Faculty Bibliography

The rate of unplanned 30-day readmissions to the hospital after discharge is being used as a marker to compare the quality of care across hospitals and to set reimbursement levels for care. While the readmission rate can be reported using administrative data, the accuracy of these data is variable, and defining which readmissions are unplanned and preventable is often difficult. The purpose of this study was to review readmissions to a single orthopedic hospital to identify the causes for readmission and, in particular, which readmissions are planned versus unplanned. Using that hospital's administrative database of patient records from 2007 to 2009, we identified all patients who were readmitted to the hospital within 30 days of a previous hospitalization for a procedure. Readmissions were broadly categorized as planned (a staged or rescheduled procedure or a direct transfer) or unplanned. Unplanned readmissions were defined as either surgical or nonsurgical complications (medical conditions not directly related to the procedure). Almost 30 percent of readmissions were planned. Of the unplanned readmissions, close to 60 percent were triggered by an infection or a concern for an infection. Nonsurgical complications accounted for 18.2 percent of unplanned readmissions. This study highlights the importance of careful data collection and abstraction when calculating early readmission rates. Preventing surgical site infection and better coordinating care between orthopedic surgeons and primary care and medical subspecialty physicians may significantly reduce readmission rates.

Background: Physiotherapy after total joint replacement enhances postoperative recovery. Implementing a pathway to include earlier postoperative mobilization can reduce the hospital length-of-stay as well as cost. Questions: Does a rapid rehabilitation program con- sisting of physical therapy on the day of surgery affect the hospital length-of-stay on patients undergoing either total hip or total knee replacements? Is there a difference in the effectiveness of rapid rehabilitation between patients under- going Total Hip and Total Knee Replacements? Can these patients tolerate day of surgery physical therapy sessions? Patients and Methods: Nine-hundred hip and knee arthro- plasty patients were divided into two groups for analysis. Group 1 participated in a rapid rehabilitation physical therapy program that began with physical therapists in the recovery room. Group 2 received a standard physical therapy protocol starting the day after surgery. Progression with rehabilitation was followed, and length of hospital stay between the two groups was compared. Results: Total length-of-stay was 3.9 days for the rapid rehabilitation group and was 4.4 days (p < 0.001) for the standard therapy group. We found the rapid rehabilitation group had a significantly shorter length-of-stay than patients who began therapy on postoperative day one. In addition to decreased length-of-stay, rapid rehabilitation also resulted in direct savings considering fewer hospital resources were utilized over the decreased time in-house. Conclusions: Rapid mobilization of total joint replace- ment patients in the recovery room can be accomplished safely and reduces the overall length of hospital stay for over 70 % of patients.

The outcomes of ACL reconstructions in terms of patient satisfaction and function are well known. Most orthopaedic surgeons feel that Medicare and other payors do not reimburse enough for this surgery. The purpose of this study is to determine how much patients are willing to pay for this surgery and compare it to reimbursement rates. METHODS: We constructed a survey which described the function and limitations of an ACL deficient knee and the expected function of that knee after an ACL reconstruction. We then asked the volunteers how much they would be willing to pay for an ACL reconstruction if it were their knee. We also gathered data on the yearly earnings and Tegner activity level of the volunteers. In all, 143 volunteers completed the survey. We computed correlation coefficients between willingness to pay and both yearly earnings and Tegner activity level. RESULTS: The average amount that the volunteers were willing to pay for an ACL reconstruction was $4,867.00. There was no correlation between yearly earnings and willingness to pay. The correlation coefficient was 0.34. There was a weak correlation between Tegner activity level and willingness to pay. This correlation coefficient was 0.81. The Medicare allowable rate for ACL reconstruction (CPT 29888) in the geographic area of the study was $1,132.00. CONCLUSION: The data demonstrates that patients are willing to pay much more than traditional payors for ACL reconstruction. These payors undervalue the benefit of this surgery to the patient. There is increasing pressure on orthopaedic surgeons to not participate in insurance plans that reimburse poorly. This places an increasing financial burden on the patient. This study suggests that patients may be willing to pay more for their surgery than their insurance plan and accept more of this burden.

Hospital readmissions are quality indicators of healthcare delivery. Our purpose is to examine the effect of a program designed to reduce readmissions after total joint replacement. We initiated a comprehensive program with 4 goals: (1) outpatient workup of venous thromboembolism; (2) decrease surgical site infection; (3) early follow-up with primary care physicians; and (4) increase physician awareness of the financial and quality-related ramifications of unplanned readmissions. We then compared readmission rates before our initiative was instituted (2005-2006) to 3 years after implementation (2007-2009). Readmission rates preintervention were 3.70 and 3.29 for total hip replacement (THR) and knee replacement (TKR), respectively. Postintervention rates fell to 1.78 and 1.98, respectively, representing a 47.2% reduction of readmission for THR and 39.8% for TKR (P<.05). These results demonstrate the success of our program in reducing readmissions. This may result in reductions in healthcare costs and improvement in quality of care.

