Differences in Reimbursements, Procedural Volumes, and Patient Characteristics Based on Surgeon Gender in Total Hip Arthroplasty

BACKGROUND

Prior studies have suggested there may be differences in reimbursement and practice patterns by gender. The purpose of this study was to comprehensively evaluate differences in reimbursement, procedural volume, and patient characteristics in total hip arthroplasty (THA) between men and women surgeons from 2013 to 2021.

METHODS

The Medicare Physician and Other Practitioners database from 2013 to 2021 was queried. Inflation-adjusted reimbursement, procedural volume, surgeon information, and patient demographics were extracted for surgeons performing over 10 primary THAs each year. Wilcoxon, t-tests, and multivariate linear regressions were utilized to compare men and women surgeons.

RESULTS

Only 1.4% of THAs billed to Medicare between 2013 and 2021 were billed by women surgeons. Men surgeons earned significantly greater reimbursement nationally in 2021 compared to women surgeons per THA ($1018.56 versus $954.17, P = 0.03), but no difference was found when assessing each region separately. Reimbursement declined at similar rates for both men and women surgeons (-18.3 versus -19.8%, P = 0.38). An increase in the proportion of women surgeons performing THA between 2013 and 2021 was seen in all regions except the South. In 2021, the proportion of all THAs performed by women surgeons was highest in the West (3.5%) and lowest in the South (1.0%). Women surgeons had comparable patient populations in terms of age, race, comorbidity status, and Medicaid eligibility to their men counterparts, but performed significantly fewer services per beneficiary (5.6 versus 8.1, P < 0.001) and fewer unique services (51.1 versus 69.6, P < 0.001).

CONCLUSIONS

Average reimbursement per THA has declined at a similar rate for men and women physicians between 2013 and 2021. Women's representation in THA surgery nationwide has nearly doubled between 2013 and 2021, with the greatest increase in the West. However, there are notable differences in billing practices between genders.

Risk Versus Reward - Hospitals Incentivized More than Surgeons to Care for Riskier Arthroplasty Patients

PURPOSE

The purpose of this study was to assess the relationship between risk and reimbursement for both surgeons and hospitals among Medicare patients undergoing primary total joint arthroplasty (TJA).

METHODS

The "2021-Medicare-Physician-and-Other-Provider" and "2021-Medicare-Inpatient-Hospitals" files were utilized. Patient comorbidity profiles were collected, including the mean patient-hierarchal-condition-category (HCC) risk score, which is a standardized metric accounting for comorbidities. Surgeon data included all primary TJA procedures (inpatient and outpatient) billed to Medicare in 2021, while hospital data included all inpatient episodes of primary TJA billed to Medicare in 2021. Surgeon and hospital reimbursements were collected. All episodes were split into a "sicker-cohort" with an HCC risk score of 1.5 or greater and a "healthier-cohort" with HCC risk scores less than 1.5. Variables were compared across cohorts.

RESULTS

In 2021, 386,355 primary total hip and knee arthroplasty procedures were billed to Medicare and were included. The mean surgeon reimbursement among the sicker cohort was $1,021.91, which was less than for the healthier cohort of $1,060.13 (P < 0.001). Meanwhile, for the hospital analysis, 112,012 Medicare patients were admitted as inpatients for primary TJA in 2021 and included. The mean reimbursement to hospitals was significantly greater for the sicker cohort at $13,950.66, compared to the healthier cohort of $8,430.46. For both the surgeon and hospital analyses, the sicker patient cohorts had a significantly higher rate of all comorbidities assessed (P < 0.001).

CONCLUSION

This study demonstrates that mean surgeon reimbursement was lower for primary TJA among sicker patients in comparison to their healthier counterparts, while hospital reimbursement was higher for sicker patients. This represents a discrepancy in the incentivization of care for complex patients, as hospitals receive increased remuneration for taking on extra risk, while surgeons get paid less on average for performing TJA on sicker patients. Such data should inform future policy to assure continued access to arthroplasty care among complex patients.

Do breast cancer patients have increased risk of complications after primary total hip and total knee arthroplasty?

Aims

Breast cancer survivors have known risk factors that might influence the results of total hip arthroplasty (THA) or total knee arthroplasty (TKA). This study evaluated clinical outcomes of patients with breast cancer history after primary THA and TKA.

Methods

Our total joint registry identified patients with breast cancer history undergoing primary THA (n = 423) and TKA (n = 540). Patients were matched 1:1 based upon age, sex, BMI, procedure (hip or knee), and surgical year to non-breast cancer controls. Mortality, implant survival, and complications were assessed via Kaplan-Meier methods. Clinical outcomes were evaluated via Harris Hip Scores (HHSs) or Knee Society Scores (KSSs). Mean follow-up was six years (2 to 15).

Results

Breast cancer patient survival at five years was 92% (95% confidence interval (CI) 89% to 95%) after THA and 94% (95% CI 92% to 97%) after TKA. Breast and non-breast cancer patients had similar five-year implant survival free of any reoperation or revision after THA (p ≥ 0.412) and TKA (p ≥ 0.271). Breast cancer patients demonstrated significantly lower survival free of any complications after THA (91% vs 96%, respectively; hazard ratio = 2 (95% CI 1.1 to 3.4); p = 0.017). Specifically, the rate of intraoperative fracture was 2.4% vs 1.4%, and venous thromboembolism (VTE) was 1.4% and 0.5% for breast cancer and controls, respectively, after THA. No significant difference was noted in any complications after TKA (p ≥ 0.323). Both breast and non-breast cancer patients experienced similar improvements in HHSs (p = 0.514) and KSSs (p = 0.132).

Conclusion

Breast cancer survivors did not have a significantly increased risk of mortality or reoperation after primary THA and TKA. However, there was a two-fold increased risk of complications after THA, including intraoperative fracture and VTE.

Preoperative Postvoid Residual Is Not Predictive of Postoperative Urinary Retention in Primary Total Joint Arthroplasty Patients

Background

Postoperative urinary retention is a common complication after total hip and knee arthroplasty. Postvoid residual (PVR) scanning is a noninvasive method commonly used to evaluate this complication. Preoperatively increased PVR (PrePVR) has been suggested as a risk factor for postoperative catheterization. The aim of this study was to prospectively assess the importance of PrePVR and its relationship with urinary catheter placement, urology consult, and length of stay postoperatively.

Methods

Data was prospectively and consecutively collected at a single institution. All patients were bladder scanned preoperatively to collect PrePVR and subsequently scanned on postoperative days zero and one to collect Postoperative PVR. Chart review was performed to determine the number of straight catheterizations, Foley placement, urology consult and length of stay as well as patient demographics.

Results

Ninety-four consecutive patients were included in this study. There was a significantly increased postoperative PVR as compared to PrePVR (48.0 mL vs 21.0 mL; P < .0001). A PrePVR >50 mL was not associated with a significant difference in PVR between before and after surgery (P = .13); length of stay (P = .08); need for straight catheterization (P = .11); postoperative Foley placement (P = 1.0); or urology consult (P = 1.0). The only significant risk factor identified for postoperative Foley catheter placement was age (77.7 vs 64.2; P = .02).

Conclusions

PrePVR >50 mL was not an accurate predictor of postoperative urinary retention after total joint arthroplasty. PVR significantly increased in all patients. Male sex and increasing age were associated with large increases in PVR postoperatively and an increased risk of catheterization.

Clostridium difficile Infection Prior to Total Hip Arthroplasty Independently Increases the Risk of Periprosthetic Joint Infection

BACKGROUND

Periprosthetic joint infection (PJI) following total hip arthroplasty (THA) is associated with major morbidity. There may be a link between the gut microbiome and an individual's overall immune system. A Clostridium difficile (C. difficile) infection portends poor gut microbiome health and has been previously associated with increased 90-day complication rates in total joint arthroplasty (TJA). The purpose of this study was to determine the effect of a previous history of C. difficile infection within 2 years of undergoing THA on PJI within 2 years postoperatively.

METHODS

Patients undergoing THA from 2010 to 2021 were identified in a patient claims database (n = 770,075). Patients who had active records 2 years before and after THA as well as a history of C. difficile infection within 2 years prior to THA (n = 1,836) were included and propensity matched to a control group using age, sex, and Elixhauser comorbidity index. The primary outcome was the 2-year incidence of postoperative PJI. The exposed C. difficile infection cohort was stratified into 4 groups based on the time proximity of the C. difficile infection. Chi-square tests and logistic regressions were used to compare the groups.

RESULTS

A C. difficile infection anytime within 2 years prior to total hip arthroplasty was independently associated with higher odds of PJI (OR [odds ratio]: 1.49 [95% CI (confidence interval) 1.09 to 2.02, P = .014]). Proximity of C. difficile infection to arthroplasty was associated with increased risk of PJI (infection 0 to 3 months before THA: OR 2.01 [95% CI 1.23 to 3.20], infection 3 to 6 months before THA: OR 1.84 [95% CI 1.06 to 3.04], infection 6 to 12 months before THA: OR 1.10 [95% CI 0.65 to 1.77], infection 1 to 2 years before THA: OR 1.40 [95% CI 0.94 to 2.06]).

CONCLUSIONS

A C. difficile infection prior to THA is an independent risk factor for PJI. Proximity of C. difficile infection is associated with increased risk of PJI. Future investigations should evaluate how to adequately optimize patients prior to THA and pursue strategies to determine appropriate timing for proceeding with THA.

Geographical Differences in Surgeon Reimbursement, Volume, and Patient Characteristics in Primary Total Hip Arthroplasty

BACKGROUND

The purpose of this study was to evaluate changes in regional and national variations in reimbursement to arthroplasty surgeons, procedural volumes, and patient populations for total hip arthroplasty (THA) from 2013 to 2021.

METHODS

The Medicare Physician and Other Practitioners database was queried for all billing episodes of primary THA for each year between 2013 and 2021. Inflation-adjusted surgeon reimbursement, procedural volume, physician address, and patient characteristics were extracted for each year. Data were stratified geographically based on the United States Census regions and rural-urban commuting codes. Kruskal-Wallis and multivariable regressions were utilized.

