comparison to no therapy, DAA prior to THA is cost-effective for HCV positive patients. THA in the setting of no therapy and DAA added 8.06 and 14.39 QALYs at a mean cost of $28,800 and $115,800. The ICER associated with HCV DAA in comparison to no therapy was $13,800/QALY, below the willingness-to-pay threshold of $50,000/QALY.

CONCLUSION

Hepatitis-C treatment with DAA prior to THA is cost-effective at all current drug list prices. Given these findings, strong consideration should be given to treating patients for HCV prior to elective THA.

Team Approach: Perioperative Management of Pilon Fractures

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Tibial pilon fractures are devastating injuries requiring complexsurgical management resulting in a challenging postoperativecourse.

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A multidisciplinary approach is required to manage these injuries in addition to patients' medical comorbidities and concomitant injuries to achieve optimal outcomes.

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The case presented here demonstrates the importance of communication and teamwork between specialties in the management of a patient with a tibial pilon fracture that was medically optimized for surgery using a team-based approach.

Preoperative Patient Expectation of Discharge Planning is an Essential Component in Total Knee Arthroplasty

Purpose

A better understanding of total knee arthroplasty (TKA) candidate expectations within the perioperative setting will enable clinicians to promote patient-centered practices, optimize recovery times, and enhance quality metrics. In the current study, TKA candidates were surveyed pre- and postoperatively to elucidate the relationship between patient expectations and length of stay (LOS).

Material and methods

This is a prospective study of patients undergoing TKA between December 2017 and August 2018. Patients were electronically administered surveys regarding their discharge plan 10 days pre-/postoperatively. All patients were categorized into three cohorts based on their LOS: 1, 2, and 3+ days. The effect of preoperative discharge education on patient postoperative satisfaction was evaluated.

Results

In total, 221 TKAs were included, of which 83 were discharged on postoperative day (POD) 1, 96 on POD-2, and 42 POD-3+. Female gender, increasing body mass index (BMI), and surgical time correlated with increased LOS. Preoperative discussions regarding LOS occurred in 84.62% (187/221) of patients but did correlate with differences in LOS. However, patients discharged on POD-1 were more inclined to same-day surgery preoperatively. Patients discharged on POD-3+ were found to be more uncomfortable regarding their discharge during the preoperative phase. Multivariable regressions demonstrated that preoperative discharge discussion was positively correlated with home discharge.

Conclusion

Physician-driven discussion regarding patient discharge did not alter patient satisfaction or length of stay but did correlate with improved odds of home discharge. These findings underscore the importance of patient education, shared decision-making, and managing patient expectations.

The impact of total knee arthroplasty on golfing activity

Background

Total knee arthroplasty (TKA) is frequently performed among individuals who golf. This study examines the effect of TKA on pre- and postoperative pain, frequency of sport participation, handicap, driving distance, use of a cart, and overall game enjoyment.

Methods

This is a survey-based retrospective review of 71 patients after primary TKA at a tertiary medical facility in upstate New York. Patients were evaluated using postoperative pain scores and asked to complete a survey that included questions about their return to sport.

Results

A total of 71 patients were included, with an average age of 70 years old. Postoperatively 85% of patients returned to play within 7.9 months, driving distance increased by 4 yards, patients' golf game improved by 1.07 strokes, and pain during and after golf was significantly decreased. Most patients did not change golf cart usage, and reported unchanged or improved performance in and enjoyment of golf.

Conclusions

We found that a majority of patients undergoing TKA returned to playing golf postoperatively. Patients were more likely to report decreased pain both before and after play and positive changes to their golf game. Our results suggest that most patients can expect to return to golf after TKA and the majority will enjoy the sport with less pain postoperatively.

The COVID-19 Pandemic and Centers of Medicaid and Medicare Services Regulatory Reform Impact on Total Hip Arthroplasty Metrics

BACKGROUND

Shifts in demand, capacity, and site of service have impacted total hip arthroplasty (THA) volumes and revenues over the 2019-2021 time period. Moving THA off the inpatient-only (IPO) list and the COVID-19 pandemic has caused a shift in delivery away from inpatient services and a decrease in demand.

METHODS

Medicare claims data were surveyed for the latest period available (April 1, 2020 to September 2020) and compared with a similar period in 2019 prior to THA removal from the IPO list and before the COVID-19 pandemic. Length of stay (LOS), admission status, site of service, discharge status, cost to CMS (Centers of Medicaid and Medicare Services), and racial disparities were analyzed.

RESULTS

From 2019 to 2020, changes in primary THA metrics occurred (overall change in total joint arthroplasty [THA plus total knee arthroplasty metrics]): CMS THA volume decreased from 78,691 to 65,360, -16% (-22%); THA performed as an outpatient increased from 0% to 51% (141%); THA performed as same-day discharge increased from 3% to 12%, 325% (221%); overall LOS decreased from 1.91 to 1.46, -23% (-11%); inpatient LOS increased from 1.92 to 2.05, 7% (16%); outpatient LOS increased from 0.92 to 0.93, 1% (-12%); discharge home increased from 82% to 91%, 12.8% (11%); and CMS spending decreased from $1,033 million to $751 million, -27% (-27%).

CONCLUSION

Medicare payments, LOS, discharge to facilities, and volume declined from 2019 to 2020 and were accelerated by IPO list changes and COVID-19 issues. Same-day discharge and hospital outpatient department cases also increased. THA metrics were not affected by race.

Perioperative Management of Hepatitis C in Patients Undergoing Total Joint Arthroplasty

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A small yet growing subset of total joint arthroplasty (TJA) candidates are diagnosed with the hepatitis C virus (HCV), which is a known risk factor for periprosthetic joint infections. Given the poor outcomes associated with TJA infection, we recommend that candidates with HCV receive treatment prior to elective TJA.

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Interferon and ribavirin have historically been the standard treatment regimen for the management of HCV; however, adverse events and an inconsistent viral response have limited the efficacy of these therapies. The advent of direct-acting antivirals has resolved many of the issues associated with interferon and ribavirin regimens.

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Despite the success of direct-acting antivirals, there are still barriers to seeking treatment for TJA candidates with HCV. Many patients are faced with financial burdens, as insurance coverage of direct-acting antiviral therapies is inconsistent and varies by the patient's state of residence and specific treatment regimen.

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TJA candidates with HCV present health-care providers with a unique set of challenges, often encompassing economic, psychosocial, and complex medical concerns. Multidisciplinary care teams can be beneficial when caring for and optimizing this patient cohort.

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Management of HCV prior to elective TJA is associated with higher up-front costs but ultimately reduces long-term patient morbidity as well as associated direct and indirect health-care expenditures.

