Faculty Bibliography

Background: The SWIFT trial, is a multi-site, prospective trial comparing knee physical function outcomes in patients with severe obesity who undergo bariatric surgery prior to TKA versus TKA only. This preliminary report compares knee outcomes in patients that completed bariatric surgery only vs. patients that had TKA without bariatric surgery.
Method(s): Knee outcomes for this analysis included Visual Analog Scale for knee pain, Timed Up and Go, 30-second Chair Stand, and 40-meter fast paced walk. The percent with >10% improvement in knee outcomes were compared between groups using logistic regression (adjusting for age and baseline BMI).
Result(s): This report includes 17 TKA eligible patients that completed 6-month follow-up after bariatric surgery and another 17 patients that completed 6-month follow-up after TKA only. The groups had a similar sex distribution (18% males in the bariatric group and 12% in TKA group, p=0.999) but the bariatric group was younger (53 vs 60, p=0.0056) and had a higher baseline BMI (47.1 vs 40.7, p=0.0020). Although the percent with >10% improvement was consistently higher in the TKA group, these differences were not significant for Visual Analog Pain Scale (48% vs 41%, p=0.762), Timed Up and Go (65% vs 59%, p=0.750), 30-second Chair Stand (77% vs 41%, p=0.091), or the 40-meter fast paced walk (76% vs 44%, p=0.147).
Conclusion(s): Bariatric surgery Results in modest improvements in knee outcomes in patients that are eligible for TKA and demonstrates potential to diminish the short term needs for knee replacement.
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Aseptic loosening and infection are two of the leading causes of revision in total knee arthroplasty. While several patient-related factors can play a role in the development of these complications, there are certain modifiable surgeon factors that can help mitigate the risk. Intraoperatively, this can begin with the curing process of bone cement which is broken down into four different stages: mixing, waiting, working, and setting. Understanding each stage of the process is beneficial in obtaining successful long-term outcomes. Developing optimal bone-cement penetration is of utmost importance in establishing a strong interface. Proper penetration of cement is dependent on multiple factors including the cement's properties along with its application to the prosthesis and bone surfaces. Combinations of different cement application techniques have yielded results with varying bone-cement interface strength. While a proper cementation technique is critical to the long-term success of a total knee replacement, other factors, such as antibiotic-loaded bone cement (ALBC), can help prevent and treat complications (such as infection). Although ALBC was not approved in North America by the Food and Drug Administration (FDA) until 2003, it was first described in 1970 and has been routinely used in revision total knee arthroplasty with reliable antibiotic elution properties and an acceptable safety profile.