RESULTS

Between 2013 and 2021, the overall THA volume and THAs per surgeon increased at the highest rate in the West (+48.2%, +20.2%). A decline in surgeon reimbursement was seen in all regions, most notably in the Midwest (-20.3%). Between 2013 and 2021, the average number of Medicare beneficiaries per surgeon declined by 12.6%, while the average number of services performed per beneficiary increased by 18.2%. In 2021, average surgeon reimbursement was the highest in the Northeast ($1,081.15) and the lowest in the Midwest ($988.03) (P < .001). Metropolitan and rural areas had greater reimbursement than micropolitan and small towns (P < .001). Patient age, race, sex, Medicaid eligibility, and comorbidity profiles differ between regions. Increased patient comorbidities, when controlling for patient characteristics, were associated with lower reimbursement in the Northeast and West (P < .01).

CONCLUSIONS

Total hip arthroplasty (THA) volume and reimbursement differ between US regions, with the Midwest exhibiting the lowest increase in volume and greatest decline in reimbursement throughout the study period. Alternatively, the West had the greatest increase in THAs per surgeon. Patient comorbidity profiles differ between regions, and increased patient comorbidity is associated with decreased reimbursement in the Northeast and the West. This information is important for surgeons and policymakers as payment models regarding reimbursement for arthroplasty continue to evolve.

Individualizing a Total Knee Arthroplasty with Three-Dimensional Planning

Total knee arthroplasty (TKA) is evolving from mechanical alignment to more individualized alignment options in an attempt to improve patient satisfaction. Thirteen-year survival of kinematically aligned prostheses has recently been shown to be similar to mechanically aligned TKA, allaying concerns of long-term failure of this newer individualized technique. There is a complex inter-relationship of three-dimensional knee and limb alignment for a TKA. This article will review planning parameters necessary to individualize each knee, along with a discussion of how these parameters are related in three dimensions. Future use of computer software and machine learning has the potential to identify the ideal surgical plan for each patient. In the meantime, the material presented here can assist surgeons as newer individual alignment planning becomes a reality.

Rheumatoid Arthritis Is Not a Contraindication to Unicompartmental Knee Arthroplasty

BACKGROUND

Rheumatoid arthritis (RA) has historically been considered a contraindication for unicompartmental knee arthroplasty (UKA). However, the widespread use of disease-modifying antirheumatic drugs has substantially improved the management of RA and prevented disease progression. The objective of this study was to ascertain whether RA impacts UKA revision-free survivorship.

METHODS

Patients undergoing UKA from 2010 to 2021 were identified in an administrative claims database (n = 105,937) using Current Procedural Terminology code 27446. All patients who underwent UKA who had a diagnosis of RA with a minimum of 2-year follow-up (n = 1,422) were propensity score matched based on age, sex, and Elixhauser Comorbidity Index to those who did not have RA (n = 1,422). Laterality was identified using the 10th Revision of International Classification of Diseases codes. The primary outcome was ipsilateral revision to total knee arthroplasty (TKA) within 2 years, and the secondary outcome was ipsilateral revision at any time.

RESULTS

Among the 1,422 patients who had a UKA and a diagnosis of RA, 37 patients (2.6%) underwent conversion to TKA within 2 years, and 48 patients (3.4%) underwent conversion to TKA at any point. In comparison, 28 patients (2.0%) in the propensity-matched control group underwent conversion to TKA within 2 years, and 40 patients (2.8%) underwent conversion to TKA at any point. Statistical analysis revealed no significant difference in conversion to TKA between patients who had and did not have RA, either within 2 years (P = .31) or anytime (P = .45).

CONCLUSIONS

Patients who had RA and underwent UKA did not have an increased risk of revision to TKA compared to those who did not have RA. This may indicate that modern management of RA could allow for expanded UKA indications for RA patients.

Periprosthetic Infection in Patients With Multiple Joint Arthroplasties

The number of total joint arthroplasties performed in the United States is increasing every year. Owing to the aging population and excellent long-term prosthesis survival, 45% of patients who undergo joint arthroplasty will receive two or more joint arthroplasties during their lifetimes. Periprosthetic joint infection (PJI) is among the most common complications after arthroplasty. Evaluation and treatment of PJI in patients with multiple joint arthroplasties is challenging, and no consensus exists for the optimal management. Multiple PJI can occur simultaneously, synchronous, or separated by extended time, metachronous. Patient risk factors for both scenarios have been reported and may guide evaluation and long-term management. Whether to perform joint aspiration for asymptomatic prosthesis in the presence of suspected PJI in patients with multiple joint arthroplasties is controversial. Furthermore, no consensus exists regarding whether patients who have multiple joint arthroplasties and develop PJI in a single joint should be considered for prolonged antibiotic prophylaxis to reduce the risk of future infections. Finally, the optimal treatment of synchronous joint infections whether by débridement, antibiotics and implant retention, and one-stage or two-stage revision has not been defined. This review will summarize the best information available and provide pragmatic management strategies.

Does Preoperative Pharmacogenomic Testing of Patients Undergoing TKA Improve Postoperative Pain? A Randomized Trial

BACKGROUND

Pharmacogenomics is an emerging and affordable tool that may improve postoperative pain control. One challenge to successful pain control is the large interindividual variability among analgesics in their efficacy and adverse drug events. Whether preoperative pharmacogenomic testing is worthwhile for patients undergoing TKA is unclear.

QUESTIONS/PURPOSES

(1) Are the results of preoperative pharmacogenetic testing associated with lower postoperative pain scores as measured by the Overall Benefit of Analgesic Score (OBAS)? (2) Do the results of preoperative pharmacogenomic testing lead to less total opioids given? (3) Do the results of preoperative pharmacogenomic testing lead to changes in opioid prescribing patterns?

METHODS

Participants of this randomized trial were enrolled from September 2018 through December 2021 if they were aged 18 to 80 years and were undergoing primary TKA under general anesthesia. Patients were excluded if they had chronic kidney disease, a history of chronic pain or narcotic use before surgery, or if they were undergoing robotic surgery. Preoperatively, patients completed pharmacogenomic testing (RightMed, OneOME) and a questionnaire and were randomly assigned to the experimental group or control group. Of 99 patients screened, 23 were excluded, one before randomization; 11 allocated patients in each group did not receive their allocated interventions for reasons such as surgery canceled, patients ultimately undergoing spinal anesthesia, and change in surgery plan. Another four patients in each group were excluded from the analysis because they were missing an OBAS report. This left 30 patients for analysis in the control group and 38 patients in the experimental group. The control and experimental groups were similar in age, gender, and race. Pharmacogenomic test results for patients in the experimental group were reviewed before surgery by a pharmacist, who recommended perioperative medications to the clinical team. A pharmacist also assessed for clinically relevant drug-gene interactions and recommended drug and dose selection according to guidelines from the Clinical Pharmacogenomics Implementation Consortium for each patient enrolled in the study. Patients were unaware of their pharmacogenomic results. Pharmacogenomic test results for patients in the control group were not reviewed before surgery; instead, standard perioperative medications were administered in adherence to our institutional care pathways. The OBAS (maximum 28 points) was the primary outcome measure, recorded 24 hours postoperatively. A two-sample t-test was used to compare the mean OBAS between groups. Secondary measures were the mean 24-hour pain score, total morphine milligram equivalent, and frequency of opioid use. Postoperatively, patients were assessed for pain with a VAS (range 0 to 10). Opioid use was recorded preoperatively, intraoperatively, in the postanesthesia care unit, and 24 hours after discharge from the postanesthesia care unit. Changes in perioperative opioid use based on pharmacogenomic testing were recorded, as were changes in prescription patterns for postoperative pain control. Preoperative characteristics were also compared between patients with and without various phenotypes ascertained from pharmacogenomic test results.

RESULTS

The mean OBAS did not differ between groups (mean ± SD 4.7 ± 3.7 in the control group versus 4.2 ± 2.8 in the experimental group, mean difference 0.5 [95% CI -1.1 to 2.1]; p = 0.55). Total opioids given did not differ between groups or at any single perioperative timepoint (preoperative, intraoperative, or postoperative). We found no difference in opioid prescribing pattern. After adjusting for multiple comparisons, no difference was observed between the treatment and control groups in tramadol use (41% versus 71%, proportion difference 0.29 [95% CI 0.05 to 0.53]; nominal p = 0.02; adjusted p > 0.99).

CONCLUSION

Routine use of pharmacogenomic testing for patients undergoing TKA did not lead to better pain control or decreased opioid consumption. Future studies might focus on at-risk populations, such as patients with chronic pain or those undergoing complex, painful surgical procedures, to test whether pharmacogenomic results might be beneficial in certain circumstances.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Posteromedial Periarticular Injection in Total Knee Arthroplasty: A Cadaveric Study

Achieving optimal pain control in total knee arthroplasty has improved with the use of regional anesthesia and periarticular injections (PAIs). When performing a PAI, the relative location of the anesthetic spread is not well defined in comparison with an adductor canal block (ACB). In this study, our aim was to evaluate the location of posteromedial PAI spread compared with a surgeon administered ACB. One PAI and one surgeon-administered ACB were performed in the contralateral limbs of four human cadavers. The injectate was composed of methylene blue dye to visually inspect the dye spread from the tip of the needle. Dissections were performed on each cadaver to quantify the dye spread from the tip of the needle and compare the location of the dye spread. Dye spread location was characterized as either entering the adductor canal or including the posterior capsule. The mean distance of dye spread from the needle tip to the proximal most aspect of the dyed tissue was 10.125 cm in the ACB group compared with 6.5 cm in the posteromedial PAI group. In the ACB group, 4 of 4 injections were present in the adductor canal block group compared with 3 of 4 in the posteromedial PAI group. The posteromedial PAI group also had 3 of 4 injections involve the area around the posterior capsule compared with 0 of 4 in the ACB group. Posteromedial PAI appears to provide local delivery to both the adductor canal and the posterior capsule. Intraoperative, surgeon-administered ACB reliably delivers injectate to the adductor canal only but may allow for more proximal dye spread. Posteromedial PAI may provide a benefit in delivering injectate to the posterior capsule in addition to the ACB. Additional clinical studies are necessary to determine the clinical effects of this finding.

Risk Factors in Patients Who Had Prior Renal or Liver Transplant Undergoing Primary Total Knee Arthroplasty

BACKGROUND

More solid organ transplant (SOT) patients are undergoing total knee arthroplasty (TKA). This study identifies risk factors for complications, implant survivorship, and mortality in TKA patients who had prior SOT.