Inpatient Opioid Consumption Variability following Total Knee Arthroplasty: Analysis of 4,038 Procedures

This study examined an early iteration of an inpatient opioid administration-reporting tool, which standardized patient opioid consumption as an average daily morphine milligram equivalence per surgical encounter (MME/day/encounter) among total knee arthroplasty (TKA) recipients. The objective was to assess the variability of inpatient opioid administration rates among surgeons after implementation of a multimodal opioid sparing pain protocol. We queried the electronic medical record at our institution for patients undergoing elective primary TKA between January 1, 2016 and June 30, 2018. Patient demographics, inpatient and surgical factors, and inpatient opioid administration were retrieved. Opioid consumption was converted into average MME for each postoperative day. These MME/day/encounter values were used to determine mean and variance of opioids prescribed by individual surgeons. A secondary analysis of regional inpatient opioid consumption was determined by patient zip codes. In total, 23 surgeons performed 4,038 primary TKA. The institutional average opioid dose was 46.24 ± 0.75 MME/day/encounter. Average intersurgeon (IS) opioid prescribing ranged from 17.67 to 59.15 MME/day/encounter. Intrasurgeon variability ranged between ± 1.01 and ± 7.51 MME/day/encounter. After adjusting for patient factors, the average institutional MME/day/encounter was 38.43 ± 0.42, with average IS variability ranging from 18.29 to 42.84 MME/day/encounter, and intrasurgeon variability ranging between ± 1.05 and ± 2.82 MME/day/encounter. Our results suggest that there is intrainstitutional variability in opioid administration following primary TKA even after controlling for potential patient risk factors. TKA candidates may benefit from the implementation of a more rigid standardization of multimodal pain management protocols that can control pain while minimizing the opioid burden. This is a level of evidence III, retrospective observational analysis.

Outcomes of a Total Joint Arthroplasty Enhanced Recovery Program in a Community Hospital Setting

BACKGROUND

Same-day discharge (SDD) total joint arthroplasty (TJA) is increasingly popular, yet there remain concerns regarding patient safety, complication rates, and unforeseen overnight admission (failure to launch; FTL). The aim of this study is to retrospectively examine the outcomes of a large consecutive SDD-TJA series in the community hospital setting.

METHODS

We retrospectively reviewed 1200 consecutive SDD-TJA candidates between March 2017 and December 2019 by 5 surgeons at a community hospital. Patient demographics, perioperative data including anesthesia type, and 30-day complications were evaluated, including FTL, infection, intraoperative fracture, postoperative periprosthetic fracture or dislocation, return to operating room, and unplanned postoperative care.

RESULTS

We included 1200 SDD patients (582/618 total hip arthroplasty/total knee arthroplasty, mean age 62.1 years, 595 females, 605 males). Spinal anesthesia was more common than general anesthesia (1087 vs 113 patients). There were 85 FTLs (7.1%), of this cohort 58.8% were female, with a mean age of 62.4 years. General anesthesia increased the risk of FTL (odds ratio 2.93). Complications resulting in FTL included block-induced neuropraxia (32.1%), orthostatic hypotension (26.1%), urinary retention (19.0%), and nausea (13.1%). Sixteen patients were readmitted within 30 days (1.3%). Six patients returned to the operating room for periprosthetic fracture (4), wound dehiscence (1), and superficial surgical site infection (1).

CONCLUSION

SDD-TJA can be safely performed at community hospitals, but general anesthesia should be avoided to decrease risk of FTL. Inpatient programs may allow young surgeons to gain experience with SDD-TJA while retaining overnight admission as a safety net for their patients.

LEVEL OF EVIDENCE

Level III (Prognostic).

Real-Time Fluoroscopic Navigation Improves Acetabular Component Positioning During Direct Anterior Approach Total Hip Arthroplasty

We investigated whether a novel, real-time fluoroscopybased navigation system optimized component positioning and leg length in fluoroscopically aided direct anterior approach total hip arthroplasty (DAA-THA). We retrospectively reviewed 75 fluoroscopically assisted DAA-THA performed by a single surgeon: 37 procedures used the software intraoperatively to overlay anteversion, inclination, and leg length information over the existing fluoroscopic radiograph with the aim of enhancing component positioning. The control group consisted of 38 procedures from the single surgeon's patient pool who had undergone non-navigated fluoroscopic assisted DAA-THA 1 month prior to the system's trial. Our results demonstrate that the navigation group measurements were significantly closer to the target numbers with less variation. The mean difference from target value were as follows: for anteversion (control: -4.68°, navigated: -01.0°), inclination (control: -1.87°, navigated: 0.8°), and leg length discrepancy (control: -2.59°, navigated: -0.98°). In addition, surgical time was shorter in the navigation group (75.7 vs. 74 minutes; p = 0.001). The real-time feedback and calculations provided by the navigation software provided a reproducible precision for component positioning and leg length measurement during DAA-THA.

Diagnosis of Guillain-Barré Syndrome After Total Hip Arthroplasty: A Case Report

CASE REPORT

A 67-year-old man presented with signs of acute periprosthetic infection after total hip arthroplasty (THA). Surgical debridement, antibiotics, and a head and liner exchange were performed. After showing no improvement, a single-stage revision was conducted. Postoperatively, he developed back pain and lower extremity weakness. Electrodiagnostic studies showed a Guillain-Barré syndrome (GBS) variant. Intravenous immunoglobulin was administered to halt disease progression. After 1 year, he still demonstrated neuromuscular deficits and required a cane for ambulation.

CONCLUSION

This case highlights GBS after THA. A high degree of clinical suspicion is essential to prevent misinterpretation as a postsurgical complication.

LEVEL OF EVIDENCE

V, case report.

Late Anterior Prosthetic Hip Dislocation Due to Yoga

The popularity of yoga and the prevalence of total hip arthroplasty (THA) have simultaneously increased in the United States. Accordingly, one can assume that the number of THA patients practicing yoga has increased. Certain yoga poses reach the extremes of hip range of motion, potentially leaving patients vulnerable to dislocation. To date, 2 cases of late posterior prosthetic hip dislocations during yoga have been reported; however, there have been no reports of anterior prosthetic hip dislocations. We present one case of late anterior prosthetic hip dislocation during yoga in a patient who underwent THA via the direct anterior approach. Prosthetic hip dislocation during yoga may be a growing concern. We provide additional evidence in support of recommendations for THA patients to safely practice yoga.