BACKGROUND CONTEXT: The discussion regarding value based care has evolved in recent years, yet the ability to report Health Related Quality of Life (HRQoL) between different disease states has been limited by lack of validated standardized metrics to compare them. The recent advent of computer adaptive Patient Reported Outcome Information System (PROMIS), which allows for standardized assessment across health conditions, provides the ability to compare differing disease states and procedures. PURPOSE: To compare baseline and postoperative PROMIS scores for patients undergoing common single-level spinal surgery procedures, total hip arthroplasty (THA) and total knee arthroplasty (TKA). STUDY DESIGN/SETTING: Retrospective clinical cohort study of patients undergoing common single-level spine surgery procedures, THA and TKA at 6-month postoperative follow-up. PATIENT SAMPLE: A total of 505 orthopedic surgical patients were included who underwent either: single level anterior cervical discectomy and fusion (ACDF, N=37), lumbar laminectomy (Lami, N=31), microscopic lumbar discectomy (MLD, N=58), transforaminal lumbar interbody fusion (TLIF, N=46), total hip arthroplasty (THA, N=131), or total knee arthroplasty (TKA, N=202) at a single institution. OUTCOME MEASURES: Baseline (BL) and 6 month (6M) PROMIS metrics (Physical Function, Pain Interference, Pain Intensity). Patients were compared by T-values, which is age and gender adjusted to give a normal distribution of the general population, as the mean is scored at 50, and each 10 point deviation reflects 1SD of the population in improving or worsening function.
METHOD(S): Patients>18 years old who underwent spine surgery (ACDF, Lami, MLD, TLIF) or adult reconstruction surgery (THA or TKA) with BL & 6M PROMIS scores of physical function, pain interference and pain intensity were separately grouped based on surgery type. Paired t-tests compared differences in BL, 6M and the change in PROMIS scores for spine vs adult reconstruction procedures.
RESULT(S): A total of 172 spine surgery patients (age=54.6+/-15.6; 42.9% female) and 333 adult reconstruction patients were compared (age=65.8+/-9.5; 59.8% female). Spine surgery patients were significantly younger (p<.01) than adult reconstruction patients. Spine surgery patients undergoing ACDF, laminectomy, MLD or TLIF all had more disability and pain at baseline than THA and TKA patients, according to physical function ([20.1, 8.71, 14.2, 9.26] vs [35.9, 35.01], p<.01), pain interference ([84.1, 89.8, 91.8, 91.0)]vs [63.9, 63.8], p<.01) and pain intensity metrics ([53.6, 58.1, 58.2, 56.1] vs [53.4, 53.8], p<.01). At 6M, spine surgery patients remained more disabled and had more pain compared to adult reconstruction patients; However, patients across all spine procedures experienced greater improvements than THA and TKA patients in terms of physical function ([+8.1, +12.1, +15.2, +12.9] vs [+5.24, +3.9], p<.01) and pain interference scores ([-15.1, -14.1, -12.5, -11.9] vs [-8.1, -6.0] p<.01). Similar improvements in pain intensity scores were seen.
CONCLUSION(S): Patients undergoing single level spinal surgery had lower initial and 6 month postoperative PROMIS scores compared to those undergoing total hip and knee arthroplasty. All procedure cohorts demonstrated meaningful improvement after orthopaedic surgical treatment, but spinal surgery patients demonstrated more improvement in physical function and pain interference scores compared to arthroplasty patients. Future study is required to assess the value base of spinal and adult reconstruction surgery, including durability. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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Background/UNASSIGNED:The most common indications for revision total hip arthroplasty are instability/dislocation and mechanical loosening. Efforts to address this have included the use of dual mobility (DM) articulations. The aim of this study is to report on the use of cemented DM cups in complex acetabular revision total hip arthroplasty cases with a high risk of recurrent instability. Methods/UNASSIGNED:A multicenter, retrospective study was conducted. Patients who received a novel acetabular construct consisting of a monoblock DM cup cemented into a fully porous metal shell were included. Outcome data included 90-day complications and readmissions, revision for any reason, and Harris Hip Scores. Results/UNASSIGNED:< .001). One (2.6%) patient experienced a dislocation on postoperative day 1, and was closed reduced with no further complications. There was 1 (2.6%) reoperation for periprosthetic joint infection treated with a 2-stage exchange. Conclusions/UNASSIGNED:In this complex series of patients, cementation of a monoblock DM cup into a newly implanted fully porous revision shell reliably provided solid fixation with a low risk of dislocation at short-term follow-up. Although longer term follow-up is needed, utilization of this novel construct should be considered in patients at high risk for instability.

Successful arthroplasty of the knee requires a stable foundation for implant placement, adequate mechanical alignment, and durable fixation. In the revision setting, the later may be difficult to obtain, especially in the setting of significant bone loss. While augments, cones, and sleeves have greatly enhanced the modern knee surgeon's ability to gain fixation in metaphyseal bone, stems continue to be a cornerstone tool in revision arthroplasty to bypass deficient or damaged bone surfaces to enhance structural stability of a revision construct. When placing a revision construct, there remains two options to assist with fixation, either fully cementing the entire implant or using a "hybrid" system, which combines an uncemented press-fit diaphyseal stem with cement in both the metaphysis and metaphysis-diaphysis junction of the keel. In this review, we discuss the history of these two techniques, evaluate the theoretical benefits and pitfalls, and assess the best evidence supporting each in the literature. To conclude, we will examine future directions and questions needed to better elucidate the best treatment options in a variety of revision scenarios.