METHODS

We identified 176 TKAs in patients who had prior SOT. Of these, 77 had a prior renal (RT), 77 had a prior liver (LT) transplant, and 22 had multiple prior transplants (MT). Median survival was estimated using Kaplan-Meier. Univariate analyses were assessed with mixed-effects logistic regressions for complications and Cox-regressions for mortality. Median follow-up was 63 months (range, 24 to 109).

RESULTS

At least one acute medical complication occurred in 25, 13, and 27% of cases with prior RT, LT, and MT, respectively (P = .12). None of the variables were significantly associated with acute medical complications. At least one surgical complication occurred in 14, 13 and 14% of cases with prior RT, LT, and MT, respectively (P = 1). Vitamin D supplementation (Odds Ratio [OR] = 0.38, P < .03) was associated with lower risk of surgical complications. Reoperation and revision rates were 5 and 3%, respectively. Older age at time of transplantation and greater level of serum creatinine at time of TKA were associated with lower risk (OR = 0.96, P = .01), and higher risk of reoperation (OR = 4.9, P = .01), respectively. Coronary artery disease was associated with higher mortality (Hazard Ratio = 2.35, P = .01).

CONCLUSIONS

Vitamin D was associated with lower surgical complications, whereas a younger age at time of transplantation increased the risk of reoperation. Additionally, SOT patients with coronary artery disease demonstrated higher mortality after TKA.

Intraosseous regional prophylaxis in total knee arthroplasty

Prophylactic antibiotics are important in reducing the risk of periprosthetic joint infection (PJI) following total knee arthroplasty. Their effectiveness depends on the choice of antibiotic and the optimum timing of their administration, to ensure adequate tissue concentrations. Cephalosporins are typically used, but an increasing number of resistant organisms are causing PJI, leading to the additional use of vancomycin. There are difficulties, however, with the systemic administration of vancomycin including its optimal timing, due to the need for prolonged administration, and potential adverse reactions. Intraosseous regional administration distal to a tourniquet is an alternative and attractive mode of delivery due to the ease of obtaining intraosseous access. Many authors have reported the effectiveness of intraosseous prophylaxis in achieving higher concentrations of antibiotic in the tissues compared with intravenous administration, providing equal or enhanced prophylaxis while minimizing adverse effects. This annotation describes the technique of intraosseous administration of antibiotics and summarizes the relevant clinical literature to date.

The Fate of the Inconclusive Periprosthetic Joint Infection Workup and Reliability of Data Points

In 2018, periprosthetic joint infection (PJI) criteria were revised to include a new category labeled "inconclusive." The purpose of this study was to characterize and describe the fate of the inconclusive PJI workup and to analyze preoperative factors associated with outcomes. We reviewed all PJI workups at our institution during a 3-year period (426 patients). Patients were labeled "infected," "not infected," or "inconclusive" according to 2018 PJI preoperative criteria. In addition to standard diagnostic variables, the presence or absence of clinical elements that increase the pretest probability of infection were collected. Patients with any missing preoperative diagnostic test results and those with clinical follow-up less than 30 days were excluded. Logistic regression was used to identify the factors associated with infection. Two hundred ninety-six workups remained after exclusion criteria were applied, consisting of 66 (22.2%) with a preoperative score of 6 or greater defined as infected, 52 (17.6%) inconclusive (score 2-5), and 178 (60.1%) not infected (score 0-1). Postoperative re-scoring of the inconclusive group based on intraoperative findings as per the 2018 criteria identified 6 of 52 (11.5%) as infected, 12 (23.1%) inconclusive, and 34 (65.4%) not infected. Among those preoperatively scored as inconclusive, variables statistically correlated with the presence of infection included history of PJI, factors that increase skin barrier penetration (eg, psoriasis and venous stasis), and presence of comorbidities predisposing to infection. For patients labeled inconclusive, clinical elements of the pretest probability for infection (eg, history of prior PJI) were as reliable as any diagnostic test, including alpha-defensin, in the diagnosis of PJI. [Orthopedics. 2023;46(5):e291-e297.].

The Current Relationship Between Surgeon Reimbursement and Patient Complexity in Arthroplasty-A Risk-Payment Analysis of All Primary Joint Replacements Billed to Medicare in 2019

BACKGROUND

The purpose of this study was to assess surgeon reimbursement among total joint arthroplasty (TJA) patients who had differing risk profiles within the Medicare population.

METHODS

The "2019 Medicare Physician and Other Provider" file was utilized. In 2019, 441,584 primary total hip and knee arthroplasty procedures were billed to Medicare Part B. All episodes were included. Patient demographics and comorbidity profiles were collected for all patients. Additionally, mean patient hierarchal condition category (HCC) risk scores and physician reimbursements were collected. All procedure episodes were split into 2 cohorts; those with an HCC risk score of 1.5 or greater, and those with patient HCC risk scores less than 1.5. Variables were averaged for each cohort and compared.

RESULTS

The mean reimbursement across all procedures was $1,068.03. For the sicker patient cohort with a mean HCC risk score of 1.5 or greater, there was a significantly higher rate of all comorbidities compared to the cohort with HCC risk score under 1.5. The mean payment across the sicker cohort was $1,059.21, while the mean payment among the cohort with HCC risk score under 1.5 was 1,073.32 (P = .032).

CONCLUSION

This study demonstrates that for Medicare patients undergoing primary TJA in 2019, the mean surgeon reimbursement was lower for primary TJA among sick patients in comparison to their healthier counterparts, although it is difficult to ascertain the impact of this discrepancy. As alternative payment models continue to undergo evaluation and development, these data will be important for the potential advancement of more equitable reimbursement models in arthroplasty care, specifically regarding surgeon reimbursement and possible risk adjustment within such models.

A Randomized Controlled Trial of Kinematically and Mechanically Aligned Total Knee Arthroplasties: Long-Term Follow-Up

BACKGROUND

The optimal alignment technique for total knee arthroplasty (TKA) remains controversial. We previously reported 6-month and 2-year results of a randomized controlled trial comparing kinematically versus mechanically aligned TKA. In the present study, we report the mean 13-year (range, 12.6-14.4) follow-up results from this trial.

METHODS

The original cohort included 88 TKAs (44 kinematically aligned using patient-specific guides and 44 mechanically aligned using conventional instrumentation), performed from 2008 to 2009. After institutional review board approval, the health records of the original 88 patients were queried. Revisions, reoperations, and complications were recorded. There were 26 patients who died, leaving 62 patients for follow-up. Of these, 48 patients (77%) were successfully contacted via phone. Reoperations and complications were documented. Furthermore, a battery of patient-reported outcome measures (PROMs) (including Western Ontario and McMaster University Index, Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score Junior, Forgotten Joint Score, Modified-Single Assessment Numerical Evaluation, and patient satisfaction) were obtained.

RESULTS

Of the original 88 patients in the study, 15 patients had at least one reoperation (17%) and 5 patients had undergone complete revision surgery (6%). There was no difference between the 2 alignment methods for major and minor reoperations (P = .66). The kinematically aligned total knees self-reported a nonstatistically significant (P = .16) improved satisfaction (96% versus 82%), but no difference in other PROMs compared to mechanically aligned TKAs.

CONCLUSION

Kinematically aligned TKA demonstrates excellent mean 13-year results, comparable to mechanically aligned TKA with similar reoperations, complications, and PROMs.

Principles of mechanical and chemical debridement with implant retention

BACKGROUND

Periprosthetic joint infection (PJI) is one of the most common causes of early revision for total hip and knee arthroplasty. Mechanical and chemical debridement typically referred to as debridement, antibiotics, and implant retention (DAIR) can be a successful technique to eradicate PJI in acute postoperative or acute hematogenous infections. This review will focus specifically on the indications, techniques, and outcomes of DAIR.

DISCUSSION

The success of mechanical and chemical debridement, or a DAIR operation, is reliant on a combination of appropriate patient selection and meticulous technique. There are many technical considerations to take into consideration. One of the most important factors in the success of the DAIR procedure is the adequacy of mechanical debridement. Techniques are surgeon-specific and perhaps contribute to the large variability in the literature on the success of DAIR. Factors that have been shown to be associated with success include the exchange of modular components, performing the procedure within seven days or less of symptom onset, and possibly adjunctive rifampin or fluoroquinolone therapy, though this remains controversial. Factors that have been associated with failure include rheumatoid arthritis, age greater than 80 years, male sex, chronic renal failure, liver cirrhosis, and chronic obstructive pulmonary disease.

CONCLUSIONS

DAIR is an effective treatment option for the management of an acute postoperative or hematogenous PJI in the appropriately selected patient with well-fixed implants.

Discordance Abounds in Minimum Clinically Important Differences in THA: A Systematic Review

BACKGROUND

The minimum clinically important difference (MCID) is intended to detect a change in a patient-reported outcome measure (PROM) large enough for a patient to appreciate. Their growing use in orthopaedic research stems from the necessity to identify a metric, other than the p value, to better assess the effect size of an outcome. Yet, given that MCIDs are population-specific and that there are multiple calculation methods, there is concern about inconsistencies. Given the increasing use of MCIDs in total hip arthroplasty (THA) research, a systematic review of calculated MCID values and their respective ranges, as well as an assessment of their applications, is important to guide and encourage their use as a critical measure of effect size in THA outcomes research.

QUESTIONS/PURPOSES

We systematically reviewed MCID calculations and reporting in current THA research to answer the following: (1) What are the most-reported PROM MCIDs in THA, and what is their range of values? (2) What proportion of studies report anchor-based versus distribution-based MCID values? (3) What are the most common methods by which anchor-based MCID values are derived? (4) What are the most common derivation methods for distribution-based MCID values? (5) How do the reported medians and corresponding ranges compare between calculation methods for each PROM?