Oral health implications in total hip and knee arthroplasty patients: A review

Over the past two decades, oral health has emerged as a health care priority. Historically, patients greater than 65 years of age, the economically disadvantaged, members of racial or ethnic minority groups, or the disabled or home bound have experienced significant barriers to routine dental care. The connection between oral health care and periprosthetic joint infections (PJI) continues to be of importance to the orthopedic surgeon, as such infections are significantly morbid and costly. This review aims to introduce the importance of oral health as a small but crucial portion of an arthroplasty patient's overall perioperative management.

Direct Anterior Approach Total Hip Arthroplasty Is Not Associated with Increased Infection Rates: A Systematic Review and Meta-Analysis

BACKGROUND

The direct anterior approach (DAA) for primary total hip arthroplasty (THA) has recently increased in popularity. Recent evidence has raised concerns about whether use of the DAA is associated with increased rates of superficial and deep infection. The aim of this study was to systematically assess the literature and comparatively evaluate the rate of superficial and deep infection following primary THA using the DAA and non-direct anterior (non-DAA) approaches.

METHODS

This study was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement. Primary outcome measures evaluated were rates of superficial and deep infection in patients undergoing DAA and non-DAA primary THA.

RESULTS

A total of 1,872 studies were identified in the original search, of which 15 studies satisfied inclusion criteria. Our analysis evaluated 120,910 primary THAs, including 14,908 DAA and 106,002 non-DAA. The rate of superficial infection was 1.08% for DAA compared with 1.24% for non-DAA (odds ratio [OR] = 1.01, 95% confidence interval [CI] = 0.79 to 1.30, p = 0.921). The rate of deep infection was 0.73% for DAA compared with 0.51% for non-DAA (OR = 1.03, 95% CI = 0.80 to 1.32, p = 0.831).

CONCLUSIONS

This study found no difference in the rate of superficial or deep infection after primary THA using the DAA versus other surgical approaches. Our results suggest that comparative infection risk need not be a primary driver in the choice of surgical approach.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Safety and Efficacy of Same-Day Hip Resurfacing

Same-day discharge (SDD) surgery in total hip arthroplasty (THA) has been shown to have similar outcomes to non-SDD THA in select patient populations. Hip resurfacing arthroplasty (HRA) is an alternative to THA for young, active patients, making them ideal candidates for SDD. This study compared the safety and efficacy of non-SDD HRA and SDD HRA for specific postoperative outcomes. An electronic data warehouse query was performed for procedures labeled "hip resurfacing." Data collected included demographics, surgical factors, and quality metrics. Statistical analyses were evaluated using a graphing and statistics software program. Categorical variables were analyzed with chi-square tests and continuous variables with Student's t tests, with P<.05 deemed significant. Sixty-three of 274 total HRAs were enrolled in this SDD HRA protocol. No significant difference was observed between SDD HRA and non-SDD HRA baseline characteristics. On postoperative day 0, 98.41% of SDD HRA recipients were discharged successfully. The SDD HRA recipients had shorter stays, with 1.59% requiring a hospital stay of 2 days or more compared with 56.87% of non-SDD HRA recipients (P<.0001). The non-SDD HRA recipients were found to have shorter surgical times than SDD HRA recipients (104.74 vs 125.51 minutes, P=.01). Rates of infection, periprosthetic fractures, emergency department visits, and hospital readmissions were equivalent (P=.99). Same-day discharge HRA is a safe and effective procedure with similar outcomes to non-SDD HRA regarding infections, fractures, emergency department visits, and readmissions. The major benefit of SDD is a shorter hospital stay that may lead to decreased cost while preserving and enhancing quality of care and patient satisfaction. [Orthopedics. 2020;43(6):e595-e600.].

Transcription Error Rates in Retrospective Chart Reviews

Electronic health record (EHR) technologies have improved the ease of access to structured clinical data. The standard means by which data are collected continues to be manual chart review. The authors compared the accuracy of manual chart review against modern electronic data warehouse queries. A manual chart review of the EHR was performed with medical record numbers and surgical admission dates for the 100 most recent inpatient venous thromboembolic events after total joint arthroplasty. A separate data query was performed with the authors' electronic data warehouse. Data sets were then algorithmically compared to check for matches. Discrepancies between data sets were evaluated to categorize errors as random vs systematic. From 100 unique patient encounters, 27 variables were retrieved. The average transcription error rate was 9.19% (SD, ±5.74%) per patient encounter and 11.04% (SD, ±21.40%) per data variable. The systematic error rate was 7.41% (2 of 27). When systematic errors were excluded, the random error rate was 5.79% (SD, ±7.04%) per patient encounter and 5.44% (SD, ±5.63%) per data variable. Total time and average time for manual data collection per patient were 915 minutes and 10.3±3.89 minutes, respectively. Data collection time for the entire electronic query was 58 seconds. With an error rate of 10%, manual chart review studies may be more prone to type I and II errors. Computer-based data queries can improve the speed, reliability, reproducibility, and scalability of data retrieval and allow hospitals to make more data-driven decisions. [Orthopedics. 2020;43(5):e404-e408.].

Cannabinoid Use in Musculoskeletal Illness: a Review of the Current Evidence

PURPOSE OF REVIEW

The use of cannabinoids has increased since legalization of recreational and medical use in the USA. It is likely that many orthopaedic patients consume cannabinoid products during the traumatic or perioperative period. The purpose of this study was to investigate the pre-clinical data evaluating the mechanism of action of cannabidiol (CBD) and Δ9-Tetrahydrocannabinol (Δ9-THC) and to evaluate the current clinical data on the use of cannabinoids in musculoskeletal illness.

RECENT FINDINGS

Recent pre-clinical studies have demonstrated that cannabinoid use and the endocannabinoid system (ECS) has an important role in bone healing and bone homeostasis. There is data that suggests that the use of cannabidiol (CBD) may increase bone healing, whereas the use of Δ9-Tetrahydrocannabinol (Δ9-THC), the major psychoactive ingredient in marijuana, likely inhibits bone metabolism and repair. The clinical implications and consumption of marijuana by orthopaedic patients have not been thoroughly evaluated. Studies have demonstrated concern for negative cardiovascular and psychiatric effects caused by marijuana use, but have not yet elucidated outcomes in the orthopaedic literature. With the recent increase in advertising of CBD products and legalization of marijuana, it is likely that many orthopaedic patients are consuming cannabinoid products. The clinical implications and consumption of these products are unclear. We need more robust and well-designed clinical studies prior to making further recommendations to our patients on the consumption of these products.

