Showing papers in "Journal of Arthroplasty in 2016"
TL;DR: A new generation of robotic systems are now being introduced into the arthroplasty arena, and early results have demonstrated improved accuracy of placement, improved satisfaction, and reduced complications.
Abstract: Robotic-assisted orthopedic surgery has been available clinically in some form for over 2 decades, claiming to improve total joint arthroplasty by enhancing the surgeon's ability to reproduce alignment and therefore better restore normal kinematics. Various current systems include a robotic arm, robotic-guided cutting jigs, and robotic milling systems with a diversity of different navigation strategies using active, semiactive, or passive control systems. Semiactive systems have become dominant, providing a haptic window through which the surgeon is able to consistently prepare an arthroplasty based on preoperative planning. A review of previous designs and clinical studies demonstrate that these robotic systems decrease variability and increase precision, primarily focusing on component positioning and alignment. Some early clinical results indicate decreased revision rates and improved patient satisfaction with robotic-assisted arthroplasty. The future design objectives include precise planning and even further improved consistent intraoperative execution. Despite this cautious optimism, many still wonder whether robotics will ultimately increase cost and operative time without objectively improving outcomes. Over the long term, every industry that has seen robotic technology be introduced, ultimately has shown an increase in production capacity, improved accuracy and precision, and lower cost. A new generation of robotic systems is now being introduced into the arthroplasty arena, and early results with unicompartmental knee arthroplasty and total hip arthroplasty have demonstrated improved accuracy of placement, improved satisfaction, and reduced complications. Further studies are needed to confirm the cost effectiveness of these technologies.
285 citations
TL;DR: Early results from the implementation of a Medicare BPCI Model 2 primary TJR program at this medical center demonstrate cost-savings and has seen cost reduction in the inpatient component over baseline.
Abstract: Background In 2011 Medicare initiated a Bundled Payment for Care Improvement (BPCI) program with the goal of introducing a payment model that would "lead to higher quality, more coordinated care at a lower cost to Medicare." Methods A Model 2 bundled payment initiative for Total Joint Replacement (TJR) was implemented at a large, tertiary, urban academic medical center. The episode of care includes all costs through 90 days following discharge. After one year, data on 721 Medicare primary TJR patients were available for analysis. Results Average length of stay (LOS) was decreased from 4.27 days to 3.58 days (Median LOS 3 days). Discharges to inpatient facilities decreased from 71% to 44%. Readmissions occurred in 80 patients (11%), which is slightly lower than before implementation. The hospital has seen cost reduction in the inpatient component over baseline. Conclusion Early results from the implementation of a Medicare BPCI Model 2 primary TJR program at this medical center demonstrate cost-savings. Level of Evidence IV economic and decision analyses—developing an economic or decision model
249 citations
TL;DR: Patients with hypoalbuminemia had a higher risk for surgical site infection, pneumonia, extended length of stay, and readmission during the 30 days after total joint arthroplasty compared to patients with normal albumin concentration.
Abstract: This study investigates the association between preoperative hypoalbuminemia, a marker for malnutrition, and complications during the 30 days after total joint arthroplasty Patients who underwent elective primary total hip and knee arthroplasty as part of the American College of Surgeons National Surgical Quality Improvement Program were identified Outcomes were compared between patients with and without hypoalbuminemia (serum albumin concentration <35 g/dL) with adjustment for patient and procedural factors A total of 49603 patients were included In comparison to patients with normal albumin concentration, patients with hypoalbuminemia had a higher risk for surgical site infection, pneumonia, extended length of stay, and readmission Future efforts should investigate methods of correcting nutritional deficiencies prior to total joint arthroplasty If successful, such efforts could lead to improvements in short-term outcomes for patients
216 citations
TL;DR: SNF or IRF discharge increases the risk of postdischarge adverse events compared to home, and home discharge is the optimal strategy for minimizing rate of severe 30-day adverse events after discharge and unplanned 30- day readmissions.
Abstract: Background This study aimed to compare risk of postdischarge adverse events in elective total joint arthroplasty (TJA) patients by discharge destination, identify risk factors for inpatient discharge placement and postdischarge adverse events, and stratify TJA patients based on these risk factors to identify the most appropriate discharge destination. Methods Patients who underwent elective primary total hip or knee arthroplasty from 2011 to 2013 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses were assessed using perioperative variables. Results A total of 106,360 TJA patients were analyzed. The most common discharge destinations included home (70%), skilled nursing facility (SNF) (19%), and inpatient rehabilitation facility (IRF; 11%). Bivariate analysis revealed that rates of postdischarge adverse events were higher in SNF and IRF patients (all P ≤ .001). In multivariate analysis controlling for patient characteristics, comorbidities, and incidence of complication predischarge, SNF and IRF patients were more likely to have postdischarge severe adverse events (SNF: odds ratio [OR]: 1.46, P ≤ .001; IRF: OR: 1.59, P ≤ .001) and unplanned readmission (SNF: OR: 1.42, P ≤ .001; IRF: OR: 1.38, P ≤ .001). After stratifying patients by strongest independent risk factors (OR: ≥1.15, P ≤ .05) for adverse outcomes after discharge, we found that home discharge is the optimal strategy for minimizing rate of severe 30-day adverse events after discharge ( P ≤ .05 for 5 out of 6 risk levels) and unplanned 30-day readmissions ( P ≤ .05 for 6 out of 7 risk levels). Multivariate analysis revealed incidence of severe adverse events predischarge, female gender, functional status, body mass index >40, smoking, diabetes, pulmonary disease, hypertension, and American Society of Anesthesiologists class 3/4 as independent predictors of nonhome discharge (all P ≤ .001). Conclusion SNF or IRF discharge increases the risk of postdischarge adverse events compared to home. Modifiable risk factors for nonhome discharge and postdischarge adverse events should be addressed preoperatively to improve patient outcomes across discharge settings.