METHODS

The EMBASE, MEDLINE, and PubMed databases were systematically reviewed from inception through March 2022 for THA studies reporting an MCID value for any PROMs. Two independent authors reviewed articles for inclusion. All articles calculating new PROM MCID scores after primary THA were included for data extraction and analysis. MCID values for each PROM, MCID calculation method, number of patients, and study demographics were extracted from each article. In total, 30 articles were included. There were 45 unique PROMs for which 242 MCIDs were reported. These studies had a total of 1,000,874 patients with a median age of 64 years and median BMI of 28.7 kg/m 2 . Women made up 55% of patients in the total study population, and the median follow-up period was 12 months (range 0 to 77 months). The overall risk of bias was assessed as moderate using the modified Methodological Index for Nonrandomized Studies criteria for comparative studies (the mean score for comparative papers in this review was 18 of 24, with higher scores representing better study quality) and noncomparative studies (for these, the mean score was 10 of a possible 16 points, with higher scores representing higher study quality). Calculated values were classified as anchor-based, distribution-based, or not reported. MCID values for each PROM, MCID calculation method, number of patients, and study demographics were extracted from each study. Anchor-based and distribution-based MCIDs were compared for each unique PROM using a Wilcoxon rank sum test, given the non-normal distribution of values.

RESULTS

The Oxford Hip Score (OHS) and the Hip Injury and Osteoarthritis Score (HOOS) Pain and Quality of Life subscore MCIDs were the most frequently reported, comprising 12% (29 of 242), 8% (20 of 242), and 8% (20 of 242), respectively. The EuroQol VAS (EQ-VAS) was the next-most frequently reported (7% [17 of 242]) followed by the EuroQol 5D (EQ-5D) (7% [16 of 242]). The median anchor-based value for the OHS was 9 (IQR 8 to 11), while the median distribution-based value was 6 (IQR 5 to 6). The median anchor-based MCID values for HOOS Pain and Quality of Life were 33 (IQR 28 to 35) and 25 (14 to 27), respectively; the median distribution-based values were 10 (IQR 9 to 10) and 13 (IQR 10 to 14), respectively. Thirty percent (nine of 30) of studies used an anchor-based method to calculate a new MCID, while 40% (12 of 30) used a distribution-based technique. Thirty percent of studies (nine of 30) calculated MCID values using both methods. For studies reporting an anchor-based calculation method, a question assessing pain relief, satisfaction, or quality of life on a five-point Likert scale was the most commonly used anchor (30% [eight of 27]), followed by a receiver operating characteristic curve estimation (22% [six of 27]). For studies using distribution-based calculations, the most common method was one-half the standard deviation of the difference between preoperative and postoperative PROM scores (46% [12 of 26]). Most reported median MCID values (nine of 14) did not differ by calculation method for each unique PROM (p > 0.05). The OHS, HOOS JR, and HOOS Function, Symptoms, and Activities of Daily Living subscores all varied by calculation method, because each anchor-based value was larger than its respective distribution-based value.

CONCLUSION

We found that MCIDs do not vary very much by calculation method across most outcome measurement tools. Additionally, there are consistencies in MCID calculation methods, because most authors used an anchor question with a Likert scale for the anchor-based approach or used one-half the standard deviation of preoperative and postoperative PROM score differences for the distribution-based approach. For some of the most frequently reported MCIDs, however, anchor-based values tend to be larger than distribution-based values for their respective PROMs.

CLINICAL RELEVANCE

We recommend using a 9-point increase as the MCID for the OHS, consistent with the median reported anchor-based value derived from several high-quality studies with large patient groups that used anchor-based approaches for MCID calculations, which we believe are most appropriate for most applications in clinical research. Likewise, we recommend using the anchor-based 33-point and 25-point MCIDs for the HOOS Pain and Quality of Life subscores, respectively. We encourage using anchor-based MCID values of WOMAC Pain, Function, and Stiffness subscores, which were 29, 26, and 30, respectively.

There are Considerable Inconsistencies Among Minimum Clinically Important Differences in TKA: A Systematic Review

BACKGROUND

Patient-reported outcome measures (PROMs) are frequently used to assess the impact of total knee arthroplasty (TKA) on patients. However, mere statistical comparison of PROMs is not sufficient to assess the value of TKA to the patient, especially given the risk profile of arthroplasty. Evaluation of treatment effect sizes is important to support the use of an intervention; this is often quantified with the minimum clinically important difference (MCID). MCIDs are unique to specific PROMs, as they vary by calculation methodology and study population. Therefore, a systematic review of calculated MCID values, their respective ranges, and assessment of their applications is important to guide and encourage their use as a critical measure of effect size in TKA outcomes research.

QUESTIONS/PURPOSES

In this systematic review of MCID calculations and reporting in primary TKA, we asked: (1) What are the most frequently reported PROM MCIDs and their reported ranges in TKA? (2) What proportion of studies report distribution- versus anchor-based MCID values? (3) What are the most common methods by which these MCID values are derived for anchor-based values? (4) What are the most common derivation methods for distribution-based values? (5) How do the reported medians and corresponding interquartile ranges (IQR) compare between calculation methods for each PROM?

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review was conducted using the PubMed, EMBASE, and MEDLINE databases from inception through March 2022 for TKA articles reporting an MCID value for any PROMs. Two independent reviewers screened articles for eligibility, including any article that calculated new MCID values for PROMs after primary TKA, and extracted these data for analysis. Overall, 576 articles were identified, 38 of which were included in the final analysis. These studies had a total of 710,128 patients with a median age of 67.7 years and median BMI of 30.9 kg/m 2 . Women made up more than 50% of patients in most studies, and the median follow-up period was 17 months (range 0.25 to 72 months). The overall risk of bias was assessed as moderate using the Jadad criteria for one randomized controlled trial (3 of 5 ideal global score) and the modified Methodological Index for Non-randomized Studies criteria for comparative studies (mean 17.2 ± 1.8) and noncomparative studies (mean 9.6 ± 1.3). There were 49 unique PROMs for which 233 MCIDs were reported. Calculated values were classified as anchor-based, distribution-based, or not reported. MCID values for each PROM, MCID calculation method, number of patients, and study demographics were extracted from each study. Anchor-based and distribution-based MCIDs were compared for each unique PROM using a Wilcoxon rank sum test given non-normal distribution of values.

RESULTS

The WOMAC Function and Pain subscores were the most frequently reported MCID value, comprising 9% (22 of 233) and 9% (22 of 233), respectively. The composite Oxford Knee Score (OKS) was the next most frequently reported (9% [21 of 233]), followed by the WOMAC composite score (6% [13 of 233]). The median anchor-based values for WOMAC Function and Pain subscores were 23 (IQR 16 to 33) and 25 (IQR 14 to 31), while the median distribution-based values were 11 (IQR 10.8 to 11) and 22 (IQR 17 to 23), respectively. The median anchor-based MCID value for the OKS was 6 (IQR 4 to 7), while the distribution-based value was 7 (IQR 5 to 10). Thirty-nine percent (15 of 38) used an anchor-based method to calculate a new MCID, while 32% (12 of 38) used a distribution-based technique. Twenty-nine percent of studies (11 of 38) calculated MCID values using both methods. For studies reporting an anchor-based calculation method, a question assessing patient satisfaction, pain relief, or quality of life along a five-point Likert scale was the most commonly used anchor (40% [16 of 40]), followed by a receiver operating characteristic curve estimation (25% [10 of 40]). For studies using distribution-based calculations, all articles used a measure of study population variance in their derivation of the MCID, with the most common method reported as one-half the standard deviation of the difference between preoperative and postoperative PROM scores (45% [14 of 31]). Most reported median MCID values (15 of 19) did not differ by calculation method for each unique PROM (p > 0.05) apart from the WOMAC Function component score and the Knee Injury and Osteoarthritis Outcome Score Pain and Activities of Daily Living subscores.

CONCLUSION

Despite variability of MCIDs for each PROM, there is consistency in the methodology by which MCID values have been derived in published studies. Additionally, there is a consensus about MCID values regardless of calculation method across most of the PROMs we evaluated.

CLINICAL RELEVANCE

Given their importance to treatment selection and patient safety, authors and journals should report MCID values with greater consistency. We recommend using a 7-point increase as the MCID for the OKS, consistent with the median reported anchor-based value derived from several high-quality studies with large patient groups that used anchor-based approaches for MCID calculation, which we believe are most appropriate for most applications in clinical research. Likewise, we recommend using a 10-point to 15-point increase for the MCID of composite WOMAC, as the median value was 12 (IQR 10 to 17) with no difference between calculation methods. We recommend use of median reported values for WOMAC function and pain subscores: 21 (IQR 15 to 33) and 23 (IQR 13 to 29), respectively.

Routine Type and Screens Are Unnecessary in Primary Total Joint Arthroplasty: Follow-up After a Change in Practice

Background

Routine type and screens (T&S) prior to total hip (THA) and total knee arthroplasty (TKA) are common despite low transfusion rates. Our institution implemented a practice change after previously demonstrating a transfusion rate of 1.06%. The purpose of this study is to present the follow-up data 1 year after the practice change of discontinuing routine T&S orders in primary total joint arthroplasty.

Methods

A practice change was implemented discontinuing routine T&S orders prior to elective primary total joint arthroplasties. We retrospectively reviewed prospectively collected data on preoperative T&S, hemoglobin values, transfusion rates, bleeding disorders, and anticoagulation status.

Results

A total of 663 patients were included in the study (273 THAs and 390 TKAs). The cumulative transfusion rate was 0.75. No patients received an intraoperative transfusion. Three patients (1.1%) received a postoperative transfusion after THA, and 3 patients (0.5%) received a transfusion after TKA. The mean preoperative hemoglobin in the transfused patients was 12.1 g/dL. Thirteen patients underwent a preoperative T&S (2.0%), and only 2 required transfusion (15.4%). Only 1 patient who required transfusion was on preoperative anticoagulation, and no patients with bleeding disorders required transfusions. Discontinuing routine T&S resulted in an estimated cost savings of $124,325.50.

Conclusions

Discontinuation of routine T&S did not result in any adverse consequences. If required, T&S can safely be performed intraoperatively or postoperatively. Surgeons may consider obtaining a T&S if their preoperative hemoglobin is less than 11-12 g/dL or if significant blood loss is expected in a complex primary total joint arthroplasty.

Increased Risk of Lateral Femoral Cutaneous Nerve Injury in Patients With Previous Hip Arthroscopy Who Underwent a Direct Anterior Approach Total Hip Arthroplasty

Purpose

To evaluate the rates of lateral femoral cutaneous nerve (LFCN) injury in patients who underwent a direct anterior approach (DAA) total hip arthroplasty (THA) with and without previous hip arthroscopy.