Chronic Obstructive Pulmonary Disease Is Associated With Higher Rates of Venous Thromboemboli Following Primary Total Knee Arthroplasty

BACKGROUND

There is discordance in the literature regarding the presence of chronic obstructive pulmonary disease (COPD) and the development of venous thromboemboli (VTEs). Therefore, the purpose of this study is to determine whether COPD patients undergoing primary total knee arthroplasty (TKA) have higher rates of (1) in-hospital lengths of stay (LOS); (2) readmissions; (3) VTEs; and (4) costs of care.

METHODS

COPD patients undergoing primary TKA were identified and matched to controls in a 1:5 ratio by age, gender, and medical comorbidities. Patients with a history of VTEs or hypercoagulable states were excluded. The query yielded 211,378 patients in the study (n = 35,230) and control (n = 176,148) cohorts. Outcomes analyzed included in-hospital LOS, readmission rates, VTEs, and costs of care. A P-value less than .01 was considered statistically significant.

RESULTS

COPD patients were found to have significantly longer in-hospital LOS (4 vs 3 days, P < .0001). Study group patients were also found to have significantly higher incidence and odds ratio (OR) of readmission rates (20.9% vs 16.3%; OR 1.36, P < .0001) and VTEs (1.75 vs .93; OR 1.18, P < .0001). Additionally, the study demonstrated that COPD patients incurred higher 90-day episode-of-care costs ($15,626.85 vs $14,471.29, P < .0001).

CONCLUSION

After adjusting for confounding variables, our study found an association between COPD and higher rates of developing VTEs following primary TKA. The study can be used by orthopedic surgeons to adequately counsel and educate these patients of the potential complications which may arise following their TKA.

Outcomes of Total Knee Arthroplasty in Human Immunodeficiency Virus-Positive Patients

Successful management of human immunodeficiency virus (HIV) has lengthened the life expectancy of HIV-positive (HIV + ) patients; consequently, increasing numbers of this patient population are candidates for total knee arthroplasty (TKA). This study seeks to provide detailed results of TKA in HIV+ patients and compare them to an HIV-negative (HIV - ) cohort. We performed a multicenter retrospective case-control study comparing 25 HIV+ patients to 25 HIV- patients undergoing TKA. The analysis included a cohort and subgroup stratification based on the presence or absence of postoperative complications. Prior to TKA, all 25 patients had a documented history of HIV infection. No intraoperative complications were reported. Ninety-day postoperative complications included knee contracture (one HIV + , no HIV - , p = 0.3124), periprosthetic joint infection requiring revision (one HIV + , no HIV - , p = 0.3124), mechanical fall requiring incision and drainage (one HIV + , no HIV - , p = 0.3124), and death (one HIV + , no HIV - , p = 0.3124). The average follow-up was 18.80 months. HIV+ patients stayed in the hospital for an average of 3.8 days following surgery, which was significantly greater than HIV- patients (2.28 days; p = 0.0040). As the life expectancy for HIV+ patients improves, a greater number will be TKA candidates. This study has shown an acceptable postoperative complication risk in an HIV+ patient population undergoing TKA, albeit with a significantly increased hospital length of stay.

Vancomycin Powder and Dilute Povidone-Iodine Lavage for Infection Prophylaxis in High-Risk Total Joint Arthroplasty

BACKGROUND

Dilute povidone-iodine lavage has been shown to be safe and effective in decreasing acute periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). Vancomycin powder is reported to be effective in preventing infection in spine surgery. We hypothesize that a "vanco-povidone protocol" (VIP) for TJA patients at high risk for infection is safe and will decrease the rate of PJI.

METHODS

High-risk TJA patients (body mass index >40, active smokers, American Society of Anesthesiologists ≥3, immunosuppression/diabetes, methicillin-resistant Staphylococcus aureus colonization, revision surgery) utilizing VIP were compared to a high-risk historical cohort not treated with VIP, at a single institution. VIP consisted of dilute povidone-iodine lavage followed by application of vancomycin powder prior to wound closure. Primary endpoint was PJI within 3 months postoperatively.

RESULTS

The historical, high-risk control cohort consisted of 3251 patients with a PJI incidence of 1.8%. A total of 1413 subjects received the VIP protocol with a PJI incidence of 1.3%. There was a 27.8% risk reduction when compared to the control group of high-risk subjects not treated with the VIP. There were no medical complications secondary to the use of VIP, no increase in vancomycin-resistant enterococcus or vancomycin-resistant Staph aureus, and no cases of acute renal impairment secondary to application of the local vancomycin.

CONCLUSIONS

PJI remains a common complication of TJA, especially in high-risk populations. This study indicates that a protocol of dilute povidone-iodine lavage combined with topical vancomycin powder is safe and may reduce PJI incidence in high-risk TJA patients. Due to low, current PJI rates, a multi-institutional randomized controlled trial is necessary to assess interventions that minimize the risk of PJI.

LEVEL OF EVIDENCE

Retrospective Observational Cohort.

The effect of patient point of entry and Medicaid status on quality outcomes following total hip arthroplasty

Aims

Previous studies have reported an increased risk for postoperative complications in the Medicaid population undergoing total hip arthroplasty (THA). These studies have not controlled for the surgeon’s practice or patient care setting. This study aims to evaluate whether patient point of entry and Medicaid status plays a role in quality outcomes and discharge disposition following THA.

Methods

The electronic medical record at our institution was retrospectively reviewed for all primary, unilateral THA between January 2016 and January 2018. THA recipients were categorized as either Medicaid or non-Medicaid patients based on a visit to our institution’s Hospital Ambulatory Care Center (HACC) within the six months prior to surgery. Only patients who had been operated on by surgeons (CML, JV, JDS, RS) with at least ten Medicaid and ten non-Medicaid patients were included in the study. The patients included in this study were 56.33% female, had a mean age of 60.85 years, and had a mean BMI of 29.14. The average length of follow-up was 343.73 days.

Results

A total of 426 hips in 403 patients were included in this study, with 114 Medicaid patients and 312 non-Medicaid patients. Medicaid patients had a significantly lower mean age (54.68 years (SD 12.33) vs 63.10 years (SD 12.38); p < 0.001), more likely to be black or ‘other’ race (27.19% vs 13.46% black; 26.32% vs 12.82% other; p < 0.001), and more likely to be a current smoker (19.30% vs 9.29%; p = 0.001). After adjusting for patient risk factors, there was a significant Medicaid effect on length of stay (LOS) (rate ratio 1.129, 95% confidence interval (CI) 1.048 to 1.216; p = 0.001) and facility discharge (odds ratio 2.010, 95% CI 1.398 to 2.890; p < 0.001). There was no Medicaid effect on surgical time (exponentiated β coefficient 1.015, 95% CI 0.995 to 1.036; p = 0.136). There was no difference in 30-day readmission, 90-day readmission, 30-day infections, 90-day infections, and 90-day mortality between the two groups.

