Faculty Bibliography

BACKGROUND:Nonmodular and modular femoral stems have been associated with complications after revision total hip arthroplasty (rTHA). As such, the ideal femoral component for rTHA remains undecided. This study aims to report outcomes of titanium, tapered-fluted, modular and nonmodular femoral components in rTHA. METHODS:From January 1, 2013 to September 30, 2017, all rTHAs using modular or nonmodular femoral stems were identified. Demographic data including age, gender, and American Society of Anesthesiologists scores were collected. Surgical details including operative time and implant cost were also collected. Clinical outcomes including length of stay, dislocation, infection, fracture, reoperation, and re-revision were collected. Statistical analysis was performed using chi-square test and Student's t-test for all categorical and continuous variables, respectively. RESULTS:One hundred forty-six rTHA cases (103 modular and 43 nonmodular) were identified with an average follow-up of 29 months (range 3-59 months). Nonmodular stems had a significantly lower cost when compared to modular implants (modular stems 120.8% higher cost; P < .001). The surgical time of nonmodular components was significantly greater (193 minutes vs 163 minutes; P = .029). There were no differences observed in any other surgical details or clinical outcomes assessed, including length of stay (P = .323), rate of re-revision of the femoral implant (P = .389), rate of re-operation (P = .383), and postop complications (P = .241), including infection (P = .095), dislocation (P = .778), and fracture (P = .959). CONCLUSIONS:Nonmodular components provide encouraging clinical results with significantly lower costs compared to modular implants in rTHA. The use of titanium, tapered-fluted, nonmodular components may offer a more cost-effective approach to rTHA compared to their modular counterparts.

Background/UNASSIGNED:There is a paucity of literature assessing whether payer type has an impact on postoperative patient-reported outcomes (PROs) after total knee arthroplasty (TKA). The aim of this study was to comparatively evaluate TKA PROs among patients with commercial and Medicare insurance. Methods/UNASSIGNED:We conducted a single-center, retrospective review of patients operated between January 2017 and March 2018. Knee Disability and Osteoarthritis Outcome Score Junior (KOOS-Jr) and Veterans RAND 12 Health Survey (VR-12) Physical Component (VR-12 PCS) and Mental Component (VR-12 MCS) PRO scores were collected prospectively at baseline and 12 weeks postoperatively via an electronic patient rehabilitation application. Univariable and multivariable linear regressions were utilized to assess the effects of patient insurance type on PRO. Results/UNASSIGNED:> .05). Conclusions/UNASSIGNED:After adjusting for patient-specific variables, PROs are similar at baseline and 12 weeks postoperatively between commercial and Medicare cohorts. For TKA candidates with similar baseline demographics, surgeons can expect similar perioperative PROs regardless of insurance type.

Oxinium is an alternative bearing surface designed to emulate the superior wear and scratch properties of ceramic femoral heads in total hip arthroplasty while minimizing the risk for brittle fracturing. However, recent studies have indicated that hip dislocation following total hip arthroplasty may be a risk factor for catastrophic failure of the femoral head. Here, we report on a novel case of a catastrophic Oxinium head and polyethylene liner failure in the absence of previous hip dislocation or trauma and review the probable failure mechanism. This report underscores the need to be vigilant about proper acetabular cup and liner seating, particularly in the setting of Oxinium femoral head use. In the event of Oxinium head failure, metallosis may compromise stabilizing soft tissues including the abductors. Dual-mobility articulation, which was successful in this case, is one option to consider when the risk for chronic redislocation is elevated.

Hip dislocation remains a major concern following total hip arthroplasty due to its high frequency and economic burden. This article evaluates the cost-effectiveness regarding dual mobility as an alternative to standard implant designs. A review of literature analyzing the PubMed Central database was undertaken using the following terms in the primary query: dual mobility, cost-effectiveness, cost-analysis, or economic analysis. Dual mobility systems may be a cost-effective alternative when the price of the implant does not exceed the traditional system by $1023. Dual mobility cups may be an essential component for the future success of value-based total hip arthroplasty.