210 citations
TL;DR: Patients with a history of chronic opioid use who successfully decreased their use of opioids before surgery had substantially improved clinical outcomes that were comparable to patients who did not use opioids at all.
Abstract: Background The purpose of this study was to assess whether weaning of opioid use in the preoperative period improved total joint arthroplasty (TJA) outcomes. Methods Forty-one patients who regularly used opioids and successfully weaned (defined as a 50% reduction in morphine-equivalent dose) before a primary total knee or hip arthroplasty were matched with a group of TJA patients who did not wean and a matched control group of TJA patients who did not use opioids preoperatively. The difference between preoperative and postoperative (at 6-12 months follow-up) patient-reported outcomes were assessed using the change in University of California, Los Angeles (UCLA) activity score, SF12v2, and The Western Ontario and McMaster Universities Arthritis Index (WOMAC). Paired t tests and 1-way repeated measures analysis of variance were performed to assess differences in TJA outcomes between groups. Results Patients using opioids who successfully weaned had greater improvements in both disease-specific and generic measures of health outcomes than patients who did not wean (WOMAC 43.7 vs 17.8, P P = .003; UCLA activity score 1.49 vs 0, P P = .409. Patients who successfully weaned from opioids had similar outcomes to control patients who did not use opioids: WOMAC 39.0 vs 43.7, P = .31; SF12v2 Physical Component Score 12.5 vs 10.5, P = .35; SF12v2 Mental Component Score 3.08 vs 2.48, P = .82; UCLA activity 1.90 vs 1.49, P = .23. Conclusion Patients with a history of chronic opioid use who successfully decreased their use of opioids before surgery had substantially improved clinical outcomes that were comparable to patients who did not use opioids at all.
208 citations
TL;DR: As Medicare payment policy for total joint arthroplasty shifts toward bundling, an awareness of factors associated with outlier costs will be requisite to remain profitable.
Abstract: Background This study evaluated the factors and costs associated with discharge destination and readmission, within 90 days of surgery, for primary or revision total knee arthroplasty (TKA) and total hip arthroplasty (THA). Methods This retrospective database analysis used health care claims from the Truven MarketScan Database (2009-2013). Patients were selected if aged ≥18 years, with continuous health plan enrollment from 3-month baseline through 3-month follow-up. Logistic regression and Cox proportional hazard models were used to analyze factors associated with discharge destination and risk of readmission. Total 90-day costs were calculated for different patient pathways of care, dependent on complications, discharge destination, and readmission status. Results A total of 323,803 primary TKA, 25,354 revision TKA, 159,390 primary THA, and 17,934 revision THA cases met selection criteria. All-cause complications occurred in 2.5%, 37.2%, 2.6%, and 35.0% of each cohort. Complications, transfusions, and length of stay ≥3 days were associated with greater odds of discharge to home with home health services or skilled nursing facility (SNF) vs home under self-care ( P P Conclusion As Medicare payment policy for total joint arthroplasty shifts toward bundling, an awareness of factors associated with outlier costs will be requisite to remain profitable.
162 citations
TL;DR: Aseptic loosening was the main failure mode in early years and mobile-bearing implants, whereas OA progression caused most failures in late years and fixed- bearing implants.
Abstract: Background Failure rates are higher in medial unicompartmental knee arthroplasty (UKA) than total knee arthroplasty. To improve these failure rates, it is important to understand why medial UKA fail. Because individual studies lack power to show failure modes, a systematic review was performed to assess medial UKA failure modes. Furthermore, we compared cohort studies with registry-based studies, early with midterm and late failures and fixed-bearing with mobile-bearing implants. Methods Databases of PubMed, EMBASE, and Cochrane and annual registries were searched for medial UKA failures. Studies were included when they reported >25 failures or when they reported early ( 10 years). Results Thirty-seven cohort studies (4 level II studies and 33 level III studies) and 2 registry-based studies were included. A total of 3967 overall failures, 388 time-dependent failures, and 1305 implant design failures were identified. Aseptic loosening (36%) and osteoarthritis (OA) progression (20%) were the most common failure modes. Aseptic loosening (26%) was most common early failure mode, whereas OA progression was more commonly seen in midterm and late failures (38% and 40%, respectively). Polyethylene wear (12%) and instability (12%) were more common in fixed-bearing implants, whereas pain (14%) and bearing dislocation (11%) were more common in mobile-bearing implants. Conclusion This level III systematic review identified aseptic loosening and OA progression as the major failure modes. Aseptic loosening was the main failure mode in early years and mobile-bearing implants, whereas OA progression caused most failures in late years and fixed-bearing implants.
158 citations
TL;DR: Outpatients experience higher rates of post-discharge complications, which may countermand cost savings, and surgeons wishing to implement outpatient total joint arthroplasty clinical pathways must focus on preventing post- Discharge medical complications to include blood management strategies.
