Faculty Bibliography

Venous thromboembolism (VTE) is a rare, but serious complication following total knee arthroplasty (TKA). Current VTE guidelines recommend pharmacologic agents with or without intermittent pneumatic compression devices (IPCDs). At our institution, both 81-mg aspirin (ASA) twice a day (BID) and portable IPCDs were previously prescribed to TKA patients at standard risk for VTE, but the IPCDs were discontinued and patients were treated with ASA alone going forward. The aim of this study is to determine if discontinued use of outpatient IPCDs is safe and does not increase the rate of VTE or any other related complications in patients following TKA. A retrospective review of 2,219 consecutive TKA cases was conducted, identifying patients with VTE, bleeding complications, infection, and mortality within 90 days postoperatively. Patients were divided into two cohorts. Patients in cohort one received outpatient IPCDs for a period of 14 days (control), while those in cohort two did not (ASA alone). All study patients received inpatient IPCDs and were maintained on 81-mg ASA BID for 28 days. A posthoc power analysis was performed using a noninferiority margin of 0.25 (α = 0.05; power = 80%), which showed that our sample size was fully powered for noninferiority for our reported deep vein thrombosis (DVT) rates, but not for pulmonary embolism (PE) rates. A total of 867 controls and 1,352 patients treated with ASA alone were identified. Only two control patients were diagnosed with a PE (0.23%), while one patient in the ASA alone group had DVT (0.07%). There was no statistical difference between these rates (p = 0.33). Furthermore, no differences were found in bleeding complications (p = 0.12), infection (p = 0.97), or 90-day mortality rates (p = 0.42) between both groups. The discontinued use of outpatient portable IPCDs is noninferior to outpatient IPCD use for DVT prophylaxis. Our findings suggest that this protocol change may be safe and does not increase the rate of VTE in standard risk patients undergoing TKA while using 81-mg ASA BID.

INTRODUCTION/BACKGROUND:Despite increased efforts towards patient optimization, some patients have undocumented conditions that can affect costs and quality metrics for institutions and physicians. This study evaluates the effect of documented and undocumented psychiatric conditions on LOS and discharge disposition following total hip arthroplasty (THA). METHODS:A retrospective review of all primary THAs from 2015-2020 at a high-volume academic orthopedic specialty hospital was conducted. Patients were separated into three cohorts: patients with a documented psychiatric diagnosis (+Dx), patients without a documented psychiatric diagnosis but with an actively prescribed psychiatric medication (-Dx), and patients without a psychiatric diagnosis or medication (control). Patient demographics, LOS, and discharge disposition were assessed. RESULTS:A total of 5,309 patients were included; 3,048 patients had no recorded psychiatric medications (control); 2,261 patients took at least one psychiatric medication, of which 1,513 (65.9%) and 748 (34.1%) patients were put in the -Dx and +Dx cohorts, respectively. ASA Class differed between groups (<0.001). The -Dx and +Dx groups had increased LOS (3.15±2.37 (75.6±56.9) and 3.12±2.27 (74.9±54.5) versus 2.42±1.70 (57.6±40.8) days (hours), p<0.001) and were more likely to be discharged to a secondary facility (23.0% and 21.7% versus 13.8%, p<0.001) than the control group. Outcomes did not significantly differ between the -Dx and +Dx cohorts. CONCLUSION/CONCLUSIONS:Most THA patients' psychiatric diagnoses were not documented. The presence of psychiatric medications was associated with longer LOS and a greater likelihood of discharge to secondary facilities. This has implications for both cost and quality metrics. Review of medications can help identify and optimize these patients before surgery.

BACKGROUND:Obesity is a recognized risk factor for severe knee osteoarthritis. However, it remains unclear how obesity prevalence trends in the current population undergoing total knee arthroplasty (TKA) compare with those seen in individuals not undergoing this procedure. In this study, we assessed the yearly trends in body mass index (BMI) and obesity rates between patients who have undergone primary TKA and those in the general population. METHODS:We retrospectively reviewed all patients ≥18 years of age from January 2013 through December 2020 who underwent primary, elective TKA and those who had an annual routine physical examination at our institution within the same period. Baseline demographic characteristics were collected. The independent samples t test was used to compare means and the chi-square test was used to compare proportions between the 2 cohorts, and a linear regression was used to determine the significance of the yearly trends. RESULTS:A total of 11,333 patients who underwent primary TKA and 1,158,168 patients who underwent an annual physical examination were included in this study. After adjusting for age, we found the mean BMI for the TKA group to be significantly greater (p < 0.001) every year compared with the annual physicals group. The proportion of patients who were categorized into any obesity class (BMI, ≥30 kg/m2), Class-I obesity (BMI, 30 to 34.9 kg/m2), Class-II obesity (BMI, 35 to 39.9 kg/m2), and Class-III obesity (BMI, ≥40 kg/m2) was significantly higher for the TKA group each year compared with the annual physicals group. An analysis of trends over time showed a significantly increasing trend (p < 0.001) in BMI and obesity rates for the annual physicals group, but a stable trend for patients undergoing TKA. CONCLUSIONS:Patients who underwent TKA continued to have higher BMI than the general population, which showed a steady increase over time. Physicians need to continue in their efforts to educate patients on weight management and healthy lifestyles to potentially delay the need for a surgical procedure. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cement fixation of the femoral stem in total hip arthroplasty, first popularized in the 1960s following the success of Sir John Charnley's design, remains a prevalent topic in arthroplasty literature today. Though this technique is still widely used among European surgeons, since the 1980s many American surgeons have shifted to the use of cementless, press-fit stems except for particular cases such as those at increased risk for periprosthetic fracture. In this article we review the history and literature regarding the use of cemented stems in total hip arthroplasty in the United States and Europe over the past 70 years.

Current trajectories are set to create a large gap between total joint arthroplasty (TJA) supply and demand. Economics dictates that when the demand of consumers (TJA patients) exceeds supply (surgeons performing TJA), a new equilibrium should ideally be established at a higher price point. However, in TJA, the price is set by the government and, therefore, not subject to traditional economic models. Thus, reimbursements for TJA have decreased steadily over time. Fee for service is no longer the dominant reimbursement model for most orthopedic care. Surgeons play a critical role in the evolution and success of Value-Based Care (VBC) models, but this work is not reflected in recent payment changes for TJA. The regulatory environment is notoriously complex and affects our patients, surgeons, and institutions. It is imperative for orthopedic surgeons to continue to advocate for themselves by engaging with leadership, responding to surveys, and balancing outside influences to preserve patient access to TJA. Future payment models for musculoskeletal care must risk-stratify patients, appropriately reimburse for the work of revision TJA, and consider non-modifiable socioeconomic factors. Perioperative orthopedic surgical home (POSH) tools can ensure early appropriate care and proper care coordination for discharge. All of these factors, despite being framed within payment policy, ultimately affect access to orthopedic care for our patients.