Faculty Bibliography

BACKGROUND: With the establishment of the Hospital Value-Based Purchasing program, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score has been incorporated into the calculation of the total performance score, which determines redistribution of up to 2% of Medicare payments. This study aims to assess whether the HCAHPS score correlates with validated outcome measures after total hip arthroplasty. METHODS: Data from 63 patients who underwent a total hip arthroplasty and completed both an HCAHPS score and patient-reported outcome measures (PROMs) at our institution during the study period from January 1, 2015 to September 2016 were analyzed. The HCAHPS overall hospital rating scores were correlated with the preoperative to postoperative change in validated PROMs, namely EuroQol-EQ-5D Instrument and Hip Disability and Osteoarthritis Outcome Score. RESULTS: There was no statistically significant correlation between the HCAHPS overall hospital rating score and PROMs. CONCLUSION: This study shows a lack of correlation between established validated PROMs used in orthopedic surgery, and the HCAHPS survey scores, an important determinant of compensation in the pay-for-performance reimbursement models.

BACKGROUND:Individuals coinfected with both hepatitis C virus (HCV) and HIV represent a unique and growing population of patients undergoing orthopaedic surgical procedures. Data regarding complications for HCV monoinfection or HIV monoinfection are robust, but there are no data available, to our knowledge, on patients who have both HCV and HIV infections. QUESTIONS/PURPOSES/OBJECTIVE:We sought to determine whether patients with coinfection differed in terms of baseline demographics and comorbidity burden as compared with patients without coinfection and whether these potential differences were translated into varying levels of postoperative complications, mortality, and hospital readmission risk. Specifically, we asked: (1) Are there demonstrable differences in baseline demographic variables between patients infected with HCV and HIV and those who do not have those infections (age, sex, race, and insurance status)? (2) Do patients with HCV and HIV infection differ from patients without those infections in terms of other medical comorbidities? (3) Do patients with HCV/HIV coinfection have a higher incidence of early postoperative complications and mortality than patients without coinfection? (4) Is the frequency of readmission greater for patients with HCV/HIV coinfection than those without? METHODS:The New York Statewide Planning and Research Cooperative System (SPARCS) database was used to identify patients undergoing THA between 2010 and 2014. The SPARCS database is particularly useful because it captures 100% of all New York State inpatient admissions while providing detailed demographic and comorbidity data for a large, heterogeneous patient population with long-term followup. Patients were stratified into four groups based on HCV/HIV status: control patients without disease, HCV monoinfection, HIV monoinfection, and coinfection. We sought to determine whether patients coinfected with HCV and HIV would differ in terms of demographics from patients without those infections and whether patients with HCV and HIV would have a greater risk of complications, longer length of stay, and hospital readmission. A total of 80,722 patients underwent THA between 2010 and 2014. A total of 98.55% (79,554 of 80,722) of patients did not have either HCV or HIV, 0.66% (530 of 80,722) had HCV monoinfection, 0.66% (534 of 80,722) HIV monoinfection, and 0.13% (104 of 80,722) were coinfected with both HCV and HIV. Multivariate analysis was performed controlling for age, sex, insurance, residency status, diagnosis, and comorbidities to allow for an equal comparison between groups. RESULTS:Patients with coinfection were more likely to be younger, male (odds ratio [OR], 2.90; 95% confidence interval [CI], 2.20-3.13; p < 0.001), insured by Medicaid (OR, 6.43; 4.41-7.55; p < 0.001), have a history of avascular necrosis (OR, 8.76; 7.20-9.53; p < 0.001), and to be homeless (OR, 6.95; 5.31-7.28; p < 0.001) as compared with patients without HIV or HCV. Additionally, patients with coinfection had the highest proportion of alcohol abuse, drug abuse, and tobacco use along with a high proportion of psychiatric disorders, including depression. HCV and HIV coinfection were independent risk factors for increased length of stay (OR, 1.97; 95% CI, 1.29-3.01; p < 0.001), having two or more in-hospital complications (OR, 1.64; 1.01-2.67; p < 0.001), and 90-day readmission rates (OR, 2.97; 1.86-4.77; p < 0.001). CONCLUSIONS:As the prevalence of HCV and HIV coinfectivity continues to increase, orthopaedic surgeons will encounter a greater number of these patients. Awareness of the demographic and socioeconomic factors leading to increased complications after THA will allow physicians to consider interventions such as in-hospital psychiatric counseling, advanced discharge planning, and coordination with social work and collaboration with HCV/HIV infectious disease specialists to improve patient health status to improve outcomes and reduce costs. LEVEL OF EVIDENCE/METHODS:Level III, therapeutic study.

