Faculty Bibliography

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

BACKGROUND:The purpose of this multicenter, randomized trial was to determine the optimal dosing regimen of tranexamic acid (TXA) to minimize perioperative blood loss in revision total hip arthroplasty. METHODS:Six centers prospectively randomized 175 patients to 1 of 4 regimens: (1) 1-g intravenous (IV) TXA prior to incision (the single-dose IV group), (2) 1-g IV TXA prior to incision followed by 1-g IV TXA after arthrotomy wound closure (the double-dose IV group), (3) a combination of 1-g IV TXA prior to incision and 1-g intraoperative topical TXA (the combined IV and topical group), or (4) 3 doses totaling 1,950-mg oral TXA (the multidose oral group). Randomization was based on revision subgroups to ensure equivalent group distribution. An a priori power analysis (α = 0.05; β = 0.80) determined that 40 patients per group were required to identify a >1-g/dL difference in postoperative hemoglobin reduction between groups. Per-protocol analysis involved an analysis of variance, Fisher exact tests, and two 1-sided t tests for equivalence. Demographic and surgical variables were equivalent between groups. RESULTS:No significant differences were found between TXA regimens when evaluating reduction in hemoglobin (3.4 g/dL for the single-dose IV group, 3.6 g/dL for the double-dose IV group, 3.5 g/dL for the combined IV and topical group, and 3.4 g/dL for the multidose oral group; p = 0.95), calculated blood loss (p = 0.90), or transfusion rates (14% for the single-dose IV group, 18% for the double-dose IV group, 17% for the combined group, and 17% for the multidose oral group; p = 0.96). Equivalence testing revealed that all possible pairings were statistically equivalent, assuming a >1-g/dL difference in hemoglobin reduction as clinically relevant. There was 1 venous thromboembolism, with no differences found between groups (p = 1.00). CONCLUSIONS:All 4 TXA groups tested had equivalent blood-sparing properties in the setting of revision total hip arthroplasty, with a single venous thromboembolism reported in this high-risk population. Based on the equivalence between groups, surgeons should utilize whichever of the 4 investigated regimens is best suited for their practice and hospital setting. Given the transfusion rate in revision total hip arthroplasty despite TXA utilization, further work is required in this area. LEVEL OF EVIDENCE:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Same-day discharge (SDD) surgery in total hip arthroplasty (THA) has been shown to have similar outcomes to non-SDD THA in select patient populations. Hip resurfacing arthroplasty (HRA) is an alternative to THA for young, active patients, making them ideal candidates for SDD. This study compared the safety and efficacy of non-SDD HRA and SDD HRA for specific postoperative outcomes. An electronic data warehouse query was performed for procedures labeled "hip resurfacing." Data collected included demographics, surgical factors, and quality metrics. Statistical analyses were evaluated using a graphing and statistics software program. Categorical variables were analyzed with chi-square tests and continuous variables with Student's t tests, with P<.05 deemed significant. Sixty-three of 274 total HRAs were enrolled in this SDD HRA protocol. No significant difference was observed between SDD HRA and non-SDD HRA baseline characteristics. On postoperative day 0, 98.41% of SDD HRA recipients were discharged successfully. The SDD HRA recipients had shorter stays, with 1.59% requiring a hospital stay of 2 days or more compared with 56.87% of non-SDD HRA recipients (P<.0001). The non-SDD HRA recipients were found to have shorter surgical times than SDD HRA recipients (104.74 vs 125.51 minutes, P=.01). Rates of infection, periprosthetic fractures, emergency department visits, and hospital readmissions were equivalent (P=.99). Same-day discharge HRA is a safe and effective procedure with similar outcomes to non-SDD HRA regarding infections, fractures, emergency department visits, and readmissions. The major benefit of SDD is a shorter hospital stay that may lead to decreased cost while preserving and enhancing quality of care and patient satisfaction. [Orthopedics. 2020;43(6):e595-e600.].

The COVID-19 pandemic has had unprecedented impact on the United States health care system. One of the consider-ations was the decision to halt elective orthopedic surgery to preserve consumption of scarce resources. However, as the number of COVID-19 cases decrease, there will be discus-sions regarding the modality of resuming elective orthopedic surgery. Ethical considerations will come to the forefront in terms of determining the best course of action, patient selection, resource rationing, and financial implications. These factors will be examined through the lens of the four tenets of bioethics, beneficence, maleficence, autonomy, and justice, to elucidate the best approach in ethically manag-ing elective orthopedic surgery during a global pandemic.

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.