Abstract: Background In the emerging fiscal climate of value-based decision-making and shared risk and remuneration, outpatient total joint arthroplasty is attractive provided the incidence of costly complications is comparable to contemporary "fast-track" inpatient pathways Methods All patients undergoing total hip arthroplasty or total knee arthroplasty between 2011 and 2013 were selected from the American College of Surgeons–National Surgical Quality Improvement Program database A propensity score was used to match 1476 fast-track (≤2 day length of stay) inpatients with 492 outpatients (3:1 ratio) Thirty-day complication, reoperation, and readmission rates were compared, both during and after hospitalization Logistic regression was used to calculate propensity score adjusted odds ratios Results After matching, outpatients had higher rates of medical complication (anytime, 100% vs 67%, P = 018; post discharge, 63% vs 11%, P P = 113; post discharge, 41% outpatients vs 01% inpatients, P P = 589) Conclusion Outpatients experience higher rates of post-discharge complications, which may countermand cost savings Surgeons wishing to implement outpatient total joint arthroplasty clinical pathways must focus on preventing post-discharge medical complications to include blood management strategies
134 citations
TL;DR: Patients underwent modular bearing exchange, including a ceramic head with a titanium sleeve in 23 of 27 cases with only one recurrence of ALTR in one of the four patients not treated with a ceramic heads.
Abstract: We reviewed 27 patients who underwent revision for an adverse local tissue reaction (ALTR) secondary to corrosion at the head-neck junction with MoP bearings. Serum cobalt and chromium levels were elevated in all cases, with a mean cobalt of 11.2 ppb and chromium of 2.2 ppb. Patients underwent modular bearing exchange, including a ceramic head with a titanium sleeve in 23 of 27 cases with only one recurrence of ALTR in one of the four patients not treated with a ceramic head. The diagnosis of ALTR secondary to corrosion is associated with cobalt levels of >1 ppb with cobalt levels elevated above chromium. Retention of a well-fixed stem and modular exchange to a ceramic head leads to resolution of symptoms and decreases in metal levels.
133 citations
TL;DR: By adding another bolus of IV-TXA, patients can gain a smaller decline of Hb, less postoperative inflammatory response, less pain, less knee swelling, better knee function, and shorter LOH.
Abstract: Background The optimal dosage and timing of tranexamic acid (TXA) in total knee arthroplasty (TKA) are undetermined. The purpose of this study was to explore the effect of multiple boluses of intravenous TXA on hidden blood loss (HBL), inflammatory response, and knee function after primary TKA without tourniquet. Methods A total of 151 patients were randomly divided into 3 groups to receive single bolus of 20 mg/kg IV-TXA before skin incision (group A), or another bolus of 10 mg/kg IV-TXA 3 hours later (group B), or another 2 boluses of 10 mg/kg IV-TXA 3 hours and 6 hours later (group C). TKAs without tourniquet were operated by 1 single surgeon. The primary outcomes were HBL and maximum hemoglobin drop. Other outcome measurements such as total blood loss, transfusion rate, inflammation markers (C-reactive protein, interleukin 6), visual analog scale pain score, limb swelling ratio, Hospital for Surgery Score, range of motion, length of hospital stay (LOH), and deep venous thrombosis were also compared. Results The mean HBL and maximum Hb drop in group C (467.6 ± 305.9 and 20.9 ± 9.3) was lower than those in group A (763.0 ± 373.3, P P P = .010; 25.2 ± 8.4, P = .036). However, such differences were not detected between groups A and B ( P = .058 and P = .080, respectively). The mean value of total blood loss in the groups A, B, and C were 967.2 ± 380.1, 803.7 ± 321.8, and 677.6 ± 326.0 mL, respectively, with a significant intergroup difference ( P Conclusion Multiple boluses of IV-TXA can effectively reduce HBL after primary TKA without tourniquet. What is the most important is that, by adding another bolus of IV-TXA, patients can gain a smaller decline of Hb, less postoperative inflammatory response, less pain, less knee swelling, better knee function, and shorter LOH.
130 citations
TL;DR: Robot-assisted UKA is cost-effective compared with traditional UKA when annual case volume exceeds 94 cases per year, but it is not cost- effective at low-volume or medium-volume arthroplasty centers.
Abstract: Background Unicompartmental knee arthroplasty (UKA) is a treatment option for single-compartment knee osteoarthritis. Robotic assistance may improve survival rates of UKA, but the cost-effectiveness of robot-assisted UKA is unknown. The purpose of this study was to delineate the revision rate, hospital volume, and robotic system costs for which this technology would be cost-effective. Methods We created a Markov decision analysis to evaluate the costs, outcomes, and incremental cost-effectiveness of robot-assisted UKA in 64-year-old patients with end-stage unicompartmental knee osteoarthritis. Results Robot-assisted UKA was more costly than traditional UKA, but offered a slightly better outcome with 0.06 additional quality-adjusted life-years at an incremental cost of $47,180 per quality-adjusted life-years, given a case volume of 100 cases annually. The system was cost-effective when case volume exceeded 94 cases per year, 2-year failure rates were below 1.2%, and total system costs were Conclusion Robot-assisted UKA is cost-effective compared with traditional UKA when annual case volume exceeds 94 cases per year. It is not cost-effective at low-volume or medium-volume arthroplasty centers.