As the emphasis on value-based care within total joint arthroplasty increases, this procedure is becoming more prevalent in the outpatient setting. The goals of this study were to report on the authors' early experiences with same-day discharge and to identify patient characteristics that are associated with failure to discharge after total hip arthroplasty within this program. All patients who were enrolled in the same-day discharge total hip arthroplasty program at the study institution between January 2015 and July 2016 were included. Demographics, baseline characteristics, and clinical and quality outcomes were compared between patients who successfully completed this program and those who did not. Of the 163 study subjects, 143 (87.7%) were discharged successfully on the same day as surgery. Women, patients younger than 40 years, and patients older than 60 years all had an increased risk of failing the program. Body mass index of 26 kg/m² or less was associated with a 40% greater risk of failure. Patients with an American Society of Anesthesiologists score of 3 had a 3-fold risk of failure compared with patients with an American Society of Anesthesiologists score of 2 or less. The screening protocol for same-day discharge at the study institution had an 87.7% rate of successful same-day discharge. Further investigation is needed to identify patients who are at risk of failing the same-day discharge initiative. [Orthopedics. 2018; 41(1):35-42.].

BACKGROUND: Chronic opioid users pose a unique challenge for orthopedic surgeons, as they often report suboptimal outcomes following total knee arthroplasty (TKA). We aim at identifying risk factors associated with patients who were preoperative chronic opioid users and continued to use 6 months following TKA. METHODS: All preoperative chronic opioid users among 338 consecutive TKA cases performed at our institution between February and June 2016 were identified and divided into 2 cohorts: patients who (1) persistently used opioids and (2) discontinued use by the 6-month time point following surgery. Baseline characteristics were compared between cohorts in order to determine risk factors for persistent opioid use following TKA. RESULTS: Of the 338 patients, 53 (15.7%) were identified as preoperative chronic opioid users. Of these, 23 (43.4%) continued chronic opioid use 6 months following surgery, whereas 14 (4.9%) previously nonchronic users were identified as new chronic users at 6 months. Characteristics that were predictive of persistent opioid use included male gender, prior injury or surgery to the ipsilateral knee, current tobacco smoking status, and a history of psychiatric disorder. Opioid dose consumption of >/=12 mg/d morphine-equivalents over the 3 months leading up to surgery had an increased risk of persistent chronic opioid use by a factor of 6. CONCLUSION: TKA candidates who have complicated medical, social, and surgical histories are at an increased risk of chronic opioid abuse postoperatively. By better understanding the risk factors associated with persistent chronic opioid use, targeted opioid reduction programs may be appropriately implemented to manage this high-risk population.

INTRODUCTION: Maintaining accuracy of component placement is an important step in ensuring the long-term stability of components during total hip arthroplasty (THA). Computer-assisted navigation has improved accuracy but errors associated with the registration process are known to impact the accuracy of final measurements. The purpose of this cadaver study was to determine the registration error associated with a novel mini-navigation system. METHODS: 3 board-certified orthopaedic surgeons performed 4 THA procedures each via the posterolateral approach on 6 cadavers (12 hips) using the mini-navigation tool. Pre- and post-operative radiographs and post-operative computed tomography (CT) images were obtained. Image analysis was performed by 2 radiologists not involved in the surgical procedures. During registration, surgeons aligned the alignment rod with the anterior pelvic plane (APP) to provide a reference plane for comparison with traditional navigation. Cup position from the device was compared with measurements gathered from post-op imaging. RESULTS: The mean difference between CT and device measurements for inclination was -1.7 degrees (standard deviation [SD] 4.9 degrees ), while the mean absolute difference was 4.2 degrees (SD 3.2 degrees ). The mean difference between anteversion angles calculated from CT scans and from the device was -3.5 degrees (SD 4.5 degrees ), with an absolute difference of 4.0 degrees (SD 4.0 degrees ). 100% (12/12) of inclination measurements and 92% (11/12) of anteversion measurements fell within both the clinical and statistical limits of agreement when analyzed via the Bland-Altman technique. CONCLUSIONS: This study demonstrates that the registration error associated with this new mini-navigation system compares favourably with the known registration error associated with traditional navigation systems.

