Lower Revenue Surplus in Medicare Advantage Versus Private Commercial Insurance for Total Joint Arthroplasty: An Analysis of a Single Payor Source at One Institution

BACKGROUND

Since the Affordable Care Act was passed in 2010, reductions in Medicare reimbursement have led to larger discrepancies between the relative cost of Medicare patients and privately insured patients. The purpose of this study was to compare reimbursement between Medicare Advantage and other insurance plans in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

Patients of a single commercial payor source who underwent primary unilateral TKA or THA at 1 institution between the dates of January 4 and June 30, 2021, were included (n = 833). Variables included insurance type, medical comorbidities, total costs, and surplus amounts. The primary outcome measure was revenue surplus between Medicare Advantage and Private Commercial plans. t-tests, Analyses of Variance, and Chi-Squared tests were used for analysis. A THA represented 47% of cases and a TKA 53%. Of these patients, 31.5% had Medicare Advantage and 68.5% had Private Commercial insurance. Medicare Advantage patients were older and had higher medical comorbidity risk for both TKA and THA.

RESULTS

Significant differences were observed in medical costs between Medicare Advantage and Private Commercial insurance for THA ($17,148 versus $31,260, P < .001) and TKA ($16,723 versus $33,593, P < .001). Additionally, differences were seen in surplus amounts between Medicare Advantage and Private Commercial insurance for THA ($3,504 versus $7,128, P < .001) and TKA ($5,581 versus $10,477, P < .001). Deficits were higher in Private Commercial patients undergoing TKA (15.2 versus 6%, P = .001).

CONCLUSION

The lower average surplus associated with Medicare Advantage plans may lead to financial strain on provider groups who care for these patients and face additional overhead costs.

Orthopedic Surgery Residencies: The Leap to Social Media

Social media has been previously shown to influence applicants' perception of plastic surgery residencies and increase their likelihood to apply, interview, and rank the program. We wanted to analyze this hypothesized trend in the context of orthopedic surgery residency while also characterizing the content of orthopedic surgery residency program accounts. A current list of US orthopedic residency programs was acquired from the American Orthopaedic Association and cross-referenced with the Accreditation Council for Graduate Medical Education webpage of all orthopedic surgery residencies. Forty-five of 185 (24%) residencies had residency-specific Instagram accounts. We analyzed the number of followers, the number of posts, and the date of the first post for each account. We characterized content by categories including science education, recruitment or hospital promotion, resident highlight, news coverage, events, and community building posts. We analyzed the "social currency" of each post and program, tracking the number of likes, comments, and followers. Twenty-seven of 45 (60%) active residency Instagram pages were created in 2020, with 13 of 45 (29%) pages created in June 2020 alone. Residency programs are increasingly turning to Instagram to showcase the residents at their programs, their lifestyles, and program strengths. Sixty percent of all orthopedic residency Instagram accounts were created in 2020 alone, likely precipitated by travel concerns from COVID-19 forcing programs to conduct online interviews and cancel away rotations this application cycle. Going forward, residency programs will continue using Instagram to recruit potential residents, leaving programs without social media accounts at a relative disadvantage in terms of visibility and their ability to recruit qualified applicants. [Orthopedics. 2023;46(5):e281-e286.].

Effects of Venous Insufficiency in Patients Undergoing Primary Total Knee Arthroplasty: An Analysis of 1.2 Million Patients

Chronic venous insufficiency (CVI) is extraordinarily prevalent in our aging population with over 30 million people in the United States suffering from the disease. There is a paucity of data analyzing the effects of CVI on outcomes following total knee arthroplasty (TKA). The purpose of this study was to utilize a nationwide administrative claims database to determine whether patients with CVI undergoing TKA have higher rates of: (1) in-hospital lengths of stay (LOS); (2) readmission rates; (3) medical complications; (4) implant-related complications; and (5) costs of care compared to controls. Using a nationwide database, we matched patients with CVI undergoing TKA to controls without CVI undergoing TKA in a 1:5 ratio by age, sex, and medical comorbidities associated with CVI. Primary outcomes analyzed within the study included LOS, 90-day readmission rates, 90-day medical complications, 2-year implant-related complications, in addition to 90-day total global episode of care costs. The query yielded 1,265,534 patients with (n = 210,926) and without (n = 1,054,608) CVI undergoing primary TKA. Patients with CVI had significantly longer LOS (4 vs. 3 days, p < 0.0001), higher 90-day readmission rates (20.96 vs. 15.34%; odds ratio [OR]: 1.46, 95% confidence interval [CI]: 1.44-1.48, p < 0.0001), and higher odds of medical complications (2.27 vs. 1.30%; OR: 1.76, 95% CI: 1.70-1.83, p < 0.0001) compared to matched controls. Patients with CVI also had higher odds of periprosthetic joint infections (2.23 vs. 1.03%; OR: 2.18, p < 0.0001) and implant-related complications in general (4.27 vs. 2.17%; OR: 2.01, 95% CI: 1.96-2.06, p < 0.0001). Additionally, patients with CVI had higher total global 90-day episode of care costs ($15,583.07 vs. $14,286.95, p < 0.0001). Patients with CVI undergoing TKA have increased LOS, higher odds of medical and implant complications, and increased costs of care compared to those without CVI. The study can be utilized by orthopaedic surgeons to counsel patients on the potential complications following this procedure. This is a level III, retrospective cohort study.