TL;DR: A positive α-defensin test result was significantly more sensitive and specific for predicting infection than current diagnostic testing and should be considered when managing periprosthetic joint infection.
Abstract: Background The purpose of this study was to test the accuracy of a single synovial fluid biomarker, α-defensin, in diagnosing periprosthetic joint infection in revision total hip and revision total knee arthroplasty. Methods A total of 102 patients comprising 116 revision total hip arthroplasty and revision total knee arthroplasty procedures performed between May 2013 and March 2014 were prospectively evaluated. Cases were categorized as infected or notinfected using Musculoskeletal Infection Society criteria. Synovial fluid was obtained and tested for α-defensin using a commercially available kit (Synovasure [CD Diagnostics, Baltimore, Maryland]). Results For first-stage and single-stage revisions, the α-defensin test had a sensitivity of 100% (95% confidence interval [CI], 86%-100%) and a specificity of 98% (95% CI, 90%-100%) with a positive predictive value of 96% (95% CI, 80%-99%) and negative predictive value of 100% (95% CI, 93%-100%). Conclusion A positive α-defensin test result was significantly more sensitive and specific for predicting infection than current diagnostic testing and should be considered when managing periprosthetic joint infection. Level of Evidence: Level III, Study of Diagnostic Test.
TL;DR: Preoperative opioid use should be disclosed as a risk factor for complication to patients and taken into consideration by physicians before initiating opioid management, according to experts.
Abstract: Background Opioid therapy is an increasingly used modality for treatment of musculoskeletal pain despite multiple associated risks. The purpose of this study was to evaluate how preoperative opioid use affects early outcomes after total joint arthroplasty. Methods A total of 174 patients undergoing total joint arthroplasty were matched by age, gender, and procedure into 3 groups stratified by preoperative opioid use (nonuser, short acting [eg, Vicodin], long acting [eg, Oxycontin]). Results Compared to nonusers, preoperative long-acting use was associated with increased postoperative mean opioid consumption (46 mg vs 366 mg mean morphine equivalents, P P = .013). Conclusion Preoperative opioid use should be disclosed as a risk factor for complication to patients and taken into consideration by physicians before initiating opioid management.
TL;DR: Increased length of stay is associated with increased complication and readmission after joint arthroplasty for patients with a hospital stay of 3 or more days, and in THA, there was an increased complication rate in patients discharged POD 0 as compared to POD 1.
Abstract: Background Length of hospital stay is a quality metric in joint arthroplasty. Rapid recovery protocols have safely reduced the average length of hospitalization, but it is unclear whether there is a difference in complication and readmission rates between patients discharged the day of surgery or on postoperative day 1 (POD 1). We calculated 30-day complication and readmission after total knee arthroplasty (TKA), total hip arthroplasty (THA), and unicompartmental knee arthroplasty (UKA) based on day of discharge. We then analyzed the rapid recovery group by comparing those discharged the day of surgery and those discharged on POD 1. Methods Patients undergoing joint arthroplasty between 2011 and 2013 were selected from the American College of Surgeons (ACS) National Surgical Quality Improvement Program. Demographics, comorbidities, and 30-day complication and readmission were determined based on discharge date. Propensity-matched comparisons were performed between patients discharged POD 0 vs POD 1. We used multivariate logistic regression to determine independent risk factors for 30-day complication and readmission. Results There was no difference in complication or readmission after TKA or UKA between POD 0 or POD 1 discharge. In the propensity-matched cohort in THA, however, there was an increased rate of any complication in the POD 0 compared with the POD 1 discharge cohort. Risk factors for complication and readmission among THA, TKA, and UKA include age >80 years and smoking, and discharge after day 3. Conclusion Increased length of stay is associated with increased complication and readmission after joint arthroplasty for patients with a hospital stay of 3 or more days. However, in THA, there was an increased complication rate in patients discharged POD 0 as compared to POD 1. Efforts to improve patient selection are expected to reduce short-term complications after outpatient joint arthroplasty. Further research is needed to determine which patients can be discharged POD 0 without increased complication after THA.
TL;DR: Although for most items, >60% of THA and TKA patients indicated that their expectations were met or exceeded, there was a substantial number of patients, particularly TKA Patients, having unfulfilled expectations.
Abstract: Background The aims of this study were to assess patients' preoperative expectations of the outcome of total hip or knee arthroplasty (THA/TKA) regarding specific aspects of functioning and to determine to what extent each expectation was fulfilled after 1 year. Methods This was a prospective cohort study. Preoperative expectations and their fulfillment after 1 year were measured with the Hospital for Special Surgery Hip/Knee arthroplasty Expectations Surveys. Preoperative and postoperative scores were subtracted to calculate whether expectations were unfulfilled, fulfilled, or exceeded. Results A total of 343 THA and 322 TKA patients with complete follow-up were included. Preoperatively, >60% of patients (both THA/TKA) expected to get back to normal or have much improvement in 19 of 20 (THA) and 12 of 19 (TKA) items. Expectations were fulfilled or exceeded in >60% of patients in all 20 items for THA and 17 of 19 items for TKA. In THA, items with the largest proportions patients with unfulfilled expectations (>30%) were “improvement in walking ability: long distances” (31%), “walking stairs” (33%), and “improve ability to cut toenails” (38%). In TKA, expectations for 12 of 19 items were unfulfilled in >30% of patients, with the largest proportions seen for “being able to kneel down” (44%) and “being able to squat” (47%). Conclusion Although for most items, >60% of THA and TKA patients indicated that their expectations were met or exceeded, there was a substantial number of patients, particularly TKA patients, having unfulfilled expectations. These need more attention in preoperative patient information and education.
