Evidence-based Perioperative Practice Utilization among Various Racial Populations-A Retrospective Cohort Trending Analysis of Lower Extremity Total Joint Arthroplasty Patients

BACKGROUND

Various studies have demonstrated racial disparities in perioperative care and outcomes. The authors hypothesize that among lower extremity total joint arthroplasty patients, evidence-based perioperative practice utilization increased over time among all racial groups, and that standardized evidence-based perioperative practice care protocols resulted in reduction of racial disparities and improved outcomes.

METHODS

The study analyzed 3,356,805 lower extremity total joint arthroplasty patients from the Premier Healthcare database (Premier Healthcare Solutions, Inc., USA). The exposure of interest was race (White, Black, Asian, other). Outcomes were evidence-based perioperative practice adherence (eight individual care components; more than 80% of these implemented was defined as "high evidence-based perioperative practice"), any major complication (including acute renal failure, delirium, myocardial infarction, pulmonary embolism, respiratory failure, stroke, or in-hospital mortality), in-hospital mortality, and prolonged length of stay.

RESULTS

Evidence-based perioperative practice adherence rate has increased over time and was associated with reduced complications across all racial groups. However, utilization among Black patients was below that for White patients between 2006 and 2021 (odds ratio, 0.94 [95% CI, 0.93 to 0.95]; 45.50% vs. 47.90% on average). Independent of whether evidence-based perioperative practice components were applied, Black patients exhibited higher odds of major complications (1.61 [95% CI, 1.55 to 1.67] with high evidence-based perioperative practice; 1.43 [95% CI, 1.39 to 1.48] without high evidence-based perioperative practice), mortality (1.70 [95% CI, 1.29 to 2.25] with high evidence-based perioperative practice; 1.29 [95% CI, 1.10 to 1.51] without high evidence-based perioperative practice), and prolonged length of stay (1.45 [95% CI, 1.42 to 1.48] with high evidence-based perioperative practice; 1.38 [95% CI, 1.37 to 1.40] without high evidence-based perioperative practice) compared to White patients.

CONCLUSIONS

Evidence-based perioperative practice utilization in lower extremity joint arthroplasty has been increasing during the last decade. However, racial disparities still exist with Black patients consistently having lower odds of evidence-based perioperative practice adherence. Black patients (compared to the White patients) exhibited higher odds of composite major complications, mortality, and prolonged length of stay, independent of evidence-based perioperative practice use, suggesting that evidence-based perioperative practice did not impact racial disparities regarding particularly the Black patients in this surgical cohort.

EDITOR’S PERSPECTIVE

Trial of Vancomycin and Cefazolin as Surgical Prophylaxis in Arthroplasty

BACKGROUND

The addition of vancomycin to beta-lactam prophylaxis in arthroplasty may reduce surgical-site infections; however, the efficacy and safety are unclear.

METHODS

In this multicenter, double-blind, superiority, placebo-controlled trial, we randomly assigned adult patients without known methicillin-resistant Staphylococcus aureus (MRSA) colonization who were undergoing arthroplasty to receive 1.5 g of vancomycin or normal saline placebo, in addition to cefazolin prophylaxis. The primary outcome was surgical-site infection within 90 days after surgery.

RESULTS

A total of 4239 patients underwent randomization. Among 4113 patients in the modified intention-to-treat population (2233 undergoing knee arthroplasty, 1850 undergoing hip arthroplasty, and 30 undergoing shoulder arthroplasty), surgical-site infections occurred in 91 of 2044 patients (4.5%) in the vancomycin group and in 72 of 2069 patients (3.5%) in the placebo group (relative risk, 1.28; 95% confidence interval [CI], 0.94 to 1.73; P = 0.11). Among patients undergoing knee arthroplasty, surgical-site infections occurred in 63 of 1109 patients (5.7%) in the vancomyin group and in 42 of 1124 patients (3.7%) in the placebo group (relative risk, 1.52; 95% CI, 1.04 to 2.23). Among patients undergoing hip arthroplasty, surgical-site infections occurred in 28 of 920 patients (3.0%) in the vancomyin group and in 29 of 930 patients (3.1%) in the placebo group (relative risk, 0.98; 95% CI, 0.59 to 1.63). Adverse events occurred in 35 of 2010 patients (1.7%) in the vancomycin group and in 35 of 2030 patients (1.7%) in the placebo group, including hypersensitivity reactions in 24 of 2010 patients (1.2%) and 11 of 2030 patients (0.5%), respectively (relative risk, 2.20; 95% CI, 1.08 to 4.49), and acute kidney injury in 42 of 2010 patients (2.1%) and 74 of 2030 patients (3.6%), respectively (relative risk, 0.57; 95% CI, 0.39 to 0.83).

CONCLUSIONS

The addition of vancomycin to cefazolin prophylaxis was not superior to placebo for the prevention of surgical-site infections in arthroplasty among patients without known MRSA colonization. (Funded by the Australian National Health and Medical Research Council; Australian New Zealand Clinical Trials Registry number, ACTRN12618000642280.).

What Is the Implant Survivorship and Functional Outcome After Total Humeral Replacement in Patients with Primary Bone Tumors?

BACKGROUND

Total humeral replacement is an option to reconstruct massive bone defects after resection of locally advanced bone tumors of the humerus. However, implant survivorship, potential risk factors for implant revision surgery, and functional results of total humeral replacement are poorly elucidated because of the rarity of the procedure.

QUESTIONS/PURPOSES

We asked: (1) What is the revision-free implant and overall limb survivorship after total humerus replacement? (2) What factors are associated with implant revision surgery? (3) What is the functional outcome of the procedure as determined by the Musculoskeletal Tumor Society (MSTS) score and the American Shoulder and Elbow Surgeons (ASES) score?

METHODS

Between August 1999 and December 2018, 666 patients underwent megaprosthetic reconstruction after resection of a primary malignant or locally aggressive/rarely metastasizing tumor of the long bones at our department. In all, 23% (154) of these patients had a primary tumor located in the humerus. During the study, we performed total humeral replacement in all patients with a locally advanced sarcoma, in patients with pathological fractures, in patients with skip metastases, or in patients with previous intralesional contaminating surgery, who would have no sufficient bone stock for a stable implant fixation for a single joint megaprosthetic replacement of the proximal or distal humerus. We performed no biological reconstructions or reconstructions with allograft-prosthetic composites. As a result, 5% (33 of 666) of patients underwent total humerus replacement. Six percent (2 of 33) of patients were excluded because they received a custom-made, three-dimensionally (3-D) printed hemiprosthesis, leaving 5% (31) of the initial 666 patients for inclusion in our retrospective analysis. Of these, 6% (2 of 31) had surgery more than 5 years ago, but they had not been seen in the last 5 years. Median (interquartile range) age at the time of surgery was 15 years (14 to 25 years), and indications for total humeral replacement were primary malignant bone tumors (n = 30) and a recurring, rarely metastasizing bone tumor (n = 1). All megaprosthetic reconstructions were performed with a single modular system. The implanted prostheses were silver-coated beginning in 2006, and beginning in 2010, a reverse proximal humerus component was used when appropriate. We analyzed endoprosthetic complications descriptively and assessed the functional outcome of all surviving patients who did not undergo secondary amputation using the 1993 MSTS score and the ASES score. The median (IQR) follow-up in all survivors was 75 months (50 to 122 months), with a minimum follow-up period of 25 months. We evaluated the following factors for possible association with implant revision surgery: age, BMI, reconstruction length, duration of surgery, extraarticular resection, pathological fracture, previous intralesional surgery, (neo-)adjuvant radio- and chemotherapy, and metastatic disease.

RESULTS

The revision-free implant survivorship at 1 year was 77% (95% confidence interval 58% to 89%) and 74% (95% CI 55% to 86%) at 5 years. The overall limb survivorship was 93% (95% CI 75% to 98%) after 1 and after 5 years. We found revision-free survivorship to be lower in patients with extraarticular shoulder resection compared with intraarticular resections (50% [95% CI 21% to 74%] versus 89% [95% CI 64% to 97%]) after 5 years (subhazard ratios for extraarticular resections 4.4 [95% CI 1.2 to 16.5]; p = 0.03). With the number of patients available for our analysis, we could not detect a difference in revision-free survivorship at 5 years between patients who underwent postoperative radiotherapy (40% [95% CI 5% to 75%]) and patients who did not (81% [95% CI 60% to 92%]; p = 0.09). The median (IQR) MSTS score in 9 of 13 surviving patients after a median follow-up of 75 months (51 to 148 months) was 87% (67% to 92%), and the median ASES score was 83 (63 to 89) of 100 points, with higher scores representing better function.