Methods

We retrospectively investigated consecutive DAA THAs performed by a single surgeon. These cases were grouped into patients with and without a history of previous ipsilateral hip arthroscopy. LFCN sensation was assessed during the initial follow-up (6 weeks) and 1-year (or most recent) follow-up visits. The incidence and character of LFCN injury was compared between the 2 groups.

Results

In total, 166 patients underwent a DAA THA with no previous hip arthroscopy, and 13 had a history of previous arthroscopy. Of the 179 total patients who underwent THA, 77 experienced some form of LFCN injury at initial follow-up (43%). The rate of injury for the cohort with no previous arthroscopy was 39% (n = 65/166) on initial follow-up, whereas the rate of injury for the cohort with a history of previous ipsilateral arthroscopy was 92% (n =12/13) on initial follow-up (P < .001). In addition, although the difference was not significant, 28% (n = 46/166) of the group without history of previous arthroscopy and 69% (n = 9/13) of the group with a history of previous arthroscopy had continued symptoms of LFCN injury at most recent follow-up.

Conclusions

In this study, patients who underwent hip arthroscopy before an ipsilateral DAA THA were at increased risk of LFCN injury compared with patients who underwent a DAA THA without a previous hip arthroscopy. At final follow-up of patients with initial LFCN injury, symptoms resolved in 29% (n = 19/65) of patients with no previous hip arthroscopy and 25% (n = 3/12) of patients with previous hip arthroscopy.

Level of Evidence

Level III, case-control study.

Primary Tritanium acetabular components have increased rates of radiolucency associated with inferior clinical outcomes at short-term follow-up

INTRODUCTION

Cementless fixation is the standard for acetabular fixation in primary total hip arthroplasty (THA). There are various surface finishes thought to improve osteointegration, although literature regarding the long-term survival of some of these surfaces is limited. Regardless of design, primary stability is essential to allow for osteointegration. Previous studies have suggested an increased rate of radiolucency and compromised short-term functional outcomes using the Tritanium primary acetabular component (Stryker, Mahwah, NJ). The purpose of this study was to compare the primary Tritanium acetabular component to another contemporary acetabular component as a control group with an established clinical record.

METHODS

444 consecutive, primary THAs performed by a single surgeon from 2008 to 2012 were reviewed. Patients were included if they had a minimum 1-year follow-up. Implant survivorship and modified Harris Hip Scores (mHHS) were recorded for all patients at final follow-up. Radiographs were evaluated by 2 surgeons at 6 weeks, 1 year, and the most recent follow-up for evidence of radiolucency and migration. Components were considered to have evidence of radiographic lucency if they had radiolucency in 2 or more DeLee zones.

RESULTS

198 patients met criteria for inclusion (96 Pinnacle, 102 Tritanium). Average follow-up was 28 (12-72) months. At final follow-up 6.2% of the Pinnacle cups and 29.4% of the Tritanium cups had radiographic evidence of loosening (p < 0.01). The average mHHS for the Tritanium group was 83.1, and 88.4 for the Pinnacle group (p < 0.01). Radiographic evidence of loosening also correlated with a lower mHHS: 75.5 versus 86.4 (p < 0.01). In patients that received Tritanium cups without screw fixation 44.6% showed radiographic evidence of loosening versus 8% that received screw fixation (p < 0.01). In total, 6 patients in the Tritanium group required revision for aseptic loosening of the acetabular component.

CONCLUSIONS

The 30% rate of radiographic loosening in the Tritanium group was significantly higher than the Pinnacle group and correlated with an inferior clinical outcome. Interestingly the use of screw augmentation was protective against radiographic evidence of loosening. This suggests that the Tritanium component may be prone to fibrous in-growth because of inadequate primary stability.

The Efficacy and Safety of Periarticular Injection in Total Joint Arthroplasty: A Direct Meta-Analysis

BACKGROUND

Periarticular injection (PAI) is administered intraoperatively to help reduce postoperative pain and opioid consumption after primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of PAI in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine.

METHODS

The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to March 2020 on PAI in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of PAI.

RESULTS

Three thousand six hundred and ninety nine publications were critically appraised to provide 60 studies regarded as the best available evidence for an analysis. The meta-analysis showed that intraoperative PAI reduces postoperative pain and opioid consumption. Adding ketorolac or a corticosteroid to a long-acting local anesthetic (eg, ropivacaine or bupivacaine) provides an additional benefit. There is no difference between liposomal bupivacaine and other nonliposomal long-acting local anesthetics. Morphine does not provide any additive benefit in postoperative pain and opioid consumption and may increase postoperative nausea and vomiting. There is insufficient evidence to draw conclusions on the use of epinephrine and clonidine.

CONCLUSION

Strong evidence supports the use of a PAI with a long-acting local anesthetic to reduce postoperative pain and opioid consumption. Adding a corticosteroid and/or ketorolac to a long-acting local anesthetic further reduces postoperative pain and may reduce opioid consumption. Morphine has no additive effect and there is insufficient evidence on epinephrine and clonidine.

Clinical outcomes and survivorship of cementless triathlon total knee arthroplasties: a systematic review

Background

Over the last decade, cementless total knee arthroplasty has demonstrated improved outcomes and survivorship due to advances in technologies of implant design, manufacturing capabilities, and biomaterials. Due to increasing interest in cementless implant design for TKA, our aim was to perform a systematic review of the literature to evaluate the clinical outcomes and revision rates of the Triathlon Total Knee system over the past decade.

Methods

A systematic review of the literature was conducted following PRISMA guidelines for patients who underwent total knee arthroplasty with cementless Triathalon Total Knee System implants. Patients had a minimum of two-year follow-up and data included clinical outcome scores and survivorship data.

Results

Twenty studies were included in the final analysis. The survivability of the Stryker Triathlon TKA due to all causes was 98.7%, with an aseptic survivability of 99.2%. The overall revision incidence per 1,000 person-years was 3.4. Re-revision incidence per 1,000 person-years was 2.2 for infection, and 1.3 for aseptic loosening. The average KSS for pain was 92.2 and the average KSS for function was 82.7.

Conclusions

This systematic review demonstrated excellent clinical outcomes and survivorship at a mean time of 3.8 years. Additional research is necessary to examine the long-term success of the Stryker Triathlon TKA and the use of cementless TKAs in obese and younger populations.

Level of evidence

III.

Higher Tissue Concentrations of Vancomycin Achieved With Low-Dose Intraosseous Injection Versus Intravenous Despite Limited Tourniquet Duration in Primary Total Knee Arthroplasty: A Randomized Trial

BACKGROUND

Vancomycin use has been suggested in high risk patients undergoing total knee arthroplasty (TKA). Previous literature has shown that a lower dose (500 mg) of vancomycin given by intraosseous regional administration (IORA) achieves tissue concentrations 4-10 times higher than intravenous (IV) administration. There is increasing interest in performing TKA with limited tourniquet inflation time. The purpose of this study is to evaluate whether IORA of vancomycin can achieve effective tissue concentrations with limited tourniquet inflation time.

METHODS

Based on prior power calculations, 24 patients undergoing primary TKA were randomized into 2 groups. Group IV-Systemic received weight-based (15 mg/kg) vancomycin with the tourniquet inflated for cementation only. Group IORA received 500 mg vancomycin via IORA after tourniquet inflation which remained inflated for 10 minutes, then reinflated for cementation only. Vancomycin concentrations from tissue, serum, and drain fluid were compared between the 2 groups.

RESULTS

Median vancomycin concentrations in tissue were significantly higher (5-15 times) at all time points in the IORA group. Concentrations in fat at the time of wound closure, after the tourniquet had been deflated for most of the procedure, were 5.2 μg/g in Group IV-Systemic and 33.1 μg/g in Group IORA (P < .001). Median bone concentrations taken just prior to cementation were 7.9 μg/g in Group IV-Systemic and 21.8 μg/g in Group IORA (P = .006). There were no complications related to IORA.

CONCLUSION

For surgeons who wish to limit tourniquet time and when indicated to use vancomycin, low-dose vancomycin IORA achieves tissue concentrations 5-15 times higher than those achieved by IV administration.

LEVEL OF EVIDENCE

Level 1 therapeutic randomized trial.

Antiseptic Irrigation Solutions Used in Total Joint Arthroplasty: A Critical Analysis Review

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There are limited data that directly compare the efficacy of antiseptic irrigation solutions used for the prevention and treatment of periprosthetic joint infections in orthopaedic procedures; there is a notable lack of prospective data.

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For prevention of periprosthetic joint infections, the strongest evidence supports the use of low-pressure povidone-iodine.

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For the treatment of periprosthetic joint infections, delivering multiple solutions sequentially may be beneficial.

Orthopaedic Residency Applicants' Perspective on Program-Based Social Media

Social media and online resources have been used in graduate medical education for years. In addition to an official residency program website, many orthopaedic surgery programs have an established social media presence to interact, educate, and engage with prospective applicants. The role of social media in orthopaedic surgery has significantly expanded in recent years. Despite its increasing use, the specific impact of social media on orthopaedic surgery residency applicants remains unknown.

Orthopaedic Surgery Away Rotations

Away rotations have become a critical factor for a successful orthopaedic surgery residency match. Away rotations significantly improve an applicant's chance of matching into an orthopaedic residency. Away rotations were limited during the 2020 to 2021 academic year because of the COVID-19 pandemic. During the 2021 to 2022 academic year, the American Association of Medical Colleges coalition recommended students only complete 1 rotation outside their home institution, whereas the American Orthopaedic Association Council of Residency Directors argued that multiple rotations should be allowed. We sought to quantify the impact of these restrictions on orthopaedic surgery applicants during the 2020 to 2021 residency application cycle.

A Plant-Based Dietary Intervention for Preoperative Glucose Optimization in Diabetic Patients Undergoing Total Joint Arthroplasty

Purpose. The purpose of this study was to assess the feasibility and effectiveness of a whole food plant-based diet (WFPBD) to improve day of surgery fasting blood glucose (FBG) among patients with type 2 diabetes (T2D). Patients and Methods. Ten patients with T2D scheduled for a total hip or total knee replacement were recruited. For 3 weeks preceding their surgeries, subjects were asked to consume an entirely WFPBD. Frozen WFPBD meals were professionally prepared and delivered to each participant for the 3 weeks prior to surgery. FBG was reassessed on the morning of surgery and compared with preintervention values. Compliance with the diet was assessed. Results. Mean age of subjects and reported duration of diabetes was 65 and 8 years, respectively, average hemoglobin A1c (HbA1c) was 6.6%, and 6 were women. Mean FBG decreased from 127 to 116 mg/dL (P = .2). Five of the subjects experienced improvement in glycemic control, with an average decline of 11 mg/dL. Conclusion. A WFPBD is a potentially effective intervention to improve glycemic control among patients with T2D during the period leading up to surgery. Future controlled trials on a larger sample of patients to assess the impact of a WFPBD on glycemic control and surgical outcomes are warranted.

