Faculty Bibliography

Surgical fixation is generally the treatment used for the repair of uncomplicated fractures of the hip. However, complications following the fixation of such fractures, such as nonunion, hardware failure, osteonecrosis, posttraumatic osteoarthritis, and infection may require salvage treatment with total hip arthroplasty. This systematic review article addresses the challenges of conversion to total hip arthroplasty after prior fixation of a hip fracture, and provides recommendations for minimizing complications related to such conversion

INTRODUCTION: Catastrophic polyethylene failure is a rare complication of ceramic-on-polyethylene total hip arthroplasty due to the favorable tribological characteristics of ceramic. Failure of the polyethylene liner can be disastrous, increasing periprosthetic osteolysis, metallosis, and risk of dislocation. Complications associated with ceramic-on-polyethylene articulations have been studied extensively, however, only few reports have described its catastrophic wear. We report such a case of complete wear of the acetabular liner in a ceramic-on-polyethylene prosthesis in a 57-year adult male. CASE REPORT: A 57-year adult male with a history of bilateral total hip arthroplasty presented to our institution with bilateral hip pain worst on the right. Range of motion was limited by pain on the right hip at the extremes of motion. Radiographs revealed severe osteolysis, heterotopic ossification, complete wear of the acetabular liner, bony impingement of the femoral greater trochanter on the acetabular rim and superior migration of the femoral head. All findings were confirmed intraoperatively. Revision of the acetabular components was performed, which successfully alleviated the patient's symptoms. CONCLUSION: Failure of the ceramic-on-polyethylene liner in our patient is due to the use of a non-cross linked polyethylene liner, a highly active lifestyle, and poor follow up. Arthroplasty surgeons should be aware of this complication especially in highly active patients with a conventional polyethylene liner and chronic hip pain.

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.

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.

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.

A 71-year-old female with a history of right total hip arthroplasty presented with an enlarging pseudotumor. Pseudotumor is a known complication following metal-on-metal and metal-on-conventional polyethylene and metal-on-highly cross-linked polyethylene implants. Revision total hip arthroplasty following resection of pseudotumor has resulted in an increase in incidence of postoperative complications. Despite stable implants, these complications arise from the amount of soft tissue damage combined with the loss of tissue support around the resected hip. Our case is a clear example of a major complication, recurrent dislocation, following resection and revision surgery.

Optimizing perioperative care to provide maximum benefit at minimum cost may be best achieved using a perioperative clinical pathway (PCP). Using our joint replacement surgical home (JSH) model PCP, we examined length of stay (LOS) following total joint arthroplasty (TJA) to evaluate patient care optimization. We reviewed a spectrum of clinical measurements in 190 consecutive patients who underwent TJA. Patients who had surgery earlier in the week and who were earlier cases of the day had a significantly lower LOS than patients whose cases started both later in the week and later in the day. Patients discharged home had significantly lower LOS than those discharged to a secondary care facility. Patients who received regional versus general anesthesia had a significantly lower LOS. Scheduling patients discharged to home and who will likely receive regional anesthesia for the earliest morning slot and earlier in the week may help decrease overall LOS.

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.