Faculty Bibliography

BACKGROUND:The Centers for Medicare & Medicaid Services (CMS)'s Bundled Payments for Care Improvement (BPCI) program provides a set payment for the provision of primary total joint arthroplasty (TJA) care regardless of age and risk factors. Published literature indicates that the cost of care per episode of TJA increases with age. We examined the implication of this relationship and the effect of projected changes of age demographics on our center's BPCI experience. METHODS:A retrospective review of prospectively collected data on 1,662 Medicare BPCI patients undergoing primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) from 2013 to 2016 at a single orthopaedic institution was performed. The relationship between age and cost of care was first determined in our analysis of our BPCI experience. We then performed a cost analysis by age group with respect to our institution's profit or loss per episode of care. A forecast for shifting age demographics in our region, modeled by the U.S. Census Bureau's Federal-State Cooperative for Population Estimates (FSCPE) and Projections (FSCPP), was used to evaluate the financial implications for our BPCI program. RESULTS:Our institution sustains a significant loss of $1,934 (p < 0.001) per case for patients 85 to 99 years of age, which is offset by profits associated with treating patients in younger age groups. This age group (85 to 99 years of age) will double by the year 2040 in our region, whereas the youngest age group (65 to 69 years of age) is projected to marginally increase by 12%. The average cost of care per primary TJA will rise because of the predicted shifting age demographics, compounded by an estimated 3% inflation rate. Utilizing the current BPCI reimbursement rate, we project an inflection point of declining profits after the year 2030 with the given projections for our regional population. CONCLUSIONS:The regional population served by our institution is aging. This shift will lead to an increased cost of care and diminishing profits for TJA after 2030. The CMS's BPCI initiative and novel alternative payment models (APMs) should consider age as a modifier for reimbursement to incentivize care for the vulnerable and older age groups. CLINICAL RELEVANCE/CONCLUSIONS:The findings of the present study are clinically relevant for decision-making regarding the allocation of resources in the setting of an aging population.

Complex regional pain syndrome (CRPS) is an uncommon cause of residual pain after total knee arthroplasty (TKA). The presentation is variable, and there is no gold standard diagnostic test. Diagnosis is more difficult after TKA because some classic signs of CRPS may be unreliable and imaging may be difficult to interpret. Early intervention is the most important factor in predicting improvement, necessitating high suspicion in patients with exaggerated pain and stiffness after excluding more common causes. This article reviews the literature regarding CRPS following TKA, explains the diagnosis, and discusses treatment. [Orthopedics. 2020;4x(x):xx-xx.].

BACKGROUND:The International Statistical Classification of Diseases, 10th Revision (ICD-10), was adopted by the United States on October 1, 2015 and expanded coding from 3800 codes with the International Statistical Classification of Diseases, Ninth Revision, procedure code system (ICD-9-PCS) to 73,000. The increase in number of codes was designed to create more accurate representations of procedures like revision total hip arthroplasties (rTHAs). However, many worry that the increased complexity leads to more inaccurate coding. The purpose of this study is to determine the accuracy of ICD-10-PCS coding for rTHA and discuss the implications on registry data. METHODS:The rTHA databases at 2 large, academic medical centers were retrospectively reviewed for all rTHAs between October 1, 2015 and July 3, 2019. The laterality and specific revised components were recorded and compared with the ICD-10-PCS codes used for each procedure. The accuracy of ICD-10-PCS codes relative to the surgical record was determined using coding guidelines published by the American Joint Replacement Registry (AJRR). RESULTS:Overall, 895 cases were reviewed. Replacement coding was 22% accurate (195 of 895). For removal and replacement coding, accuracy dropped to 17% (152 of 895). All procedures had at least 1 rTHA trigger code that would signify correctly to AJRR that an rTHA occurred. CONCLUSION/CONCLUSIONS:In this study, the percent of correctly coded rTHA was low. All rTHA procedures had at least 1 AJRR trigger code; therefore, an rTHA would have been appropriately captured by AJRR. But these inaccuracies should make one pause when using ICD-10-PCS procedural data to try to evaluate specific rTHA details from administrative claims databases and ward against expanding ICD-10-PCS as a means to collect implant survival and registry data.