Surgical Ergonomics and Musculoskeletal Pain in Arthroplasty Surgeons

BACKGROUND

One occupational hazard inherent to total joint replacement surgeons is procedural-related musculoskeletal pain (MSP). The purpose of this study is to identify the prevalence of work-related MSP among arthroplasty surgeons and analyze associated behaviors, attitudes, and beliefs toward surgical ergonomics.

METHODS

A survey was sent to members of the American Association of Hip and Knee Surgeons. The survey included 3 main sections: demographics, symptoms by body part, and attitudes/beliefs/behaviors regarding surgical ergonomics. Pain was reported using the Numeric Rating Scale (0 = no pain, 10 = maximum pain), and well-being was assessed using the Maslach Burnout Inventory.

RESULTS

In total, 586 surgeons completed the survey: 96.1% male and 3.9% female. Most surgeons (96.5%) experience procedural-related MSP. Collectively, surgeons reported an average pain score of 3.7/10 (standard deviation ±1.95). Significant levels of MSP (≥5/10) were most common in the lower back (34.2%), hands (24.8%), and the neck (21.2%). There was a positive association among higher MSP and burnout (P < .001), callousness toward others (P = .005), and decreased overall happiness (P < .001). MSP was also found to have a significant impact on surgeon behavior including the degree of irritability (P < .001), alcohol intake (P < .001), and poor sleep patterns (P < .001).

CONCLUSION

The prevalence of MSP among arthroplasty surgeons is extremely high. This study demonstrates that MSP has a significant impact on career attitudes, lifestyle, and overall surgeon well-being. This study may also contribute to future work to prevent cumulative chronic ailments, disability, and lost productivity of arthroplasty surgeons through promotion of improved ergonomics and risk-reduction strategies.

LEVEL OF EVIDENCE

IV.

Cost-effectiveness of Single vs Double Debridement and Implant Retention for Acute Periprosthetic Joint Infections in Total Knee Arthroplasty: A Markov Model

Background

Periprosthetic joint infection (PJI) is a common cause of revision total knee surgery. Although debridement and implant retention (DAIR) has lower success rates in the chronic setting, it is an accepted treatment of acute PJI, whether postoperatively or with late hematogenous seeding. There are two broad DAIR strategies: single debridement and planned double debridement. The purpose of this study is to evaluate the cost-effectiveness of single vs double DAIR for acute PJI in total knee arthroplasty.

Methods

A decision tree using single or double DAIR as the treatment strategy for acute PJI was constructed. Quality-adjusted life years and costs associated with the two treatment arms were calculated. Treatment success rates, failure rates, and mortality rates were derived from the literature. Medical costs were derived from both the literature and Medicare data. A cost-effectiveness plane was constructed from multiple Monte Carlo trials. A sensitivity analysis identified parameters most influencing the optimal strategy decision.

Results

Double DAIR was the optimal treatment strategy both in terms of the health utility state (82% of trials) and medical cost (97% of trials). Strategy tables demonstrated that as long as the success rate of double debridement is 10% or greater than the success rate of a single debridement, the two-stage protocol is cost-effective.

Conclusions

A double DAIR protocol is more cost-effective than single DAIR from a societal perspective.

A Comprehensive Monetary Analysis of Inpatient Total Hip and Knee Arthroplasties Billed to Medicare by Hospitals: 2011-2017

BACKGROUND

Total joint arthroplasty (TJA) has been a recent target of reimbursement reform. As such, the purpose of this study was to evaluate trends in Medicare reimbursement to hospitals for TJA patients from 2011 to 2017.

METHODS

The Inpatient Utilization and Payment Public Use File was queried for all primary total hip and knee arthroplasty episodes. This file includes all services billed to Medicare via the Inpatient Prospective Payment System. Extracted data included hospital charges and amount paid by Medicare. All data were adjusted for inflation to 2017 US dollars. Multiple linear mixed-model regression analyses were conducted to assess change over time, and geo-modelling was used to represent reimbursement by location.

RESULTS

A total of 3,368,924 primary TJA procedures were billed to Medicare by hospitals from 2011 to 2017 and included in the study. The mean inflation-adjusted Medicare payment to hospitals for DRG 469 decreased from $22,783.66 to $19,604.62 per procedure (-$3179.04; -14.0%; P < .001) and decreased from $13,290.79 to $11,771.54 for DRG 470 (-$1519.25; -11.4%, P = .011) from 2011 to 2017. Meanwhile, the mean charge submitted by hospitals increased by $6483.39 and $5115.60 for DRGs 469 and 470, respectively (+7.4% for 469, +9.3% for 470; P < .001). Medicare reimbursement to hospitals varied by state.

CONCLUSION

During the study period, the mean Medicare reimbursement to hospitals decreased for TJA from 2011 to 2017. Meanwhile, the average charge submitted by hospitals increased. As alternative payment models continue to undergo evaluation and development, these data are important for the advancement of more agreeable reimbursement models in arthroplasty care.

Temporal Analysis of Medicare Physician Reimbursement and Procedural Volume for all Hip and Knee Arthroplasty Procedures Billed to Medicare Part B From 2000 to 2019

BACKGROUND

The purpose of this study was to evaluate trends in annual arthroplasty volume among the Medicare population, as well as assess true Medicare reimbursement to physicians for all hip and knee arthroplasty procedures billed to Medicare since year 2000.

METHODS

The publicly available Medicare Part B National Summary Data File from years 2000 to 2019 was utilized. Collected data included true physician reimbursements for all primary total hip and knee, unicompartmental knee, and revision hip/knee arthroplasty procedures from 2000 to 2019. Monetary data was adjusted for inflation to year 2019 dollars. Change was assessed and compared by procedure type.

RESULTS

From 2000 to 2019, physicians billed Medicare Fee-for-service for 8,363,821 hip and knee arthroplasty procedures. During this time, the annual number of included arthroplasty procedures billed to Medicare increased by 100%. From 2000 to 2019 across all included procedures, the mean physician reimbursement after adjusting for inflation decreased by -$729.82 (-38.9%) per procedure. This varied by procedure type. Unicompartmental knee arthroplasty was the only procedure to experience an increased mean reimbursement when adjusting for inflation, increasing by $241.40 (+16.6%) per procedure from 2000 to 2019.

CONCLUSION

This study demonstrates decreasing Medicare reimbursement to physicians within hip and knee arthroplasty from 2000 to 2019 when adjusting for inflation. This study is important for informing the potential development of more equitable payment models and maintaining access for arthroplasty care moving forward.

Acute or chronic periprosthetic joint infection? Using the ESR ∕ CRP ratio to aid in determining the acuity of periprosthetic joint infections

Introduction: The gold standard for determining the duration of periprosthetic joint infection (PJI) is a thorough history. Currently, there are no well-defined objective criteria to determine the duration of PJI, and little evidence exists regarding the ratio between ESR (mm/h) and CRP (mg/L) in joint arthroplasty. This study suggests the ESR  /  CRP ratio will help differentiate acute from chronic PJI. Methods: Retrospective review of patients with PJI was performed. Inclusion criteria: patients > 18  years old who underwent surgical revision for PJI and had documented ESR and CRP values. Subjects were divided into two groups: PJI for greater (chronic) or less than (acute) 4 weeks and the ESR  /  CRP ratio was compared between them. Receiver-operating characteristic (ROC) curves were evaluated to determine the utility of the ESR  /  CRP ratio in characterizing the duration of PJI. Results: 147 patients were included in the study (81 acute and 66 chronic). The mean ESR  /  CRP ratio in acute patients was 0.48 compared to 2.87 in chronic patients ( p < 0.001 ). The ESR  /  CRP ROC curve demonstrated an excellent area under the curve (AUC) of 0.899. The ideal cutoff value was 0.96 for ESR  /  CRP to predict a chronic ( > 0.96 ) vs. acute ( < 0.96 ) PJI. The sensitivity at this value was 0.74 (95 % CI 0.62-0.83) and the specificity was 0.90 (95 % CI 0.81-0.94). Conclusions: The ESR  /  CRP ratio may help determine the duration of PJI in uncertain cases. This metric may give arthroplasty surgeons more confidence in defining the duration of the PJI and therefore aid in treatment selection.

A Contemporary Classification System of Femoral Bone Loss in Revision Total Hip Arthroplasty

BACKGROUND

Current femoral bone loss classification systems in revision total hip arthroplasty were created at a time when the predominant reconstructive methods used cylindrical porous-coated cobalt-chrome stems. As these stems have largely been replaced by fluted-tapered titanium stems, the ability of these classification systems to help guide implant selection is limited. The purpose of this study was to describe a novel classification system based on contemporary reconstructive techniques.

METHODS

We reviewed the charts of all patients who underwent femoral component revision at our institution from 2007 through 2019. Preoperative images were reviewed, and FBL was rated according to the Paprosky classification and compared to ratings using our institution's NCS. Rates of reoperation at the time of most recent follow-up were determined and compared.

RESULTS

Four-hundred and forty-two femoral revisions in 330 patients with a mean follow-up duration of 2.7 years were identified. Femoral type according to Paprosky and NCS were Paprosky I (36, 8.1%), II (61, 13.8%), IIIA (180, 40.7%), IIIB (116, 26.2%), and IV (49 11.1%) and NCS 1 (35, 7.9%), 2 (364, 82.4%), 3 (8, 1.8%), 4 (27, 6.1%), and 5 (8, 1.8%). Of the 353 nonstaged rTHAs, there were 42 cases requiring unplanned reoperation (11.9%), including infection (18, 5.1%), instability (10, 2.8%), femoral loosening (5, 1.4%), and various other causes (9, 2.5%). The NCS was more predictive of reoperation than the Paprosky classification (Fisher's exact test, P = .008 vs P = ns, respectively).

