Faculty Bibliography

The objective of this study was to evaluate the efficacy of respiratory synchronized compression devices (RSCDs) versus nonsynchronized intermittent pneumatic compression devices (NSIPCDs) in preventing venous thromboembolism (VTE) after total joint arthroplasty. A systematic literature review was conducted. Data regarding surgical procedure, deep vein thrombosis, pulmonary embolism, mortality, and adverse events were abstracted. Compared with control groups, the risk ratio of deep vein thrombosis development was 0.51 with NSIPCDs and 0.47 with RSCDs. This review demonstrates that RSCDs may be marginally more effective at preventing VTE events than NSIPCDs. Furthermore, the addition of mechanical prophylaxis to any chemoprophylactic regimen increases VTE prevention.

Adverse local tissue reaction, osteolysis, and subsequent increased incidence of failure have been associated with metal-on-metal (MoM) total hip arthroplasty (THA). We present the case of a 68-year-old woman with rheumatoid arthritis who has undergone left THA with a MoM bearing. Seven years postoperatively, she presented with 6 weeks of severe left hip pain. Sequential radiographs and advanced imaging demonstrated a rapid onset of extensive acetabular osteolysis with pelvic discontinuity and pseudotumor formation. She underwent revision THA using a cup-cage construct with a satisfactory outcome. In this article, we review current evidence-based management options for pelvic discontinuity, as well as other complications related to MoM THA.

BACKGROUND: High body mass index (BMI) is associated with significant complications in patients undergoing total joint arthroplasty. Many studies have evaluated this trend, but few have looked at the rates of complications based on BMI as a continuous variable. The purpose of this study was to stratify obese patients into 3 BMI categories and evaluate their rates of complications and gauge whether transitioning from higher to lower BMI category lowers complication. METHODS: Patients undergoing primary total joint arthroplasty were selected from the National Surgical Quality Improvement Program database from 2008-2015 and arranged into 3 groups based on BMI: O1 (BMI 30-34.9 kg/m2), O2 (BMI 35-39.9 kg/m2), and O3 (BMI >40 kg/m2). Thirty-day complications were recorded and evaluated utilizing univariate and multivariate analyses stratified by BMI. RESULTS: A total of 268,663 patients were identified. Patients with a BMI >30 kg/m2 had more infectious and medical complications compared with nonobese patients. Furthermore, there were increased complications as the BMI categories increased. Patients with a BMI >40 kg/m2 (O3) had longer operating times, length of stay, higher rates of readmissions, reoperations, deep venous thrombosis, renal insufficiency, superficial infections, deep infections, and wound dehiscence. These trends were present when comparing the O2 with O1 category as well. CONCLUSION: We have demonstrated increased rates of medical and surgical complications in obese patients. Furthermore, we demonstrated a stepwise increase in complication rates when transitioning to higher BMI groups. Based on our data, we believe that preoperative counseling and interventions to decrease BMI should be explored before offering elective surgery to obese patients.

BACKGROUND: Irrigation and debridement with modular component and liner exchange (IDLE) is a low morbidity procedure for treatment of periprosthetic joint infection (PJI) with reported failure rates exceeding 50%. Dilute povidone-iodine lavage has been shown to be safe and effective in decreasing acute PJI in primary total joint arthroplasty. Vancomycin powder has also shown to be effective in preventing infection in spine surgery. We hypothesize that a vancomycin povidone-iodine protocol (VIP) used in conjunction with IDLE can increase infection-free survivorship after acute PJI. METHODS: This is a single institution retrospective review of all PJIs treated with IDLE and VIP since March 2014. A consecutive matched control group of patients treated with IDLE for PJI for 2 years prior to March 2014 was also included for analysis. Primary outcome was failure, defined as return to operating room for an infection-related problem. Secondary outcome was chronic suppression with antibiotics at final follow-up. Minimum follow-up was 1 year. RESULTS: A total of 36 patients in the VIP group and 38 patients in control group were identified. In the VIP group, 16.7% (6/36) failed at final follow-up compared to 37% failure rate (14/38) in the control group (P < .05). Three patients in the VIP group were on chronic antibiotic suppression at final follow-up. There were no medical complications secondary to the VIP. CONCLUSIONS: The VIP group demonstrated a significant reduction in reinfection and failure rate following IDLE. The authors believe that a VIP is an effective adjunct for treating PJI with irrigation and debridement.