Characteristics and trends of the most cited papers in robotic assisted arthroplasty

Purpose

To compile and analyze the top 50 most frequently cited articles published on robotic-assisted arthroplasty, allowing clinicians to effectively identify the most influential literature pertaining to this topic.

Methods

Guidelines set by the Preferred Reporting Items for Systematic Reviews were used as the foundation for data collection and analysis. All papers pertaining to robotic-assisted arthroplasty were retrieved using the Scopus database. Data including: manuscript title, authors, total citation count, level of evidence, journal, publication year, and country of publication was extracted from a final list of articles.

Results

The top 50 publications regarding robotic assisted arthroplasty were cited a total of 4530 times (including self-citations), with an average total of 91. The years with the most publications in the top 50 were: 2017, 2018, and 2019, producing 7, 6, and 5 papers, respectively. Only 4 papers in the top 50 were published prior to the year 2003. The most common level of evidence was level V, and the most common category was Clinical Outcomes (74%). The United States contributed half of the 50 articles, and Princess Grace Hospital and University of London were the most contributory institutions, each with 6 of the top 50 articles.

Conclusion

This analysis provides a comprehensive review of the most cited and influential papers in robotic-assisted arthroplasty. Understanding these trends in the literature will ultimately pave the way for physicians and researchers to continue to innovate and research in a targeted manner as they gain an understanding of what has been studied and what remains inadequately explored.

Level of evidence

3.

The Biomechanical Burden of Orthopaedic Procedures and Musculoskeletal Injuries Sustained by Surgeons: A Systematic Review

Category:

Other; Trauma

Introduction/Purpose:

Orthopaedic surgeons are at high risk for experiencing work-related musculoskeletal injuries and chronic pain. This is largely due to daily exposure to repetitive large magnitude forces, altered posture from the use of leaded vests, and prolonged standing often in irregular body positions. We sought to synthesize available evidence regarding 1) the biomechanics of orthopaedic surgery and 2) musculoskeletal injuries sustained by orthopaedic surgeons with subsequent treatment and consequences.

Methods:

To conduct this systematic review, we queried four databases (PubMed, Embase, MEDLINE, and Web of Science) for original research studies presenting on the biomechanics of orthopaedic surgery or musculoskeletal injuries sustained by orthopaedic surgeons. Studies were excluded if they were not original research (i.e., reviews) or reported on injuries to patients, non-musculoskeletal injuries, or non-orthopaedic subspecialties. The literature search yielded 3,202 publications, 36 of which were included in the final analysis.

Results:

Eight studies reported on the biomechanics of orthopaedic surgery. Surgeons spent an average 41.6% of time slouched during surgeries. Head and whole spine angles were closest to natural standing position when using a microscope for visualization and with higher surgical field heights. Use of lead aprons resulted in a shifted weight distribution on the forefoot, gain in thoracic kyphosis, and increase in lateral deviation from postural loading. Twenty-eight studies reported on musculoskeletal conditions experienced by orthopaedic surgeons. The overall prevalence of musculoskeletal symptoms or injury involving any body region ranged from 44-97%. Prevalence by body region in decreasing order were as follows: lower back (15.2-89.5%), hip/thigh (4.4- 86.6%), neck (2.4-74%), hand/wrist (10.5-54%), shoulder (7.1-48.5%), elbow (3.1-28.3%), knee/lower leg (7.9-27.4%), and foot/ankle (7-25.7%). Of surgeons with any reported musculoskeletal symptom or injury, 27-65.7% required nonoperative treatment, 3.2- 34.3% required surgery, and 33.3-59.3% indicated that their operative performance was affected.

Conclusion:

The orthopaedic surgeon population experiences a high prevalence of musculoskeletal symptoms and injuries, likely secondary to the biomechanical burdens of tasks required of them during strenuous operations. Ergonomic interventions must be taken within the operating room to reduce this prevalence, increase the physical well-being of orthopaedic surgeons, and reduce the healthcare costs associated with time off work and early retirement as a result of musculoskeletal conditions.

The 50 Most-Cited Articles Regarding Hip Resurfacing

Background

Hip resurfacing arthroplasty is an accepted treatment option for young patients presenting with osteoarthritis of the hip. The purpose of this review was to evaluate and identify the top 50 most-cited articles pertaining to hip resurfacing, to help clinicians identify influential articles and navigate the literature more effectively.

