Faculty Bibliography

Background:In Canada, health care is covered by provincial health insurance programs; patients do not directly participate in paying for their acute care expenses. The aim of this study is to assess the willingness of Canadian patients to contribute to the costs of novel total joint arthroplasty implants. Methods:We administered a questionnaire to patients attending an outpatient arthroplasty clinic in Ontario. In the questionnaire, the longevity and risk of complications of a “standard” implant were described. We asked if participants would be willing to contribute to the cost of 3 novel implants that had differing longevities and risks of complications compared with the standard implant. Results:One hundred and fifteen patients completed our questionnaire. Up to 62% of patients were willing to contribute a copayment to get an implant with greater longevity. Willingness to pay decreased to 40% for an implant with greater longevity but an increased risk of complications. Forty percent of participants were willing to pay for an implant with the same longevity as the standard implant but a decreased risk of complications. Participants with a higher income were more willing than other participants to contribute to the cost of a novel implant with greater longevity or lower complication rates. Conclusion:This study demonstrated that up to 62% of our sample of patients in Ontario were willing to share the costs of a novel total joint replacement implant. Willingness to pay was associated with the proposed benefits of the implant and certain patient characteristics. Our study shows that a high proportion of Canadian patients may be willing to copay to have access to new technologies.

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:Patients with developmental dysplasia of the hip (DDH) require special surgical considerations for total hip arthroplasty (THA). Despite the difficulties posed by the population's anatomical abnormalities, few large evaluations of postoperative outcomes exist. This study seeks to characterize outcomes following primary THA among patients diagnosed with DDH. METHODS:A retrospective review was conducted at a tertiary care center on all THA patients between June 2011 and March 2018. Inclusion criteria for this study included any patient diagnosed with DDH undergoing primary THA. Baseline information, operative reports, and postoperative outcomes were pulled from the medical record. RESULTS:. Most patients were female (82%). The majority of hips (89%, n = 344) were Crowe type 1, followed by 2 (6.9%, n = 26), 3 (2.6%, n = 10), and 4 (1.3%, n = 5). Most hips were Hartofilakidis Class A (83%, n = 320), followed by Class B (15%, n = 59), then C (1.6%, n = 6). Mean follow-up was 24.8 months. Revision THA was required in 19 (4.9%) cases, with the most common indications being infection (2.1%) and periprosthetic fracture (1.0%). Readmission rates were 1.8% (7 hips) and 2.9% (11 hips) at 30-day and 90-day, respectively. The 30-day and 90-day ED visit rates were 1.3% (5 hips) and 2.1% (8 hips), respectively. No complications were seen following 344 (87%) THAs. CONCLUSION/CONCLUSIONS:Despite their surgical complexity, DDH patients on average have notably low rates of revision and dislocation. Longer follow-up is needed to better assess outcomes after THA in this complex patient population.

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:Previous reports establish that infection with hepatitis C virus (HCV) predisposes total joint arthroplasty (TJA) recipients to poor postoperative outcomes. The purpose of the present study is to assess whether variation in HCV VL influences perioperative outcomes following TJA. METHODS:A multicenter retrospective review of all patients diagnosed with HCV who underwent primary TJA between January 2005 and April 2018 was conducted. Patients were stratified into 2 cohorts: (1) patients with an undetectable VL (U-VL) and (2) patients with a detectable VL (D-VL). Kaplan-Meier survivorship analysis was calculated with revision TJA as the end point. Subanalysis on the VL profile was done. RESULTS:A total of 289 TJAs were included (U-VL:118 TJAs; D-VL:171 TJAs). Patients in the D-VL cohort had longer operative times (133.9 vs 109.2 minutes), higher intraoperative blood loss (298.4 vs 219.5 mL), longer inpatient hospital stays (4.0 vs 2.9 days), more postoperative infections (11.7% vs 4.2%), and an increased risk for revision TJA (12.9% vs 5.1%). Kaplan-Meier demonstrated that the U-VL cohort trended toward better survivorship (P = .17). On subanalysis of low and high VL, no difference in outcomes was appreciated. CONCLUSION/CONCLUSIONS:TJA recipients with a detectable HCV VL have longer operative times, experience more intraoperative blood loss, have longer hospital length of stay, and are more likely to experience infection and require revision TJA. The blood loss, hospital length of stay, and revision rate findings should be interpreted with caution, however, as there are confounding factors. Our findings suggest that HCV VL is a modifiable risk factor that, can reduce the risk of infection and revision surgery. Additionally, serum HCV VL was not correlated with outcomes.

