Faculty Bibliography

BACKGROUND:The effect of surgeon practice and patient care setting have not been studied in the Medicaid population undergoing total knee arthroplasty (TKA). This study aims to evaluate whether point of entry and Medicaid status affect outcomes following TKA. METHODS:The electronic medical record at our urban, academic, tertiary care hospital system was retrospectively reviewed for all primary, unilateral TKA during January 2016 and January 2018. Outpatient visits within the 6-month preoperative period categorized TKA recipients as either Hospital Ambulatory Clinic Centers patients with Medicaid insurance or private office patients with non-Medicaid insurers. RESULTS:There were 174 Medicaid patients and 317 non-Medicaid patients for 491 total patients. Medicaid patients were significantly younger (62.6 ± 1.6 vs 65.4 ± 1.1 years, P < .01), of "other' ethnicity (43.1% vs 25.6%, P < .01), and to be a current smoker (9.3% vs 6.6%, P = .02). There was no difference in gender, body mass index, and American Society of Anesthesiologists score. After controlling for patient factors, the Medicaid effect was insignificant for surgical time (exponentiated β 0.93, 95% confidence interval [CI] 0.86-1.01, P = .076) and facility discharge (odds ratio 1.58, 95% CI 0.71-3.51, P = .262). Medicaid status had a significant effect on length of stay (LOS) (rate ratio 1.21, 95% CI 1.02-1.43, P = .026). CONCLUSION/CONCLUSIONS:Multivariable analysis controlling for patient factors demonstrated that Medicaid coverage had minimal effect on surgical time and facility discharge. Medicaid patients had significantly longer LOS by one-half day. These results indicate that comparable outcomes can be achieved for Medicaid patients following TKA provided that the surgeon and care setting are similar. However, increased care coordination and preoperative education may be necessary to normalize disparities in hospital LOS. LEVEL OF EVIDENCE/METHODS:III, retrospective observational analysis.

AIMS/OBJECTIVE:Previous studies have reported an increased risk for postoperative complications in the Medicaid population undergoing total hip arthroplasty (THA). These studies have not controlled for the surgeon's practice or patient care setting. This study aims to evaluate whether patient point of entry and Medicaid status plays a role in quality outcomes and discharge disposition following THA. METHODS:The electronic medical record at our institution was retrospectively reviewed for all primary, unilateral THA between January 2016 and January 2018. THA recipients were categorized as either Medicaid or non-Medicaid patients based on a visit to our institution's Hospital Ambulatory Care Center (HACC) within the six months prior to surgery. Only patients who had been operated on by surgeons (CML, JV, JDS, RS) with at least ten Medicaid and ten non-Medicaid patients were included in the study. The patients included in this study were 56.33% female, had a mean age of 60.85 years, and had a mean BMI of 29.14. The average length of follow-up was 343.73 days. RESULTS:A total of 426 hips in 403 patients were included in this study, with 114 Medicaid patients and 312 non-Medicaid patients. Medicaid patients had a significantly lower mean age (54.68 years (SD 12.33) vs 63.10 years (SD 12.38); p < 0.001), more likely to be black or 'other' race (27.19% vs 13.46% black; 26.32% vs 12.82% other; p < 0.001), and more likely to be a current smoker (19.30% vs 9.29%; p = 0.001). After adjusting for patient risk factors, there was a significant Medicaid effect on length of stay (LOS) (rate ratio 1.129, 95% confidence interval (CI) 1.048 to 1.216; p = 0.001) and facility discharge (odds ratio 2.010, 95% CI 1.398 to 2.890; p < 0.001). There was no Medicaid effect on surgical time (exponentiated β coefficient 1.015, 95% CI 0.995 to 1.036; p = 0.136). There was no difference in 30-day readmission, 90-day readmission, 30-day infections, 90-day infections, and 90-day mortality between the two groups. CONCLUSION/CONCLUSIONS:2020;102-B(7 Supple B):78-84.

BACKGROUND:Total hip arthroplasty (THA) candidates have historically received high doses of opioids within the perioperative period; however, the amounts are being continually reduced as awareness of opioid abuse spreads. Here we seek to evaluate the effectiveness of a novel opiate-sparing protocol (OSP) for primary THAs in reducing opiate administrations, while maintaining similar levels of pain control and postoperative function. METHODS:All patients undergoing primary THA between January 1, 2019 and June 30, 2019 were placed under a novel OSP. Data were prospectively collected as part of standard of care. To assess the primary outcome of opiate consumption, nursing documented opiate administration events were converted into morphine milligram equivalences (MMEs) per patient encounter per 24-hour interval. Postoperative pain and functional status were assessed as secondary outcomes using the Verbal Rating Scale for pain and the Activity Measure for Post-Acute Care scores, respectively. RESULTS:One thousand fifty primary THAs had received our institution's OSP, and 953 patients were utilized as our historical control. OSP patients demonstrated significantly lower 0-24, 24-48, and 48-72 hours with less opiate administration variance (total MME: Control 75.55 ± 121.07 MME vs OSP 57.10 ± 87.48 MME; 24.42% decrease, P < .001). Although pain scores reached statistical significance between 0 and 12 (Control 2.09 vs OSP 2.36, P < .001), their differences were not clinically significant. Finally, OSP patients demonstrated a trend toward higher Activity Measure for Post-Acute Care scores across all 6 domains (total scores: Control 20.53 ± 3.67 vs OSP 20.76 ± 3.64, P = .18). CONCLUSION/CONCLUSIONS:Implementation of an OSP can significantly decrease the utilization of opioids in the immediate postoperative period. Inpatient opioid administration can be significantly reduced while maintaining a comparable and non-inferior level of pain and function.