CONCLUSION

We present a novel femoral classification system that can help guide contemporary implant selection.

The Double DAIR: A 2-Stage Debridement with Prosthesis-Retention Protocol for Acute Periprosthetic Joint Infections

Background

Debridement and implant retention (DAIR) has variable success as a treatment for acute periprosthetic joint infection (PJI), with generally poor outcomes reported in the literature¹. Because of the unacceptably high failure rate of DAIR, we implemented a 2-stage debridement protocol that includes the use of high-dose antibiotic beads between stages for the treatment of acute PJI. In 2 previous studies, with an average follow-up of 3.5 years in each study, we reported overall infection-control rates of 87% and 90%^2,3.

Description

Following exposure of the joint, cultures are obtained, and all modular components are removed, scrubbed, and soaked in an antiseptic solution. A thorough irrigation and debridement with complete synovectomy is performed, followed by temporary reinsertion of the original modular parts. High-dose antibiotic cement beads are inserted into the joint, and the joint is closed. Approximately 5 to 6 days later, a second debridement is performed, the beads are removed, and the new modular, sterile components are implanted. The patient is placed on a course of intravenous and, later, oral antibiotics, in addition to a standard postoperative rehabilitation protocol.

Alternatives

Long-term suppressive antibiotic therapy.One-stage DAIR.One-stage exchange arthroplasty.Two-stage exchange arthroplasty.Resection arthroplasty.Amputation.

Rationale

The treatment of acute PJI has historically consisted of a single irrigation and debridement, with exchange of modular parts and retention of the components, followed by intravenous antibiotic therapy. Despite having lower rates of patient morbidity compared with a 2-stage exchange arthroplasty, this more traditional procedure also has a higher rate of failure, with reported rates as high as 60% to 84%^4-12. The utility of component retention continues to be a topic of debate¹³. Alternatives to component retention include both 1- and 2-stage exchange procedures. Although these modalities offer potentially higher rates of infection control, they are associated with substantial patient morbidity, particularly in patients with well-fixed implants^14-16. Furthermore, exchange procedures may result in substantial iatrogenic bone loss, which can be problematic in revision total joint arthroplasty procedures, in which bone stock may already be limited. The double-DAIR protocol offers infection-control rates that are comparable with those of component-exchange procedures, but with the lower patient morbidity associated with component-retention procedures. Furthermore, the double-DAIR procedure provides the added benefit of retaining important bone stock.

Expected Outcomes

The success rate for the double-DAIR procedure has been reproducible, with infection-control rates of 87% and 90% reported in 2 studies from a single cohort at our institution^2,3. These rates represent a substantial improvement compared with a single irrigation and debridement¹, and are on par with those reported for 2-stage exchange arthroplasty procedures^17-21. The infection-control rates of the double-DAIR procedure did not significantly vary depending on whether infection occurred following a total knee or total hip arthroplasty. However, not surprisingly, patients who underwent debridement following a revision procedure had a lower rate of success (77.1% successful infection control) compared with patients debrided following a primary procedure (93.8% successful infection control). We could not demonstrate an association with organism and success or failure of treatment.Although not significant, there was a trend toward an association between the time from symptom onset to initial treatment and infection control (p = 0.07)². Patients with successful infection control underwent the initial debridement an average of 6.2 days after symptom onset, compared with 10.7 days in patients in whom treatment had failed. Several other studies have demonstrated that successful infection control is associated with earlier initial irrigation and debridement^22-27. We strongly support that, in the setting of confirmed acute PJI, prompt initiation of treatment optimizes the chances for successful infection control.

Important Tips

Thorough debridement is key to successful infection control of infection.Antibiotic-loaded bone cement has repeatedly been demonstrated to be safe, and we recommend its use^28-31.Extended oral antibiotics following debridement with component retention can increase infection-free survivorship³².

Intraosseous Regional Administration of Antibiotic Prophylaxis in Total Knee Arthroplasty

Background

Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA), and perioperative antibiotics are commonly administered to try to mitigate the chance of infection. Intraosseous regional administration (IORA) of prophylactic antibiotics during TKA is a method of antibiotic delivery that has been shown to achieve markedly higher tissue concentrations at much lower doses. Other advantages include ease of administration, ability to time the antibiotic delivery with the surgical start time for maximal effectiveness, and less systemic side effects. The concept is similar to a Bier block, except that IORA involves the use of antibiotics instead of local anesthetic to perfuse the limb and is given via intraosseous rather than intravenous access.

Description

After standard patient preparation and draping, the tourniquet is inflated and an intraosseous needle is inserted into the proximal medial face of the tibia, just medial and slightly above the level of the tubercle. A large syringe containing the desired antibiotic (typically 500 mg vancomycin suspended in normal saline solution) is connected to the needle and the solution is administered over 1 to 2 minutes. The intraosseous needle can then be removed and the surgical procedure proceeds as it normally would per surgeon preference and technique.

Alternatives

Systemic administration of intravenous antibiotics, vancomycin powder, and antibiotic-impregnated cement are alternative options that can be utilized during TKA.

Rationale

IORA has several distinct advantages over other methods of antibiotic delivery, including the ability to (1) deliver antibiotic directly to the surgical bed and avoid systemic delivery, (2) precisely time and quickly administer antibiotics to achieve highest concentrations at the start of and throughout the surgical procedure, and (3) avoid several common and potentially serious side effects, especially those associated with antibiotics such as vancomycin.

Expected Outcomes

This technique for antibiotic delivery achieves markedly higher tissue concentrations compared with systemic administration, without prolonged preoperative infusion times. Intraosseous delivery optimizes timing and reduces the risk of systemic side effects while simultaneously providing equal or enhanced antibiotic prophylaxis in TKA. This delivery mechanism is especially useful in patients who are at high risk for infection and in the revision TKA setting. Further, there is little to no additional risk and the use of this method does not substantially prolong operative time.

Important Tips

The proximal aspect of the tibia is the optimal injection site because the cortex is thinner in this region, making needle insertion easier. Additionally, the metaphyseal bone allows faster flow rates for the infusion. We have found that insertions made slightly more proximally are easier and have faster flow rates. Of note, although the antibiotic is infused into the tibia, as seen in the attached technique video, intraosseous administration achieves rapid uptake into the vascular tree. Therefore, all tissues distal to the tourniquet, including the femur and patella, will receive this optimal dose as well.We prefer the use of a power driver (EZ-IO; Teleflex); however, manual needles (Cook Medical) can also be utilized. Longer needles are available if needed for obese patients.Flow rates are variable and the infusion typically takes 1 to 2 minutes to complete. If the flow rate is slow, twisting and withdrawing the needle slightly (2 to 4 mm) may increase the rate. This contrasts with the 1 to 2-hour intravenous infusion time required when vancomycin is administered systemically.In our experience, intraosseous injection is still successful in the case of a previous high tibial osteotomy, although the flow rate may be slower.In complex revision cases with compromised proximal tibial bone, the medial malleolus is an alternative site for intraosseous administration.Choice of antibiotic: as vancomycin is difficult to adequately administer intravenously, it is ideally suited for IORA. We have studied and utilized a 500-mg dose of vancomycin suspended in a solution of 140 mL of normal saline solution (prepared by our pharmacy). Of note, we have not found rapid infusion of intraosseous vancomycin to cause red-man syndrome as it would with rapid systemic infusion. This is because of the lower dose of 500 mg and the use of the tourniquet, which keeps the antibiotic in the local tissues about the knee without allowing systemic exposure. All patients, regardless of weight or the size of their limb, receive the dose of 500 mg of vancomycin.As cefazolin does not have the same difficulties with intravenous administration, we continue to use standard intravenous prophylaxis with an appropriate weight-based dose of cefazolin prior to incision.Indications for IORA of vancomycin include clinical scenarios in which vancomycin would be administered intravenously. These indications include revision TKA, obesity (body mass index >40 kg/m²), diabetes, beta-lactam allergy, known colonization with methicillin-resistant Staphylococcus aureus (MRSA), patients coming from institutions with a high prevalence of MRSA, previous ligamentous surgical procedure or osteotomies, and current or recent smokers. IORA can be utilized even in the primary TKA setting if the patient is considered high-risk as defined by the criteria above. We also use IORA during reimplantation following 2-stage exchange for PJI and in patients undergoing irrigation and debridement for acute PJI when the organism has been identified preoperatively.

Routine Type and Screens Are Unnecessary for Primary Total Hip and Knee Arthroplasties at an Academic Hospital

Background

Despite decreasing transfusion rates, routine type and screens are frequently used before primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). The aims of this study were to characterize transfusion rates and identify any factors that affect the likelihood of transfusion to determine if it is safe to discontinue routine preoperative type and screens at an academic hospital.

Methods

A retrospective chart review was performed for all patients who underwent primary THA or TKA in 2019 at an academic institution by a fellowship-trained arthroplasty surgeon. Data on preoperative type and screens, transfusion rates, bleeding disorders, and anticoagulation status were obtained. Patients were considered to have a preoperative type and screen if it was performed within 30 days before surgery.

Results

Overall, 379 patients were included in the study. Of these, 210 underwent primary THA and 169 underwent primary TKA. Four patients received transfusions during their hospitalization for a cumulative transfusion rate of 1.06%. No patients received an intraoperative transfusion. One (0.59%) patient received a postoperative transfusion after TKA, and 3 (1.43%) patients received a postoperative transfusion after THA. The mean preoperative hemoglobin of the 4 transfused patients was 10.8 g/dL.

Conclusions

In summary, performing a preoperative routine type and screen is likely unnecessary at academic medical centers. Consideration for obtaining a type and screen may include complex primary surgeries or when patients have preoperative hemoglobin of less than 11 g/dL. Ultimately, preoperative type and screen should be considered on a case-by-case basis using clinical judgment.

Can a Convolutional Neural Network Classify Knee Osteoarthritis on Plain Radiographs as Accurately as Fellowship-Trained Knee Arthroplasty Surgeons?

BACKGROUND

Osteoarthritis (OA) is the leading cause of disability among adults in the United States. As the diagnosis is based on the accurate interpretation of knee radiographs, use of a convolutional neural network (CNN) to grade OA severity has the potential to significantly reduce variability.

