Faculty Bibliography

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 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.

INTRODUCTION/BACKGROUND:Acetylsalicylic acid (aspirin) is a commonly prescribed medication, especially in the age group of individuals who undergo elective total hip arthroplasty (THA). Preoperative discontinuation of aspirin is believed to reduce intraoperative bleeding and other complications, but it may increase the risk of perioperative cardiovascular events. In this study we have sought to evaluate the safety of continuous aspirin treatment in patients undergoing elective THA. MATERIALS AND METHODS/METHODS:This is a retrospective analysis of a consecutive cohort who underwent elective THA in a tertiary medical center between 2011 and 2018. The cohort was divided into two groups-one that received continuous preoperative aspirin treatment and one that did not. Blood loss, peri- and postoperative complications, readmissions, and short- and long-term mortality were compared between groups. RESULTS:Out of 757 consecutive patients (293 males, 464 females) who underwent elective primary THA, 552 were in the "non-aspirin" group and 205 were in the "aspirin" group and were not treated preoperative with other medication affecting hemostasis. Perioperative continuation of aspirin treatment did not significantly increase perioperative bleeding, as indicated by changes in hemoglobin levels (P = 0.72). There were no significant differences in short- and long-term mortality (P = 0.47 and P = 0.4, respectively) or other perioperative complications, such as readmission (P = 0.78), deep or superficial infection (P = 1 and P = 0.47, respectively), and cardiovascular events (none in both groups). CONCLUSION/CONCLUSIONS:Peri-operative continuation of aspirin treatment in patients undergoing elective primary THA did not increase perioperative complications or mortality compared to the non-aspirin-treated patients. The protective effects of aspirin from postoperative thrombotic and cardiovascular events are well documented. The current findings dispute the need to preoperatively withhold aspirin treatment in patients undergoing elective primary THA.

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:Patients with anterior cruciate ligament (ACL) injuries and reconstruction are at an increased risk of developing osteoarthritis requiring total knee arthroplasty (TKA). There have been few studies analyzing the impact of prior ACL reconstruction (ACLR) on surgical time and perioperative complications following TKA. PURPOSE/OBJECTIVE:The purpose of the current study was to compare surgical time and the rate of select early postoperative complications following TKA in patients with a history of ACLR to patients without prior ligament reconstruction. METHODS:We identified 116 patients who underwent TKA at our institution with a history of ACL reconstruction on the operative knee. These patients were propensity score matched to a control cohort of 348 patients undergoing TKA without a prior ACLR based on age, body mass index, sex, race, smoking status, surgeon, and year of surgery. Outcomes of interest for the current analysis were surgical time, incidence of postoperative wound complications, length of stay, discharge disposition, and 30-day readmission rate. RESULTS:There was no statistically significant difference between the ACLR and non-ACLR groups with respect to surgical time (108.23 ± 45.57 minutes vs. 102.72 ± 38.73 minutes, p = 0.205). There was also no significant difference in length of hospital stay, discharge disposition, incidence of postoperative wound complications, 30-day readmission rate, or reoperation rate. CONCLUSION/CONCLUSIONS:In this matched cohort analysis, we found no difference between patients undergoing TKA after ACLR and patients undergoing TKA for primary osteoarthritis with respect to perioperative complications and select postoperative outcomes, including the rate of reoperations. The current data demonstrates no significant impact of prior ACLR on the surgical time required to perform the arthroplasty.

There is a paucity of literature regarding the short-term readmission, reoperation, and complication rates of patellofemoral arthroplasty (PFA). The purpose of this study is to determine the incidence and risk factors of 30-day postoperative complications in patients undergoing PFA. A retrospective cohort study of subjects who underwent PFA from 2010 to 2015 was performed using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Perioperative outcomes and 30-day postoperative complications were ascertained, and patient demographics and comorbidities were analyzed using linear and binomial logistic regression analyses to determine risk factors for postoperative complications. Among the 1,069 patients identified in the NSQIP database, there was a 30-day readmission rate of 4.3% and a 30-day reoperation rate of 1.5%. The leading complications identified were bleeding requiring transfusion (11.7%), urinary tract infection (0.8%), and deep vein thrombosis (DVT) (0.8%). Younger age was a risk factor for superficial wound infection (p = 0.012). Older age was a significant risk factor for longer hospital stays, readmission, bleeding requiring transfusion, urinary tract infection, and pneumonia (p < 0.05 for all). Male sex was a risk factor for longer operation time and DVT (p = 0.001 and p = 0.017, respectively), while female sex was associated with greater incidence of bleeding requiring transfusion (p = 0.049). Elevated body mass index (BMI) was a risk factor for longer hospital stays, greater total operation time, and bleeding requiring transfusion (p < 0.001, p < 0.001, and p = 0.001, respectively). Nonwhite race was a significant risk factor for readmission (p = 0.008). This represents the largest study on early readmissions and the associated risk factors after PFA. PFA 30-day readmission and reoperation rates were <5%. Older age and elevated BMI were both identified as risk factors for adverse perioperative outcomes, including longer operation times, longer hospital stays, and bleeding requiring transfusion.