CONCLUSION

Total humeral replacement after resection of locally advanced bone tumors appears to be associated with a good functional outcome in patients who do not die of their tumors, which in our study was approximately one- third of those who were treated with a resection and total humerus prosthesis. However, the probability of early prosthetic revision surgery is high, especially in patients undergoing extraarticular resections, who should be counseled accordingly. Still, our results suggest that if the prosthesis survives the first year, further risk for revision appears to be low. Future studies should reexamine the effect of postoperative radiotherapy on implant survival in a larger cohort and evaluate whether the use of soft tissue coverage with plastic reconstructive surgery might decrease the risk of early revisions, especially in patients undergoing extraarticular resections.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Are responders to patient health surveys representative of those invited to participate? An analysis of the Patient-Reported Outcome Measures Pilot from the Australian Orthopaedic Association National Joint Replacement Registry

Background

Patient-reported outcome measures (PROMs) are commonly used to evaluate surgical outcome in patients undergoing joint replacement surgery, however routine collection from the target population is often incomplete. Representative samples are required to allow inference from the sample to the population. Although higher capture rates are desired, the extent to which this improves the representativeness of the sample is not known. We aimed to measure the representativeness of data collected using an electronic PROMs capture system with or without telephone call follow up, and any differences in PROMS reporting between electronic and telephone call follow up.

Methods

Data from a pilot PROMs program within a large national joint replacement registry were examined. Telephone call follow up was used for people that failed to respond electronically. Data were collected pre-operatively and at 6 months post-operatively. Responding groups (either electronic only or electronic plus telephone call follow up) were compared to non-responders based on patient characteristics (joint replaced, bilaterality, age, sex, American Society of Anesthesiologist (ASA) score and Body Mass Index (BMI)) using chi squared test or ANOVA, and PROMs for the two responder groups were compared using generalised linear models adjusted for age and sex. The analysis was restricted to those undergoing primary elective hip, knee or shoulder replacement for osteoarthritis.

Results

Pre-operatively, 73.2% of patients responded electronically and telephone follow-up of non-responders increased this to 91.4%. Pre-operatively, patients responding electronically, compared to all others, were on average younger, more likely to be female, and healthier (lower ASA score). Similar differences were found when telephone follow up was included in the responding group. There were little (if any) differences in the post-operative comparisons, where electronic responders were on average one year younger and were more likely to have a lower ASA score compared to those not responding electronically, but there was no significant difference in sex or BMI. PROMs were similar between those reporting electronically and those reporting by telephone.

Conclusion

Patients undergoing total joint replacement who provide direct electronic PROMs data are younger, healthier and more likely to be female than non-responders, but these differences are small, particularly for post-operative data collection. The addition of telephone call follow up to electronic contact does not provide a more representative sample. Electronic-only follow up of patients undergoing joint replacement provides a satisfactory representation of the population invited to participate.

Payments for outpatient joint replacement surgery: A comparison of hospital outpatient departments and ambulatory surgery centers

OBJECTIVE

To compare commercial insurance payments for outpatient total knee and hip replacement surgeries performed in hospital outpatient departments (HOPDs) and in ambulatory surgery centers (ASCs).

DATA SOURCES

A large national claims database that contains information on actual prices paid to providers over the period 2014-2017.

DATA COLLECTION

We identified all patients receiving total knee replacement surgery and total hip replacement surgery in HOPDs and in ASCs for each of the 4 years.

STUDY DESIGN

For each year, we conducted descriptive and statistical patient-level analyses of the facility component of payments to HOPDs and to ASCs.

PRINCIPAL FINDINGS

For each procedure and for each year, ASC payments exceeded HOPD payments by a wide margin; however, the gap across settings declined over time. In 2014, knee replacement payments to HOPDs (n = 67) were $6016 compared to $23 244 in ASCs (n = 68). By 2017, payments to HOPDs (n = 223) had grown to $10 060 compared to $18 234 in ASCs (n = 602). Similarly, for hip replacements, HOPD payments (n = 43) rose from $6980 in 2014 to $11 139 in 2017 (n = 206) and in ASCs fell from $28 485 in 2014 (n = 82) to $18 595 in 2017 (n = 465).

CONCLUSIONS

Results suggest that for total joint replacement, common perceptions of cost savings from transition of services from hospitals to ASCs may be misguided.

Factors associated with emergency department presentation after total joint arthroplasty: a population-based retrospective cohort study

BACKGROUND

Unplanned visits to the emergency department after total joint arthroplasty are far more common than unplanned readmissions. Our objectives were to characterize the prevalence of presentation to an emergency department for any reason after total joint arthroplasty and to identify risk factors for such visits.

METHODS

Using health administrative databases, we conducted a population-based retrospective cohort study of adults (19-89 yr of age) who received their first primary elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) procedure for arthritis between April 2011 and March 2016 in Ontario. We made univariate comparisons between patients who presented to the emergency department within 30 days of surgery and those who did not in. We determined differences in use of health care services between groups by comparing the change in use in the year before and after surgery between patients who presented to the emergency department and those who did not. We developed logistic regression models for the occurrence of an emergency department visit using backward variable elimination.

RESULTS

We identified 42 273 total hip recipients and 70 725 total knee recipients, of whom 5640 (13.3%) and 11 224 (15.9%), respectively, presented to the emergency department within 30 days of surgery. Fewer than 1% of these patients required admission, and nearly half (45%) went to a different institution from where they had their surgery. Among both THA and TKA recipients, patients who presented to the emergency department had a net increase in their median annual health care costs (THA: $501, TKA: $682), compared to a net decrease for the cohort as a whole. Factors associated with increased risk of an emergency visit included increased patient age, male sex, rural residence and various comorbidities. Predictive regression models showed poor discriminative ability for both THA (C-statistic 0.57) and TKA (C-statistic 0.58) recipients.

INTERPRETATION

One in 7 patients presented to the emergency department within 30 days of THA or TKA. Some may conceivably have been managed remotely, and very few required readmission. There is a crucial need for strategies to minimize these events.

Increased risk of eczema after joint replacement: A population-based retrospective cohort study

There are very few reports of eczema and other prosthetic-related allergic skin complications following arthroplasty. We aimed to assess the risk of eczema after joint replacement.We performed a retrospective population-based cohort study in 2024 joint replacement patients using the Longitudinal Health Insurance Database. For comparison, 8096 controls were selected, with 4 control subjects for each joint replacement patient matched for age, sex, and index year, to assess eczema risk. We examined 14-year cumulative eczema incidence associated with age, sex, immunity, disease history, and joint replacement location.Eczema rates in the joint replacement patients were 38% higher than in the control group (57.90 vs 41.84 per 1000 person-years, respectively). Compared with the control group, joint replacement patients showed a 1.35-fold increased risk of eczema according to the multivariable Cox model (95% Confidence interval [CI] = 1.23-1.49). Knee replacement patients had higher eczema risk compared with the control group (Hazard ratio [HR] = 1.45, 95% CI = 1.33-1.70). Stratified by study period, the joint replacement cohort had a higher eczema risk after the 3-month follow-up.Our study revealed that joint arthroplasty increased risk of eczema in this 14-year follow-up study, and this was not related to personal atopic history or gender.

Association of the Mandatory Medicare Bundled Payment With Joint Replacement Outcomes in Hospitals With Disadvantaged Patients

IMPORTANCE

Medicare's Comprehensive Care for Joint Replacement (CJR) model rewards or penalizes hospitals on the basis of meeting spending benchmarks that do not account for patients' preexisting social and medical complexity or high expenses associated with serving disadvantaged populations such as dual-eligible patients (ie, those enrolled in both Medicare and Medicaid). The CJR model may have different implications for hospitals serving a high percentage of dual-eligible patients (termed high-dual) and hospitals serving a low percentage of dual-eligible patients (termed low-dual).

OBJECTIVE

To examine changes associated with the CJR model among high-dual or low-dual hospitals in 2016 to 2017.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study comprised 3 analyses of high-dual or low-dual hospitals (n = 1165) serving patients with hip or knee joint replacements (n = 768 224) in 67 treatment metropolitan statistical areas (MSAs) selected for CJR participation and 103 control MSAs. The study used Medicare claims data and public reports from 2012 to 2017. Data analysis was conducted from February 1, 2019, to August 31, 2019.