Conclusion

After controlling for patient variables, there was a statistically significant Medicaid effect on LOS and facility discharge. These results indicate that clinically similar outcomes can be achieved for Medicaid patients; however, further work is needed on maximizing social support and preoperative patient education with a focus on successful home discharge. Cite this article: Bone Joint J 2020;102-B(7 Supple B):78–84.

Preoperative Chronic Opioid Use and Its Effects on Total Knee Arthroplasty Outcomes

Unsafe opioid distribution remains a major concern among the total knee arthroplasty (TKA) population. Perioperative opioid use has been shown to be associated with poorer outcomes in patients undergoing TKA including longer length of stay (LOS) and discharges to extended care facilities. The current study aims to detail perioperative opioid use patterns and investigate the effects of preoperative chronic opioid use on perioperative quality outcomes in TKA patients. A retrospective analysis was performed on 338 consecutive TKAs conducted at our institution. Two cohorts were compared in this study-preoperative chronic opioid users and nonchronic opioid users. Opioid usage patterns and quality metrics were collected and analyzed over a 3-month preoperative and a 6-month postoperative period. Fifty-four (16.0%) preoperative chronic opioid users were identified out of the total 338 patients included in the study. Preoperative chronic opioid users experienced significantly longer LOS (2.9 vs 2.6 days; p = 0.026). Patients who remained persistent chronic users throughout the preoperative and postoperative stages demonstrated a significantly longer LOS (3.4 days vs 2.5 days; p = 0.017) compared with those who were no longer chronically using opioids by the 6 months postoperative period. By the 6 months postoperative time point, preoperative chronic users were consuming eight times the morphine-equivalents (mg/day) compared with nonchronic users (p < 0.001). Preoperative chronic opioid use was associated with substantially higher usage patterns throughout the postoperative stages. Such opioid use patterns were associated with longer LOS. Given that perioperative chronic opioid use has shown to negatively impact TKA outcomes, future studies refining current perioperative management strategies are warranted. This is a Level II, prognostic study.

Total Knee Arthroplasty Is Safe in Jehovah's Witness Patients-A 12-Year Perspective

Despite the evolution of blood management protocols, total knee arthroplasty (TKA) occasionally requires allogeneic blood transfusion. This poses a particular challenge for Jehovah's Witnesses (JW) who believe that the Bible strictly prohibits the use of blood products. The aim of this study was to compare JW and a matched-control cohort of non-JW candidates undergoing TKA to assess the safety using modern blood management protocols. Fifty-five JW patients (63 knees) who underwent TKA at our institution between 2005 and 2017 were matched to 63 non-JW patients (63 knees). Patient demographics, intraoperative details, and postoperative complications including in-hospital complications, revisions, and 90-day readmissions were collected and compared between the groups. Additionally, subgroup analysis was performed comparing JW patients who were administered tranexamic acid (TXA) between the two groups. Baseline demographics did not vary significantly between the study cohorts. The mean follow-up was 3.1 years in both the JW and non-JW cohorts. Postoperative complications, including in-hospital complications (7.9 vs. 4.8%; p = 0.47), revision TKA (1.6 vs. 1.6%; p = 1.00), and 90-day readmission (1.6 vs. 4.8%; p = 0.31) were not significantly different between the JW and non-JW groups. Subgroup analysis demonstrated JW patients who received TXA had a significantly lower decline in postoperative hemoglobin (Hgb) (8.6 vs. 14.0%; p < 0.01). At a follow-up of up to 12 years, JW patients who underwent TKA have outcomes equivalent to non-JW patients without the need for transfusion. Our findings support that surgeons are more likely to optimize JW patients preoperatively with iron and folate supplementation. Despite these variations in preoperative optimization efforts, no significant difference with regard to Hgb or hematocrit levels was demonstrated. Level of evidence is III, retrospective observational study.

Undetectable Hepatitis C Viral Load Is Associated With Improved Outcomes Following Total Joint Arthroplasty

BACKGROUND

Previous reports establish that infection with hepatitis C virus (HCV) predisposes total joint arthroplasty (TJA) recipients to poor postoperative outcomes. The purpose of the present study is to assess whether variation in HCV VL influences perioperative outcomes following TJA.

METHODS

A multicenter retrospective review of all patients diagnosed with HCV who underwent primary TJA between January 2005 and April 2018 was conducted. Patients were stratified into 2 cohorts: (1) patients with an undetectable VL (U-VL) and (2) patients with a detectable VL (D-VL). Kaplan-Meier survivorship analysis was calculated with revision TJA as the end point. Subanalysis on the VL profile was done.

RESULTS

A total of 289 TJAs were included (U-VL:118 TJAs; D-VL:171 TJAs). Patients in the D-VL cohort had longer operative times (133.9 vs 109.2 minutes), higher intraoperative blood loss (298.4 vs 219.5 mL), longer inpatient hospital stays (4.0 vs 2.9 days), more postoperative infections (11.7% vs 4.2%), and an increased risk for revision TJA (12.9% vs 5.1%). Kaplan-Meier demonstrated that the U-VL cohort trended toward better survivorship (P = .17). On subanalysis of low and high VL, no difference in outcomes was appreciated.

CONCLUSION

TJA recipients with a detectable HCV VL have longer operative times, experience more intraoperative blood loss, have longer hospital length of stay, and are more likely to experience infection and require revision TJA. The blood loss, hospital length of stay, and revision rate findings should be interpreted with caution, however, as there are confounding factors. Our findings suggest that HCV VL is a modifiable risk factor that, can reduce the risk of infection and revision surgery. Additionally, serum HCV VL was not correlated with outcomes.

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

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.

Manipulation under Anesthesia: Does Polyethylene Thickness Matter?

Total knee arthroplasty (TKA) has been established as the most effective treatment for end-stage, symptomatic osteoarthritis of the knee. However, improper polyethylene size selection has been proposed to predispose patients to postoperative stiffness following TKA. The aim of this study is to evaluate if there is a correlation between the use of the thinnest tibial implant thickness and implant manufacturer with the likelihood of undergoing manipulation under anesthesia (MUA). A retrospective review of unilateral TKAs performed between January 2012 and November 2015 was performed. Each knee implant system was normalized by total tibial component thickness for each individual implant system (metal back plus polyethylene) and reaggregated to assess the difference in MUA rates when comparing the thinnest tibial component thickness against the next two sizes. Subset analysis was performed comparing the thinnest tibial component thickness for each individual implant system versus (1) all other tibial component sizes and (2) tibial components one and two sizes larger. A total of 2,728 patients were retrospectively evaluated, of which 71 (2.60%) underwent MUA. Combined tibial component thickness ranged from 8 to 21 mm. When aggregated together to compare the MUA rate between the thinnest liner and the next two sizes, no statistically significant difference was observed (p = 1). Subset analysis demonstrated inconsistent significant differences in MUA rates. Our results suggest that the polyethylene liner thickness alone is not a predictor of postoperative knee stiffness necessitating MUA. When selecting a polyethylene liner, a proper fit maximizing flexion/extension stability is the most crucial factor.