BACKGROUND/UNASSIGNED:There are currently a lack of investigations that characterised narcotic utilisation following revision total hip arthroplasty (THA). We sought to determine if immediate post-surgical opioid use was different between revision THA and primary THA. METHODS/UNASSIGNED:A single institution total joint arthroplasty database was used to identify adult patients who underwent revision THA or primary THA from 2016 to 2019. Morphine milligram equivalents (MME) were calculated for different time periods. RESULTS/UNASSIGNED:6977 patients were identified, 89.72% primary THA and 10.28% revision THA. Aggregate opioid consumption was higher for revision THA patients (317.40 MME vs. 93.01 MME), as was opioid consumption in the first 24 hour and second 24-hour periods. Visual analogue pain (VAS) scores were significantly higher in the 0-12 hour postoperative and the 12-24 hours postoperative periods in the revision THA group. CONCLUSIONS/UNASSIGNED:Patients undergoing revision THA had significantly higher narcotic utilisation than those undergoing primary THA, particularly in the first 24 hours postoperatively.

Background/UNASSIGNED:The impact of tobacco use on perioperative complications, hospital costs, and survivorship in total joint arthroplasty (TJA) is well established. The aim of this study is to report the impact of tobacco cessation on outcomes after TJA and to measure the impact of a voluntary smoking cessation program (SCP) on self-reported smoking quit rates in a premier academic medical center. Methods/UNASSIGNED:A seven-year (2013-2019) SCP database was provided by the Integrative Health Promotion Department and Infection Prevention and Control Department. We evaluated program and smoking status, patient demographics, length of stay (LOS), and 90-day post-operative infection rates and readmission rates. The primary outcome was quit rates based on SCP enrollment status. The secondary outcomes measured infection rates, readmission rates, and LOS based on enrollment status and/or quit rate. Results/UNASSIGNED:A total of 201 eligible patients were identified: 137 patients in the SCP (intervention) group and 64 in the self-treatment (control) group. SCP patients trended towards higher quit rates (43% vs 33%, p = 0.17), shorter LOS (2.47 vs 2.62 days, p = 0.52), lower infection rates (7.3% vs 12.5%, p = 0.27) and slightly higher readmission rates (5.8% vs 4.7%, p = 0.73). In a sub-analysis, self-reported smokers demonstrated statistically significant decrease in infection (3.7% vs 12.5%, p = 0.03). Conclusion/UNASSIGNED:There was a statistically significant decrease in infection rates in patients who self-reported quitting tobacco prior to TJA. Additionally, quit rates for patients who participated in a voluntary SCP trended towards increased pre-operative cessation. Further efforts to increase tobacco cessation prior to TJA and examine the impact on patient outcomes are needed.

Background/UNASSIGNED:The majority of hip arthroplasties in the United States utilize cementless acetabular and femoral components. Despite their similarities, stem geometry can still differ. The purpose of this study is to compare the clinical results of two wedge-type stem designs. Methods/UNASSIGNED:A retrospective study of patients who underwent primary THA utilizing a direct anterior approach between January 2016 and January 2017. Two cohorts were established based on femoral stem design implanted. Descriptive patient characteristics and surgical and clinical data was extracted which included surgical time, length of stay (LOS), presence of pain (categorized as groin, hip, or thigh pain) at the latest follow-up, and revisions. Immediate postoperative radiographs were compared with the latest follow-up radiographs to assess limb length discrepancies, stem alignment, and stem subsidence. Results/UNASSIGNED:A total of 544 patients were included. 297 patients received the Group A stem (morphometric) and 247 patients received the Group B stem (flat-tapered). A significantly higher proportion of Group B stems subsided ≥3 mm and were in varus alignment than the Group A design. Additionally, a significantly greater number of patients who received the Group B stem reported postoperative hip and thigh pain. The logistic regression found that the Group B stem was 2.32 times more likely to subside ≥3 mm than the Group A stem. Conclusion/UNASSIGNED:Our study suggests modestly improved radiographic and clinical outcomes and fewer instances of thigh pain, subsidence, and varus alignment in the patients who received the Group Ahip stem. Further studies are warranted to assess long-term significance.

Total hip arthroplasty dislocations that occur inside Lewinnek's anatomical safe zone represent a need to better understand the hip-spine relationship. Unfortunately, the use of obtuse and redundant terminology to describe the hip-spine relationship has made it a relatively inaccessible topic in orthopaedics. However, with a few basic definitions and principles, the hip-spine relationship can be simplified and understood to prevent unnecessary dislocations following total hip arthroplasty.In the following text, we use common language to define a normal and abnormal hip-spine relationship, present an algorithm for recognising and treating a high-risk hip-spine patient, and discuss several common, high-risk hip-spine pathologies to apply these concepts. Simply, high-risk hip-spine patients often require subtle adjustments to acetabular anteversion based on radiographic evaluations and should also be considered for a high-offset stem, dual-mobility articulation, or large femoral head for additional protection against instability and dislocation.