Faculty Bibliography

BACKGROUND: Preoperative risk stratification and optimization of preoperative care may be helpful in reducing readmission rates after primary total joint arthroplasty. Assessment of the predictive value of individual modifiable risk factors without a tool to assess cumulative risk may not provide proper risk stratification of patients with regard to potential readmissions. As part of a Perioperative Orthopaedic Surgical Home model, we developed a scoring system, the Readmission Risk Assessment Tool (RRAT), which allows for risk stratification in patients undergoing elective primary total joint arthroplasty at our institution. The purpose of this study was to analyze the relationship between the RRAT score and readmission after primary hip or knee arthroplasty. METHODS: The RRAT, which is scored incrementally on the basis of the number and severity of modifiable comorbidities, was used to generate readmission scores for a cohort of 207 readmitted patients and two cohorts (one random and one age-matched) of 234 non-readmitted patients each. Regression analysis was performed to assess the strength of association of individual risk factors and the RRAT score with readmissions. We also calculated the odds and odds ratio (OR) at each RRAT score level to identify patients with relatively higher risk of readmission. RESULTS: There were 207 (2.08%) readmissions among 9930 patients over a six-year period (2008 through 2013). Surgical site infection was the most common cause of readmission (ninety-three cases, 45%). The median RRAT scores were 3 (IQR [interquartile range], 1 to 4) and 1 (IQR, 0 to 2) for readmitted and non-readmitted groups, respectively. An RRAT score of >/=3 was significantly associated with higher odds of readmission. CONCLUSIONS: Population health management, cost-effective care, and optimization of outcomes to maximize value are the new maxims for health-care delivery in the United States. We found that the RRAT score had a significant association with readmission after joint arthroplasty and could potentially be a clinically useful tool for risk mitigation.

Higher PJI rates may be related to identifiable risk factors, which may or may not be modifiable. Identifying risk factors preoperatively provides opportunities for modification and potentially decreasing the incidence of PJI. The purposes of this study were to: (1) retrospectively identify and quantify risk factors for PJI following primary TKA, and (2) to classify those significant risk factors as either non-modifiable or modifiable for intervention prior to surgery. Optimization of modifiable risk factors such as Staphylococcus aureus colonization, and tobacco use prior to primary TKA may decrease the incidence of periprosthetic joint infection after primary TKA, thereby reducing morbidity and the costs associated with treating those infections.

We aimed to examine and quantify the combined association of patient sociodemographic, preoperative comorbidities and intraoperative factors with extended and prolonged length of stay (LOS) following primary total hip arthroplasty. Longer LOS was associated with Age (>/=65years), BMI >/=30kg/m2, ASA score >2, minority race/ethnicity, low SES, general anesthesia, comorbidities of the Circulatory, Genitourinary and Respiratory systems, and operating time. Collectively, being of low SES, advanced age (>/=65years) and minority race/ethnicity was most significantly associated with prolonged LOS (>7days). The combined associations of lower SES, female gender, advanced age, non-Caucasian race/ethnicity and certain comorbidities presented a synergistically elevated risk for longer LOS and may warrant the need to consider sociodemographic status when allocating resources to hospitals serving such patients.

The steadily increasing demand for orthopedic surgeries and declining rates of reimbursement by Medicare and other insurance providers have led many hospitals to look for ways to control the cost of these surgeries. We reviewed administrative records for a 1-year period and recorded total number of surgical cases, number of cases in which an implant was wasted, and cost of each wasted implant. We determined cost incurred because of implant waste, percentage of cases that involved waste, percentage of total implant cost wasted, and average cost of waste per case. We then analyzed the data to determine if case volume or years in surgical practice affected amount of implant waste. Results showed implant waste represents a significant cost for orthopedic procedures within all subspecialties and is an important factor to consider when developing cost-reduction strategies.

STRUCTURED ABSTRACT: Study Design. Retrospective cohort studyObjective. To determine predictors of and 30-day complications associated with blood transfusion volume following posterior spinal fusion for adolescent idiopathic scoliosis (AIS)Summary of Background Data. Posterior arthrodesis is a common procedure performed for AIS, and patients frequently require perioperative blood transfusions. Few studies, however, have examined the rates and potential complications associated with blood transfusion volume. METHODS: Patients undergoing posterior arthrodesis for AIS were selected from the National Surgical Quality Improvement Program (NSQIP) Pediatric database from 2012 to 2013. Patients were stratified based on blood transfusion volume and patient demographics and comorbidities, operative characteristics, and 30-day complications were recorded. Multivariate analyses were performed to determine predictors of transfusion as well as the effect of transfusion volume on 30-day complication rates. RESULTS: A total of 1691 patients were included. Male gender (p = 0.010), esophageal or GI disease (p = 0.016), cardiac risk factors (p = 0.037), preoperative inotrope requirement (p = 0.031), total operative time >/= 300 minutes (p < 0.001), and posterior arthrodesis of 13 or more vertebral segments (p < 0.001) were independent risk factors for requiring a blood transfusion. Total transfusion volume >/= 20 mL/kg was the minimum volume independently associated with increased rates of total complications (p = 0.018) with a complication rate of 5.9%. CONCLUSION: We present the first large, comprehensive analysis of complications related to blood transfusion events and transfusion volume on short-term postoperative complications following posterior arthrodesis for AIS. While transfusion in general is not associated with 30-day adverse events, a volume of 20 mL/kg was associated with higher complication rates.