BACKGROUND:We sought to identify differences between total joint arthroplasties (TJAs) performed by adult reconstruction fellowship-trained surgeons (FT) than non-fellowship-trained surgeons (NFT). METHODS:A single-institution database was utilized to identify patients who underwent elective TJA between 2016 and 2019. RESULTS:In total, 16,882 TJAs were identified: 9111 total hip arthroplasties (THAs) and 7771 total knee arthroplasties (TKAs). Patients undergoing THA by FT surgeons were older (63.11 vs 61.84 years, P < .001), more likely to be white, insured by Medicare, and less likely to be active smokers (P < .0001). Both surgical time (90.03 vs 113.1 minutes, P < .0001) and mean length of stay (LOS) (1.85 vs 2.72 days, P < .0001) were significantly shorter for THAs performed by FT surgeons than NFT surgeons. A significantly greater percentage of patients were discharged home after THA by FT surgeons than NFT surgeons (88.7% vs 85.2%, P = .002). FT patients were quicker to mobilize with therapy and required 25% less opioids. TKAs performed by FT surgeons were associated with shorter surgical times (87.4 vs 94.92 minutes, P < .0001), LOS (2.62 vs 2.84 days, P < .0001), and nearly 19% less opioid requirement in the peri-operative period. In addition to higher Activity Measure for Post-Acute Care scores associated with FT surgeons after TKA, a significantly greater percentage of patients were discharged home after TKA by FT surgeons than NFT surgeons (83.97% vs 80.16%, P < .001). CONCLUSION/CONCLUSIONS:For both THA and TKA, patients had significantly shorter surgical times, LOS, and required less opioids when their procedure was performed by FT surgeons compared to NTF surgeons. Patients who had their TJA performed by a FT surgeon achieved higher Activity Measure for Post-Acute Care scores and were discharged home more often than NFT surgeons. In an era of value-based care, more attention should be paid to the patient outcomes and financial implications associated with arthroplasty fellowship training. LEVEL III EVIDENCE/UNASSIGNED:Retrospective Cohort Study.

BACKGROUND:Total knee arthroplasty (TKA) provides excellent results across a variety of pathologies. As greater focus is placed on the opioid epidemic, we sought to determine if patients presenting for TKA via the Medicaid clinic (Medicaid) differed in terms of their opioid requirements compared to patients presenting via private office clinics (non-Medicaid). METHODS:A single-institution total joint arthroplasty database was utilized to identify patients who underwent elective TKA between January 2016 and May 2019. Medicaid clinic patients were insured by some form of Medicaid, whereas private office patients had commercial or Medicare insurance. Morphine milligram equivalents (MMEs) and Activity Measure for Post-Acute Care scores were calculated. RESULTS:A total of 6509 patients were identified: 413 (6.35%) Medicaid and 6096 (93.65%) non-Medicaid. Medicaid patients were younger (63.32 vs 66.21 years, P < .0001), less likely to be of Caucasian race (21.31% vs 56.82%, P < .0001), and more likely to be active smokers (11.14% vs 7.73%, P < .0001). Although surgical time and home discharge rates were similar, Medicaid patients had longer length of stay (2.80 vs 2.46 days, P < .0001). Opioid requirements were higher for Medicaid patients (200.1 vs 132.2 MMEs, P < .0001), paralleling higher pain scores (3.03 vs 2.55, P < .0001). No differences were found in Activity Measure for Post-Acute Care scores (18.47 vs 18.77, P = .1824). CONCLUSION/CONCLUSIONS:Medicaid patients tended to be younger, of minority race, and active smokers compared to non-Medicaid patients. Medicaid patients demonstrated worse postoperative pain scores and required 51% greater MMEs immediately following TKA, highlighting the need for preoperative counseling in traditionally at-risk socioeconomic groups. LEVEL OF EVIDENCE/METHODS:III, Retrospective Observational Analysis.

