Faculty Bibliography

The geometry of the intercondylar box plays a significant role in the development of patellar clunk syndrome. We reviewed the incidence of patella clunk at mid-to-long-term follow-up of a rotating high-flex versus fixed bearing posterior stabilized TKA design. 188-mobile and 223-fixed bearing TKAs were reviewed for complications, incidence of patellar clunk, treatment, recurrence rates, range of motion, and patient satisfaction. Patellar clunk developed in 22 knees in the mobile (11.7%) and in 4 (1.8%) in the fixed bearing group (P<0.001). 23 out of 26 cases resolved with a single arthroscopic treatment and 2 resolved with a second procedure. The mean postoperative range of motion was 122.4 degrees . All but one patient reported overall satisfaction with the index procedure. In contrast with other recent studies we found a significant incidence of patellar clunk in high-flex mobile bearings. Despite the high rate of patellar clunk syndrome, overall patients did well and were satisfied with their outcomes.

Length of stay (LOS) after total joint arthroplasty (TJA) impacts the expense to the hospital. Our purpose was to evaluate the impact that day of surgery has on postoperative LOS. 547 patients who had a primary TJA at two tertiary care hospitals were identified retrospectively. TJA patients admitted on day of surgery and who had primary elective surgery were included in our sample. Patients were subdivided into one of four groups: those who had operations on Monday, Tuesday, Thursday, and Friday respectively. Patients who had surgery on Thursday and Friday had significantly longer LOS when compared to Monday and Tuesday. This variation in LOS between the groups may be due to inconsistencies in weekend functionality, less experienced part-time staffing, and inaccessibility of rehabilitation personnel.

This study investigated the impact of metabolic syndrome (MetS) on perioperative and postoperative complication rates: the results of a cohort of 168 total hip and knee arthroplasties, 63 of normal weight, 105 with obesity without risk factors for metabolic syndrome and 39 with obesity and other factors that classify them with metabolic syndrome. Patients with metabolic syndrome were more likely to have complications than those without metabolic syndrome (P=0.0156). Perioperative and postoperative complication rates for the MetS and control groups were 35.9% and 16.3%, respectively. Elevated BMI was the element of MetS that had the largest impact on post-surgical complication rates, and this was statistically significant (P=0.0028). The presence of MetS in patients undergoing total joint arthroplasty has a significant impact on surgical complication rates. This cannot be attributed to the BMI component alone, and may help guide efforts of patient optimization prior to total joint arthroplasty.

As health care organizations adapt to more accountable financial models, it is increasingly important to assess how patients value new technologies, and their willingness to contribute to their cost. A questionnaire described features of a 'standard' implant including its longevity and risk of complications. We asked if participants would be willing to contribute to the cost of 3 novel implants with differing longevity and risk of complications. Our cohort included 195 patients, 45% were willing to add a co-pay to increase the longevity. Willingness to pay decreased to 26% with increased risk of complications, and 29% were willing to pay for a decreased risk of complications. Patients with higher education level, private insurance and males were more willing to contribute for a novel prosthesis. This study demonstrated that 26%-45% of patients are willing to share costs of a novel prosthesis. Willingness to pay was associated with the proposed implant benefits and with patient characteristics.

While total knee arthroplasty (TKA) has been shown to have excellent outcomes, a significant proportion of patients experience relatively poor post-operative function. In this study, we test the hypothesis that the level of osteoarthritic symptoms in the contralateral knee at the time of TKA is associated with poorer post-operative outcomes in the operated knee. Using longitudinal cohort data from the Osteoarthritis Initiative (OAI), we included 171 patients who received a unilateral TKA. We compared pre-operative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores in the contralateral knee to post-operative WOMAC scores in the index knee. Pre-operative contralateral knee WOMAC scores were associated with post-operative index knee WOMAC Total scores, indicating that the health of the pre-operative contralateral knee is a significant factor in TKA outcomes.