TL;DR: Investigation of the use of opiate medication in the preoperative and postoperative patient undergoing primary total joint arthroplasty found opiates are frequently prescribed by providers other than the surgeon preoperatively and postoperatively.
Abstract: Background As opioid use increases nationally, the arthroplasty surgeon is likely to see more patients taking opioid analgesics on initial presentation The purpose of this study was to investigate the use of opiate medication in the preoperative and postoperative patient undergoing primary total joint arthroplasty Methods From October 2010 to November 2011, data on 367 consecutive patients who underwent primary total joint arthroplasty were reviewed Using the Michigan Automated Prescription System database, data were collected on opiate use from 3 months preop to 12 months postop Patients were grouped by preoperative opiate use Patients with ≥2 opiate prescriptions filled per 6-week period before surgery were considered chronic opiate users Results Three hundred fifteen patients fit our inclusion/exclusion criteria There were 158 primary total knee and 157 primary total hip arthroplasty patients At 1 year after operation, 64% of chronic opiate users were still being prescribed opiates compared with 22% of the control group ( P P = 123) Of all the opiate prescriptions, 77% were written by a practitioner other than the surgeon Conclusions Opiates are frequently prescribed by providers other than the surgeon preoperatively and postoperatively The use of opiates that were presumably prescribed to treat joint pain was continued for more than 1 year postoperatively in 64% of cases Patients taking multiple opiates or more potent opiates preoperatively filled more prescriptions postoperatively Chronic use of opiates negatively influenced the discharge disposition
TL;DR: An alarmingly high THA dislocation rate has been demonstrated among THA patients with concurrent spinopelvic fusion at the authors' institution and within a large national database (8.3%).
Abstract: Background The purpose of this study was to determine the prevalence of concurrent spinopelvic fusion and THA and identify the risk of THA dislocation in patients with concurrent spinopelvic fusion. Methods We retrospectively reviewed an institutional database of spinal deformity patients and the Humana Inc data set to identify patients with concurrent THA and spinopelvic fusion. The prevalence of concurrent THA and spinopelvic fusion was identified, as was the risk of dislocation for all cohorts. Results Of 328 patients with spinopelvic fusions at our institution, 15 patients (4.6%) were found to have concurrent THA. Similarly, within the Humana database among 1049 patients with spinopelvic fusion, 4.6% had a concurrent THA. Among the 58,692 THA patients identified, only 0.1% had a concurrent spinopelvic fusion. A THA dislocation was observed in 3 of 15 patients (20.0%) and 3 of 18 THA (16.7%) within our institutional review. Within the Humana database, 8.3% of patients with THA and spinopelvic fusion went on to have a dislocation of their THA compared to 2.9% of patients with THA and no history of spinopelvic fusion (relative risk: 2.9 [1.2-7.6]). Conclusion Among patients with spinopelvic fusion, the prevalence of concurrent THA is 4.6%, and among primary THA patients, the prevalence of concurrent spinopelvic fusion is 0.1%. An alarmingly high THA dislocation rate has been demonstrated among THA patients with concurrent spinopelvic fusion at our institution (20%) and within a large national database (8.3%).
TL;DR: Hospital readmissions after THA and TKA are common and costly.
Abstract: Background The Bundled Payment for Care Improvement (BPCI) Initiative is a Centers for Medicare and Medicaid Services program designed to promote coordinated and efficient care. This study seeks to report costs of readmissions within a 90-day episode of care for BPCI Initiative patients receiving total knee arthroplasty (TKA) or total hip arthroplasty (THA). Methods From January 2013 through December 2013, 1 urban, tertiary, academic orthopedic hospital admitted 664 patients undergoing either primary TKA or THA through the BPCI Initiative. All patients readmitted to our hospital or an outside hospital within 90-days from the index episode were identified. The diagnosis and cost for each readmission were analyzed. Results Eighty readmissions in 69 of 664 patients (10%) were identified within 90-days. There were 53 readmissions (45 patients) after THA and 27 readmissions (24 patients) after TKA. Surgical complications accounted for 54% of THA readmissions and 44% of TKA readmissions. These complications had an average cost of $36,038 (range, $6375-$60,137) for THA and $38,953 (range, $4790-$104,794) for TKA. Eliminating the TKA outlier of greater than $100,000 yields an average cost of $27,979. Medical complications of THA and TKA had an average cost of $22,775 (range, $5678-$82,940) for THA and $24,183 (range, $3306-$186,069) for TKA. Eliminating the TKA outlier of greater than $100,000 yields an average cost of $11,682. Conclusion Hospital readmissions after THA and TKA are common and costly. Identifying the causes for readmission and assessing the cost will guide quality improvement efforts.
TL;DR: Neither approach has a compelling advantage over each other, including no difference in the dislocation risk, on the basis of short-term outcome and complication data.