Material and methods

Clarivate Analytics Web of Science was used to identify all articles related to hip resurfacing. The screening was based on the number of citations for each article. The final list of articles was further reviewed, and further data including manuscript title, authors, total citation count, year of publication, journal, country of origin, and level of evidence were extracted.

Results

The most-cited publication was “Pseudotumors associated with metal-on-metal hip resurfacings”, which was cited 704 times. The average total number of citations per publication was 203. The most prolific publication year was 2008 with 8 publications, and the most recent article was published in 2012. The journals with the most attributable publications were Journal of Bone and Joint Surgery and Clinical and Orthopedic Related Research.

Conclusions

This review provides a comprehensive analysis of the most-cited articles pertaining to hip resurfacing.

Level of evidence

III.

Electric scooters as a source of orthopedic injuries at a Level-I trauma center

Introduction

Electric scooter rentals are offered by major ridesharing companies as a new and alternative method for urban travel in major metropolitan areas. The correlation between motorized electric scooter rental services and orthopedic injuries has not been well scrutinized. The purpose of our study is to evaluate orthopedic injuries sustained by motorized scooter riders and their potential correlation with patient demographics and associated injuries.

Methods

We retrospectively reviewed level 1 trauma center patients with orthopedic injuries sustained while riding motorized electric scooters from 4/2019-11/2019. Demographics, fracture characteristics, and patient management were examined.

Results

Sixty-two patients sustained 86 orthopedic injuries. There were 56 (65.1%) upper extremity and 29 (33.7%) lower extremity injuries. Six patients (9.7%) suffered open injuries and 30 (48.4%) sustained injuries that required surgery. Anatomic location of the injury was associated with both the presence of open fracture and needing surgery (P = 0.016 and P less than 0.001, respectively). Also, the presence of multiple orthopedic injuries was associated with the need for surgery (P less than 0.001). Scooter collision events were significantly associated with multiple orthopedic and the presence of non-orthopedic injuries (P less than 0.01 and P less than 0.01).

Conclusion

Electric scooter accidents can result in orthopedic injuries, many of which require surgery. Caution should be exercised when riding electric scooters, and special attention should be given by trauma centers and emergency departments to patients who present after electric scooter injury as the potential for orthopedic injury is high with this mechanism of injury.

Nationwide analysis on the impact of peripheral vascular disease following primary total knee arthroplasty: A matched-control analysis

BACKGROUND

As the prevalence of peripheral vascular disease (PVD) continues to increase nationwide, studies demonstrating its effects following primary total knee arthroplasty (TKA) are limited. Therefore, the purpose of this study was to evaluate whether patients with PVD have higher rates of: 1) in-hospital lengths of stay (LOS); 2) readmissions; 3) medical complications; 4) implant-related complications; and 5) costs of care.

METHODS

Using a nationwide database, patients with PVD undergoing primary TKA were identified and matched to controls in a 1:5 ratio by age, sex, and medical comorbidities. The query yielded 1,547,092 between the cohorts. Outcomes analyzed included: in-hospital LOS, readmission rates, complications, and costs of care. A p-value less than 0.004 was considered statistically significant.

RESULTS

PVD patients had significantly longer in-hospital LOS (4-days vs. 3-days, p < 0.0001). Additionally, the study cohort had a higher incidence and odds (OR) of readmissions (20.5 vs. 15.2%; OR: 1.43, 95% CI: 1.42-1.45, p < 0.0001), medical complications (2.46 vs. 1.32%; OR: 1.88, CI: 1.83-1.94, p < 0.0001), and implant-related complications (3.82 vs. 2.18%; OR: 1.78, CI: 1.26-1.58, p < 0.0001). Additionally, the study found patients with PVD had higher day of surgery (p < 0.0001) and 90-day costs of care (p < 0.0001).

CONCLUSIONS

After adjusting for confounding variables the results of the study show patients with PVD undergoing primary TKA have longer in-hospital LOS; in addition to higher rates of complications, readmissions, and costs of care. The study can be utilized by orthopaedists to adequately counsel patients of the potential complications following their procedure.

Thromboprophylaxis across orthopaedic surgery: Bibliometric analysis of the most cited articles

PURPOSE

One of the most common adverse events after orthopaedic surgery, with a potential for subsequent serious morbidity and mortality is venous thromboembolism (VTE). Bibliometric analysis has been performed regarding many topics and across orthopaedics. As DVT prophylaxis is a major component of both orthopaedic surgery considerations and research, a bibliometric analysis in this area would prove beneficial in not only in understanding the research done in the field thus far, but would also direct future research efforts.

