Faculty Bibliography

BACKGROUND:In response to the COVID-19 pandemic, hospitals in the United States were recommended to stop performing elective procedures. This stoppage has led to the cancellation of a large number of hip and knee arthroplasties. The effect of this on patients' physical mental and economic health is unknown. METHODS:A survey was developed by the AAHKS Research Committee to assess pain, anxiety, physical function, and economic ability of patients to undergo a delayed operation. Six institutions conducted the survey to 360 patients who had to have elective hip and knee arthroplasty cancelled between March and July of 2020. RESULTS:Patients were most anxious about the uncertainty of when their operation could be rescheduled. Although 85% of patients understood and agreed with the public health measures to curb infections, almost 90% of patients plan to reschedule as soon as possible. Age and geographic region of the patients affected their anxiety. Younger patients were more likely to have financial concerns and concerns about job security. Patients in the Northeast were more concerned about catching COVID-19 during a future hospitalization. CONCLUSIONS:Patients suffering from the pain of hip and knee arthritis continue to struggle with pain from their end-stage disease. They have anxiety about the COVID-19 pandemic. Few patients feel they will be limited financially and 90% want to have surgery as soon as possible. Age and physical location of the patients affect their causes for anxiety around their future surgery.

AIMS/OBJECTIVE:Previous studies have reported an increased risk for postoperative complications in the Medicaid population undergoing total hip arthroplasty (THA). These studies have not controlled for the surgeon's practice or patient care setting. This study aims to evaluate whether patient point of entry and Medicaid status plays a role in quality outcomes and discharge disposition following THA. METHODS:The electronic medical record at our institution was retrospectively reviewed for all primary, unilateral THA between January 2016 and January 2018. THA recipients were categorized as either Medicaid or non-Medicaid patients based on a visit to our institution's Hospital Ambulatory Care Center (HACC) within the six months prior to surgery. Only patients who had been operated on by surgeons (CML, JV, JDS, RS) with at least ten Medicaid and ten non-Medicaid patients were included in the study. The patients included in this study were 56.33% female, had a mean age of 60.85 years, and had a mean BMI of 29.14. The average length of follow-up was 343.73 days. RESULTS:A total of 426 hips in 403 patients were included in this study, with 114 Medicaid patients and 312 non-Medicaid patients. Medicaid patients had a significantly lower mean age (54.68 years (SD 12.33) vs 63.10 years (SD 12.38); p < 0.001), more likely to be black or 'other' race (27.19% vs 13.46% black; 26.32% vs 12.82% other; p < 0.001), and more likely to be a current smoker (19.30% vs 9.29%; p = 0.001). After adjusting for patient risk factors, there was a significant Medicaid effect on length of stay (LOS) (rate ratio 1.129, 95% confidence interval (CI) 1.048 to 1.216; p = 0.001) and facility discharge (odds ratio 2.010, 95% CI 1.398 to 2.890; p < 0.001). There was no Medicaid effect on surgical time (exponentiated β coefficient 1.015, 95% CI 0.995 to 1.036; p = 0.136). There was no difference in 30-day readmission, 90-day readmission, 30-day infections, 90-day infections, and 90-day mortality between the two groups. CONCLUSION/CONCLUSIONS:2020;102-B(7 Supple B):78-84.

BACKGROUND:Revision THA represents approximately 5% to 10% of all THAs. Despite the complexity of these procedures, revision arthroplasty service lines are generally absent even at high-volume orthopaedic centers. We wanted to evaluate whether financial compensation is a barrier for the development of revision THA service lines as assessed by RVUs. QUESTIONS/PURPOSES/OBJECTIVE:Therefore, we asked: (1) Are physicians fairly compensated for revision THA on a per-minute basis compared with primary THA? (2) Are physicians fairly compensated for revision THA on a per-day basis compared with primary THA? METHODS:Our deterministic financial model was derived from retrospective data of all patients undergoing primary or revision THA between January 2016 and June 2018 at an academic healthcare organization. Patients were divided into five cohorts based on their surgical procedure: primary THA, head and liner exchange, acetabular component revision THA, femoral component revision THA, and combined femoral and acetabular component revision THA. Mean surgical times were calculated for each cohort, and each cohort was assigned a relative value unit (RVU) derived from the 2018 Center for Medicaid and Medicare assigned RVU fee schedule. Using a combination of mean surgical time and RVUs rewarded for each procedure, three models were developed to assess the financial incentive to perform THA services for each cohort. These models included: (1) RVUs earned per the mean surgical time, (2) RVUs earned for a single operating room for a full day of THAs, and (3) RVUs earned for two operating rooms for a full day of primary THAs versus a single rooms for a full day of revision THAs. A sixth cohort was added in the latter two models to more accurately reflect the variety in a typical surgical day. This consisted of a blend of revision THAs: one acetabular, one femoral, and one full revision. The RVUs generated in each model were compared across the cohorts. RESULTS:Compared with primary THA by RVU per minute, in revision THA, head and liner exchange demonstrated a 4% per minute deficit, acetabular component revision demonstrated a 29% deficit, femoral component revision demonstrated a 32% deficit, and full revision demonstrated a 27% deficit. Compared with primary service lines with one room, revision surgeons with a variety of revision THA surgeries lost 26% potential relative value units per day. Compared with a two-room primary THA service, revision surgeons lost 55% potential relative value units per day. CONCLUSIONS:In a comparison of relative value units of a typical two-room primary THA service line versus those of a dedicated revision THA service line, we found that revision specialists may lose between 28% and 55% of their RVU earnings. The current Centers for Medicare and Medicaid Services reimbursement model is not viable for the arthroplasty surgeon and limits patient access to revision THA specialists. LEVEL OF EVIDENCE/METHODS:Level III, economic and decision analysis.