Abstract: Background The direct anterior approach (DAA) for total hip arthroplasty (THA) has rapidly become popular, but there is little consensus regarding the risks and benefits of this approach in comparison with a modern posterior approach (PA). Methods A total of 2147 patients who underwent DAA THA were propensity score matched with patients undergoing PA THA on the basis of age, gender, body mass index, and American Society of Anesthesia classification using data from a state joint replacement registry. Mean age of the matched cohort was 64.8 years, mean body mass index was 29.1 kg/m 2 , and 53% were female. Multilevel logistic regression models using generalized estimating equations to control for grouping at the hospital level were used to identify differences in various outcomes. Results There was no difference in the dislocation rate between patients undergoing DAA (0.84%) and PA (0.79%) THA. Trends indicating a slightly longer length of stay with the PA and a slightly greater risk of fracture, increased blood loss, and hematoma with the DAA are consistent with previous studies. Conclusion On the basis of short-term outcome and complication data, neither approach has a compelling advantage over each other, including no difference in the dislocation risk.
TL;DR: Utilizing a posterior approach specific safe zone of 10-25° anteversion and 30-50° abduction may minimize THA dislocations.
Abstract: Background Acetabular component orientation influences joint stability in total hip arthroplasty (THA). The purpose of this study was to evaluate the effect of cup orientation and other variables on hip dislocation risk and to define a posterior approach specific safe zone. Methods A cohort of 1289 posterior approach primary THA cases was prospectively followed and component position measured radiographically. Results Cup malposition, with respect to the Lewinnek safe zone, was an independent risk factor for dislocation (OR1.88). Modifying the anteversion safe zone limits to 10-25° strongly predicted increased dislocation risk (OR2.69). No dislocations occurred within a zone defined by a circle centered at 41.4° abduction and 17.1° anteversion, radius 4.3°. Conclusion Utilizing a posterior approach specific safe zone of 10-25° anteversion and 30-50° abduction may minimize THA dislocations. Level of Evidence Level III
TL;DR: A new prediction tool for patient satisfaction following TKA may allow surgeons and patients to evaluate the risks and benefits of surgery on an individual basis and help in patient selection.
Abstract: Background Total knee arthroplasty (TKA) is a proven and cost-effective treatment for osteoarthritis. Despite the good to excellent long-term results, some patients remain dissatisfied. Our study aimed at establishing a predictive model to aid patient selection and decision-making in TKA. Methods Using data from our prospective arthroplasty outcome database, 113 patients were included. Preoperatively and postoperatively, the patients completed 107 questions in 5 questionnaires: Knee Injury and Osteoarthritis Outcome Score, Oxford Knee Score, Pain Catastrophizing Scale, Euroqol questionnaire, and Knee Scoring System. First, outcome parameters were compared between the satisfied and dissatisfied group. Second, we developed a new prediction tool using regression analysis. Each outcome score was analyzed with simple regression. Subsequently, the predictive weight of individual questions was evaluated applying multiple linear regression. Finally, 10 questions were retained to construct a new prediction tool. Results Overall satisfaction rate in this study was found to be 88%. We identified a significant difference between the satisfied and dissatisfied group when looking at the preoperative questionnaires. Dissatisfied patients had more preoperative symptoms (such as stiffness), less pain, and a lower quality of life. They were more likely to ruminate and had a lower preoperative Knee Scoring System satisfaction score. The developed prediction tool consists of 10 simple but robust questions. Sensitivity was 97% with a positive-predictive value of 93%. Conclusions Based upon preoperative parameters, we were able to partially predict satisfaction and dissatisfaction after TKA. After further validation, this new prediction tool for patient satisfaction following TKA may allow surgeons and patients to evaluate the risks and benefits of surgery on an individual basis and help in patient selection.
TL;DR: Depression or anxiety was a predictor of increased complications after TJA, and all efforts need to be invested to minimize complications and the added cost in patients with depression or anxiety undergoing TJA.
Abstract: Introduction The outcome of total joint arthroplasty (TJA) may be affected by numerous factors including the mental health status of patients and the presence of psychological disorders Therefore, the present study was designed and conducted to determine the impact of concomitant psychiatric disorders on the hospitalization charges and complications in patients with preoperative depression or anxiety undergoing TJA. Materials and Methods International Classification of Diseases, Ninth Revision, codes were used to identify perioperative complications in patients with and without concomitant diagnosis of depression or anxiety who underwent TJA at our institution during 2009. Hospitalization charges and complications were compared for patients with and without depression or anxiety undergoing TJA. Results Respectively, 12.7% and 6.4% of knee and the hip arthroplasty patients had concomitant depression or anxiety. In the knee but not the hip group, the charge was $3420 higher in patients with depression/anxiety ( P Discussion Depression or anxiety was a predictor of increased complications after TJA. Therefore, patients with depression or anxiety undergoing TJA need to be counselled appropriately, and all efforts need to be invested to minimize complications and the added cost in these patients.
TL;DR: Compared with controls, patients with prior SA had significantly higher rates of complications including dislocation and any prosthetic-related complication after primary total hip arthroplasty (THA).