Background/Purpose: High body mass index (BMI, kg/m2) is a modifiable risk factor that has been associated with the development and progression of osteoarthritis (OA) and knee pain. While total knee arthroplasty (TKA) is the gold standard for the treatment of end stage OA, morbidly obese patients (BMI>=40kg/m2) are often required to lose weight prior to TKA due to increased surgical risk and a higher rate of complications. While conservative weight-loss often fails to help these patients, bariatric surgery can be an alternative option. Here we present interim data from the trial entitled "Surgical Weight-loss to Improve Functional Status Trajectories following arthroplasty for painful knee osteoarthritis". This current multi-center, prospective study compares pain and functional outcomes in patients receiving bariatric surgery prior to TKA versus obese patients who go straight to TKA.
Method(s): Patients with BMI >=40 kg/m2 and painful knee osteoarthritis who met the indications for TKA were recruited at four hospital centers. Patients with a BMI >35 kg/m2 were also recruited if they had a qualifying comorbid condition including obstructive sleep apnea, diabetes, hypertension or hyperlipidemia. Patients were assigned to either the bariatric (BAR) or TKA arm based on surgical choice (goal n=150 for each arm), with all bariatric patients having anatomy-altering sleeve gastrectomy or gastric bypass. At baseline and several time points after surgery (Figure 1), we documented height, weight, the Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog pain (VAS) scales, and the Western Ontario and McMaster Universities Arthritis Index (WOMAC), and had patients perform functional assessments (Timed-Up and Go, 30-second Chair Stand and 40-meter fast paced walk test). We targeted minimum detectable change (MDC) in outcomes for the VAS for knee pain (33% reduction), Timed Up and Go (decrease by 2 seconds), 30-second Chair Stand (increase by 2 reps), 40-meter fast paced walk (increase by 0.16 m/s), WOMAC score (16% reduction), and the KOOS pain score (10-point improvement). Using a logistic regression to adjust for age and baseline BMI, we compared the percentage of patients in the two arms who achieved an MDC for the various outcomes.
Result(s): To date, 25 BAR and 28 TKA patients have completed their follow-up visits through at least 6 months. Although there was a similar sex distribution, the bariatric group was younger (52 vs 60 years old, p=0.0023) with a higher baseline BMI (47.0 vs 41.6 p=0.0006). Most bariatric patients achieved comparable improvement to the TKA cohort with regards to the benchmarks of the 30-second Chair Stand (TKA 54% vs BAR 33%, p=0.156), KOOS pain score (TKA 91% vs BAR 67%, p=0.130), the Visual Analog Pain Scale (TKA 50% vs BAR 39%, p=0.466), Timed Up and Go test (TKA 43% vs BAR 22%, p=0.141) and the 40-meter fast paced walk (TKA 61% vs BAR 35%, p=0.073). The TKA cohort had a greater percent with a MDC for the WOMAC (TKA 88% vs BAR 54%, p=0.030).
Conclusion(s): In morbidly obese patients who are eligible for TKA, bariatric surgery may result in modest improvements in knee outcomes and may eventually delay the need for a TKA

STUDY DESIGN/METHODS:Retrospective analysis of outcomes in single-level spine and primary hip and knee arthroplasty patients. OBJECTIVE:Compare baseline and post-operative outcomes in patients undergoing spine surgery procedures with total hip arthroplasty (THA) and total knee arthroplasty (TKA) to further define outcomes in orthopedic surgery. SUMMARY OF BACKGROUND DATA/BACKGROUND:Computer-adaptive Patient Reported Outcome Information System (PROMIS) allows for standardized assessment of the Health Related Quality of Life across different disease states. METHODS:Patients who underwent spine surgery (anterior cervical discectomy and fusion, cervical disc replacement, lumbar laminectomy, microscopic lumbar discectomy, transforaminal lumbar interbody fusion or adult reconstruction surgery (THA, TKA) were grouped. Mean Charlson Comorbidity Index (CCI), Baseline (BL) and 6-month (6 M) PROMIS scores of Physical Function, Pain Interference, and Pain Intensity were determined. Paired t-tests compared differences in CCI, BL, 6 M, and change in PROMIS scores for spine and adult reconstruction procedures. RESULTS:304 spine surgery patients (Age=58.1 ± 15.6; 42.9% Female) and 347 adult reconstruction patients (Age=62.9 ± 11.8; 54.1% Female) were compared. Spine surgery groups had more disability and pain at baseline than adult reconstruction patients according to Physical Function [(21.0, 22.2, 9.07, 12.6, 10.4) vs (35.8, 35.0), respectively, p < .01], Pain Interference [(80.1, 74.1, 89.6, 92.5, 90.6) vs (64.0, 63.9), respectively, p < .01] and Pain Intensity [(53.0, 53.1, 58.3, 58.5, 56.1) vs (53.4, 53.8), respectively, p < .01]. At 6 M, spine surgery patients remained more disabled and had more pain compared to adult reconstruction patients. Over the 6-month timespan, spine patients experienced greater improvements than adult reconstruction patients in terms of Physical Function [(+8.7, +22.2, +9.7, +12.9, +12.1) vs (+5.3, +3.9), respectively, p < .01] and Pain Interference scores [(-15.4, -28.1, -14.7, -13.1, -12.3) vs (-8.3, -6.0), respectively, p < .01]. CONCLUSIONS:Spinal surgery patients had lower BL and 6 M PROMIS scores, but greater relative improvement in PROMIS scores compared to adult reconstruction patients. LEVEL OF EVIDENCE/METHODS:3.

