Pain-management protocol aimed at reducing opioids following total knee arthroplasty does not negatively impact patient satisfaction.

BACKGROUND: Prior research has demonstrated that the prescription of opioid medications may be associated with the desire to treat pain in order to achieve favorable patient satisfaction. The purpose of the current study was to investigate the effect of decreased opioid prescribing following total knee arthroplasty (TKA) on survey-administered patient satisfaction scores. METHOD: This study is a retrospective review of prospectively collected survey data for patients who underwent primary elective TKA for the treatment of osteoarthritis (OA) between September 2014 and June 2019. All patients included had completed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) survey information. Patients were stratified into two cohorts based on whether their surgery took place prior to or subsequent to the implementation of an institutional-wide opioid-sparing regimen. RESULTS: Of the 613 patients included, 488 (80%) were in the pre-protocol cohort and 125 (20%) in the post-protocol cohort. Rate of opioid refills (33.6% to 11.2%; p < 0.001) as well as length of stay (LOS, 2.40 ± 1.05 to 2.13 ± 1.13 days; p = 0.014) decreased significantly after protocol change while rate of current smokers increased significantly (4.1% to 10.4%; p = 0.011). No significant difference was observed in "top box" percentages for satisfaction with pain control (Pre: 70.5% vs Post: 72.8%; p = 0.775). CONCLUSIONS: Protocols calling for reduced prescription of opioids following TKA resulted in significantly lower rates of opioid refills, and were associated with significantly shorter LOS, while causing no statistically significant deleterious changes in patient satisfaction, as measured by HCAPS survey. LOE: III. CLINICAL RELEVANCE: This study suggests that HCAPS scores are not negatively impacted by a reduction in postoperative opioid analgesics.

Hospital Revenue, Cost, and Contribution Margin in Inpatient Versus Outpatient Primary Total Joint Arthroplasty.

BACKGROUND: Removal of primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA) from the inpatient-only list has financial implications for both patients and institutions. The aim of this study was to evaluate and compare financial parameters between patients designated for inpatient versus outpatient total joint arthroplasty. METHODS: We reviewed all patients who underwent TKA or THA after these procedures were removed from the inpatient-only list. Patients were statistical significance into cohorts based on inpatient or outpatient status, procedure type, and insurance type. This included 5,284 patients, of which 4,279 were designated inpatient while 1,005 were designated outpatient. Patient demographic, perioperative, and financial data including per patient revenues, total and direct costs, and contribution margins (CMs) were collected. Data were compared using t-tests and Chi-squared tests. RESULTS: Among Medicare patients receiving THA, CM was 89.1% lower for the inpatient cohort when compared to outpatient (P < .001), although there was no statistical significance difference between cohorts for TKA (P = .501). Among patients covered by Medicaid or Government-managed plans, CM was 120.8% higher for inpatients receiving THA (P < .001) when compared to outpatients and 136.3% higher for inpatients receiving TKA (P < .001). CONCLUSION: Our analyses showed that recent costs associated with inpatient stay inconsistently match or outpace additional revenue, causing CM to vary drastically depending on insurance and procedure type. For Medicare patients receiving THA, inpatient surgery is financially disincentivized leaving this vulnerable patient population at a risk of losing access to care. LEVEL III EVIDENCE: Retrospective Cohort Study.

Discontinuation of the liposomal delivery of bupivacaine has no effect on pain management after primary total knee arthroplasty : no effect on pain scores, opioid consumption, or functional status.