Abstract: Background Degenerative hip disorders often coexist with degenerative changes of the lumbar spine. Limited data on this patient population suggest inferior functional improvement and pain relief after surgical management. The purpose of this study is to compare the rates of prosthetic-related complication after primary total hip arthroplasty (THA) in patients with and without prior lumbar spine arthrodesis (SA). Methods Medicare patients (n = 811,601) undergoing primary THA were identified and grouped by length of prior SA (no fusion, 1-2 levels fused [S-SAHA], and ≥3 levels fused [L-SAHA]). Results Compared with controls, patients with prior SA had significantly higher rates of complications including dislocation (control: 2.36%; S-SAHA: 4.26%; and L-SAHA: 7.51%), revision (control: 3.43%, S-SAHA: 5.55%, and L-SAHA: 7.77%), loosening (control: 1.33%, S-SAHA: 2.10%, and L-SAHA: 3.04%), and any prosthetic-related complication (control: 7.33%, S-SAHA: 11.15% [relative risk: 1.52], and L-SAHA: 14.16% [relative risk: 1.93]) within 24 months ( P Conclusion The interplay of coexisting degenerative hip and spine disease deserves further attention of both arthroplasty and spine surgeons.
TL;DR: Intraoperative force-sensing has potential in providing real-time objective data to optimize TKA outcomes and some early outcomes may improve by balancing TKAs within 60 lbs difference, according to a multicenter, retrospective study.
Abstract: Background The optimal "target" ligament balance for each patient undergoing total knee arthroplasty (TKA) remains unknown. The study purpose was to determine if patient outcomes are affected by intraoperative ligament balance measured with force-sensing implant trials and if an optimal "target" balance exists. Methods A multicenter, retrospective study reviewed consecutive TKAs performed by 3 surgeons. TKA's were performed with standard surgical techniques and ligament releases. After final implants were made, sensor-embedded smart tibial trials were inserted, and compartment forces recorded throughout the range of motion. Clinical outcome measures were obtained preoperatively and at 4 months. Statistical analysis correlated ligament balance with clinical outcomes. Results One hundred eighty-nine consecutive TKAs were analyzed. Patients were grouped by average medial and lateral compartment force differences. Twenty-nine TKAs (15%) were balanced within 15 lbs and 53 (28%) were "balanced" greater than 75 lbs. Greater improvement in University of California Los Angeles activity level was associated with a mediolateral force difference P = .006). Knee Society objective, function, and satisfaction scores, and self-reported health state were unrelated to mediolateral balance in the knee. Conclusion Intraoperative force-sensing has potential in providing real-time objective data to optimize TKA outcomes. These data support some early outcomes may improve by balancing TKAs within 60 lbs difference. Close follow-up is warranted to determine if gait pattern adaptations affect longer term outcomes with greater or less ligament "imbalance."
TL;DR: After PPFx, patients have a 24% risk of either death or reoperation at 1 year, and risk of reoperation is minimized with greater span of fixation and performance of revision arthroplasty.
Abstract: Background Data addressing risk factors predictive of mortality and reoperation after periprosthetic femur fractures (PPFxs) are lacking. This study examined survivorship and risk ratios for mortality and reoperation after surgical treatment for PPFx and associated clinical risk factors. Methods A retrospective review was performed for 291 patients treated surgically for PPFx between 2004 and 2013. Primary outcomes were death and reoperation. Results Mortality at 1 year was 13%, whereas the rate of reoperation was 12%. Greater span of fixation and revision arthroplasty (vs open reduction internal fixation) trended toward a lower likelihood of reoperation. Conclusion After PPFx, patients have a 24% risk of either death or reoperation at 1 year. Factors contributing to increased mortality are nonmodifiable. Risk of reoperation is minimized with greater span of fixation and performance of revision arthroplasty.
TL;DR: This large multicenter study of consecutive AA THAs demonstrates an acceptable risk profile within the first 90 days after surgery.
Abstract: Background Few publications have raised concern with the safety of the anterior approach (AA) to total hip arthroplasty (THA). The purpose of this study is to report the early complications with AA THA in a combined, multicenter patient population from three different institutions. Methods The study cohort consisted of 5090 consecutive primary procedures in 4473 patients who had undergone THA utilizing the anterior approach between August 2006 and July 2013. Surgeries were performed by five surgeons at three sites that maintain prospective databases. Preoperative, intraoperative, and postoperative data were recorded on all patients. Demographic data including age, gender, and BMI were queried, as well as all intraoperative and postoperative complications in the first 90 days. Results The 5090 patients had a mean body mass index of 27.5, and mean age of 63.6 years. The overall 90-day complication rate was 1.9%. There were 41 intraoperative femur fractures including 29 calcar fractures, 9 greater trochanter fractures and 3 femoral shaft fractures. There were 7 postoperative femur fractures including 3 greater trochanter fractures, 2 calcar fractures, and 2 femur fractures. Other complications included 15 superficial infections, 5 deep infections, 12 dislocations, 8 hematomas, 3 cases of cellulitis, 2 sciatic nerve palsies, 1 peroneal nerve palsy, and intrapelvic bleed. The nonsurgical complication rate was 1.4%. Deep vein thrombosis occurred in 0.3% of cases. Conclusion This large multicenter study of consecutive AA THAs demonstrates an acceptable risk profile within the first 90 days after surgery.
TL;DR: There is an increased risk of PJI when THA is performed within 3 months of hip injection, and it is recommended that patients and their surgeons consider delaying elective THA until 3 months after an injection to avoid this elevated risk of infection.