BACKGROUND:The Bundled Payments for Care Improvement initiative was developed to reduce costs associated with total joint arthroplasty through a single payment for all patient care from index admission through a 90-day post-discharge period, including care at skilled nursing facilities (SNFs). The aim of this study is to investigate whether forming partnerships between hospitals and SNFs could lower the post-discharge costs. We hypothesize that institutionally aligned SNFs have lower post-discharge costs than non-aligned SNFs. METHODS:A cohort of 615 elective, primary total hip and knee arthroplasty subjects discharged to an SNF under the Bundled Payments for Care Improvement from 2014 to 2016 were included in our analysis. Patients were grouped into one of the 3 categories of SNF alignment: group 1: non-partners; group 2: agreement-based partners; group 3: institution-owned partners. Demographics, comorbidities, length of stay (LOS) at SNF, and associated costs during the 90-day post-operative period were compared between the 3 groups. RESULTS:Mean index hospital LOS was statistically shortest in group 3 (mean 2.7 days vs 3.5 for groups 1 and 2, P = .001). SNF LOS was also shortest in group 3 (mean 11 days vs 19 and 21 days in groups 2 and 1 respectively, P < .001). Total SNF costs and total 90-day costs were both significantly lower in group 3 compared with groups 1 and 2 (P < .001 for all), even after controlling for medical comorbidities. CONCLUSION/CONCLUSIONS:Institution-owned partner SNFs demonstrated the shortest patient LOS, and the lowest SNF and total 90-day costs, without increased risk of readmissions, compared with other SNFs.

Background/UNASSIGNED:The use of perioperative surgical wound dressings is an important factor in the mitigation of infection following total joint arthroplasty (TJA). Few studies have been published comparing wound dressings and infection rates after TJA. Methods/UNASSIGNED:MEDLINE, PubMed, and EMBASE were searched for studies published between 2006 and 2016 reporting infection rates in patients using various wound dressings after undergoing TJA. All studies comparing Hydrofibre dressings to Standard dressings or Absorbent dressings were included in this meta-analysis. Studies looking at TJA secondary to trauma were excluded. Two individuals independently extracted data, and study results were divided based on type of treatment. The primary outcome was to compare the infection rate of Hydrofibre dressings to that of both Standard Dressings and Absorbent dressings. Results/UNASSIGNED:Of a total of 3721 participants, 1483 were treated with Standard dressings (non-impregnated gauze), 1911 with Hydrofibre dressings, and 327 with Absorbent dressings. The risk ratio for infection comparing Standard with Hydrofibre was 4.16 (95% confidence interval, 1.71-10.16) as compared to 2.60 (95% confidence interval, 0.66-10.27) when comparing Absorbent with Hydrofibre dressings. Conclusions/UNASSIGNED:Our analysis suggests that Hydrofibre dressings may be significantly better than Standard and Absorbent dressings with respect to reducing infection. However, given the observed heterogeneity and small number of studies included, more comparative studies are needed to definitively recommend superiority among dressings following TJA. Level of Evidence/UNASSIGNED:Level 1.

Background/UNASSIGNED:We sought to develop an objective implant selection guideline based on the ratio of patient body mass index (BMI) to age in order to select implants preoperatively and reduce cost while maintaining quality. The BMI-to-age ratio can be used to distinguish patient demand and select those patients who may benefit from newer technology and higher cost implants and those who would do well with standard-demand implants. Methods/UNASSIGNED:A retrospective analysis investigated the types of implants received by patients undergoing total knee arthroplasty from January 2012 to August 2014. Patients with a BMI-to-age ratio >0.60 were categorized as high demand and were eligible for either a high-demand implant or a standard-demand implant. Patients with a BMI-to-age ratio ≤0.60 were recognized as standard demand and would be eligible for only standard-demand implants. The actual implant received was identified and compared with the implant as predicted by the BMI-to-age ratio and potential cost savings were identified. Results/UNASSIGNED:A total of 1507 operative knees were identified. The high-demand implant carries a 31% greater cost than that of a standard-demand implant. Thirty-eight of 1084 high-demand implants were placed in standard-demand knees. An additional 1.1% cost was realized with 38 standard-demand knees receiving high-demand implants and 28.6% if high-demand knees had been used in all standard-demand patients. Conclusions/UNASSIGNED:Limiting the use of high-demand implants to high-functional-demand patients based on the BMI-to-age ratio may guide the surgeon's choice in optimizing implant selection while providing value-based purchasing criteria to the selection of total knee arthroplasty implants.

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.