AIMS: Liposomal bupivacaine (LB) as part of a periarticular injection protocol continues to be a highly debated topic in total knee arthroplasty (TKA). We evaluated the effect of discontinuing the use of LB in a periarticular protocol on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. METHODS: On 1 July 2019, we discontinued the use of intraoperative LB as part of a periarticular injection protocol. A consecutive group of patients who received LB as part of the protocol (Protocol 1) and a subsequent group who did not (Protocol 2) were compared. All patients received the same opioid-sparing protocol. Verbal rating scale (VRS) pain scores were collected from our electronic data warehouse and averaged per patient per 12-hour interval. Events relating to the opiate administration were derived as morphine milligram equivalences (MMEs) per patient per 24-hour interval. The Activity Measure for Post-Acute Care (AM-PAC) tool was used to assess the immediate postoperative function. RESULTS: A total of 888 patients received Protocol 1 and while 789 received Protocol 2. The mean age of the patients was significantly higher in those who did not receive LB (66.80 vs 65.57 years, p = 0.006). The sex, BMI, American Society of Anesthesiologists physical status score, race, smoking status, marital status, operating time, length of stay, and discharge disposition were similar in the two groups. Compared with the LB group, discontinuing LB showed no significant difference in postoperative VRS pain scores up to 72 hours (p > 0.05), opioid administration up to 96 hours (p > 0.05), or AM-PAC scores within the first 24 hours (p > 0.05). CONCLUSION: The control of pain after TKA with a multimodal management protocol is not improved by the addition of LB compared with traditional bupivacaine. Cite this article: Bone Joint J 2021;103-B(6 Supple A):102-107.

Incomplete Administration of Intravenous Vancomycin Prophylaxis is Common and Associated With Increased Infectious Complications After Primary Total Hip and Knee Arthroplasty.

BACKGROUND: Vancomycin is often used as antimicrobial prophylaxis in patients undergoing total hip or knee arthroplasty. Vancomycin requires longer infusion times to avoid associated side effects. We hypothesized that vancomycin infusion is often started too late and that delayed infusion may predispose patients to increased rates of surgical site infections and prosthetic joint infections. METHODS: We reviewed clinical data for all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients at our institution between 2013 and 2020 who received intravenous vancomycin as primary perioperative gram-positive antibiotic prophylaxis. We calculated duration of infusion before incision or tourniquet inflation, with a cutoff of 30 minutes defining adequate administration. Patients were divided into two groups: 1) appropriate administration and 2) incomplete administration. Surgical factors and quality outcomes were compared between groups. RESULTS: We reviewed 1047 primary THA and TKA patients (524 THAs and 523 TKAs). The indication for intravenous vancomycin usage was allergy (61%), methicillin-resistant staphylococcus aureus colonization (17%), both allergy and colonization (14%), and other (8%). 50.4% of patients began infusion >30 minutes preoperatively (group A), and 49.6% began infusion <30 minutes preoperatively (group B). Group B had significantly higher rates of readmissions for infectious causes (3.6 vs 1.3%, P = .017). This included a statistically significant increase in confirmed prosthetic joint infections (2.2% vs 0.6%, P = .023). Regression analysis confirmed <30 minutes of vancomycin infusion as an independent risk factor for PJI when controlling for comorbidities (OR 5.22, P = .012). CONCLUSION: Late infusion of vancomycin is common and associated with increased rates of infectious causes for readmission and PJI. Preoperative protocols should be created to ensure appropriate vancomycin administration when indicated.

Patient Satisfaction After Total Hip Arthroplasty Is Not Influenced by Reductions in Opioid Prescribing.

BACKGROUND: Opioids have played an important part in post-operative analgesia, but concerns with associated morbidity and the fate of leftover pills have prompted the creation of opioid-sparing protocols. The purpose of this study is to investigate the impact of the implementation of an opioid-sparing protocol on survey-based patient satisfaction scores following total hip arthroplasty (THA). METHODS: This study is a retrospective review of prospectively collected data on patients who underwent primary THA between November 2014 and July 2019. Inclusion criteria consisted of primary elective THA with complete Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey information. Cohorts were separated based on their date of surgery relative to the start of an institutional opioid-sparing-protocol in October 2018. Discharge prescriptions and refills were recorded on chart review and converted to milligram morphine equivalents (MME) for comparison between different opioids. HCAHPS results were analyzed for percentage of "top box" ratings for comparison between the 2 groups. RESULTS: In total, 1003 patients met inclusion criteria: 804 pre-protocol and 199 post-protocol. Mean length of stay decreased from 1.74 ± 1.03 to 1.50 ± 1.11 days (P < .001). Pre-operative Visual Analog Scale pain decreased from 7.00 ± 2.30 to 6.41 ± 2.66 (P = .011) as did the rate of opioid refills (15.6%-9.1%; P = .019). Quantity of opioid medication prescribed upon discharge also decreased from 432 ± 298 to 114 ± 156 MME (P < .001). There was no change in "top box percentages" for satisfaction with pain control (79.7% pre-protocol, 82.1% post-protocol; P = .767). There was a significant increase in proportion of patients reporting top box satisfaction with their overall surgical experience after protocol implementation (88.2%-94.0%; P = .018). CONCLUSION: A reduction in opioids prescribed after THA is not associated with a decrease in patient satisfaction with regard to pain control, as measured by the HCAHPS survey, nor is it associated with an increase in post-operative opioid refills. LOE: III. CLINICAL RELEVANCE: This study suggests that HCAHP scores are not negatively impacted by a reduction in post-operative opioid analgesics.