BACKGROUND:The Bundled Payment Care Improvement (BPCI) initiative aims to improve quality of patient care while mitigating cost. How patient age and frailty affect reimbursement after hip and knee total joint arthroplasty (TJA) is not known. This study evaluates if patient age and frailty affect cost of care. METHODS:A retrospective review of prospectively collected data of 1821 patients undergoing TJA at our institution under the BPCI initiative was performed from 2013 to 2016. We recorded demographics for patients and calculated their modified frailty index (mFI). Cost of care was obtained for each patient. Statistical analyses included t-test and analysis of variance to evaluate age and frailty as independent categorical variables. Beta coefficients were utilized to evaluate age as a continuous variable. Multivariate linear regression models evaluated age and frailty's combined contribution to cost. RESULTS:Age was evaluated as a categorical variable, with the median age of our sample population the categorical cutoff. Age ≥72 years and increasing mFI score were associated with statistically significant increased cost. Increasing age demonstrated a statistically significant increase in cost of 0.68% per incremental age increase. Multivariate evaluation of increasing age and mFI revealed a statistically significant increase in cost for mFI score ≥2. CONCLUSION/CONCLUSIONS:Increasing age and frailty increase cost associated with TJA. The BPCI initiative over-simplifies the cost associated with TJA. Concerningly, this information could deincentivize care to older, higher risk patients. Objective patient-specific and risk-adjusted stratification of BPCI pricing is necessary to be considered as a valid financial model.

BACKGROUND:A better understanding of patient expectations within the perioperative setting will enable clinicians to better tailor care to the needs of the total hip arthroplasty (THA) recipient. Such an approach will promote patient-centered decision-making and optimize recovery times while enhancing mandated hospital quality metrics. In the present study, we preoperatively and postoperatively surveyed THA candidates to elucidate the relationship between patient expectations and length of stay (LOS). METHODS:This is a multi-institutional prospective study among THA candidates. Patients were surveyed regarding discharge planning 1 week preoperatively and postoperatively to capture perioperative patient expectations and correlate with inpatient LOS. RESULTS:In total, 93 THAs performed by 6 high-volume orthopedic surgeons at 2 medical centers. Our results demonstrated that patients of male gender and commercial insurance had significantly (P < .05) shorter LOS. Shorter LOS patients demonstrated significantly higher levels of LOS acceptance ("very comfortable" rate in same-day discharge: 75.0% and next-day discharge: 63.8%; 2 days: 40.7%; 3+ days: 42.9%; P < .05) and a higher likelihood to participate in SDD programs. Postoperatively, patients with a shorter LOS had more acceptance to their LOS, albeit not statistically significant (P = .20). CONCLUSION/CONCLUSIONS:Our results suggest that guiding patient expectations within the perioperative setting is an essential component for successful and timely discharge after THA. Having clear and transparent discussion with the surgical team regarding the perioperative course can improve a THA candidate's understanding and buy-in with the postoperative plan, regardless of LOS. Finally, inpatient LOS does not appear to affect patient satisfaction. LEVEL OF EVIDENCE/METHODS:Level II, prospective observational study.