EXPOSURES

The CJR model holds participating hospitals accountable for the spending and quality of care during care episodes for patients with hip or knee joint replacement, including hospitalization and 90 days after discharge.

MAIN OUTCOMES AND MEASURES

The primary outcomes were total episode spending, discharge to institutional postacute care facility, and readmission within the 90-day postdischarge period; bonus and penalty payments for each hospital; and reductions in per-episode spending required to receive a bonus for each hospital.

RESULTS

In total, 1165 hospitals (291 high-dual and 874 low-dual) and 768 224 patients with joint replacement (494 013 women [64.3%]; mean [SD] age, 76 [7] years) were included. An episode-level triple-difference analysis indicated that total spending under the CJR model decreased at high-dual hospitals (by $851; 95% CI, -$1556 to -$146; P = .02) and low-dual hospitals (by $567; 95% CI, -$933 to -$202; P = .003). The size of decreases did not differ between the 2 groups (difference, -$284; 95% CI, -$981 to $413; P = .42). Discharge to institutional postacute care settings and readmission did not change among both hospital groups. High-dual hospitals were less likely to receive a bonus compared with low-dual hospitals (40.3% vs 59.1% in 2016; 56.9% vs 76.0% in 2017). To receive a bonus, high-dual hospitals would be required to reduce spending by $887 to $2231 per episode, compared with only $89 to $215 for low-dual hospitals.

CONCLUSIONS AND RELEVANCE

The study found that high- and low-dual hospitals made changes in care after CJR implementation, and the magnitude of these changes did not differ between the 2 groups. However, high-dual hospitals were less likely to receive a bonus for spending cuts. Spending benchmarks for CJR would require high-dual hospitals to reduce spending more substantially to receive a financial incentive.

Assessment for Perioperative Hyperglycemia Prior to Total Joint Replacement in Patients With and Without Diabetes

This cohort study examines rates of screening for hyperglycemia before total joint replacement among Medicare enrollees with and without diabetes.

Association of Bundled Payments for Joint Replacement Surgery and Patient Outcomes With Simultaneous Hospital Participation in Accountable Care Organizations

Importance

An increasing number of hospitals have participated in Medicare's bundled payment and accountable care organization (ACO) programs. Although participation in bundled payments has been associated with savings for lower-extremity joint replacement (LEJR) surgery, simultaneous participation in ACOs may be associated with different outcomes given the prevalence of LEJR among patients receiving care at ACO participant organizations and potential overlap in care redesign strategies adopted under the 2 payment models.

Objective

To examine whether simultaneous participation in a Medicare Shared Savings Program (MSSP) ACO affects the association between hospitals' participation in LEJR episodes under the Bundled Payments for Care Improvement (BPCI) initiative and patient outcomes compared with participation in the BPCI initiative alone.

Design, Setting, and Participants

This cohort study, conducted from January 1 to May 31, 2019, used 2011 to 2016 Medicare claims data and incorporated an instrumental variable with a difference-in-differences method among 483 008 fee-for-service Medicare beneficiaries undergoing LEJR surgery at 212 bundled payment participant hospitals, 105 coparticipant hospitals, and 1413 nonparticipant hospitals in the United States.

Exposures

Hospital participation in both the BPCI initiative and the MSSP (coparticipants), BPCI only (bundled payment participants), or neither (nonparticipants).

Main Outcomes and Measures

Changes in clinical outcomes and mean LEJR episode spending.

Results

A total of 483 008 patients (mean [SD] age, 73.0 [8.4] years; 308 173 [63.8%] female) were included in the study. No differential changes were found in patient and hospital characteristics across participation groups. In adjusted analysis, coparticipants had 1.5% (95% CI, 0.7%-2.2%; P < .001) more unplanned readmissions than did bundled payment participants. Compared with bundled payment participants, coparticipants also had differentially greater decreases in hospital length of stay (adjusted difference-in-differences value, -5.3%; 95% CI, -7.1% to -3.5%; P < .001) and home health care use (adjusted difference-in-differences value, -3.4%; 95% CI, -4.5% to -2.3%; P < .001) and greater increases in postdischarge outpatient follow-up (adjusted difference-in-differences value, 2.1%; 95% CI, 0.9%-3.3%; P < .001). Coparticipants and bundled payment participants did not have differential changes in episode spending (adjusted difference-in-differences value, 0.4%; 95% CI, -0.7% to 1.6%; P = .46), although both groups had more decreased spending compared with nonparticipants.

Conclusions and Relevance

Among bundled payment participants, coparticipation in ACOs was not associated with LEJR episode savings but was associated with differential changes in postacute care use patterns and unplanned readmissions. These findings support the longer-term benefits of LEJR bundles and suggest that coparticipants may adopt care redesign strategies that differ from hospitals with bundled payments only.

Effect of Tanezumab on Joint Pain, Physical Function, and Patient Global Assessment of Osteoarthritis Among Patients With Osteoarthritis of the Hip or Knee: A Randomized Clinical Trial

IMPORTANCE

Patients with osteoarthritis (OA) may remain symptomatic with traditional OA treatments.

OBJECTIVE

To assess 2 subcutaneous tanezumab dosing regimens for OA.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, double-blind, multicenter trial from January 2016 to May 14, 2018 (last patient visit). Patients enrolled were 18 years or older with hip or knee OA, inadequate response to OA analgesics, and no radiographic evidence of prespecified joint safety conditions.

INTERVENTIONS

Patients received by subcutaneous administration either tanezumab, 2.5 mg, at day 1 and week 8 (n = 231); tanezumab, 2.5 mg at day 1 and 5 mg at week 8 (ie, tanezumab, 2.5/5 mg; n = 233); or placebo at day 1 and week 8 (n = 232).

MAIN OUTCOMES AND MEASURES

Co-primary end points were change from baseline to week 16 in Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) Pain (0-10, no to extreme pain), WOMAC Physical Function (0-10, no to extreme difficulty), and patient global assessment of osteoarthritis (PGA-OA) (1-5, very good to very poor) scores.

RESULTS

Among 698 patients randomized, 696 received 1 or more treatment doses (mean [SD] age, 60.8 [9.6] years; 65.1% women), and 582 (83.6%) completed the trial. From baseline to 16 weeks, mean WOMAC Pain scores decreased from 7.1 to 3.6 in the tanezumab, 2.5 mg, group; 7.3 to 3.6 in the tanezumab, 2.5/5 mg, group; and 7.3 to 4.4 in the placebo group (least squares mean differences [95% CI] vs placebo were -0.60 [-1.07 to -0.13; P = .01] for tanezumab, 2.5 mg, and -0.73 [-1.20 to -0.26; P = .002] for tanezumab, 2.5/5 mg). Mean WOMAC Physical Function scores decreased from 7.2 to 3.7 in the 2.5-mg group, 7.4 to 3.6 in the 2.5/5-mg group, and 7.4 to 4.5 with placebo (differences vs placebo, -0.66 [-1.14 to -0.19; P = .007] for tanezumab, 2.5 mg, and -0.89 [-1.37 to -0.42; P < .001] for tanezumab, 2.5/5 mg). Mean PGA-OA scores decreased from 3.4 to 2.4 in the 2.5-mg group, 3.5 to 2.4 in the 2.5/5-mg group, and 3.5 to 2.7 with placebo (differences vs placebo, -0.22 [-0.39 to -0.05; P = .01] for tanezumab, 2.5 mg, and -0.25 [-0.41 to -0.08; P = .004] for tanezumab, 2.5/5 mg). Rapidly progressive OA occurred only in tanezumab-treated patients (2.5 mg: n = 5, 2.2%; 2.5/5 mg: n = 1, 0.4%). The incidence of total joint replacements was 8 (3.5%), 16 (6.9%), and 4 (1.7%) in the tanezumab, 2.5 mg; tanezumab, 2.5/5 mg; and placebo groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with moderate to severe OA of the knee or hip and inadequate response to standard analgesics, tanezumab, compared with placebo, resulted in statistically significant improvements in scores assessing pain and physical function, and in PGA-OA, although the improvements were modest and tanezumab-treated patients had more joint safety events and total joint replacements. Further research is needed to determine the clinical importance of these efficacy and adverse event findings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02697773.