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

BACKGROUND

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a nationally standardized tool to assess patient experience between hospitals. The HCAHPS survey can affect hospital reimbursement. This study aims to determine if HCAHPS scores vary by a number of demographic variables in patients undergoing primary total knee arthroplasty (TKA).

METHODS

Patients who underwent primary TKA and returned a completed HCAHPS survey were included in this study. HCAHPS surveys were collected from our institution's Center for Quality and Patient Safety department, which was cross-referenced with our hospital's electronic data warehouse. Patient demographics, surgical factors, and quality outcomes were queried, and multivariable linear regression was performed.

RESULTS

In total, 1028 HCAHPS questionnaires after primary TKA were evaluated. The average age of patients was 65.9 ± 9.0 years and 67.9% (698 patients) were female. Average body mass index was 32.5 ± 6.9 kg/m². Sixty-nine percent of the patients (1287 patients) were discharged home versus 10.3% (106 patients) to another facility. Mean length of stay was 2.9 ± 1.4 days. Age was correlated with a 0.3% decrease in top-box response rate (P < .01) for each 1-year increase in age. Compared to Caucasian race, African American race was correlated with a 5.6% increased rate for top-box response (P < .01), while Asian race (P = .42) and unknown race (P = 1.00) demonstrated no significant difference. Marital status demonstrated that divorced/separated status resulted in a significant 5.4% decrease in top-box response rates (P < .05). Similarly, single (P = .12) and widowed (P = .09) statuses also demonstrated a trend toward lower top-box response rates when compared to married or partnered patients. For each day increase in length of stay, HCAHPS top-box response rates decrease by 1.6% (P < .01). Gender, body mass index, smoking status, insurance type, and discharge disposition were not found to be significantly correlated with HCHAPS top-box response rate (P > .05).

CONCLUSION

HCAHPS scores in patients undergoing primary TKA are influenced not just by hospital and surgeon factors such as length of stay but by demographic variables such as age, race, and marital status. As surgeons become more involved with the burden of improving patient experience, they should be aware that static demographic variables can have a significant effect on HCAHPS scores.

Revision Versus Primary Hospital Consumer Assessment of Healthcare Providers and Systems Scores in Total Joint Arthroplasty

BACKGROUND

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score is a nationally standardized measure of a patient's inpatient experience. This study aims to assess whether HCAHPS scores differ between patients undergoing primary total joint arthroplasty (TJA) and patients undergoing revision TJA.

METHODS

Patients who underwent primary or revision total hip or total knee arthroplasty (THA or TKA) and returned a completed HCAHPS survey were included in this study. HCAHPS scores were collected from our institution's Center for Quality and Patient Safety department, which was cross-referenced with our hospital's electronic data warehouse. Patient demographics, surgical factors, and quality outcomes were queried. Appropriate statistical analyses were performed using MatLab 2017a and P-values less than .05 were deemed significant.

RESULTS

In total, 523 primary and 59 revision THA recipients completed HCAHPS surveys at our institution between October 2011 and November 2016. During this same period, 507 primary TKA recipients and 40 revision TKA recipients completed HCAHPS surveys. Compared to revision THA, primary THA patients had a significantly higher top box for overall hospital ratings (58.46% vs 41.38%), felt that nurses listened to them carefully (84.3% vs 72.88%), and felt that they clearly understood the role of each medication (69.48% vs 56.90%). Moreover, 18 of 20 HCAHPS question responses favored primary THA despite not reaching significance for the majority of HCAHPS questions. Patients with revision TKA demonstrated a significantly higher incidence of "top box" choices for quieter rooms and a trend favoring better HCAHPS scores in revision TKA in a further 12 of 20 HCAHPS responses.

CONCLUSION

Patients undergoing primary THA report higher HCAHPS scores than those undergoing revision THA, while revision TKA demonstrated a general trend toward higher scores when compared to primary TKA patients. This publicly reported quality measurement metric which factors into physician reimbursement may be biased by the patient's health status, the complexity of the surgical procedure, and length of stay in hospital rather than a true reflection of the quality of their hospital experience.

Modifying Patient Expectations Can Enhance Total Hip Arthroplasty Postoperative Satisfaction

BACKGROUND

A better understanding of patient expectations within the perioperative setting will enable clinicians to better tailor care to the needs of the total hip arthroplasty (THA) recipient. Such an approach will promote patient-centered decision-making and optimize recovery times while enhancing mandated hospital quality metrics. In the present study, we preoperatively and postoperatively surveyed THA candidates to elucidate the relationship between patient expectations and length of stay (LOS).

METHODS

This is a multi-institutional prospective study among THA candidates. Patients were surveyed regarding discharge planning 1 week preoperatively and postoperatively to capture perioperative patient expectations and correlate with inpatient LOS.

RESULTS

In total, 93 THAs performed by 6 high-volume orthopedic surgeons at 2 medical centers. Our results demonstrated that patients of male gender and commercial insurance had significantly (P < .05) shorter LOS. Shorter LOS patients demonstrated significantly higher levels of LOS acceptance ("very comfortable" rate in same-day discharge: 75.0% and next-day discharge: 63.8%; 2 days: 40.7%; 3+ days: 42.9%; P < .05) and a higher likelihood to participate in SDD programs. Postoperatively, patients with a shorter LOS had more acceptance to their LOS, albeit not statistically significant (P = .20).

CONCLUSION

Our results suggest that guiding patient expectations within the perioperative setting is an essential component for successful and timely discharge after THA. Having clear and transparent discussion with the surgical team regarding the perioperative course can improve a THA candidate's understanding and buy-in with the postoperative plan, regardless of LOS. Finally, inpatient LOS does not appear to affect patient satisfaction.

LEVEL OF EVIDENCE

Level II, prospective observational study.

Arthrofibrosis After Total Knee Arthroplasty: Pathophysiology, Diagnosis, and Management

Arthrofibrosis is the pathologic stiffening of a joint caused by an exaggerated inflammatory response. As a common complication following total knee arthroplasty (TKA), this benign-appearing connective tissue hyperplasia can cause significant disability among patients because the concomitant knee pain and restricted range of motion severely hinder postoperative rehabilitation, clinical outcomes, and basic activities of daily living. The most effective management for arthrofibrosis in the setting of TKA is prevention, including preoperative patient education programs, aggressive postoperative physical therapy regimens, and anti-inflammatory medications. Operative treatments include manipulation under anesthesia, arthroscopic debridement, and quadricepsplasty.