METHODS

Knee radiographs from consecutive patients presenting to a large academic arthroplasty practice were obtained retrospectively. These images were rated by 4 fellowship-trained knee arthroplasty surgeons using the International Knee Documentation Committee (IKDC) scoring system. The intraclass correlation coefficient (ICC) for surgeons alone and surgeons with a CNN that was trained using 4755 separate images were compared.

RESULTS

Two hundred eighty-eight posteroanterior flexion knee radiographs (576 knees) were reviewed; 131 knees were removed due to poor quality or prior TKA. Each remaining knee was rated by 4 blinded surgeons for a total of 1780 human knee ratings. The ICC among the 4 surgeons for all possible IKDC grades was 0.703 (95% confidence interval [CI] 0.667-0.737). The ICC for the 4 surgeons and the trained CNN was 0.685 (95% CI 0.65-0.719). For IKDC D vs any other rating, the ICC of the 4 surgeons was 0.713 (95% CI 0.678-0.746), and the ICC of 4 surgeons and CNN was 0.697 (95% CI 0.663-0.73).

CONCLUSIONS

A CNN can identify and classify knee OA as accurately as a fellowship-trained arthroplasty surgeon. This technology has the potential to reduce variability in the diagnosis and treatment of knee OA.

Screening for Periprosthetic Joint Infections With ESR and CRP: The Ideal Cutoffs

BACKGROUND

The purpose of this study was to (1) determine the sensitivity and specificity of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) when screening for a periprosthetic joint infection (PJI) using the standard MSIS cutoff of 30 mm/h and 10 mg/L, respectively, and (2) determine the optimal ESR and CRP cutoff to achieve a sensitivity ≥95%.

METHODS

We retrospectively analyzed 81 PJI patients and 83 noninfected arthroplasty patients. We calculated the sensitivity and specificity (and 95% confidence intervals) for ESR and CRP at thresholds of 30 mm/h and 10 mg/L, respectively. We determined the optimal cutoff for both ESR and CRP to yield a sensitivity greater than or equal to 95%.

RESULTS

The ESR cutoff that resulted in a sensitivity ≥ to 95% (95% CI: 85.2-97.6%) was 10 mm/h, and the CRP cutoff that resulted in a sensitivity ≥ to 95% (95% CI: 87.1-98.4%) was 5 mg/L. The sensitivity and specificity with a combined ESR and CRP of 10 mm/h and 5 mg/L was 100% (95% CI: 94.1-100%) and 54.7% (95% CI: 46.4-62.3%).

CONCLUSION

When using ESR and CRP as a screening tool with the accepted cutoffs of 30 mm/h and 10 mg/L, there is an unacceptably low sensitivity and a high number of false negatives. Therefore, further recommendation must be given to lowering these thresholds to avoid the devastating morbidity of a missed PJI.

LEVEL OF EVIDENCE

III.

Frequency, Cost, and Clinical Significance of Incidental Findings on Preoperative Planning Images for Computer-Assisted Total Joint Arthroplasty

BACKGROUND

The frequency of incidental findings with computer-assisted total joint arthroplasty (CA TJA) preoperative imaging and their clinical significance are currently unknown.

METHODS

We reviewed 573 patients who underwent primary CA TJA requiring planning imaging. Incidental findings were defined as reported findings excluding those related to the planned arthroplasty. Secondary outcomes were additional tests or a delay in surgery. Associated charges were obtained from our institution's website. Charge and incidence data were combined with TJA volumes obtained from the 2016 National Inpatient Sample to model costs to the healthcare system.

RESULTS

Overall, 262 patients (45.7%) had at least 1 incidental finding, 144 patients (25.1%) had 2, and 65 (11.3%) had 3. The most common finding types were musculoskeletal (MSK, 67.7%), digestive (19.5%), cardiovascular (4.9%), and reproductive (4.7%). Also, 9.3% of patients had at least 1 non-MSK incidental finding. Both MSK and non-MSK incidental findings were more common with total hip arthroplasty compared to total knee arthroplasty (67.9% vs 42.2%, P < .0001, and 15.4% vs 8.3%, P < .05, respectively). Further testing was required in 6 cases (1.0%); 1 case required delay in surgery (0.2%). Using the 2016 volume of TJA procedures and assuming a 10%, 15%, and 25%, utilization rate of image-based CA TJA, the annual cost of additional testing was $2.7 million (95% confidence interval, $1.1-$6.3 million), $4.1 million ($1.6-$9.5 million), and $6.9 million (95% confidence interval, $2.7-$15.8 million), respectively.

CONCLUSION

Incidental findings are relatively common on planning images. Stakeholders should be aware of the hidden costs of incidental findings given the increasing popularity of image-based CA TJA.

Minimum Clinically Important Difference: Current Trends in the Orthopaedic Literature, Part I: Upper Extremity: A Systematic Review

BACKGROUND

The minimum clinically important difference (MCID) attempts to define the patient's experience of treatment outcomes. Efforts at calculating the MCID have yielded multiple and inconsistent MCID values. The purposes of this review were to describe the usage of the MCID in the most recent orthopaedic literature, to explain the limitations of its current uses, and to clarify the underpinnings of MCID calculation. Subsequently, we hope that the information presented here will help practitioners to better understand the MCID and to serve as a guide for future efforts to calculate the MCID. The first part of this review focuses on the upper-extremity orthopaedic literature. Part II will focus on the lower-extremity orthopaedic literature.

METHODS

A review was conducted of the 2014 to 2016 publications in The Journal of Arthroplasty, The Journal of Bone & Joint Surgery, The American Journal of Sports Medicine, Foot & Ankle International, Journal of Orthopaedic Trauma, Journal of Pediatric Orthopaedics, and Journal of Shoulder and Elbow Surgery. Only clinical science articles utilizing patient-reported outcome measure (PROM) scores were included in the analysis. A keyword search was then performed to identify articles that calculated or referenced the MCID. Articles were then further categorized into upper-extremity and lower-extremity publications. MCID utilization in the selected articles was subsequently characterized and recorded.

RESULTS

The MCID was referenced in 129 (7.5%) of 1,709 clinical science articles that utilized PROMs: 52 (40.3%) of 129 were related to the upper extremity, 5 (9.6%) of 52 independently calculated MCID values, and 47 (90.4%) of 52 used previously published MCID values as a gauge of their own results. MCID values were considered or calculated for 16 PROMs; 12 of these were specific to the upper extremity. Six different methods were used to calculate the MCID. Calculated MCIDs had a wide range of values for the same PROM (e.g., 8 to 36 points for Constant-Murley scores and 6.4 to 17 points for American Shoulder and Elbow Surgeons [ASES] scores).

CONCLUSIONS

Determining useful MCID values remains elusive and is compounded by the proliferation of PROMs in the field of orthopaedics. The fundamentals of MCID calculation methods should be critically evaluated. If necessary, these methods should be corrected or abandoned. Furthermore, the type of change intended to be measured should be clarified: beneficial, detrimental, or small or large changes. There should also be assurance that the calculation method actually measures the intended change. Finally, the measurement error should consistently be reported.

CLINICAL RELEVANCE

The MCID is increasingly used as a measure of patients' improvement. However, the MCID does not yet adequately capture the clinical importance of patients' improvement.

Patellar osteolysis after total knee arthroplasty with patellar resurfacing: a potentially underappreciated problem

Osteolysis of the patella following total knee arthroplasty is both uncommon and poorly described in the literature. We describe 3 cases of total knee arthroplasty with patella resurfacing that later presented with anterior knee pain with patellar osteolysis without evidence of patellar implant failure: 2 males and 1 female patient, all with bilateral knee osteoarthritis. Osteolysis of the patella was identified radiographically between 2 and 16 years from the index procedure. We theorize that high pressures across the patella-femoral joint, in obese or muscular patients, may play a role in the formation of these patellar osteolytic lesions. We suspect that the prevalence of this phenomenon is under-recognized in the literature and may increase with longer term follow-up and awareness.

Tourniquet Use in Total Knee Arthroplasty

Tourniquet use in total knee arthroplasty has become a controversial topic. There are several benefits of its use including improved visualization, decreased blood loss, shorter operative times, and improved antibiotic delivery. Conversely, there are several significant downsides associated with tourniquet use including postoperative pain, neuromuscular injuries, wound complications, reperfusion injury, increased risk of thrombosis, patellar tracking issues, delayed rehabilitation including decreased postoperative range of motion, and its negative effect on patients with vascular disease. However, objectively, the literature does not definitively push us toward or away from the use of a tourniquet. Furthermore, several alternatives have been developed to help mitigate some of the adverse effects associated with its use. This article summarizes the evidence for and against tourniquet use and provides an evidence-based approach to help guide surgeons in their own practice.

Measuring Tibial Component Rotation Following Total Knee Arthroplasty: What Is the Best Method?

BACKGROUND

Tibial component malrotation is associated with pain, stiffness, and altered patellofemoral kinematics in total knee arthroplasty (TKA). However, measuring tibial component rotation following TKA is difficult. Proposed protocols utilizing computed tomography (CT) lack validity and can be time-consuming. This study aimed to (1) compare the reproducibility of the Berger (two-dimensional CT) and Mayo (three-dimensional CT) protocols and (2) validate a simple measurement technique using an anatomical distance on two-dimensional axial CT-the Center of the Tibial tray to the tip of the Tibial Tubercle (CTTT).

METHODS

Rotational alignment of 70 TKA patients was evaluated by 3 independent observers using the Berger, Mayo, and CTTT protocols. The inter-rater and intra-rater interclass correlation coefficients, mean difference between measurements, and the mean measurement times were calculated.

RESULTS

The intra-rater reliability for all 3 protocols was rated as "very good" (Mayo 0.96, Berger 0.85, and CTTT 0.85). The inter-rater reliability for the Mayo and the Berger method was rated as "very good" (0.87 and 0.83, respectively), and the CTTT was rated as "good" (0.79). Comparing the CTTT to the Mayo method produced an r² value of 0.73 with 92% of CTTT measurements ≤6 mm having <9° of tibial component internal rotation and 93% of patients with a CTTT ≥10 mm having ≥9° internal rotation.

CONCLUSION

Three-dimensional CT is the gold standard for measuring tibial component rotational alignment. The CTTT has the strongest correlation to the Mayo method and can be reliably used as a rapid screening tool.