Osteoarthritis

Osteoarthritis is a leading cause of disability and source of societal cost in older adults. With an ageing and increasingly obese population, this syndrome is becoming even more prevalent than in previous decades. In recent years, we have gained important insights into the cause and pathogenesis of pain in osteoarthritis. The diagnosis of osteoarthritis is clinically based despite the widespread overuse of imaging methods. Management should be tailored to the presenting individual and focus on core treatments, including self-management and education, exercise, and weight loss as relevant. Surgery should be reserved for those that have not responded appropriately to less invasive methods. Prevention and disease modification are areas being targeted by various research endeavours, which have indicated great potential thus far. This narrative Seminar provides an update on the pathogenesis, diagnosis, management, and future research on osteoarthritis for a clinical audience.

Impact of the definition of osteoarthritis and of the timing of its onset on the association between type 2 diabetes mellitus and osteoarthritis: Clinical Practice Research Datalink

AIMS

In a previous case-control study in a large primary care database, the Clinical Practice Research Datalink (CPRD), type 2 diabetes mellitus (T2DM) was associated with a decreased rate of total joint replacement (TJR). As this was in contrast to the hypothesis, selection bias due to the used definition of osteoarthritis (OA) or misclassification of the onset of OA were raised as possible explanations. We therefore aimed to explore the effect of the definition of OA, and hypothesized timing of its onset on the association between T2DM and OA.

METHODS

All patients using a non-insulin anti-hyperglycaemic drug (NIAD) between 1989 and 2012 in the CPRD were included and matched to unexposed patients. Cox proportional hazard models were fitted estimating the risk of TJR or OA in T2DM patients compared to patients without T2DM. These analyses were repeated in sensitivity scenarios and joint-specific analyses. To assess whether misclassification of onset of OA may affect the association, analyses were repeated with addition of a latency period of up to 10 years after start of follow-up.

RESULTS

The use of TJR as a proxy for OA (hazard ratio (HR) = 0.74; 95% Confidence Interval (CI) = 0.70-0.78) resulted in a HR that was approximately 0.2 lower than when OA diagnostic codes were used (HR = 0.93; 95% CI = 0.90-0.95). The joint-specific subgroup analyses, sensitivity scenarios, and latency analyses showed similar results.

CONCLUSION

When examining the association between T2DM and OA, the use of TJR as a proxy for OA resulted in a 20% lower estimate than the OA diagnosis.

Cost Savings in a Surgeon-Directed BPCI Program for Total Joint Arthroplasty

BACKGROUND

There are few studies available on the savings generated and strategies employed for cost reduction in total joint arthroplasty. In this study, our organization-a group of private practices partnering with a consultant-aimed to analyze the impact of a preoperative protocol on overall cost savings.

MATERIALS AND METHODS

Using administrative data from the Medicare Bundled Payments for Care Improvement (BPCI) initiative, 771 consecutive total joint arthroplasty patients from 2009-2014 were compared with 408 consecutive BPCI patients from 2014-2017. The 30-day episode and Medicare part B total cost of care was analyzed. This included inpatient and post-discharge expenditure, laboratory and imaging costs, physician and ER visits, and readmission.

RESULTS

Average total episode cost declined by $3,174 or 13% from $23,925 to $20,752 (p<0.001) in the BPCI period. Readmission rate was unchanged (p=0.20), and there was a 48% reduction in the percent of patients presenting to the emergency room (p=.03). There was a decline of $2,647 (78%) in skilled nursing cost per case, which represented the majority of savings. Post-discharge imaging, laboratory test claims, postoperative emergency room visits, primary care physician (PCP) visits, and cost per episode all decreased. The decrease in PCP utilization did not result in increased medical complications or readmissions.

CONCLUSION

Our preoperative patient-education protocol has decreased non-home discharge, unnecessary postoperative physician visits, and diagnostic testing resulting in an episode cost savings of 13%. With Advanced BPCI on the horizon, orthopedic surgeon control as the awardee of the bundle, combined with an increasing focus on patient education, will continue to lower costs and improve patient care.

Postoperative Joint Replacement Complications in Swedish Patients With a Family History of Venous Thromboembolism

IMPORTANCE

The associations of a family history of venous thromboembolism (FH-VTE) with postoperative venous thromboembolism (VTE) and major bleeding after joint replacement surgical procedures are unknown.

OBJECTIVE

To determine the risk of VTE and major bleeding in patients after primary hip or knee replacement surgical procedures.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study using nationwide population-based databases of Swedish patients without a history of VTE who underwent joint replacement surgical procedures. Patients who had primary hip or knee replacement surgical procedures between July 1, 2005, and August 31, 2012, were identified. Patients born after 1931 without previous VTE were identified in the Swedish Multi-Generation Register. Only individuals with at least 1 parent and 1 full sibling alive between 1964 and the date for the surgical procedure were included. The data analysis was performed from September 1, 2017, to June 15, 2018.

EXPOSURES

Family history of VTE in a parent and/or a full sibling before the date of the surgical procedure.

MAIN OUTCOMES AND MEASURES

Venous thromboembolism and major bleeding within 90 days of the surgical procedure.

RESULTS

Of 69 505 study participants, 37 989 (54.7%) were women, and the median (interquartile range) age at the date of discharge was 65 (59-70) years. A total of 803 of 69 505 (1.2%) patients experienced postoperative VTE and 1285 (1.8%) experienced major bleeding. The cumulative VTE risk for those with FH-VTE was 231 of 15 858 (1.5%) and for those without an FH-VTE was 572 of 53 647 (1.1%) (P < .001). The cumulative bleeding risk for those with FH-VTE was 261 of 15 858 (1.6%) and for those without an FH-VTE was 1024 of 53 647 (1.9%) (P = .03). There was an association of patients with an FH-VTE who had increased VTE risk (adjusted hazard ratio [HR], 1.36; 95% CI, 1.17-1.59) and reduced bleeding risk (adjusted HR, 0.84; 95% CI, 0.74-0.97). There was an interaction between time after discharge and FH-VTE regarding VTE and major bleeding. An FH-VTE was not associated with VTE after discharge during the first week (HR, 1.13; 95% CI, 0.86-1.49). After 7 days from discharge, FH-VTE was associated with VTE (HR, 1.49; 95% CI, 1.24-1.79). An FH-VTE reduced major bleeding risk during the first 7 days after discharge (HR, 0.78; 95% CI, 0.66-0.91) but not thereafter (HR, 1.10; 95% CI, 0.84-1.44). Postoperative VTE heritability (SE) was 20% (6%).

CONCLUSIONS AND RELEVANCE

Familial and most likely genetic factors appear to affect VTE and major bleeding risk following hip and knee replacement surgical procedures. Prolonged VTE prophylaxis might be beneficial in predisposed individuals. There may be a possible evolutionary advantage of prothrombotic genes protecting against traumatic bleeding.

Insulin-Dependent Diabetes Is an Independent Risk Factor for Complications and Readmissions After Total Joint Replacements

This study examined the risk for postoperative complications, reoperations, and readmissions for patients with insulin-dependent diabetes mellitus (IDDM), patients with non-insulin-dependent diabetes mellitus (NIDDM), and patients without diabetes undergoing total joint replacements (TJRs). The American College of Surgeons National Surgical Quality Improvement Program database was queried for all primary TJRs in 2015. The study identified 78,744 TJRs (84.1% nondiabetic patients, 12.0% NIDDM, and 3.9% IDDM). Multiple logistic regression models identified IDDM as an independent risk factor for increased blood loss, myocardial infarctions, pneumonia, renal insufficiency, urinary tract infections, and readmissions when compared with both NIDDM and nondiabetics. Risk for wound complications and reoperations were comparable between all three groups. IDDM increases the risk for medical complications and readmissions after TJRs. Physicians must counsel patients on the increased risks associated with IDDM before elective surgery and provide appropriate medical support for these patients. (Journal of Surgical Orthopaedic Advances 27(4):294-298, 2018).

What Influences How Patients with Depression Rate Hospital Stay After Total Joint Arthroplasty?

BACKGROUND

Recent healthcare reform has spurred important changes to provider reimbursement. With the implementation of the Value Based Purchasing program, significant weight is placed on patient experience of care. The Press Ganey (PG) survey is currently used by over 10,000 hospitals, as it serves to help optimize patient satisfaction. However, confounding factors, such as clinical depression, are not screened against by PG. Thus, arthroplasty surgeons performing lower extremity total joint arthroplasty (TJA) may have difficulty optimizing patient satisfaction while caring for patients with clinical depression. Therefore, we asked: 1) What Press Ganey elements affect the overall hospital rating in patients who suffer from clinical depression? and 2) Are survey responses different between patients who do and do not have clinical depression?