Electronic health record (EHR) technologies have improved the ease of access to structured clinical data. The standard means by which data are collected continues to be manual chart review. The authors compared the accuracy of manual chart review against modern electronic data warehouse queries. A manual chart review of the EHR was performed with medical record numbers and surgical admission dates for the 100 most recent inpatient venous thromboembolic events after total joint arthroplasty. A separate data query was performed with the authors' electronic data warehouse. Data sets were then algorithmically compared to check for matches. Discrepancies between data sets were evaluated to categorize errors as random vs systematic. From 100 unique patient encounters, 27 variables were retrieved. The average transcription error rate was 9.19% (SD, ±5.74%) per patient encounter and 11.04% (SD, ±21.40%) per data variable. The systematic error rate was 7.41% (2 of 27). When systematic errors were excluded, the random error rate was 5.79% (SD, ±7.04%) per patient encounter and 5.44% (SD, ±5.63%) per data variable. Total time and average time for manual data collection per patient were 915 minutes and 10.3±3.89 minutes, respectively. Data collection time for the entire electronic query was 58 seconds. With an error rate of 10%, manual chart review studies may be more prone to type I and II errors. Computer-based data queries can improve the speed, reliability, reproducibility, and scalability of data retrieval and allow hospitals to make more data-driven decisions. [Orthopedics. 2020;43(x):xx-xx.].

BACKGROUND:Hip fractures have significant economic implications as a result of their associated direct and indirect medical costs. Under alternative payment models, it has become increasingly important for institutions to find avenues by which costs could be reduced while maintaining outcomes in these cases. METHODS:A multi-institutional retrospective analysis of Medicare patients who underwent total hip arthroplasty (THA) for femoral neck fracture was conducted to assess the impact of fellowship training in adult reconstruction (AR) on the total costs of the 90-day episode of care. Patients were divided into 2 cohorts according to fellowship training status of the operating surgeon: (1) AR-trained and (2) other fellowship training (non-AR). The primary outcome was the total cost of the 90-day episode of care converted to a percentage of the bundled payment target price. RESULTS:A total of 291 patients who underwent THA for the treatment of a femoral neck fracture were included. The average total cost percentage of the 90-day episode of care was significantly lower for the AR cohort 70.9% (±36.6%) than the non-AR cohort 82.6% (±36.1%) (P < .01). After controlling for baseline demographics in the multivariable logistic regression, the care episodes in which the operating surgeons were AR fellowship-trained were still found to be significantly lower, at a rate of 0.87 times the costs of the non-AR surgeons (95% confidence interval 0.78-0.97, P = .011). In addition, the non-AR cohort exceeded the bundle target price more frequently than the AR cohort, 49 (28.7%) vs 16 (13.3%) (P = .02). CONCLUSION/CONCLUSIONS:In an era of bundled payments, ascertaining factors that may increase the value of care while decreasing the cost is paramount for institutions and policymakers alike. The results presented in this study suggest that in the femoral neck fracture population, surgeons trained in AR achieve lower total costs for the THA episode of care. Furthermore, non-AR fellowship-trained surgeons exceeded the bundled payment target more frequently than the AR surgeons.

BACKGROUND:To determine if preoperative characteristics and postoperative outcomes of a first total knee arthroplasty (TKA) were predictive of characteristics and outcomes of the subsequent contralateral TKA in the same patient. METHODS:Retrospective administrative claims data from (SPARCS) database were analyzed for patients who underwent sequential TKAs from September 2015 to September 2017 (n = 5,331). Hierarchical multivariable Poisson regression (length of stay [LOS]) and multivariable logistic regression (all other outcomes), controlling for sex, age, and Elixhauser comorbidity scores were performed. RESULTS:The cohort comprised 65% women, with an average age of 66 years and an average duration of 7.3 months between surgeries (SD: 4.7 months). LOS was significantly shorter for the second TKA (2.6 days) than for the first TKA (2.8 days; P < .001). Patients discharged to a facility after their first TKA had a probability of 76% of discharge to facility after the second TKA and were significantly more likely to be discharged to a facility compared with those discharged home after the first TKA (odds ratio [OR]: 63.7; 95% confidence interval [CI]: 52.1-77.8). The probability of a readmission at 30 and 90 days for the second TKA if the patient was readmitted for the first TKA was 1.0% (OR: 3.70; 95% CI: 0.98-14.0) and 6.4% (OR: 9; 95% CI: 5.1-16.0), respectively. Patients with complications after their first TKA had a 27% probability of a complication after the second TKA compared with a 1.6% probability if there was no complication during the first TKA (OR: 14.6; 95% CI: 7.8.1-27.2). CONCLUSION/CONCLUSIONS:The LOS, discharge disposition, 90-day readmission rate, and complication rate for a second contralateral TKA are strongly associated with the patient's first TKA experience. The second surgery was found to be associated with an overall shorter LOS, fewer readmissions, and higher likelihood of home discharge. LEVEL OF EVIDENCE/METHODS:Level 3-retrospective cohort study.