BACKGROUND:The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score is a nationally standardized measure of a patient's inpatient experience. This study aims to assess whether HCAHPS scores differ between patients undergoing primary total joint arthroplasty (TJA) and patients undergoing revision TJA. METHODS:Patients who underwent primary or revision total hip or total knee arthroplasty (THA or TKA) and returned a completed HCAHPS survey were included in this study. HCAHPS scores were collected from our institution's Center for Quality and Patient Safety department, which was cross-referenced with our hospital's electronic data warehouse. Patient demographics, surgical factors, and quality outcomes were queried. Appropriate statistical analyses were performed using MatLab 2017a and P-values less than .05 were deemed significant. RESULTS:In total, 523 primary and 59 revision THA recipients completed HCAHPS surveys at our institution between October 2011 and November 2016. During this same period, 507 primary TKA recipients and 40 revision TKA recipients completed HCAHPS surveys. Compared to revision THA, primary THA patients had a significantly higher top box for overall hospital ratings (58.46% vs 41.38%), felt that nurses listened to them carefully (84.3% vs 72.88%), and felt that they clearly understood the role of each medication (69.48% vs 56.90%). Moreover, 18 of 20 HCAHPS question responses favored primary THA despite not reaching significance for the majority of HCAHPS questions. Patients with revision TKA demonstrated a significantly higher incidence of "top box" choices for quieter rooms and a trend favoring better HCAHPS scores in revision TKA in a further 12 of 20 HCAHPS responses. CONCLUSION/CONCLUSIONS:Patients undergoing primary THA report higher HCAHPS scores than those undergoing revision THA, while revision TKA demonstrated a general trend toward higher scores when compared to primary TKA patients. This publicly reported quality measurement metric which factors into physician reimbursement may be biased by the patient's health status, the complexity of the surgical procedure, and length of stay in hospital rather than a true reflection of the quality of their hospital experience.

BACKGROUND:As the clinical and financial environments of total joint arthroplasty (TJA) have evolved over the last several decades so has the role of the surgeon in providing this care to patients. Our objective was to examine current practices and influential factors among fellowship-trained arthroplasty surgeons. METHODS:An electronic survey was sent to all surgeons who had completed one of the three high-volume adult reconstruction fellowships from the years 2007-2016. The survey consisted of 34 questions regarding current practice characteristics, case volumes for primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA), use of advanced technologies, choice of surgical approach and implant design, factors influencing their choices, and their involvement in implant selection and contract negotiations. RESULTS:Questionnaires were sent to 53 surgeons; 52 were completed. Sixty percent of respondents performed at least 100 TKAs and 84% performed at least 50 THAs annually. Ninety-four percent use a single company's implant for more than 90% of primary TKA and THA. Fellowship or residency experience was the most significant influence on TKA and THA implant selection for 62% and 45% of surgeons, respectively, while contracts of their current institution were the primary influence for 17% and 12%, respectively. Fifty-five percent of surgeons used some advanced technology of which 16% said this influenced their implant choice. Eighty-six percent perform the majority of cases at centers performing at least 200 TJAs per year, and 39% participate in implant contract negotiations. CONCLUSION/CONCLUSIONS:Despite changes in the economic environment of TJA, this study demonstrates that experience with a specific implant during training, particularly fellowship, is the most influential factor for implant selection among fellowship-trained arthroplasty surgeons.

BACKGROUND:Short-stem (SS) hip prostheses for total hip arthroplasty (THA) have gained popularity as surgeons strive to reproduce physiological stress distributions at the proximal femur. Additionally, as THA indications continue to target younger populations, preservation of femoral bone stock for potential revision surgeries is particularly appealing. However, little is known regarding the short-term complications of each variety of short stem during the learning curve period. The purpose of this study is to evaluate the short-term complications among the THA recipients with the use of a novel SS hip prosthesis. METHODS:A retrospective chart review was performed of all patients undergoing primary THA utilizing an Echo Bi-Metric Microplasty hip stem. Patient demographics, surgical factors, complications and quality outcomes were collected utilizing our institution's data warehouse and verified by chart review. RESULTS:In total, 182 SSs were implanted in 168 patients undergoing primary THA. Of these, 5 (2.9%) patients sustained a periprosthetic fracture. Two fractures occurred during the index hospital admission, and 3 occurred in the post-discharge period. Subset analysis demonstrated that 4 (80%) fractures had occurred during the initial learning curve period, within the first 30 surgical cases with a SS. CONCLUSION/CONCLUSIONS:Short-stem hip prostheses are a safe alternative for THA. The results of the present study demonstrate a fracture incidence of 2.9% among patients. However, surgeons should remain cautious when utilizing new implant system and expect a learning curve. In this study, 80% of periprosthetic fractures following SS THA occurred within the first 30 cases for experienced arthroplasty-trained surgeons.