MATERIALS AND METHODS

We queried our institutional PG database for patients who underwent a TJA from November 2009 to January 2015. Our search yielded 1,454 patients, of which 204 suffered from depression and 1,250 did not. Multiple regression analysis was performed to determine the influence (b weight) of selected PG survey domains on overall hospital rating. The weighted mean for domain was also calculated.

RESULTS

Multiple regression analyses showed that overall hospital ratings were significantly influenced by communication with nurses (b-weight = 0.881, p< 0.001) in post-TJA patients with depression. The remaining domains were not statistically significant. There were no significant differences in individual PG elements for patients who did and did not have depression.

CONCLUSION

Overall patient satisfaction among patients with depression was greatly influenced by communication with nurses. Understanding these challenges may encourage care coordination across disciplines for the management of patients with depression before and after surgery. As a result, this could optimize orthopedic surgery outcomes, but, more importantly, patient health and satisfaction, while reducing costs of care.

Hospital effect on infections after four major surgical procedures: outlier and volume-outcome analysis using all-inclusive state data

BACKGROUND

Hospital volume is known to have a direct impact on the outcomes of major surgical procedures. However, it is unclear if the evidence applies specifically to surgical site infections.

AIMS

To determine if there are procedure-specific hospital outliers [with higher surgical site infection rates (SSIRs)] for four major surgical procedures, and to examine if hospital volume is associated with SSIRs in the context of outlier performance in New South Wales (NSW), Australia.

METHODS

Adults who underwent one of four surgical procedures (colorectal, joint replacement, spinal and cardiac procedures) at a NSW healthcare facility between 2002 and 2013 were included. The hospital volume for each of the four surgical procedures was categorized into tertiles (low, medium and high). Multi-variable logistic regression models were built to estimate the expected SSIR for each procedure. The expected SSIRs were used to compute indirect standardized SSIRs which were then plotted in funnel plots to identify hospital outliers.

FINDINGS

One hospital was identified to be an overall outlier (higher SSIRs for three of the four procedures performed in its facilities), whereas two hospitals were outliers for one specific procedure throughout the entire study period. Low-volume facilities performed the best for colorectal surgery and worst for joint replacement and cardiac surgery. One high-volume facility was an outlier for spinal surgery.

CONCLUSIONS

Surgical site infections seem to be mainly a procedure-specific, as opposed to a hospital-specific, phenomenon in NSW. The association between hospital volume and SSIRs differs for different surgical procedures.

[What can we learn in future from the data of the German Arthroplasty Registry (EPRD) in comparison to other registries?]

The German Arthroplasty Registry (EPRD) was founded in 2010 and has been in full operation since 2014. Previous attempts at a systematic data collection of elective and non-elective knee and hip replacement in Germany failed mainly because of the long-term lack of funding. The EPRD is an interdisciplinary collaborative partnership between the German Association of Orthopedics and Orthopedic Surgery (DGOOC), all implant manufacturers of the German Medical Technology Association (BVMed), health insurers (AOK and the Association of Additional Healthcare Insurance) and hospitals (German Hospital Federation). As part of this cooperation a worldwide unique implant database has been set up, which includes all relevant components and a detailed description of implant specifications. This implant library enables a detailed evaluation of implant survival, revision rates and possible inferior implant performance of knee and hip replacements in Germany. At the end of 2015 the EPRD encompassed over 200,000 registered operations. Due to the high number of hip and knee arthroplasties in Germany with many different implants from different manufacturers there will be a rapid growth of data that are available for a national and also international comparison of the results.

How Many Temporomandibular Joint Total Joint Alloplastic Implants Will Be Placed in the United States in 2030?

PURPOSE

The purpose of this study is to provide a statistical projection of the number of alloplastic temporomandibular joint (TMJ) total joint replacements (TJRs) that will be performed in the United States through the year 2030.

MATERIALS AND METHODS

The program directors of all 101 Commission on Dental Accreditation-accredited oral and maxillofacial surgery training programs in the United States were surveyed online by use of a questionnaire developed using Redcap (Chicago, IL) over a 6-week period (February 2015-March 2015). The questionnaire included 19 questions related to each program's TMJ disorder and TMJ TJR curricula, as well as clinical experience. In addition, members of the American Society of Temporomandibular Joint Surgeons were surveyed online using Redcap and via direct survey forms. Moreover, requests for the total number of TMJ TJR devices produced and implanted during the same period were made to the 3 manufacturers of Food and Drug Administration-approved TMJ TJR devices in the United States.

RESULTS

The response rate among program directors was 52.5%, and the total number of TMJ TJR devices implanted in oral and maxillofacial surgery programs in 2005 was 412. This total increased by 38% to 572 in 2014. Statistically, this projects an increase of 58% over the next 16 years to 902 TMJ TJR operations by 2030 (95% prediction limits, 768 and 1,037). The total number of TMJ TJR devices distributed by one manufacturer increased from 430 in the year 2000 to 1,004 in 2014 (133%). By use of these data, statistically over the next 16 years, the number of TMJ TJR devices distributed by this company is projected to be 1,658 (95% prediction limits, 1,380 and 1,935).

CONCLUSIONS

The data presented in this study show an increasing demand for the use of TMJ TJR devices in the management of end-stage TMJ disorders to the year 2030.

Racial Disparities in Lower Extremity Arthroplasty Outcomes and Use

Race-associated disparities often occur in patients who undergo lower extremity total joint arthroplasty (TJA). Although it is imperative to elucidate and describe the disparities in race and ethnicity that may influence patient perception, satisfaction, and surgical outcomes, there is a paucity of reports detailing the nature of potential racial disparities in TJA. Therefore, the purpose of this review was to examine racial and ethnic disparities in the (1) physician-patient relationship; (2) use of TJA; (3) intraoperative and 30-day postoperative complications; and (4) patient-reported outcomes. Although there are limited studies that evaluated this topic, it has been shown that there are race-specific differences in physician-patient relationships. Specifically, African American patients report lower satisfaction rates in communication with their physician than their Caucasian counterparts and physicians were more apt to describe African Americans as less "medically cooperative." The majority of the studies the authors found regarding TJA use indicated that African Americans and Hispanics were less likely to undergo lower extremity TJA than Caucasians. Furthermore, racial minorities may have higher 30-day readmission and intra- and postoperative complication rates compared with Caucasians. Despite these compelling findings, concrete conclusions are difficult to make due to the presence of multiple confounding patient factors, and more studies examining the racial and ethnic disparities in patients with TJA are needed.

Massachusetts health reform and disparities in joint replacement use: difference in differences study

OBJECTIVE

To estimate the impact of the insurance expansion in 2006 on use of knee and hip replacement procedures by race/ethnicity, area income, and the use of hospitals that predominantly serve poor people ("safety net hospitals").

DESIGN

Quasi-experimental difference in differences study examining change after reform in the share of procedures performed in safety net hospitals by race/ethnicity and area income, with adjustment for patients' residence, demographics, and comorbidity.

SETTING

State of Massachusetts, United States.

PARTICIPANTS

Massachusetts residents aged 40-64 as the target beneficiaries of reform and similarly aged residents of New Jersey, New York, and Pennsylvania as the comparison (control) population.

MAIN OUTCOMES MEASURES

Number of knee and hip replacement procedures per 10 000 population and use of safety net hospitals. Procedure counts from state discharge data for 2.5 years before and after reform, and multivariate difference in differences. Poisson regression was used to adjust for demographics, economic conditions, secular time, and geographic factors to estimate the change in procedure rate associated with health reform by race/ethnicity and area income.

RESULTS

Before reform, the number of procedures (/10 000) in Massachusetts was lower among Hispanic people (12.9, P<0.001) than black people (28.1) and white people (30.1). Overall, procedure use increased 22.4% during the 2.5 years after insurance expansion; reform in Massachusetts was associated with a 4.7% increase. The increase associated with reform was significantly higher among Hispanic people (37.9%, P<0.001) and black people (11.4%, P<0.05) than among white people (2.8%). Lower income was not associated with larger increases in procedure use. The share of knee and hip replacement procedures performed in safety net hospitals in Massachusetts decreased by 1.0% from a level of 12.7% before reform. The reduction was larger among Hispanic people (-6.4%, P<0.001) than white people (-1.0%), and among low income residents (-3.9%, p<0.001) than high income residents (0%).

CONCLUSIONS

Insurance expansion can help reduce disparities by race/ethnicity but not by income in access to elective surgical care and could shift some elective surgical care away from safety net hospitals.