Perioperative Orthopedic Surgical Home: Optimizing Total Joint Arthroplasty Candidates and Preventing Readmission

BACKGROUND

It is well recognized that unplanned readmissions following total joint arthroplasty (TJA) are more prevalent in patients with comorbidities. However, few investigators have delayed surgery and medically optimized patients prior to surgery. In its current form, the Perioperative Orthopedic Surgical Home (POSH) is a surgeon-led screening and optimization initiative targeting 8 common modifiable comorbidities.

METHODS

A total of 4188 patients who underwent TJA between January 2014 and December 2016 were retrospectively screened by the Readmission Risk Assessment tool (RRAT) score. one thousand one hundred and ninety four subjects had a preoperative RRAT score ≥3 and were eligible for inclusion. Patients were then separated into 2 cohorts based on whether they were enrolled into the POSH initiative (POSH; n = 216) or continued with surgery (non-POSH; n = 978) despite their risk.

RESULTS

Since the implementation of the POSH initiative, patients with RRAT scores ranging from 3 to 5 have experienced lower 30-day (1.6% vs 5.3%, P = .03) and 90-day (3.2% vs 7.4%, P < .05) readmission rates when compared to the non-POSH cohort. Only 15.3% of medically optimized patients enrolled in the POSH initiative were discharged to a post-acute care facility, whereas 23.4% of non-POSH patients were discharged to a post-acute care facility (P = .01). There were no differences in length of stay and infection rates between the 2 cohorts. Moreover, 90-day episode-of-care costs were 14.9% greater among non-POSH Medicare TJA recipients and 32.6% higher if a readmission occurred.

CONCLUSION

The identification and medical optimization of comorbidities prior to surgical intervention may enhance the value of care TJA candidates receive. A standardized multidisciplinary approach to the medical optimization of high-risk TJA candidates may improve patient engagement and perioperative outcomes, while reducing cost associated with TJA.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Study.

The preoperative management of Hepatitis C may improve the outcome after total knee arthroplasty

AIMS

With an ageing population of patients who are infected with hepatitis C virus (HCV), the demand for total knee arthroplasty (TKA) in this high-risk group continues to grow. It has previously been shown that HCV infection predisposes to poor outcomes following TKA. However, there is little information about the outcome of TKA in patients with HCV who have been treated successfully. The purpose of this study was to compare the outcomes of TKA in untreated HCV patients and those with HCV who have been successfully treated and have a serologically confirmed remission.

PATIENTS AND METHODS

A retrospective review of all patients diagnosed with HCV who underwent primary TKA between November 2011 and April 2018 was conducted. HCV patients were divided into two groups: 1) those whose HCV was cured (HCV-C); and 2) those in whom it was untreated (HCV-UT). All variables including demographics, HCV infection characteristics, surgical details, and postoperative medical and surgical outcomes were evaluated. There were 64 patients (70 TKAs) in the HCV-C group and 63 patients (71 TKAs) in the HCV-UT cohort. The mean age at the time of surgery was 63.0 years (sd 7.5; 44 to 79) in the HCV-C group and 61.7 years (sd 6.9; 47 to 88) in the HCV-UT group.

RESULTS

HCV-UT patients had a significantly longer mean hospital stay (3.4 days vs 2.9 days; p = 0.04), were more likely to be transferred to the intensive care unit (14.1% vs 4.3%; p = 0.04), and were significantly more often discharged to a post-acute care facility (39.4% vs 14.3%; p < 0.01). HCV-UT patients had significantly more postoperative infections (15.5% vs 4.3%; p = 0.03), surgical complications (21.1% vs 7.1%; p = 0.02), and revision TKA (12.7% vs 1.4%; p < 0.01) than HCV-C patients.

CONCLUSION

The preoperative treatment of HCV can reduce the risk of complications, including prosthetic joint infection and revision TKA. We recommend that HCV treatment regimens should be integrated into the preoperative optimization protocol for this high-risk group of patients. Cite this article: Bone Joint J 2019;101-B:667-674.

A dedicated revision total knee service: a surgeon’s perspective

AIMS

Revision total knee arthroplasty (rTKA) accounts for approximately 5% to 10% of all TKAs. Although the complexity of these procedures is well recognized, few investigators have evaluated the cost and value-added with the implementation of a dedicated revision arthroplasty service. The aim of the present study is to compare and contrast surgeon productivity in several differing models of activity.

MATERIALS AND METHODS

All patients that underwent primary or revision TKA from January 2016 to June 2018 were included as the primary source of data. All rTKA patients were categorized by the number of components revised (e.g. liner exchange, two or more components). Three models were used to assess the potential surgical productivity of a dedicated rTKA service : 1) work relative value unit (RVU) versus mean surgical time; 2) primary TKA with a single operating theatre (OT) versus rTKA with a single OT; and 3) primary TKA with two OTs versus rTKA with a single OT.

RESULTS

In total, 4570 procedures were performed: 4128 primary TKAs, 51 TKA liner exchanges, and 391 full rTKAs. Surgical time was significantly different between the primary TKA, liner exchange, and rTKA cohorts (100.6, 97.1, and 141.7 minutes, respectively; p < 0.001). Primary TKA yielded a mean of 7.1% more RVU/min per procedure than rTKA. Our one-OT model demonstrated that primary TKA (n = 4) had a 1.9% RVU/day advantage over rTKA (n = 3). If two OTs are used for primary TKA (n = 6), the outcome strongly favours primary TKA by an added 34.6% RVUs/day.

CONCLUSION

Our results suggest that a dedicated rTKA service would lead to lower surgeon remuneration based on the current RVU paradigm. Revision arthroplasty specialists may need additional or alternative incentives to promote the development of a dedicated revision service. Through such an approach, healthcare organizations could enhance the quality of care provided, but surgeon productivity measures would need to be adjusted to reflect the burden of these cases. Cite this article: Bone Joint J 2019;101-B:675-681.

Total Hip Arthroplasty in Human Immunodeficiency Virus-Positive Patients: A Concise Follow-Up at 10 to 14 Years

BACKGROUND

Advancements in the management of human immunodeficiency virus (HIV) now permit HIV-positive patients to have longer life spans, increasing their cumulative risk of developing an advanced degenerative joint disease, necessitating total hip arthroplasty (THA). The purpose of this study was to provide an extended follow-up on a previously published study on a cohort of HIV-positive THA recipients in an effort to confirm the safety and longevity of THA in this population.