Utilization of a Novel Opioid-Sparing Protocol in Primary Total Hip Arthroplasty Results in Reduced Opiate Consumption and Improved Functional Status.

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: 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.

Modifying Patient Expectations Can Enhance Total Hip Arthroplasty Postoperative Satisfaction.

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: 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: Level II, prospective observational study.

Creation of an Online Wiki Improves Post-Operative Surgical Protocol Adherence in Arthroplasty Patients.

BACKGROUND: Perioperative care pathways are tools used in high-volume clinical settings to standardize care, reduce variability, and improve outcomes. However, the mechanism by which the information is transmitted to other caregivers is often inconsistent and error-prone. At our institution, we developed an online, user-editable ("wiki") database to communicate post-operative protocols. The purpose of this study is to evaluate the hypothesis that implementation of the wiki would improve protocol adherence and reduce unintentional deviations inpatient care. METHODS: We conducted a retrospective review of patients who underwent primary lower extremity arthroplasty at our institution during three 6-month time periods including immediately before, 6 months after, and 2 years following introduction of the wiki. Adherence to defined perioperative care pathways (laboratory studies, post-operative imaging, perioperative antibiotics, and inpatient pain medications) was compared between the groups. RESULTS: After wiki implementation, adherence to protocols improved significantly for laboratory orders (P < .0001), imaging (P < .001), pain control regimen (P = .03), and overall protocol adherence (P < .001). Improvements were seen in some areas almost immediately, while others did not show improvements until 2 years after implementation. Costs associated with unnecessary testing were reduced by 82%. CONCLUSION: Development of an online wiki for tracking post-operative protocols improves care pathway adherence and reduces variability in care while lowering costs associated with unnecessary testing, although some benefits may not be immediately realized. Several practical barriers to implementing the wiki are also discussed, along with proposed solutions.

Hemiarthroplasty for Displaced Femoral Neck Fractures in the Elderly Has a Low Conversion Rate.

BACKGROUND: Hemiarthroplasty (HA) has been a mainstay treatment for displaced femoral neck fractures for many years. The purpose of this study was to report the conversion rate of HA to total hip arthroplasty (THA) for displaced femoral neck fractures and compare outcomes between implant constructs (bipolar vs unipolar), fixation options (cemented vs cementless stems), and age groups (<75 years vs ≥75 years). METHODS: We retrospectively reviewed the results of a consecutive cohort of 686 patients who underwent HA for the treatment of femoral neck fractures at our institution between 1999 and 2013 with a minimum of 2-year follow-up. RESULTS: The overall component revision rate, including conversion to THA, revision HA, revision with open reduction internal fixation, and Girdlestone procedure, was 5.6% (39/686). Seventeen patients (2.5%) were converted from HA to THA at an average of 1.9 years after index procedure. A significantly lower conversion rate of 1.4% (7/499 patients) was found in the older patient cohort (≥75 years old) compared to 5.3% (11/187) in the younger cohort. The most common causes for conversion surgery to THA were acetabular wear (5 patients), aseptic loosening (4 patients), and periprosthetic fracture (3 patients). There was a significantly lower rate of periprosthetic fracture (0.4% vs 2.5%, P value .025) in the cemented implant group compared to the cementless group. We observed a higher rate of dislocations in the bipolar vs unipolar group (3.8% vs 1%, P value .02) and no other significant differences between these groups. CONCLUSION: We observed a low reoperation rate for this cohort of patients, relatively higher conversion rates for the younger population, fewer periprosthetic fractures with the use of cemented stems, and no advantage of bipolar over unipolar prostheses.