BACKGROUND:Opioid prescriptions and subsequent opioid-related deaths have increased substantially in the past several decades. Orthopedic surgery ranks among the highest of all specialties with respect to the amount of opioids prescribed. We present here the outcomes of our opioid-sparing pain management pilot protocol for total hip arthroplasty (THA). METHODS:A retrospective study was conducted to assess outcomes before and after the implementation of an opioid-sparing pain management protocol for THA. Patients were divided into 2 cohorts for comparison: (1) traditional pain management protocol and (2) opioid-sparing pain management protocol. The Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, pain severity using a Visual Analog Scale, and inpatient morphine milligram equivalents (MMEs) per day were compared between the 2 cohorts. RESULTS:No statistically significant difference was observed in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement between the 2 cohorts at any time point (P > .05). Although there was a significant decrease in pain scores over time (P < .01), there was no statistically significant difference in the rates of change between the 2 pain management protocols at any time point (P = .463). Inpatient opioid consumption was significantly lower for the opioid-sparing cohort in comparison to the traditional cohort (14.6 ± 16.7 vs 25.7 ± 18.8 MME/d, P < .001). Similarly, the opioid-sparing cohort received significantly less opioids than the traditional cohort during the post discharge period (13.9 ± 24.2 vs 80.1 ± 55.9 MME, P < .001). CONCLUSION/CONCLUSIONS:The results of this study suggest that an opioid-sparing protocol reduces opioid consumption and provides equivalent pain management and patient-reported outcomes during the 90-day THA episode of care relative to a traditional opioid-based regimen. These findings may help decrease the risk of adverse events associated with postoperative opioid use and provide a means of decreasing the opioid footprint in clinical practice.

BACKGROUND:Unplanned readmissions following elective total hip (THA) and knee (TKA) arthroplasty as a result of surgical complications likely have different quality improvement targets and cost implications than those for nonsurgical readmissions. We compared payments, timing, and location of unplanned readmissions with Center for Medicare and Medicaid Services (CMS)-defined surgical complications to readmissions without such complications. METHODS:We performed a retrospective analysis on unplanned readmissions within 90 days of discharge following elective primary THA/TKA among Medicare patients discharged between April 2013 and March 2016. We categorized unplanned readmissions into groups with and without CMS-defined complications. We compared the location, timing, and payments for unplanned readmissions between both readmission categories. RESULTS:Among THA (N = 23,231) and TKA (N = 43,655) patients with unplanned 90-day readmissions, 27.1% (n = 6307) and 16.4% (n = 7173) had CMS-defined surgical complications, respectively. These readmissions with surgical complications were most commonly at the hospital of index procedure (THA: 84%; TKA: 80%) and within 30 days postdischarge (THA: 73%; TKA: 77%). In comparison, it was significantly less likely for patients without CMS-defined surgical complications to be rehospitalized at the index hospital (THA: 63%; TKA: 63%; P < .001) or within 30 days of discharge (THA: 58%; TKA: 59%; P < .001). Generally, payments associated with 90-day readmissions were higher for THA and TKA patients with CMS-defined complications than without (P < .001 for all). CONCLUSION/CONCLUSIONS:Readmissions associated with surgical complications following THA and TKA are more likely to occur at the hospital of index surgery, within 30 days of discharge, and cost more than readmissions without CMS-defined surgical complications, yet they account for only 1 in 5 readmissions.

AIMS/OBJECTIVE:This aim of this study was to assess the feasibility of designing and introducing generic 3D-printed instrumentation for routine use in total knee arthroplasty. MATERIALS AND METHODS/METHODS:Instruments were designed to take advantage of 3D-printing technology, particularly ensuring that all parts were pre-assembled, to theoretically reduce the time and skill required during surgery. Concerning functionality, ranges of resection angle and distance were restricted within a safe zone, while accommodating either mechanical or anatomical alignment goals. To identify the most suitable biocompatible materials, typical instrument shapes and mating parts, such as dovetails and screws, were designed and produced. RESULTS:Before and after steam sterilization, dimensional analysis showed that acrylonitrile butadiene styrene could not withstand the temperatures without dimensional changes. Oscillating saw tests with slotted cutting blocks produced debris, fractures, or further dimensional changes in the shape of Nylon-12 and polymethylmethacrylate (MED610), but polyetherimide ULTEM 1010 was least affected. CONCLUSION/CONCLUSIONS:2019;101-B(7 Supple C):115-120.

AIMS/OBJECTIVE:The best marker for assessing glycaemic control prior to total knee arthroplasty (TKA) remains unknown. The purpose of this study was to assess the utility of fructosamine compared with glycated haemoglobin (HbA1c) in predicting early complications following TKA, and to determine the threshold above which the risk of complications increased markedly. PATIENTS AND METHODS/METHODS:This prospective multi-institutional study evaluated primary TKA patients from four academic institutions. Patients (both diabetics and non-diabetics) were assessed using fructosamine and HbA1c levels within 30 days of surgery. Complications were assessed for 12 weeks from surgery and included prosthetic joint infection (PJI), wound complication, re-admission, re-operation, and death. The Youden's index was used to determine the cut-off for fructosamine and HbA1c associated with complications. Two additional cut-offs for HbA1c were examined: 7% and 7.5% and compared with fructosamine as a predictor for complications. RESULTS:Overall, 1119 patients (441 men, 678 women) were included in the study. Fructosamine level of 293 µmol/l was identified as the optimal cut-off associated with complications. Patients with high fructosamine (> 293 µmol/l) were 11.2 times more likely to develop PJI compared with patients with low fructosamine (p = 0.001). Re-admission and re-operation rates were 4.2 and 4.5 times higher in patients with fructosamine above the threshold (p = 0.005 and p = 0.019, respectively). One patient (1.7%) from the elevated fructosamine group died compared with one patient (0.1%) in the normal fructosamine group (p = 0.10). These complications remained statistically significant in multiple regression analysis. Unlike fructosamine, all three cut-offs for HbA1c failed to show a significant association with complications. CONCLUSION/CONCLUSIONS:2019;101-B(7 Supple C):3-9.