Reverse Shoulder Arthroplasty in the United States: A Comparison of National Volume, Patient Demographics, Complications, and Surgical Indications

BACKGROUND

Shoulder arthroplasty is increasing in the United States. Reverse shoulder arthroplasty (RSA) has emerged as an alternative treatment for end-stage glenohumeral pathology. Until recently, administrative coding practices have not differentiated RSA from traditional total shoulder arthroplasty (TSA), and thus national procedural volume has been unknown. The purpose of this study was to define the utilization, patient characteristics, indications and complications for RSA, and contrast these to TSA and hemiarthroplasty (HA).

METHODS

The 2011 Nationwide Inpatient Sample (HCUP-NIS) dataset was queried using ICD-9-CM codes to identify patients undergoing RSA, TSA, or HA. We used weighted estimates of national procedure volume, per-capita utilization, patient comorbidities, and inpatient complications denned by the Agency for Healthcare Research and Quality (AHRQ) and identified them using standard methods described by Elixhauser. ANOVA statistical analysis was used and significance was denned as p value <0.05.

RESULTS

In 2011, 66,485 patients underwent shoulder arthroplasty; there were 21,692 cases of RSA, 29,359 of TSA, and 15,434 of HA. Utilization of RSA and TSA increased between 2002-2011, and decreased for HA. RSA patients were older (72.7 years vs 67.4 TSA vs 66.8 HA) and more commonly female. Comorbidity burden was highest in patients undergoing HA. Inpatient complications were highest after RSA (p < 0.001). When compared to TSA, RSA was more commonly used in the setting of rotator cuff disease, and posttraumatic sequelae (p<0.001).

CONCLUSIONS

Our findings represent the first national estimates of RSA within the United Sates. RSA is a significant contributor to increasing shoulder arthroplasty utilization nationally representing one-third of arthroplasty cases. Conditions traditionally managed with HA in older populations appear to now be more commonly managed with RSA. RSA is performed on older patients with expanded indications.

Risk of venous thromboembolism after shoulder arthroplasty in the Medicare population

BACKGROUND

Chemoprophylaxis for venous thromboembolism (VTE) is considered standard of care after lower but not after upper extremity arthroplasty. Medicare claims data were analyzed to determine the national incidence of symptomatic VTE after shoulder arthroplasty during the index surgical admission and after discharge.

METHODS

Incidence of VTE was compared between shoulder arthroplasty and lower extremity arthroplasty, and patient-specific risk factors for pulmonary embolism were determined for shoulder arthroplasty. Finally, the incidence of surgical site bleeding was determined for each type of procedure.

RESULTS

VTE complications occurred in 1.2% of lower extremity and 0.53% of shoulder arthroplasties. Patient factors that were associated with an increased risk of VTE included a principal diagnosis of fracture, history of VTE, cardiac arrhythmia, presence of a metastatic tumor, coagulopathy, congestive heart failure, alcohol abuse, and obesity. Adjusted rates of VTE were generally higher for lower extremity compared with shoulder arthroplasties. Prevalence of readmission for VTE was higher for shoulder hemiarthroplasty than for total shoulder arthroplasty. Wound hematoma rates were similar between shoulder and lower extremity procedures.

CONCLUSIONS

VTE rates after shoulder arthroplasty were generally lower than those after lower extremity arthroplasty. We believe that the risk of bleeding combined with the lower rates of VTE with existing lower rates of chemoprophylaxis does not warrant the routine use of anticoagulation. Use of mechanical prophylaxis combined with aspirin may be sufficient for shoulder arthroplasty patients who are not at increased risk of VTE. Chemoprophylaxis with agents other than aspirin may be warranted in patients with a demonstrated risk of VTE.

Patient age is a factor in early outcomes after shoulder arthroplasty

BACKGROUND

Elderly and young patients alike are undergoing shoulder replacement at increased rates. In an era of outcomes reporting, risk adjustment, and cost containment, identifying patients likely to have adverse events is increasingly important. Our objective was to determine whether patient age is independently associated with postoperative in-hospital complications or increased hospital charges after shoulder arthroplasty.

METHODS

We used the Nationwide Inpatient Sample to analyze 58,790 patients undergoing total shoulder arthroplasty or hemiarthroplasty between 2000 and 2008. Multivariate analysis with logistic regression modeling was used to compare groups. Our objective was to determine whether age had an independent impact on the likelihood of postoperative in-hospital complications, mortality rate, length of stay, or charges after shoulder arthroplasty.

RESULTS

Patients aged 80 years or older had an increased in-hospital mortality rate (0.5%) compared with patients aged 50 to 79 years (0.1%) and patients aged younger than 50 years (0.1%). Predictors of death included female gender, total shoulder arthroplasty versus hemiarthroplasty, and Deyo score. Increased age was associated with slightly increased hospital charges. Length of stay was longer in patients aged 80 years or older compared with younger patients. After shoulder arthroplasty, postoperative anemia occurred more often in patients aged 80 years or older. Other postoperative complications including pulmonary embolism, infection, and cardiac complications were similar among groups.

CONCLUSION

Older patients tend to have longer hospital stays, an increased incidence of postoperative anemia, and slightly higher charges after shoulder arthroplasty. Advanced age is not associated with an increased incidence of pulmonary embolism, infection, and cardiac complications. Further research is warranted to explain the relationship between age and early postoperative outcomes.

Factors affecting hospital charges after total shoulder arthroplasty: an evaluation of the National Inpatient Sample database

BACKGROUND

The number of total shoulder arthroplasties (TSA) performed in the United States increases yearly. At the same time, cost containment in health care continues to be a major concern. Therefore, it is imperative to identify specific variables that affect the cost of shoulder arthroplasty.

METHODS

The U.S. National Inpatient Sample database was queried (1993-2010) to evaluate total hospital charges for shoulder arthroplasty. Etiology of arthritis, multiple medical comorbidities, and patient and hospital demographics were evaluated for their effect on total inpatient hospital charges by a multivariate analysis.

RESULTS

Hospital charges for TSA increased from 1993 to 2010. Gender, race, and obesity were not associated with these differences in hospital charges. Post-traumatic and rheumatoid arthritis resulted in increased hospital charges; however, osteoarthritis resulted in decreased charges from the baseline. Multiple comorbidities (diabetes, lung disease, heart disease, and kidney disease) resulted in increased hospital charges after TSA. Regionally, the western and southern United States had the highest total charges above baseline. Larger hospitals and private urban hospitals also showed charges above baseline.

CONCLUSIONS

The factors related to increased hospital charges after TSA are multifactorial and include medical comorbidities, patient demographics, and regionalization. As the future of health care continues to evolve, it is important for practitioners, legislators, insurance administrators, and hospitals to recognize factors that increase costs.

The contribution of reverse shoulder arthroplasty to utilization of primary shoulder arthroplasty

BACKGROUND

We assessed the contribution of reverse shoulder arthroplasty to overall utilization of primary shoulder arthroplasty and present age- and sex-stratified national rates of shoulder arthroplasty. We also assessed contemporary complication rates, mortality rates, and indications for shoulder arthroplasty, as well as estimates and indications for revision arthroplasty.

METHODS

We used the Nationwide Inpatient Samples for 2009 through 2011 to calculate estimates of shoulder arthroplasty and assessed trends using Joinpoint (National Cancer Institute, Bethesda, MD) regression.

RESULTS

The cumulative estimated utilization of primary shoulder arthroplasty (anatomic total shoulder arthroplasty, hemiarthroplasty, and reverse shoulder arthroplasty) increased significantly from 52,397 procedures (95% confidence interval [CI], 47,093-57,701) in 2009 to 67,184 cases (95% CI, 60,638-73,731) in 2011. Reverse shoulder arthroplasty accounted for 42% of all primary shoulder arthroplasty procedures in 2011. The concomitant diagnosis of osteoarthritis and rotator cuff impairment was found in only 29.8% of reverse shoulder arthroplasty cases. The highest rate of reverse shoulder arthroplasty was in the 75- to 84-year-old female subgroup (77 per 100,000 persons; 95% CI, 67-87). Revision cases comprised 8.8% and 8.2% of all shoulder arthroplasties in 2009 and 2011, respectively, and 35% of revision cases were because of mechanical complications/loosening whereas 18% were because of dislocation.