BACKGROUND:Total hip arthroplasty (THA) candidates have historically received high doses of opioids within the perioperative period; however, the amounts are being continually reduced as awareness of opioid abuse spreads. Here we seek to evaluate the effectiveness of a novel opiate-sparing protocol (OSP) for primary THAs in reducing opiate administrations, while maintaining similar levels of pain control and postoperative function. METHODS:All patients undergoing primary THA between January 1, 2019 and June 30, 2019 were placed under a novel OSP. Data were prospectively collected as part of standard of care. To assess the primary outcome of opiate consumption, nursing documented opiate administration events were converted into morphine milligram equivalences (MMEs) per patient encounter per 24-hour interval. Postoperative pain and functional status were assessed as secondary outcomes using the Verbal Rating Scale for pain and the Activity Measure for Post-Acute Care scores, respectively. RESULTS:One thousand fifty primary THAs had received our institution's OSP, and 953 patients were utilized as our historical control. OSP patients demonstrated significantly lower 0-24, 24-48, and 48-72 hours with less opiate administration variance (total MME: Control 75.55 ± 121.07 MME vs OSP 57.10 ± 87.48 MME; 24.42% decrease, P < .001). Although pain scores reached statistical significance between 0 and 12 (Control 2.09 vs OSP 2.36, P < .001), their differences were not clinically significant. Finally, OSP patients demonstrated a trend toward higher Activity Measure for Post-Acute Care scores across all 6 domains (total scores: Control 20.53 ± 3.67 vs OSP 20.76 ± 3.64, P = .18). CONCLUSION/CONCLUSIONS:Implementation of an OSP can significantly decrease the utilization of opioids in the immediate postoperative period. Inpatient opioid administration can be significantly reduced while maintaining a comparable and non-inferior level of pain and function.

BACKGROUND:The ideal femoral component in revision total hip arthroplasty (rTHA) remains undetermined; however, tapered, fluted, titanium (TFT) stems are now widely used with favorable results in all types of revision scenarios. With both modular and monoblock TFT stem options, neither has been proven to be superior. Femoral stem subsidence has been linked to aseptic loosening, instability, and leg length discrepancy. This study aims to assess stem subsidence of modular and monoblock TFT stems at a single urban orthopedic specialty hospital within a tertiary academic medical center. METHODS:Electronic medical records of rTHAs performed between January 2013 and March 2018 utilizing modular and monoblock TFT stems were examined. Data collected included baseline demographics, surgical indication, femoral Paprosky classification, and stem subsidence at most recent follow up (3 months to 3 years). Two-sample t-tests and chi-squared tests were used for statistical analysis. RESULTS:A total of 186 patients (106 modular, 80 monoblock) were included in the analysis. Modular stems underwent significantly greater subsidence than monoblock stems at latest radiographic follow-up (3.9 ± 2.6 vs 2.3 ± 2.5 mm, P < .001). A significantly greater proportion of modular stems underwent >5 mm of subsidence at latest follow-up (29.2% vs 11.3%, P < .001). CONCLUSION/CONCLUSIONS:Monoblock TFT stems have displayed promising clinical results in prior studies, and now have been shown to decrease the incidence of postoperative subsidence. With the potential for stem subsidence to lead to aseptic loosening, limb length discrepancy, and instability, the orthopedic surgeon should weigh the risks and benefits of utilizing modular vs monoblock TFT stems in rTHA.

Background/UNASSIGNED:There is a scarcity of studies investigating narcotic use after revision total knee arthroplasty (TKA). We compared immediate postsurgical narcotic consumption after revision TKA and primary TKA. Methods/UNASSIGNED:A single-institution database was used to identify patients who underwent revision TKA or primary TKA between 2016 and 2019. Morphine milligram equivalents (MMEs) were calculated to discern narcotic usage, and pain visual analog score was also used. Results/UNASSIGNED:< .0001), as well as for the 24- to 48-hour time period. The visual analog pain scores were also higher for the revision TKA group. Conclusion/UNASSIGNED:The revision TKA group had a higher opioid requirement, most significant during the first 24 hours postoperatively, and expressed more pain in the acute postoperative period.

Dual mobility constructs have become an increasingly popular option for primary and revision total hip arthroplasty. Two monoblock implants and three modular implants are available for use in the United States. Although short- and mid-term outcome data have been positive overall for these systems, each construct has unique features that the orthopaedic surgeon might consider when selecting the appropriate implant for his or her patient. In this review article, we discuss the design specifications and published literature for each dual mobility system and organize this information into a concise resource that can be easily referenced during preoperative planning.