Abstract: Background Intraarticular injections are both diagnostic and therapeutic for patients with osteoarthritis. A potential risk of periprosthetic joint infection (PJI) after total hip arthroplasty (THA) may occur from direct inoculation and/or immune suppression by corticosteroids. Large population-level databases were used to evaluate hip injection on the 1-year rate of PJI in patients undergoing primary THA. Methods State-level ambulatory surgery and inpatient databases for Florida and California (2005-2012) were used to identify primary THA patients with 1-year preoperative and postoperative windows to evaluate possible injections or PJI, respectively. Patients were grouped as no injection or as THA performed 6-12 months, 3-6 months, or 0-3 months after injection. Risk adjustment was performed with multivariable regression. Results A total of 173,958 patients were included; 5421 (3.1%) underwent THA after an injection: 1395 (1.1%) of patients after 6-12 months, 1863 patients after 3-6 months, and 2163 (1.2%) after 0-3 months. In the 0-3 month group, PJI was significantly increased at 3 months (1.58%, P = .015), 6 months (1.76%, P = .022), and 1 year (2.04%, P = .031) compared with the noninjection control group (1.04%, 1.21%, and 1.47%, respectively). There were no differences in the 3- to 6-month and 6- to 12-month injection groups. Conclusion There is an increased risk of PJI when THA is performed within 3 months of hip injection. We recommend that patients and their surgeons consider delaying elective THA until 3 months after an injection to avoid this elevated risk of infection.
TL;DR: Two-stage reimplantation, despite 19% recurrence, had the highest success rate and guidelines need to be established for their specific indications.
Abstract: Background The purpose of this study was to determine the incidence of subsequent reinfections after initial treatment of an infected total knee arthroplasty, identify risk factors leading to reinfection, and compare results among the varying treatment modalities. Methods A total of 1,493,924 primary TKA patients were identified from the Medicare data between October 1, 2005, and December 31, 2011. Patients who encountered periprosthetic joint infection (PJI) after TKA were identified using International Classification of Diseases, Ninth Revision, Clinical Modification code 996.66. The risk of subsequent PJI was stratified based on the first-line treatment and compared between the various first-line treatment groups. Results A total of 16,622 patients (1.1%) were diagnosed with PJI. The Kaplan-Meier risk of PJI was 0.77% at 1 year and 1.58% at 6 years. Age ( P P P P = .036), census region ( P = .031), gender ( P P Conclusion Two-stage reimplantation, despite 19% recurrence, had the highest success rate. Given the higher failure rates of I&D and single-stage revisions, guidelines need to be established for their specific indications.
TL;DR: Serum cobalt and chromium levels and Oxford scores were obtained at minimum two year follow-up for 100 consecutive patients who had THA with MDM components and use of MDM implants in only patients at high risk for dislocation following THA is recommended.
Abstract: Dual mobility acetabular components can reduce the incidence of total hip arthroplasty (THA) instability. Modular dual mobility (MDM) components facilitate acetabular component implantation. However, corrosion can occur at modular junctions. Serum cobalt and chromium levels and Oxford scores were obtained at minimum two year follow-up for 100 consecutive patients who had THA with MDM components. Average Oxford score was 43 (range 13-48). Average serum cobalt and chromium values were 0.7 mcg/L (range, 0.0 to 7.0) and 0.6 mcg/L (range, 0.1 to 2.7), respectively. MARS MRI was performed for four patients with pain and elevated serum cobalt levels. Two of these studies were consistent with adverse local tissue reaction. We recommend use of MDM implants in only patients at high risk for dislocation following THA.
TL;DR: Promoting care coordination across disciplines for management of nonorthopedic comorbidities before surgery, particularly in higher risk patients with depression, could optimize orthopedic surgery outcomes, patient well-being, and costs of care.
Abstract: Background Hospital readmission after total joint arthroplasty accounts for substantial resource consumption. Depression has been shown to impact postsurgical outcomes. We therefore aimed to study the association of depression with risk of readmission after total joint arthroplasty. Methods Retrospective cohort data from the population-based California Healthcare Cost and Utilization Project database from 2007 to 2010 were analyzed using multivariable logistic regression to predict odds of 90-day readmission after hospital discharge for primary total knee arthroplasty (TKA, n = 132,422) or total hip arthroplasty (THA, n = 65,071) arthroplasty in adults ages 50+ years. We included the primary exposure of depression and controlled for age, sex, race/ethnicity, Medicaid insurance, comorbidities, and admission year. Results Overall 90-day readmission rates were approximately 8% for TKA and THA. Even after controlling for other chronic conditions and nonmodifiable covariates, we found depression predicted higher likelihood of readmission. The odds of readmission for subjects with depression were 21%-24% higher overall (odds ratio for TKA: 1.21, 95% confidence interval: 1.13-1.29; odds ratio for THR: 1.24, 95% confidence interval: 1.13-1.35; P P Conclusion Depression is associated with a significantly higher risk of readmission after THA and TKA. Hospital readmissions must be minimized to improve care quality, while making these procedures fiscally feasible. Promoting care coordination across disciplines for management of nonorthopedic comorbidities before surgery, particularly in higher risk patients with depression, could optimize orthopedic surgery outcomes, patient well-being, and costs of care. Therefore, every effort to address depression before surgery is warranted.