BACKGROUND:The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a nationally standardized tool to assess patient experience between hospitals. The HCAHPS survey can affect hospital reimbursement. This study aims to determine if HCAHPS scores vary by a number of demographic variables in patients undergoing primary total knee arthroplasty (TKA). METHODS:Patients who underwent primary TKA and returned a completed HCAHPS survey were included in this study. HCAHPS surveys were collected from our institution's Center for Quality and Patient Safety department, which was cross-referenced with our hospital's electronic data warehouse. Patient demographics, surgical factors, and quality outcomes were queried, and multivariable linear regression was performed. RESULTS:. Sixty-nine percent of the patients (1287 patients) were discharged home versus 10.3% (106 patients) to another facility. Mean length of stay was 2.9 ± 1.4 days. Age was correlated with a 0.3% decrease in top-box response rate (P < .01) for each 1-year increase in age. Compared to Caucasian race, African American race was correlated with a 5.6% increased rate for top-box response (P < .01), while Asian race (P = .42) and unknown race (P = 1.00) demonstrated no significant difference. Marital status demonstrated that divorced/separated status resulted in a significant 5.4% decrease in top-box response rates (P < .05). Similarly, single (P = .12) and widowed (P = .09) statuses also demonstrated a trend toward lower top-box response rates when compared to married or partnered patients. For each day increase in length of stay, HCAHPS top-box response rates decrease by 1.6% (P < .01). Gender, body mass index, smoking status, insurance type, and discharge disposition were not found to be significantly correlated with HCHAPS top-box response rate (P > .05). CONCLUSION/CONCLUSIONS:HCAHPS scores in patients undergoing primary TKA are influenced not just by hospital and surgeon factors such as length of stay but by demographic variables such as age, race, and marital status. As surgeons become more involved with the burden of improving patient experience, they should be aware that static demographic variables can have a significant effect on HCAHPS scores.

BACKGROUND:The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score is a nationally standardized measure of a patient's inpatient experience. This study aims to assess whether HCAHPS scores differ between patients undergoing primary total joint arthroplasty (TJA) and patients undergoing revision TJA. METHODS:Patients who underwent primary or revision total hip or total knee arthroplasty (THA or TKA) and returned a completed HCAHPS survey were included in this study. HCAHPS scores were collected from our institution's Center for Quality and Patient Safety department, which was cross-referenced with our hospital's electronic data warehouse. Patient demographics, surgical factors, and quality outcomes were queried. Appropriate statistical analyses were performed using MatLab 2017a and P-values less than .05 were deemed significant. RESULTS:In total, 523 primary and 59 revision THA recipients completed HCAHPS surveys at our institution between October 2011 and November 2016. During this same period, 507 primary TKA recipients and 40 revision TKA recipients completed HCAHPS surveys. Compared to revision THA, primary THA patients had a significantly higher top box for overall hospital ratings (58.46% vs 41.38%), felt that nurses listened to them carefully (84.3% vs 72.88%), and felt that they clearly understood the role of each medication (69.48% vs 56.90%). Moreover, 18 of 20 HCAHPS question responses favored primary THA despite not reaching significance for the majority of HCAHPS questions. Patients with revision TKA demonstrated a significantly higher incidence of "top box" choices for quieter rooms and a trend favoring better HCAHPS scores in revision TKA in a further 12 of 20 HCAHPS responses. CONCLUSION/CONCLUSIONS:Patients undergoing primary THA report higher HCAHPS scores than those undergoing revision THA, while revision TKA demonstrated a general trend toward higher scores when compared to primary TKA patients. This publicly reported quality measurement metric which factors into physician reimbursement may be biased by the patient's health status, the complexity of the surgical procedure, and length of stay in hospital rather than a true reflection of the quality of their hospital experience.

BACKGROUND:A better understanding of patient expectations within the perioperative setting will enable clinicians to better tailor care to the needs of the total hip arthroplasty (THA) recipient. Such an approach will promote patient-centered decision-making and optimize recovery times while enhancing mandated hospital quality metrics. In the present study, we preoperatively and postoperatively surveyed THA candidates to elucidate the relationship between patient expectations and length of stay (LOS). METHODS:This is a multi-institutional prospective study among THA candidates. Patients were surveyed regarding discharge planning 1 week preoperatively and postoperatively to capture perioperative patient expectations and correlate with inpatient LOS. RESULTS:In total, 93 THAs performed by 6 high-volume orthopedic surgeons at 2 medical centers. Our results demonstrated that patients of male gender and commercial insurance had significantly (P < .05) shorter LOS. Shorter LOS patients demonstrated significantly higher levels of LOS acceptance ("very comfortable" rate in same-day discharge: 75.0% and next-day discharge: 63.8%; 2 days: 40.7%; 3+ days: 42.9%; P < .05) and a higher likelihood to participate in SDD programs. Postoperatively, patients with a shorter LOS had more acceptance to their LOS, albeit not statistically significant (P = .20). CONCLUSION/CONCLUSIONS:Our results suggest that guiding patient expectations within the perioperative setting is an essential component for successful and timely discharge after THA. Having clear and transparent discussion with the surgical team regarding the perioperative course can improve a THA candidate's understanding and buy-in with the postoperative plan, regardless of LOS. Finally, inpatient LOS does not appear to affect patient satisfaction. LEVEL OF EVIDENCE/METHODS:Level II, prospective observational study.