STUDY DESIGN.: Retrospective review of medical records. OBJECTIVE.: We reviewed all early readmissions after elective spine surgery at a single orthopedic specialty hospital to analyze the causes of unplanned readmissions. SUMMARY OF BACKGROUND DATA.: Recent advances in techniques and instrumentation have made more complex spinal surgeries possible, although sometimes with more complications. Early readmission rate is being used as a marker to evaluate quality of care. There is little data available regarding the causes of early readmissions after spine surgery. METHODS.: Using the hospital's administrative database of patient records from 2007 to 2009, all patients who underwent spine surgery and were readmitted to the hospital within 30 days were identified and broadly categorized as planned (a staged or rescheduled procedure or a direct transfer) or unplanned. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Analysis was focused on 12 common spine procedures based on the principle procedure International Classification of Diseases, Ninth Revision, Clinical Modification code for the patient's initial admission. The readmission rate was calculated for each procedure. RESULTS.: A total of 156 early readmissions were identified, of which 141 were unplanned. Of the unplanned readmissions, the most common causes were infection or a concern for an infection (45 patients, 32% of unplanned readmissions), nonsurgical complications (31 patients, 22% of readmissions), complications requiring surgical revision (21 patients, 15% of readmissions), and wound drainage (12 patients, 9% of readmissions). Fifty-seven percent of unplanned readmissions required a return to the operating room (76% of infections or concern for infection). The average length of stay for the unplanned readmissions was 6.5 days. When using the 12 most common procedures based on the International Classification of Diseases, Ninth Revision, Clinical Modification, the early readmission rate was 3.8% (141 early readmissions in 3673 procedures). CONCLUSION.: Infection, medical complications after surgery, and surgical complications requiring revision of implants are the primary causes of unplanned early readmissions and spine surgery. Further studies are necessary to identify patients and procedures most associated with readmission.

Preoperative screening and decolonization of methicillin-sensitive and methicillin-resistant Staphylococcus aureus (MSSA and MRSA, respectively) are advocated to reduce surgical site infections. We determined the rate and duration of decolonization in patients undergoing elective orthopedic surgery. Patients undergoing elective orthopedic surgery were seen in our preoperative testing program (PAT) and had their anterior nares cultured for MRSA and MSSA. All patients were treated with intranasal mupirocin and a topical chlorhexidine solution. A cohort of patients returned to PAT before a subsequent elective procedure and were recultured. All culture results and time between PAT visits were recorded, and the rates of successful initial and persistent decolonization were determined. Six hundred ten patients visited PAT 1290 times. Overall, 94 (70.1%) of 134 patients with initially MRSA- or MSSA-positive cultures remained decolonized at a mean time of 156 days (SD=140), whereas 40 patients (29.9%) were not decolonized by the time of repeat testing at a mean time of 213 days (SD=187). At repeat testing, there were 2 newly MRSA-positive and 35 newly MSSA-positive patients. Staphylococcus aureus decolonization with intranasal mupirocin and topical chlorhexidine was effective but not persistent in a significant proportion of patients. A small number of previously uncolonized patients became colonized. Staphylococcus aureus screening and decolonization protocols must be repeated before any readmission, regardless of prior colonization status.

The purposes of this study were to examine the cost-effectiveness of this technology and to determine improvements in patient outcome needed to make custom total knee cutting blocks cost-effective. A Markov decision model was used to evaluate the cost-effectiveness of custom cutting blocks compared with traditional instrumentation in total knee arthroplasty. The analysis demonstrates routine use of custom cutting blocks for total knee arthroplasty will not be cost-effective unless it results in a significantly reduced revision rate. The reduction necessary increases with increasing costs for the custom blocks. Further research will be necessary to determine if this can be achieved using custom cutting blocks. Patients, surgeons, payers, and institutions should consider this when determining their support of this technology in the absence of supportive data

Hamstring injuries are a frequent injury in athletes. Proximal injuries are common, ranging from strain to complete tear. Strains are managed nonoperatively, with rest followed by progressive stretching and strengthening. Reinjury is a concern. High grade complete tears are better managed surgically, with reattachment to the injured tendon or ischial tuberosity. Distal hamstring injury is usually associated with other knee injuries, and isolated injury is rare.

All physicians are faced at some time with fundamental challenges while striving to respect the principle canons which define a physician's ethical code. These canons are: 1. Primacy of patient interests, 2. Patient confidentiality, 3, Informed consent, and 4. Maintenance of a high standard of care. Athletes, because of their focus on performance, often present unique situations which lead to ethical challenges not seen in the general patient population. Adherence to the four principle ethical canons guides physicians to make ethical decisions when dealing with these unique patients.

The American Board of Orthopaedic Surgery requires that each board-certified orthopaedic surgeon recertify every 10 years. This formal procedure of demonstrating competence as a surgeon, which used to be known as recertification, has been replaced by a more comprehensive process termed maintenance of certification (MOC). Even an experienced orthopaedic surgeon may find achieving MOC a daunting prospect. Simply preparing for and taking the recertification examination is an enormous challenge, but it is important to remember that the examination is merely one aspect of maintaining certification. Prior to sitting for the examination, each physician is required to complete the other MOC requirements, including amassing continuing medical education credits, compiling a case list, and soliciting peer recommendations. Familiarity with the MOC process, understanding the details of the examination, and proper preparation techniques will help orthopaedic surgeons gain insights into how to approach MOC.