The Centers for Medicare & Medicaid Services considers readmissions within 30 days of discharge to be a quality indicator. Hospitals' and eventually physicians' readmission rates will be used to determine payment for services. It is imperative that health care providers understand which patients are at risk for readmission so that they can apply the appropriate preventive interventions. The research team analyzed all orthopedic admissions and readmissions at their institution from September 2008 to April 2011 in this study. Preparing for the next stage in health care reform, identifying any preoperative factors that may place certain patients into a "high-risk" category for readmission following an orthopedic procedure is of paramount importance. This data analysis of more than 13 000 patients noted that race-based and income-based risk factors did not translate into significant risk factors or predictors of 30-day readmission following orthopedic admission.

The demand for spinal surgery and its costs have both risen over the past decade. In 2008 the aggregate hospital bill for surgical care of all spinal procedures was reported to be $33.9 billion. One key driver of rising costs is spinal implants. In 2011 our institution implemented a cost containment programme for spinal implants which was designed to reduce the prices of individual spinal implants and to reduce the inter-surgeon variation in implant costs. Between February 2012 and January 2013, our spinal surgeons performed 1493 spinal procedures using implants from eight different vendors. By applying market analysis and implant cost data from the previous year, we established references prices for each individual type of spinal implant, regardless of vendor, who were required to meet these unit prices. We found that despite the complexity of spinal surgery and the initial reluctance of vendors to reduce prices, significant savings were made to the medical centre. Cite this article: 2015; 97-B:1102-5.

Infection is a rare, serious complication following total joint arthroplasty and constitutes a considerable emotional and financial burden for patients, surgeons, and healthcare systems. Prevention of surgical site and periprosthetic joint infections is crucial. This requires knowledge of the microorganisms that commonly cause these infections, including Staphylococcus species. Selection of the appropriate antibiotic regimen to treat infection remains controversial, but cefazolin and cefuroxime are the most commonly recommended antibiotics for prophylaxis. Appropriate timing of administration before surgery, with redosing performed as needed, can help to ensure optimal antibiotic concentration during surgery. Given the increasing evidence that S aureus colonization is a risk factor for periprosthetic joint infection, an exploration of the potential benefits of preoperative S aureus carrier screening and decolonization protocols is warranted. The use of antibiotic-loaded bone cement in primary total joint arthroplasty and antibiotic powder at wound closure are other controversial topics that require additional research.

BACKGROUND: Orthopaedic surgery is a major risk factorfor venous thromboembolism (VTE) manifesting as deep veinthrombosis (DVT) or pulmonary embolism (PE). Variouspatient characteristics alter the likelihood of a postoperativeVTE, and there is substantial ambiguity in current VTEprophylaxis guidelines. PURPOSE: To determine if particular patient characteristicsare risk factors for VTE following major orthopaedicsurgery. METHODS: Data was reviewed from 201 patients presentingwith either a PE or DVT following spine surgery or jointreplacement from October 2009 through June 2013. Thefollowing characteristics were reviewed for each patient:VTE event date, surgery date and type, comorbidities andpre-existing conditions, calculated comorbidity level, bodymass index, prophylaxis type, time to initiation of chemoprophylaxis,time to epidural removal, and VTE event type.The control patients were randomly selected from a groupof 13,782 patients during the same period. RESULTS: A history of VTE (p < 0.0001), Factor V Leidendisorder (p = 0.04) and the use of general anesthesia (p =0.05) were significant risk factors for postoperative VTE.The frequency of VTE decreased following hip and kneearthroplasty during the study period and remained constantfor spine surgery. DVTs occurred 14.2 days later than PEs(p < 0.0001). Over 90% of PEs and 33.3% to 75% of DVTswere diagnosed in the first week following surgery. CONCLUSIONS: A prior history of VTE, Factor V Leidendisorder and general anesthesia increases the risk of VTEpostoperatively. The probability of PE beyond the secondpostoperative week is low.