CONCLUSIONS

The utilization of primary shoulder arthroplasty significantly increased in just a 3-year time span, with a major contribution from reverse shoulder arthroplasty in 2011. Indications appear to have expanded because a large percentage of patients did not have rotator cuff pathology. The burden from revision arthroplasties was also substantial, and efforts to optimize outcomes and longevity of primary shoulder arthroplasty are needed.

Nationwide shoulder arthroplasty rates and revision burden in Germany: analysis of the national hospitalization data 2005 to 2006

BACKGROUND

The aim of this study was to provide nationwide shoulder arthroplasty rates in Germany based on the national hospitalization file and to estimate the revision burden for shoulder arthroplasty and its determinants.

METHODS

We analyzed the nationwide, population-based, German diagnosis-related groups data from the years 2005 and 2006. Procedure codes and diagnosis were analyzed for each hospitalization. Overall, 16,488 primary shoulder arthroplasties and 1302 revisions were performed during the study period. Age-standardized rates, age-specific rates, rates by indication, and revision burden were calculated.

RESULTS

The age-standardized hemiarthroplasty (HA) rates were 3.6 per 100,000 person-years (standard error [SE], 0.1) for men and 9.3 per 100,000 person-years (SE, 0.1) for women and clearly exceeded the age-standardized total shoulder arthroplasty (TSA) rates of 1.7 per 100,000 person years (SE, 0.1) for men and 3.7 per 100,000 person-years (SE, 0.1) for women. The revision burden was 4.7% for HA and 15.0% for TSA. Multivariable-adjusted analysis showed increasing age was associated with a lower relative burden of revision, and an increased Charlson comorbidity index and male gender were associated with a higher relative burden of revision. The adjusted relative burden of revision was considerably higher for TSA than for HA (adjusted relative burden of revision, 2.89; 95% confidence interval, 2.60-3.22).

CONCLUSION

We found more than 2-fold higher primary rates for HA than for TSA and up to 3-fold higher shoulder arthroplasty rates for women than for men. TSA had a 3-fold higher relative burden of revision than HA.

Rate of venous thromboembolism among surgical patients in Australian hospitals: a multicentre retrospective cohort study

OBJECTIVES

Despite the burden of venous thromboembolism (VTE) among surgical patients on health systems in Australia, data on VTE incidence and its variation within Australia are lacking. We aim to explore VTE and subsequent mortality rates, trends and variations across Australian acute public hospitals.

SETTING

A large retrospective cohort study using all elective surgical patients in 82 acute public hospitals during 2002-2009 in New South Wales, Australia.

PARTICIPANTS

Patients underwent elective surgery within 2 days of admission, aged between 18 and 90 years, and who were not transferred to another acute care facility; 4 362 624 patients were included.

OUTCOME MEASURES

VTE incidents were identified by secondary diagnostic codes. Poisson mixed models were used to derive adjusted incidence rates and rate ratios (IRR).

RESULTS

2/1000 patients developed postoperative VTE. VTE increased by 30% (IRR=1.30, CI 1.19 to 1.42) over the study period. Differences in the VTE rates, trends between hospital peer groups and between hospitals with the highest and those with the lowest rates were significant (between-hospital variation). Smaller hospitals, accommodated in two peer groups, had the lowest overall VTE rates (IRR=0.56:0.33 to 0.95; IRR=0.37:0.23 to 0.61) and exhibited a greater increase (64% and 237% vs 19%) overtime and greater between-hospital variations compared to larger hospitals (IRR=8.64:6.23 to 11.98; IRR=8.92:5.49 to 14.49 vs IRR=3.70:3.32 to 4.12). Mortality among patients with postoperative VTE was 8% and remained stable overtime. No differences in post-VTE death rates and trends were seen between hospital groups; however, larger hospitals exhibited less between-hospital variations (IRR=1.78:1.30 to 2.44) compared to small hospitals (IRR>23). Hospitals performed differently in prevention versus treatment of postoperative VTE.

CONCLUSIONS

VTE incidence is increasing and there is large variation between-hospital and within-hospital peer groups suggesting a varied compliance with VTE preventative strategies and the potential for targeted interventions and quality improvement opportunities.

Total joint arthroplasty surgery: does day of surgery matter?

Length of stay (LOS) after total joint arthroplasty (TJA) impacts the expense to the hospital. Our purpose was to evaluate the impact that day of surgery has on postoperative LOS. 547 patients who had a primary TJA at two tertiary care hospitals were identified retrospectively. TJA patients admitted on day of surgery and who had primary elective surgery were included in our sample. Patients were subdivided into one of four groups: those who had operations on Monday, Tuesday, Thursday, and Friday respectively. Patients who had surgery on Thursday and Friday had significantly longer LOS when compared to Monday and Tuesday. This variation in LOS between the groups may be due to inconsistencies in weekend functionality, less experienced part-time staffing, and inaccessibility of rehabilitation personnel.

Disclosing total waiting times for joint replacement: evidence from the English NHS using linked HES data

For the last decade, stringent monitoring of waiting time performance targets provided English hospitals with incentives to reduce official waiting times for elective surgery. It is less clear whether the total amount of time patients waited in secondary care, from first referral to outpatient clinic until treatment, has also fallen. We used Hospital Episode Statistics inpatient data for patients undergoing total joint replacement during a period of active monitoring of targets (between 2006/7 and 2008/9) and linked it to outpatient data to reconstruct patients' pathway in the 3 years before surgery and provide alternative measurements of waiting times. Our findings suggest that although official waiting times decreased drastically in our study period, total waiting time in secondary care has not declined. Patients with shorter official waits spent a longer time in a 'work-up' period prior to inclusion in the official waiting list, and socio-economic inequities persisted in waiting times for joint replacement. We found no evidence that target policies achieved efficiency gains during our study period.

Impact of chronic kidney disease stage on lower-extremity arthroplasty

End-stage renal disease and dialysis is commonly associated with poor outcomes after joint replacement surgery. The goal of this study was to evaluate postoperative complications in patients with less advanced chronic kidney disease undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). Patients who underwent THA or TKA between 2004 and 2011 with stage 1, 2, or 3 chronic kidney disease were retrospectively reviewed via an electronic medical record. The authors compared 377 patients who had stage 1 to 2 chronic kidney disease with 402 patients who had stage 3 chronic kidney disease. No significant differences in 90-day readmission or revision rates were found between the stage 1 to 2 and stage 3 patient groups. For patients with stage 3 chronic kidney disease, the overall mortality rate was greater than that in patients with stage 1 to 2 chronic kidney disease. However, when adjusted for comorbid disease, no significant increases were seen in joint infection, readmission, or early revision between patients with stage 1 to 2 chronic kidney disease vs patients with stage 3 chronic kidney disease. The overall incidence of infection was high (3.5%) but far less than reported for patients with end-stage renal disease, dialysis, and kidney transplant. In conclusion, patients with stage 1, 2, or 3 chronic kidney disease may have a higher than expected rate of prosthetic joint infection (3.5%) after total joint arthroplasty. Patients with stage 3 chronic kidney disease are at higher risk for postoperative mortality compared with those with lesser stages of kidney disease.

Trends in the use of total ankle replacement and ankle arthrodesis in the United States Medicare population

BACKGROUND

Total ankle replacement (TAR) has gained acceptance as an alternative to traditional ankle arthrodesis (AA) for end-stage ankle arthritis. Little is known about long-term trends in volume, utilization, and patient characteristics. The objective of this study was to use longitudinal data to examine temporal trends in TAR and AA.

METHODS

We identified all United States fee-for-service Medicare beneficiaries who underwent TAR and AA between 1991 and 2010 (n = 5871 and 29 532, respectively). We examined changes in patient demographics and comorbidity, nationwide and hospital volume, per capita utilization, and length of stay (LOS).

RESULTS

Between 1991 and 2010, both TAR and AA patients had modest shifts in characteristics, with higher rates of diabetes and obesity. Overall, TAR Medicare volume increased by more than 1000% from 72 procedures in 1991 to 888 in 2010, while per-capita standardized utilization increased 670.8% (P < .001). AA volume increased 35.8% from 1167 procedures in 1991 to 1585 in 2010, while per-capita standardized utilization declined 15.6% (P < .001). The percentage of all US hospitals performing TAR increased nearly 4-fold from 3.1% in 1991 to 12.6% in 2010, while the proportion performing AA remained relatively unchanged. LOS decreased dramatically from 8.7 days in 1991 to 2.3 days in 2010 in TAR and from 5.5 days to 3.2 days in AA (P < .001).