Despite the evolution of blood management protocols, total knee arthroplasty (TKA) occasionally requires allogeneic blood transfusion. This poses a particular challenge for Jehovah's Witnesses (JW) who believe that the Bible strictly prohibits the use of blood products. The aim of this study was to compare JW and a matched-control cohort of non-JW candidates undergoing TKA to assess the safety using modern blood management protocols. Fifty-five JW patients (63 knees) who underwent TKA at our institution between 2005 and 2017 were matched to 63 non-JW patients (63 knees). Patient demographics, intraoperative details, and postoperative complications including in-hospital complications, revisions, and 90-day readmissions were collected and compared between the groups. Additionally, subgroup analysis was performed comparing JW patients who were administered tranexamic acid (TXA) between the two groups. Baseline demographics did not vary significantly between the study cohorts. The mean follow-up was 3.1 years in both the JW and non-JW cohorts. Postoperative complications, including in-hospital complications (7.9 vs. 4.8%; p = 0.47), revision TKA (1.6 vs. 1.6%; p = 1.00), and 90-day readmission (1.6 vs. 4.8%; p = 0.31) were not significantly different between the JW and non-JW groups. Subgroup analysis demonstrated JW patients who received TXA had a significantly lower decline in postoperative hemoglobin (Hgb) (8.6 vs. 14.0%; p < 0.01). At a follow-up of up to 12 years, JW patients who underwent TKA have outcomes equivalent to non-JW patients without the need for transfusion. Our findings support that surgeons are more likely to optimize JW patients preoperatively with iron and folate supplementation. Despite these variations in preoperative optimization efforts, no significant difference with regard to Hgb or hematocrit levels was demonstrated. Level of evidence is III, retrospective observational study.

BACKGROUND:Opioid addiction affects patients of every race, sex, and socioeconomic status. Overprescribing is a known cause of the opioid crisis. Various agencies have implemented requirements and programs to combat practitioner overprescribing; however, there can be adverse ethical consequences when regulations are used to influence physician behavior. We aimed to explore the ethical aspects of some of these interventions. METHODS:We reviewed various interventions for opioid prescribing through the lens of ethical inquiry. Specifically, we evaluated (1) requirements for educational programs for prescribers and patients, (2) prescription monitoring programs, (3) prescription limits, (4) development of condition-specific pain management guidelines, (5) increased utilization of naloxone, and (6) opioid disposal programs. We also evaluated patient satisfaction survey questions relating to pain. RESULTS:The present analysis demonstrated that the following regulatory interventions are ethically sound: requirements for educational programs for prescribers and patients, robust prescription monitoring programs that cross state lines, increased prescribing of naloxone for at-risk patients, development of condition-specific pain management guidelines, improvement of opioid disposal programs, and elimination of pain-control questions from patient satisfaction surveys. However, implementation of strict prescribing limits without accommodation for procedure and patient characteristics may have negative ethical consequences. CONCLUSIONS:Although the importance of addressing the current opioid crisis cannot be understated, as surgeons, we must examine ethical implications of any new regulations that affect musculoskeletal patient care.

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:Gastrointestinal (GI) complications following total joint arthroplasty (TJA) are uncommon but can be associated with substantial morbidity and mortality. The current literature on GI complications that warrant invasive procedures after TJA is lacking. This study reviews the incidence and outcomes of GI complications after TJA that went on to require invasive procedures. METHODS:All TJA patients at our institution between January 2012 and May 2018 who had GI complications requiring an invasive procedure within 30 days of TJA were identified and retrospectively chart reviewed. Descriptive statistics were used to evaluate these patients. RESULTS:Of 19,090 TJAs in a 6-year period, 34 patients (0.18%) required invasive procedures for GI complications within 30 days of the index surgery. Twenty-two (64%) of the required procedures were endoscopy for suspected GI bleeding. Within this cohort, aspirin was the most common thromboprophylaxis used (63.6% of patients) and smoking was more prevalent (9.1% current smokers) (P = .28). Of the remaining 12 GI procedures required, 75% were exploratory laparotomies, 44.4% of which were performed for obstruction. Three (33.3%) of the exploratory laparotomy patients died during the study period. CONCLUSION/CONCLUSIONS:GI complications necessitating surgical intervention after TJA are rare. Suspected GI bleeding is the most common indication for intervention and is typically managed endoscopically. Other complications, such as GI obstruction, often require more extensive intervention and open procedures. Though rare, GI complications following TJA can lead to detrimental outcomes, significant patient morbidity, and occasionally mortality; therefore, a heightened awareness of these complications is warranted.