METHODS

The Web of Science (WoS) database from the Institute of Scientific Information (ISI) was used to compile articles for bibliometric analysis using Boolean search: ((Orthopaedic∗ OR Orthopaedic∗) AND (thromboprophylaxis OR Thromboembolism OR Deep vein thrombosis OR thrombus OR embolism OR anticoagulation OR Embolus OR prophylaxis)).

RESULTS

The Top 100 cited articles included in the final list generated a total of 21,099 citations. The highest cited article was Prevention of venous thromboembolism by Geerts et al. published in Chest, which had a total of 2802 on WoS, and a calculated citation density of 215.54 of citations/years since publication. Comparing the overall citation against the year of publication there was a slight positive trend favoring more recent publications (R-value: 0.142; adjusted R-squared: 0.01; p = 0.16). Analysis of an articles Level of Evidence (LOE), 17 were grade with a level of I.

CONCLUSIONS

Orthopaedic thromboprophylaxis is an ever-changing field that is at the forefront of orthopaedic literature. The significant trend favoring high quality research within orthopaedic thromboprophylaxis demonstrates the importance of this topic and there was a need for a guide to best understand the evolution of DVT prophylaxis.

Unicondylar Knee Arthroplasty: A Bibliometric Analysis of the 50 Most Commonly Cited Studies

Background

Unicondylar knee arthroplasty (UKA) is an accepted treatment option for unicompartmental femorotibial degeneration and is gaining in popularity. The goal of this review is to evaluate the top 50 most cited articles pertaining to UKA to better help surgeons understand the trends, identify influential articles, and navigate this body of literature more effectively.

Methods

The Institute for Scientific Information Web of Knowledge database was used to identify all articles related to UKA. The initial screening was based on the number of citations for each article. The list was then refined to include only peer-reviewed original articles, review articles, or editorials. Data were extracted from the articles to rank the articles in the descending order from the most citations to the least.

Results

Initial search yielded 1844 articles. Fifty were identified to match the study criteria. The highest ranked article was cited a total of 463 times, whereas the lowest ranked article was cited 101 times. The average total number of citations per publication was 162. The earliest article on the list was published in 1978. The majority of publications assessed long-term outcomes of UKA (n = 6, 52%). The majority of articles were graded a level of evidence of III (n = 21 42%), whereas only 3 articles were graded a level I.

Conclusions

This review provides a quantitative analysis of the most-cited literature pertaining to UKA, which has a paucity of level I studies.

Solitary Osteochondroma of the Spine-A Case Series: Review of Solitary Osteochondroma With Myelopathic Symptoms

STUDY DESIGN

Case series and literature review.

OBJECTIVE

There is a growing body of literature supporting that osteochondroma of the spine may not be as rare as previously documented. The purpose of this study was to perform an updated review and present our experience with 4 cases of solitary osteochondroma of the spine, including surgical treatment and subsequent outcomes.

METHODS

A review of 4 cases and an updated literature review.

RESULTS

All 4 cases were diagnosed as solitary osteochondroma of the spine based on clinical and histopathologic findings. Majority of the lesions arose from the posterior column with one case showing extension into the middle column with clinical neurologic sequelae. Treatment strategies for all cases included complete marginal excision of the lesions using a posterior approach. All 4 cases showed no radiographic evidence of recurrence. The literature review yielded 132 cases of solitary osteochondroma and 17 case associated with multiple hereditary exostosis. Out of the 132 cases, 36 presented with myelopathic symptoms.

CONCLUSION

Osteochondroma of the spine may not be as rare as previously reported. The best approach to treatment in almost all symptomatic cases include wide surgical excision of the tumor. This should include complete resection of the cartilaginous cap of the tumor in an effort to prevent recurrence. When excision is performed properly, the outcomes are excellent with very low recurrence of the tumor.

Surgical Wound Classification and Surgical Site Infections in the Orthopaedic Patient

INTRODUCTION

The Centers for Disease Control and Prevention created a surgical wound classification system (SWC: I, clean; II, clean/contaminated; III, contaminated; and IV, dirty) to preemptively identify patients at risk of surgical site infection (SSI). The validity of this system is yet to be demonstrated in orthopaedic surgery. We hypothesize a poor association between the SWC and the rate of subsequent SSI in orthopaedic trauma cases.

METHODS

Nine hundred fifty-six orthopaedic cases were reviewed. Wounds were risk stratified intraoperatively using the SWC grades (I-IV). SSI was diagnosed clinically or with objective markers. The SWC was compared with SSI rates using a Fisher exact test. Significance was set at P < 0.05.

RESULTS

Four hundred patients met the selection criteria. The rate of infection was not significantly different across the SWC grades (P = 0.270). There was a significantly higher risk of SSI among patients with diabetes (P = 0.028).

CONCLUSIONS

The Centers for Disease Control and Prevention SWC showed poor utility in predicting and risk stratifying postoperative SSIs in orthopaedic surgical cases.