Is Physician Quality Reporting System Worth the Cost to Report to Center for Medicare and Medicaid Services?

BACKGROUND: The Center for Medicare and Medicaid Services (CMS) has proposed a move to payment based on patient-reported outcomes (PROs), and failure to report on PROs will result in a penalty of 2% in 2016. However, the cost to the physician to collect PROs is not known. METHODS: Using data from the 2013 Medical Group Management Association Compensation and Financial survey and Center for Medicare and Medicaid Services reimbursement, a calculation was performed to determine the cost to the physician to report on PROs for patients undergoing total knee arthroplasty and total hip arthroplasty. Using Medical Group Management Association and Medicare fee for service rates, calculations were performed based on an annual volume of 200 Medicare operative cases (125 total knee arthroplasties, 75 total hip arthroplasties) with 1000 new patients (level 4) and 2000 established patients (level 3) visits. A range of start-up and annual costs necessary to collect PROs including hardware, software, and personnel costs was calculated and then compared with the calculated 2% Medicare penalty for failing to report PROs in 2016. RESULTS: The cost to collect PROs ranged from $47,973 to $56,288 which far outweighed the penalty of $2954 in 2016 for failing to report these measures. CONCLUSION: With the move toward requiring surgeons to report PROs for reimbursement, the current financial model would prove to be cost prohibitive and the incentive to report PROs might be too costly to gain wide acceptance.

Own the Bone, a System-Based Intervention, Improves Osteoporosis Care After Fragility Fractures.

BACKGROUND: The goal of this study was to evaluate the effectiveness of the American Orthopaedic Association's Own the Bone secondary fracture prevention program in the United States. METHODS: The objective of this quality improvement cohort study was dissemination of Own the Bone and implementation of secondary prevention (osteoporosis pharmacologic and bone mineral density [BMD] test recommendations). The main outcome measures were the number of sites implementing Own the Bone and implementation of secondary prevention, i.e., orders for BMD testing and/or pharmacologic treatment. The 177 sites participating in the program were academic and community hospitals, orthopaedic surgery groups, and a health system; data were obtained from the first 125 sites utilizing its registry, between January 1, 2010, and March 31, 2015. It included all patients, aged 50 years or older, presenting with fragility fractures (n = 23,132) who were enrolled in the Own the Bone web-based registry. The interventions were education, development of program elements, dissemination, implementation, and evaluation of the Own the Bone program at participating sites. RESULTS: A growing number of institutions implemented Own the Bone (14 sites in 2005-2006 to 177 sites in 2015). After consultation, 53% of patients had a BMD test ordered and/or pharmacologic therapy for osteoporosis. CONCLUSIONS: The Own the Bone intervention has succeeded in improving the behaviors of medical professionals in the areas of osteoporosis treatment and counseling, BMD testing, initiation of pharmacotherapy, and coordination of care for patients who have experienced a fragility fracture.

The Cemented Unipolar Prosthesis for the Management of Displaced Femoral Neck Fractures in the Dependent Osteopenic Elderly.