BACKGROUND: Compared to total knee arthroplasty (TKA) for primary osteoarthritis, conversion TKAs in the post-traumatic setting are associated with increased operative times, infection rates, and readmissions. We aim at determining how post-traumatic osteoarthritis and previous knee surgery influence postoperative outcomes in conversion TKA. METHODS: Seventy-two conversion TKA procedures with prior knee trauma at a single institution between April 2012 and 2016 were examined. Twenty-seven (37.5%) cases had a preoperative site-specific diagnosis such as fracture of the proximal tibia, distal femur, or patella whereas 45 (62.5%) cases had a preoperative diagnosis of significant soft-tissue trauma. These 2 groups were compared in terms of total implant cost, length of stay, complications, and readmission and reoperation rates. A subanalysis was conducted to evaluate the effects of previous knee surgery on surgical outcomes. RESULTS: The postfracture TKA cohort suffered significantly higher early surgical site complications (22% vs 4.4%, P = .02) and 90-day readmissions (14.8% vs 2.2%, P = .042) compared to the soft-tissue trauma cohort. Operative time, total implant costs, length of stay, medical complications, 30-day readmissions, and 90-day reoperation rates did not significantly differ. It was also found that patients with multiple prior knee surgeries compared to one prior knee surgery are younger (53.0 vs 63.1, P = .003), healthier, and receive significantly more expensive implants (1.72 vs 1.07, P = .026). In addition, patients with previous open reduction internal fixations experience more surgical site complications than patients with previous arthroscopies (31% vs 3.3%, P = .042). CONCLUSION: Patients with previous site-specific fracture are more likely to experience surgical site complications and 90-day readmissions after conversion TKA than patients with previous soft-tissue knee trauma. Multiple previous knee surgeries appear to serve as an independent factor in the selection of costlier implants irrespective of preoperative diagnosis.

Total knee arthroplasty (TKA) is the most commonly performed inpatient surgical procedure within the USA and is estimated to reach 3.48 million procedures annually by 2030. As value-based care initiatives continue to focus on hospital readmission rates and patient satisfaction, it has become essential for health care providers to develop and implement a multidisciplinary approach to enhance TKA outcomes while minimizing unnecessary expenditures. Through this necessity, clinical care pathways have been developed to standardize, organize, and improve the quality and efficiency of patient care while simultaneously encouraging the collaboration among various medical care providers. Here, we review several systems based programs and specialty care practices that can be adopted into the standard orthopedic practice.

BACKGROUND:Atsttrin, an engineered protein composed of three tumor necrosis factor receptor (TNFR)-binding fragments of progranulin (PGRN), shows therapeutic effect in multiple murine models of inflammatory arthritis . Additionally, intra-articular delivery of PGRN protects against osteoarthritis (OA) progression. The purpose of this study is to determine whether Atsttrin also has therapeutic effects in OA and the molecular mechanisms involved. METHODS:Surgically induced and noninvasive rupture OA models were established in mouse and rat, respectively. Cartilage degradation and OA were evaluated using Safranin O staining, immunohistochemistry, and ELISA. Additionally, expressions of pain-related markers, degenerative factors, and anabolic and catabolic markers known to be involved in OA were analyzed. Furthermore, the anabolic and anti-catabolic effects and underlying mechanisms of Atsttrin were determined using in-vitro assays with primary chondrocytes. RESULTS:Herein, we found Atsttrin effectively prevented the accelerated OA phenotype associated with PGRN deficiency. Additionally, Atsttrin exhibited a preventative effect in OA by protecting articular cartilage and reducing OA-associated pain in both nonsurgically induced rat and surgically induced murine OA models. Mechanistic studies revealed that Atsttrin stimulated TNFR2-Akt-Erk1/2-dependent chondrocyte anabolism, while inhibiting TNFα/TNFR1-mediated inflammatory catabolism. CONCLUSIONS:These findings not only provide new insights into the role of PGRN and its derived engineered protein Atsttrin in cartilage homeostasis as well as OA in vivo, but may also lead to new therapeutic alternatives for OA as well as other relative degenerative joint diseases.

BACKGROUND: Pain catastrophizing has been suggested as a prospective risk factor for poor postoperative pain outcomes in total joint arthroplasty (TJA). However, results from the previous studies have been mixed and have not controlled for postoperative opiate analgesic intake. This study investigates pain catastrophizing and postoperative pain intensity in TJA patients, adjusting for analgesic intake. We hypothesized that "pain catastrophizers" would exhibit higher pain scores and increased analgesic requirements postoperatively. METHODS: In this prospective cohort study, patients were defined as catastrophizers (PCS > 30), or non-catastrophizers (PCS /= 3 postoperative days differed in VAS pain scores ("non-catastrophizers" = 5.08 vs. "catastrophizers" = 7.13; p = 0.002) and were 2.4 times more likely to be catastrophizers than non-catastrophizers (p = 0.042). There were no differences in the remaining secondary outcomes. CONCLUSION: The pain catastrophizing scale is a poor predictor of postoperative pain at 3-month follow-up. However, it may be a risk factor for increased LOS.