CONCLUSION

Between 1991 and 2010, Medicare beneficiaries undergoing either TAR or AA became more medically complex. Both volume and per-capita utilization of TAR increased dramatically but remained nearly constant for AA. At the same time, mean hospital volume for both procedures remained low. Further research should be directed toward determining design, surgeon, and hospital variables that relate to optimal outcomes following TAR, which has become increasingly used for the treatment of ankle arthritis.

LEVEL OF EVIDENCE

Level III, comparative series.

Musculoskeletal healthcare disparities: influence of patient sex, race, and ethnicity on utilization of total joint arthroplasty

Total joint arthroplasty is an effective treatment of musculoskeletal diseases including osteoarthritis, rheumatoid arthritis, trauma, and other diseases of the major joints. Based on data obtained from the National Inpatient Survey from 2000 through 2010, substantial differences in the rates of utilization of total hip, knee, and shoulder arthroplasty were detected with respect to race, ethnicity, and gender/sex. The results of this study support the likelihood that it is the interaction between multiple factors (patient, physician, and system/institutional) that contributes to musculoskeletal health disparities. Our study shows that disparities in the utilization of total joint arthroplasty that were evident in 2000 continue to exist. Additional studies evaluating innovative approaches to reducing musculoskeletal disparities relating to total joint arthroplasty are needed.

Variation in use of reverse total shoulder arthroplasty across hospitals

BACKGROUND

The opportunity for variation exists in the choice between anatomic and reverse total shoulder arthroplasty. Quality improvement methods seek to reduce variation. We used supply-chain data to characterize variation in the selection of anatomic versus reverse total shoulder arthroplasty across hospitals and to analyze the effect of hospital volume on this variation.

METHODS

Mendenhall Associates, Inc (Ann Arbor, MI, USA) provided us with a database of hospital supply-chain data from orthopaedic surgical cases. This study included hospitals in which at least one total shoulder arthroplasty was performed. We calculated, for each hospital, the percentages of each type of prosthesis implanted and examined the distribution of these percentages across all hospitals. We also divided the sample of hospitals into tertiles, by volume of total shoulder arthroplasties performed, and examined the distributions of percentage reverse shoulder arthroplasty performed in each tertile.

RESULTS

Across all hospitals, we saw wide variation in the volume of total shoulder arthroplasties and the percentage of reverse shoulder arthroplasties performed. Hospitals with lower total shoulder arthroplasty volumes exhibited greater variation in the percentages of each type of total shoulder arthroplasty performed. Higher volume hospitals exhibited smaller variation.

CONCLUSIONS

This study revealed wide variation in the selection of anatomic and reverse total shoulder arthroplasty across all hospitals and an inverse relationship between hospital volume and variation. This variation signals uncertainty about the best application of each device and that there is need for improvement in the consistency of treatment of patients with shoulder disease.

LEVEL OF EVIDENCE

Level II, cost-effectiveness study, economic and decision analysis.

The economic recession and its effect on utilization of elective total joint arthroplasty

The United States economy entered a recession in December 2007. This study aims to determine whether the utilization of elective orthopedic surgeries has been impacted by this recession. From January 2007 to December 2009 at a single private practice in New Jersey, 4820 total joint replacement procedures were scheduled, of which 649 of those were cancelled. The rate of cancellation for financial reasons was compared to multiple economic measures by linear regression analysis. The results show that the rate of financially motivated cancellations increased over time concurring with multiple financial markers reflecting the economic recession. The results suggest that the recession has created a financial barrier for a significant number of Americans, leading to decreased utilization of care. While there was a statistically significant increase in cancellations for financial reasons, the overall rate of cancellations in the total joint population is still low, representing only about 1% of all cases.

Inpatient procedures in elderly women: an analysis over time

OBJECTIVES

To describe inpatient surgical and diagnostic/therapeutic procedures in women ≥65 years old and assess procedure trends over time.

STUDY DESIGN

Procedure data for all women ≥65 years was collected using the National Hospital Discharge Survey, a federal dataset drawn from a representative sampling of U.S. inpatient hospitals which includes patient and hospital demographics and ICD-9-CM diagnosis and procedure codes for admissions from 1979 to 2006.

MAIN OUTCOME MEASURES

Age-adjusted rates (AAR) per 1000 women were created using 1990 U.S. Census data to compare trends over time.

RESULTS

Over 96 million procedures were performed in women age≥65 years from 1979 to 2006. Women age≥65 years constituted 17% of women with ≥1 inpatient procedure in 1979, rising to 32% in 2006. The most common surgical procedures were lower extremity joint replacement, open reduction internal fixation, and cholecystectomy. The most common concurrent diagnosis was femoral neck fracture. Women with femoral neck fracture were more likely to undergo open reduction internal fixation compared to joint replacement. AARs for ORIF fell from 4.3 to 3.2 (p=.02) from 1979 to 2006, while AARs for joint replacement increased from 0.2 to 3.4 (p≤.001, 1979-1988; p=.14, 1990-2006).

CONCLUSIONS

The rate of women age≥65 years undergoing inpatient procedures has increased dramatically in the last 30 years. Hip fracture was the most common diagnosis for elderly women, highlighting the impact of osteoporosis and falls and the importance of prevention strategies and optimization of peri-operative care in this population. Further comparative study of hip fracture treatment strategies in this population is needed.

[Research and analysis of failure data of contemporary artificial joint registration system]

This paper is aimed to focus on the joint prosthesis failure event, to collect the statistic data about the failure of artificial joints issued by authoritative organizations at home and aboard, and to compare the functions of different types of the artificial joints. We generalized and compared current study analyzing the failure reason and type of joint prosthesis, and categorized the failure events according to the failure occurring time, i. e. short-term, medium-term and long-term. This paper could be helpful for improving and summarizing of artificial joint replacement surgery, and could put forward the requirements for the future artificial joints.

[Innovative materials in orthopaedics: the crosslinked polyethylene (XPE)]

More than 150.000 hip and knee arthroplasties are performed every year in Italy. More than 50% of the patients receive a polyethylene component (Ultra High Molecular Weight PolyEthylene, UHMWPE). Polyethylene abrasive wear induces over time in vivo a foreign-body response and consequently osteolysis, pain and need of implant revision. Furthermore, oxidative wear due to gamma-rays sterilization caused in the '90ies several and severe failures. To solve these problems, since then, the orthopaedics research has been addressed to: 1) develop new cross linked polyethylene with a higher molecular mass than UHMWPE and, consequently, a higher abrasive wear resistance; 2) avoid the oxidative wear induced by gamma-rays sterilization, by using other sterilization methods and by stabilizing UHMWPE by means of antioxidants such as Vitamin E. According to the most recent studies, performed on limited cohorts and mostly funded by manufacturers, cross linked polyethylene shows a better abrasive wear resistance if compared to the conventional polyethylene but no significant differences have been detected in the clinical outcomes. Clinical follow up of Vitamin E stabilized PE are not yet available. The organization of national arthroplasties registries, able to trace and characterize the implanted devices and based on the whole patients population, will facilitate the early detection of devices that show a performance inferior than the expected one. In Italy, the National Institute of Health has been entrusted by the Ministry of Health to organize the national arthroplasty registry.

Hereditary hemochromatosis as a risk factor for joint replacement surgery

OBJECTIVE

Hemochromatosis is an inherited disease with iron overload and joint involvement resembling osteoarthritis. To determine the rate of joint replacement surgery in patients with hemochromatosis, we performed a cross-sectional cohort study.

METHODS

A total of 199 individuals with hereditary hemochromatosis were included. The prevalence of joint replacement surgery in hip, knee, and ankle joints because of secondary osteoarthritis was assessed. Data were compared with 917 healthy subjects from the population-based Bruneck study.

RESULTS

A total of 32 of 199 individuals with hemochromatosis received joint replacement surgery with a total number of 52 joints replaced. Compared with expected rates in healthy individuals, patients with hemochromatosis had a significantly higher risk for joint replacement surgery (odds ratio 9.0; confidence interval, 4.6-17.4). Joint replacement occurred significantly earlier in life in patients with hemochromatosis; 21.9% of the patients with hemochromatosis and 1.7% of healthy individuals required joint replacement before the age of 50 years (P=.0027). Moreover, patients with hemochromatosis were more likely to require multiple joint replacements (8.5%) than the control group (expected rate 0.3%; P=.0001).

CONCLUSION

Hemochromatosis is a risk factor for joint replacement surgery because of severe secondary osteoarthritis.