BACKGROUND: Significant variability exists across orthopedic surgeons in the management of the displaced femoral neck fracture in the elderly patient (>75 years old). These patients tend to be less healthy, have inferior bone quality, and gait instability leading to increased risk of periprosthetic fracture, compromised implant fixation, dislocation, and need for revision. The surgeon's goals should be to restore mobility while eliminating pain and need for reoperation. METHODS: In this review article, we examine the best available evidence in the literature to determine which strategy achieves optimal outcomes. We examine outcome studies comparing use of hemiarthroplasty and total hip arthroplasty, unipolar and bipolar hemiarthroplasty, and cemented vs cementless fixation of femoral stems. RESULTS AND CONCLUSIONS: For the active, healthy, and lucid patient, or one who has preexisting groin pain, who sustains a displaced femoral neck fracture, the literature supports a total hip arthroplasty. Patients sustaining a displaced femoral neck fracture and who are less active, have decreased bone mass, and are at increased risk of falls would benefit most from a device that optimally balances the need for revision surgery, restores ambulation, and eliminates pain. Thus, the current evidence favors cemented, unipolar hemiarthroplasty for the dependent osteopenic elderly patient with a displaced femoral neck fracture.

Current controversies in partial knee arthroplasty.

Partial knee arthroplasty has enjoyed renewed interest during the past decade. It is helpful to be familiar with the classic and current indications, contraindications, and technical aspects of partial knee arthroplasty, including patellofemoral, medial unicompartmental, and lateral unicompartmental knee arthroplasty. Various implant choices for partial knee arthroplasty can be compared and evaluated based on patient characteristics, design qualities, and reported outcomes. It is also helpful to review the indications and techniques for performing medial or lateral unicompartmental knee arthroplasty in combination with arthroscopically assisted reconstruction of the anterior cruciate ligament.

Early adverse results with bicompartmental knee arthroplasty: a prospective cohort comparison to total knee arthroplasty.

This prospective cohort study compares functional outcomes of bicompartmental knee arthroplasty (BKA) and total knee arthroplasty (TKA) in patients with osteoarthritis (OA) of the patellofemoral and medial compartments. Eligibility criteria included bicompartmental OA with less than grade 2 OA in the lateral compartment and intact cruciate ligaments. Fifty-six patients met eligibility criteria (21 BKA, 33 TKA). Enrolled participants completed Short-Form 12 and Western Ontario and McMaster Universities Osteoarthritis Index assessments at baseline and postoperatively at 3 months, 1 year, and 2 years. In the early postoperative period, the BKA cohort had significantly less pain (P = .020) and better physical function (P = .015). These trends did not continue past 3 months. When adjusting for age, sex, body mass index, and preoperative status, only 3-month Western Ontario and McMaster Universities Osteoarthritis Index stiffness scores significantly differed between cohorts (P = .048). Despite less early stiffness in the BKA cohort, a significantly higher BKA complication rate (P = .045) has led us to recommend TKA for patients with this pattern of OA.

The effect of fixation technique on the stiffness of comminuted Vancouver B1 periprosthetic femur fractures.

The purpose of this study was to evaluate the stiffness of 3 different constructs for the fixation of comminuted Vancouver B1 periprosthetic femoral shaft fractures: a single lateral locking plate, a single lateral locking plate plus an anterior strut allograft, and a lateral locking plate plus an anterior locking plate. The axial stiffness, lateral bending stiffness, and torsional stiffness of 10 synthetic periprosthetic femur fracture models were tested. Differences in stiffness between constructs were determined with a 1-way repeated-measures analysis of variance. Fixation technique was found to have a significant effect for all loading modalities (P < .0001). A lateral locked plate plus an anterior locked plate was significantly stiffer than the allograft that in turn was significantly stiffer than the single plate (P < .0001).

Blood conservation in primary total hip arthroplasty.

Total hip arthroplasty is characterized by significant blood loss. The principal aim of blood management in joint replacement surgery is to minimize both the risks associated with surgical blood loss and the risks associated with allogenic blood transfusion. In the 1980s, the AIDS epidemic triggered the development of a variety of innovative approaches to conserving blood and reducing the need for allogenic transfusion to replace surgical blood loss. Subsequently, the safety of the blood supply was dramatically improved, changes in surgical technique led to decreased surgical blood loss, and changes in transfusion thresholds made the need for transfusion less common. The review re-examines the options available for the management of blood loss in total joint replacement and defines parameters that can be used preoperatively to predict which patients are likely to benefit from these interventions, given the clinical realities of the 21st century.