Discharge destination to skilled nursing facilities (SNF) following total joint arthroplasty (TJA) plays an important role in healthcare costs. The pre-operative, intra-operative, and post-operative factors of 50 consecutive patients discharged to an SNF following TJA were compared to that of 50 consecutive patients discharged to home. Patients discharged to SNFs had slower pre-operative Get Up and Go scores (TGUG), lower pre-operative EQ-5D scores, higher ASA scores, increased hospital length of stay, increased self-reported post-operative pain, and decreased physical therapy achievements. We believe that the results of this study indicate that patients who get discharged to SNFs fit a certain criteria and this may be used to guide post-operative discharge destination during pre-operative planning, which can help lower costs while helping decrease the length of inpatient stay.

The Patient Protection and Affordable Care Act (PPACA) is expected to increase health care availability through Medicaid expansion. The objective of this study was to evaluate potential effects of the PPACA by examining access to total hip arthroplasty in Southern California. 39 orthopaedic surgeons were called to schedule a hip arthroplasty. Insurances used included a Preferred Provider Organization (PPO), Medicare, and three income-based insurances. There was a significant difference in acceptance rate when comparing PPO and Medicare patients with income-based insurances (P < 0.001). This study showed that in Southern California, patients with income-based insurances are limited in the number of surgeons from whom they can receive care. Thus, although the PPACA will increase the number of insured patients, it may not similarly increase access to providers.

We hypothesized that a postoperative clinical telemedicine tool will be effective in reducing the total number of unscheduled postoperative clinic visits and calls while increasing patient satisfaction. The medical charts of 34 patients who underwent telemedicine follow-up during their postoperative care were compared to that of 44 patients who did undergo telemedicine follow-up. There were 14 unscheduled clinic visits in the non-telemedicine follow-up group compared to only 3 in the telemedicine follow-up group (P = 0.01). There were 40 in-clinic calls made by patients in the non-telemedicine follow-up group compared to only 6 made by patients in the telemedicine group (P < 0.01). In addition, patients who underwent telemedicine follow-up rated their postoperative satisfaction higher than those who did not undergo telemedicine follow-up.

BACKGROUND: The perioperative setting in the United States is noted for variable and fragmented care that increases the chance for errors and adverse outcomes as well as the overall cost of perioperative care. Recently, the American Society of Anesthesiologists put forward the Perioperative Surgical Home (PSH) concept as a potential solution to this problem. Although the PSH concept has been described previously, "real-life" implementation of this new model has not been reported. METHODS: Members of the Departments of Anesthesiology and Perioperative Care and Orthopedic Surgery, in addition to perioperative hospital services, developed and implemented a series of clinical care pathways defining and standardizing preoperative, intraoperative, postoperative, and postdischarge management for patients undergoing elective primary hip (n = 51) and knee (n = 95) arthroplasty. We report on the impact of the Total Joint Replacement PSH on length of hospital stay (LOS), incidence of perioperative blood transfusions, postoperative complications, 30-day readmission rates, emergency department visits, mortality, and patient satisfaction. RESULTS: The incidence of major complication was 0.0 (0.0-7.0)% and of perioperative blood transfusion was 6.2 (2.9-11.4)%. In-hospital mortality was 0.0 (0.0-7.0)% and 30-day readmission was 0.7 (0.0-3.8)%. All Surgical Care Improvements Project measures were at 100.0 (93.0-100.0)%. The median LOS for total knee arthroplasty and total hip arthroplasty, respectively, was (median (95% confidence interval [interquartile range]) 3 (2-3) [2-3] and 3 (2-3) [2-3] days. Approximately half of the patients were discharged to a location other than their customary residence (70 to skilled nursing facility, 1 to rehabilitation, 39 to home with organization health services, and 36 to home). CONCLUSIONS: We believe that our experience with the Total Joint Replacement PSH program provides solid evidence of the feasibility of this practice model to improve patient outcomes and achieve high patient satisfaction. In the future, the impact of LOS on cost will have to be better quantified. Specifically, future studies comparing PSH to traditional care will have to include consideration of postdischarge care, which are drivers of the perioperative costs.