As bundled reimbursement models continue to evolve, there is a continued effort to increase the value of care for patients undergoing arthroplasty. The authors sought to evaluate the effect of surgeon specialization (arthroplasty vs non-arthroplasty) on acute outcomes for patients with hip fracture who underwent total hip arthroplasty (THA), in an effort to determine whether the value of care can be improved by surgeons specializing in these procedures. They performed a multicenter retrospective cohort study of patients who had hip fracture and were treated with THA between June 2013 and February 2018 at 2 academic institutions that were involved in bundled reimbursement initiatives. Patients were stratified based on the subspecialty training of the operative surgeon (fellowship-trained adult reconstruction vs other orthopedic sub-specialty), and 90-day readmissions, length of stay, and discharge disposition were compared between groups. A total of 291 patients were included in the final cohort, with 120 (41.2%) undergoing surgery performed by a fellowship-trained adult reconstruction surgeon. No significant difference was found in age, sex, race, or American Society of Anesthesiologists score between the 2 groups. In addition, no significant difference was found in length of stay, discharge to a facility, or 90-day readmissions on univariable or multivariable analysis when adjusted for age, sex, body mass index, and American Society of Anesthesiologists score. This study showed that the acute outcomes used to assess the value of care for patients undergoing THA were not significantly different when the surgery was performed by an adult reconstruction specialist compared with other orthopedic surgeons at 2 high-volume academic centers with perioperative care pathways. Alternative modalities to significantly improve acute postoperative outcomes in a bundled reimbursement model must be investigated. [Orthopedics. 2020;43(5):e442-e446.].

BACKGROUND:The direct anterior approach (DAA) in total hip arthroplasty (THA) has gained popularity because of potential decreased postoperative pain and quicker recovery after surgery in comparison to the posterior approach (PA). With a growing focus on patient-reported outcome (PRO) measurements after surgery, we sought to determine if one approach led to better PRO scores as determined by the Forgotten Joint Score-12 (FJS-12) questionnaire. METHODS:A retrospective chart review of primary THAs between September 2016 and September 2019 at a single academic hospital was conducted. Demographic and clinical data in addition to FJS-12 scores were collected. Two groups were created based on THA approach. Frequency rates, means, and standard deviations were used to describe baseline patient characteristics. Differences in demographic data were accounted for using linear regression models. RESULTS:A total of 1469 cases were identified, with 830 using the DAA and 639 the PA. Significant demographic differences were observed between the 2 groups. However, when controlling for this, there were no differences in FJS-12 scores between approaches at 1 and 1.75 years (P = .232 and P = .486, respectively). At 12 weeks, DAA patients had higher satisfaction (59.21 vs 46.8; P = .006). When controlling for surgeon case volume, no differences in FJS-12 were observed at any of the time points (P = .536, P = .452, and P = .967, respectively) CONCLUSION: DAA THA patients trended toward better PRO scores than their PA counterparts. However, when controlling for surgeon case volume, no differences were observed, which suggests that surgeon case volume and experience have an important effect on patient satisfaction and FJS-12 scores.

BACKGROUND:We sought to determine if immediate postsurgical pain, opioid use, and clinical function differed between unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). METHODS:A single-institution database was utilized to identify patients who underwent elective total joint arthroplasty between 2016 and 2019. RESULTS:In total, 6616 patients were identified: 98.20% TKA (6497) and 1.80% (119) UKA. UKA patients were younger, had lower body mass index, and more often male than the TKA cohort. Aggregate opioid consumption (75.94 morphine milligram equivalents vs 136.5 morphine milligram equivalents; P < .001) along with the first 24-hour and 48-hour usage was significantly less for UKA as compared to TKA. Similarly, pain scores (1.98 vs 2.58; P < .001) were lower for UKA while Activity Measure for Post-Acute Care mobilization scores were higher (21.02 vs 18.76; P < .001). UKA patients were able to be discharged home on the day of surgery 37% of the time as compared to 2.45% of TKA patients (P < .0001). Notably, when comparing UKA and TKA patients who were discharged home on the day of surgery, no differences regarding pain scores, opioid utilization, or mobilization were observed. CONCLUSION/CONCLUSIONS:UKA patients are younger, have lower body mass index and American Society of Anesthesiologists scores, and more often male than TKA patients. UKA patients had significantly shorter length of stay than TKA patients and were discharged home more often than TKA patients, on both the day of surgery and following hospital admission. Most notably, UKA patients reported lower pain scores and were found to require 45% lower opioid medication in the immediate postsurgical period than TKA patients. Surprisingly, UKA and TKA patients discharged on the day of surgery did not differ in terms of pain scores, opioid utilization, or mobilization, suggesting that our rapid rehabilitation UKA protocols can be successfully translated to outpatient TKAs with similar outcomes. LEVEL III EVIDENCE/UNASSIGNED:Retrospective Cohort Study.