METHODS

This study is a follow-up on a previous study comprised of 41 hips in 31 HIV-positive THA recipients. At this follow-up, 5 patients from the original cohort required contralateral THA. Postoperative complications were recorded up to the patient's last follow-up date. A survivorship analysis was performed using the Kaplan-Meier method with revision THA as the end point.

RESULTS

Since the last report, 2 additional hips were revised (one for aseptic loosening and one for a periprosthetic fracture), and 5 patients underwent contralateral THA. This resulted in a total of 5 (13.8%) hips requiring revision THA at the latest follow-up. The mean follow-up interval for the original cohort and for the contralateral 5 hips was 78.9 ± 50.2 months and 54.6 ± 45.3 months, respectively. Kaplan-Meier survivorship analysis with revision THA for any reason as the end point demonstrated survivorship of 93% (2 years), 90% (5 years), and 81% (10 and 14 years) after primary THA, respectively.

CONCLUSION

Our study suggests that it is possible to achieve a low incidence of postoperative infection in HIV-positive THA recipients. In addition, our study demonstrates that non-hemophiliac HIV-positive patients have comparable revision rates to previously published reports on HIV-negative patients of similar age, underscoring the clinical efficacy of highly active antiretroviral therapy.

Payer type does not impact patient-reported outcomes after primary total knee arthroplasty

Background

There is a paucity of literature assessing whether payer type has an impact on postoperative patient-reported outcomes (PROs) after total knee arthroplasty (TKA). The aim of this study was to comparatively evaluate TKA PROs among patients with commercial and Medicare insurance.

Methods

We conducted a single-center, retrospective review of patients operated between January 2017 and March 2018. Knee Disability and Osteoarthritis Outcome Score Junior (KOOS-Jr) and Veterans RAND 12 Health Survey (VR-12) Physical Component (VR-12 PCS) and Mental Component (VR-12 MCS) PRO scores were collected prospectively at baseline and 12 weeks postoperatively via an electronic patient rehabilitation application. Univariable and multivariable linear regressions were utilized to assess the effects of patient insurance type on PRO.

Results

In total, 193 TKA candidates had commercial (n = 91) or Medicare (n = 102) as their primary payer type. Demographic variables including age, gender, body mass index, and race varied significantly between the cohorts (P < .05). Length of stay and discharge disposition also varied significantly (P < .05). When compared with commercial payers, Medicare beneficiaries demonstrated a 4.13 ± 2.06 increase in Knee Disability and Osteoarthritis Outcome Score JR. scores at baseline (P < .05). However, after adjusting for patient-specific demographic and perioperative variables, all PROs recorded in this study were similar between the 2 payer groups at baseline and 12 weeks postoperatively (P > .05). Furthermore, ΔPRO scores from baseline to 12 weeks were also similar (P > .05).

Conclusions

After adjusting for patient-specific variables, PROs are similar at baseline and 12 weeks postoperatively between commercial and Medicare cohorts. For TKA candidates with similar baseline demographics, surgeons can expect similar perioperative PROs regardless of insurance type.

Preoperative optimization for vascular involvement complicating revision total hip arthroplasty

Vascular complications in revision total hip arthroplasty may occur in cases where the components of the hip implant migrate through the acetabular wall, through the iliopectineal line of the pelvis, and into the pelvic cavity. This migration may lead to substantial intrapelvic vascular compromise, drastically increasing the surgical complexity and potential risk for morbidity and mortality in these surgical cases. Here, we present a case of a 78-year-old woman with significant acetabular protrusio, which resulted in intraoperative compromise of the external iliac artery with rapid extravasation. As a result of prudent preoperative planning, interdisciplinary collaboration, and precautionary measures, significant patient morbidity and mortality was averted.

Level of Evidence

Level V, Case Report.

Liner dissociation leading to catastrophic failure of an Oxinium femoral head

Oxinium is an alternative bearing surface designed to emulate the superior wear and scratch properties of ceramic femoral heads in total hip arthroplasty while minimizing the risk for brittle fracturing. However, recent studies have indicated that hip dislocation following total hip arthroplasty may be a risk factor for catastrophic failure of the femoral head. Here, we report on a novel case of a catastrophic Oxinium head and polyethylene liner failure in the absence of previous hip dislocation or trauma and review the probable failure mechanism. This report underscores the need to be vigilant about proper acetabular cup and liner seating, particularly in the setting of Oxinium femoral head use. In the event of Oxinium head failure, metallosis may compromise stabilizing soft tissues including the abductors. Dual-mobility articulation, which was successful in this case, is one option to consider when the risk for chronic redislocation is elevated.

Outpatient Total Hip Arthroplasty Has Minimal Short-Term Complications With the Use of Institutional Protocols

BACKGROUND

Interest in outpatient/same-day discharge (SDD) total hip arthroplasty (THA) has been increasing over the last several years. There is considerable debate in the literature regarding the complication and readmission rates of these patients. To evaluate and validate the safety and efficacy of our institutional SDD THA care pathway, we compared the outcomes of patients undergoing SDD THA with patients who had a similar comorbidity profile and underwent inpatient THA.

METHODS

A retrospective review was conducted on 164 patients who underwent SDD THA from January 2015 to September 2016. The Risk of Readmission Tool, a validated risk stratification instrument, was applied to all inpatient THAs performed from June 2014 to December 2016. A cutoff Risk of Readmission Tool score < 3 was used to produce a cohort of 1858 inpatient THA patients, all of whom had a similar risk profile to patients who underwent SDD THA. Medicare patients were excluded from the inpatient THA cohort, which left a final inpatient sample of 1315 patients. Each cohort was evaluated for demographic variables, length of stay, 30-/90-day readmissions, and discharge disposition.

RESULTS

The SDD THA cohort had significantly lower body mass index (26.9 vs 28.2 kg/m²; P = .002), had fewer minorities (89.6% vs 66.3% Caucasians; P < .001), was exclusively commercial insurance (100% vs 36.3%), had a shorter length of stay (0.37 vs 2.3 days, P < .001), and was exclusively discharged home (100% vs 92.6%). There was no statistically significant difference in 30-day readmission rates between either cohort (SDD 0.6% vs inpatient 1.6%; P = .325). However, the SDD cohort had a significantly lower rate of 90-day readmissions than the inpatient cohort (0.6% vs 3.6%; P = .014).

CONCLUSION

The use of an institutional SDD THA care pathway can produce results with equivalent or better short-term outcomes than that of traditional inpatient THA.