Prior Authorization Leads to Administrative Burden and Delays in Treatment in Primary Total Joint Arthroplasty Patients.

BACKGROUND: The prior authorization (PA) process is often criticized by physicians due to increased administrative burden and unnecessary delays in treatment. The effects of PA policies on total hip arthroplasty (THA) and total knee arthroplasty (TKA) have not been well described. The purpose of this study was to analyze the use of PA in a high-volume orthopaedic practice across 4 states. METHODS: We prospectively collected data on 28,725 primary THAs and TKAs performed at our institution between 2020 and 2023. Data collected included patient demographics, payer approval or denial, time to approval or denial, the number of initial denials, the number of peer-to-peer (P2P) or addenda, and the reasons for denial. RESULTS: Seven thousand five hundred twenty eight (56.4%) patients undergoing THA and 8,283 (54%) patients undergoing TKA required PA, with a mean time to approval of 26.3 ± 34.6 and 33.7 ± 41.5 days, respectively. Addenda were requested in 608 of 7,528 (4.6%) THA patients and 737 of 8,283 (8.9%) TKA patients. From a total of 312 (4.1%) THA patients who had an initial denial, a P2P was requested for 50 (0.7%) patients, and only 27 (0.4%) were upheld after the PA process. From a total of 509 (6.1%) TKA patients who had an initial denial, a P2P was requested for 55 (0.7%) patients, and only 26 (0.3%) were upheld after the PA process. The mean time to denial in the THA group was 64.7 ± 83.5, and the most common reasons for denial were poor clinical documentation (25.9%) and lack of coverage (25.9%). The mean time to denial in the TKA group was 63.4 ± 103.9 days, and the most common reason for denial was not specified by the payer (46.1%). CONCLUSIONS: The use of PA to approve elective THA and TKA led to increased surgical waiting times and a high administrative burden for surgeons and healthcare staff.

Outcomes of Metaphyseal Cones and Stem Fixation Following Rotating Hinge in Complex Primary and Revision Total Knee Arthroplasty.

BACKGROUND: Although hinged prostheses have been used successfully in complex revision total knee arthroplasty (TKA), concerns exist regarding early failure due to aseptic loosening and other mechanical complications. The use of metaphyseal cones and hybrid cement fixation have been studied in unlinked constrained primary or revision TKA, but their impact on the survivorship of hinged prostheses has yet to be investigated. METHODS: We identified a consecutive series of 164 hinged prostheses and collected data on demographics, indications, complications, and re-revisions in patients who had fully cemented versus hybrid stems, with and without metaphyseal cones. A multivariate analysis was performed to identify independent variables associated with re-revision as the primary end point. RESULTS: In total, 84 patients (51.2%) had fully cemented stems, and 80 patients (48.8%) had hybrid stems. Cones were used in 73 patients (44.5%). At a mean follow-up of 3.4 ± 2.2 years, 42 patients underwent re-revision (25.8%), most commonly for infection (12.2%), followed by loosening (6.7%) and periprosthetic fracture (3.7%). Patients who had fully cemented stems had lower re-revision rates than hybrid fixation constructs (19 versus 26%, P = .043). Using multivariable regression, a construct with hybrid fixation with cones (odds ratio = 2.39; P = .037) was an independent risk factor for failure. Utilization of cones alone did not have an effect on re-revision rates at 3.4-year follow-up. CONCLUSIONS: While we found no difference with the use of cones, patients undergoing revision TKA with a hinge prosthesis and fully cemented stems had better overall survivorship than hybrid stems.

Routine Preoperative Dental Clearance for Total Joint Arthroplasty: Is There a Benefit?

Background Periprosthetic joint infections (PJIs) place significant psychological and financial burdens on patients and healthcare systems. One measure to reduce the risk of PJIs is preoperative dental screening, for which there is no current consensus recommendation. This study aims to determine whether there is a difference in the rate of PJI and microorganism profile in patients who did and did not obtain preoperative dental clearance. Methodology A retrospective review was conducted among patients undergoing primary total hip arthroplasty and total knee arthroplasty from 2017 to 2021. A cohort of 8,654 patients who underwent routine dental clearance was matched with a cohort of patients who did not. Surgeons who changed their dental clearance protocol were also identified, and the rates of PJIs were compared before and after. Results No statistically significant difference was seen in the rate of PJIs between patients who did and did not undergo routine preoperative dental clearance. No statistically significant difference was seen in the rate of PJIs before and after for surgeons who changed their dental clearance protocol. The microorganism profile between the groups was also found to be without differences. Conclusions Eliminating dental clearance from routine preoperative clearance does not appear to increase the rates of acute PJIs following elective total joint arthroplasty (TJA) or to change the organism profile of the infections that did occur. It may be reasonable to not require routine preoperative dental clearance or to practice selective dental clearance in patients undergoing elective TJA, especially given the increased financial cost and delay in care experienced by patients.

The Dome Technique for Managing Massive Anterosuperior Medial Acetabular Bone Loss in Revision Total Hip Arthroplasty: Short-Term Outcomes.

Purpose: The dome technique is a technique used in performance of revision total hip arthroplasty (THA) involving intraoperative joining of two porous metal acetabular augments to fill a massive anterosuperior medial acetabular bone defect. While excellent outcomes were achieved using this surgical technique in a series of three cases, short-term results have not been reported. We hypothesized that excellent short-term clinical and patient reported outcomes could be achieved with use of the dome technique. Materials and Methods: A multicenter case series was conducted for evaluation of patients who underwent revision THA using the dome technique for management of Paprosky 3B anterosuperior medial acetabular bone loss from 2013-2019 with a minimum clinical follow-up period of two years. Twelve cases in 12 patients were identified. Baseline demographics, intraoperative variables, surgical outcomes, and patient reported outcomes were acquired. Results: The implant survivorship was 91% with component failure requiring re-revision in only one patient at a mean follow-up period of 36.2 months (range, 24-72 months). Three patients (25.0%) experienced complications, including re-revision for component failure, inter-prosthetic dual-mobility dissociation, and periprosthetic joint infection. Of seven patients who completed the HOOS, JR (hip disability and osteoarthritis outcome score, joint replacement) survey, five patients showed improvement. Conclusion: Excellent outcomes can be achieved using the dome technique for management of massive anterosuperior medial acetabular defects in revision THA with survivorship of 91% at a mean follow-up period of three years. Conduct of future studies will be required in order to evaluate mid- to long-term outcomes for this technique.

A Video Teaching Tool Is Effective for Training Residents in Hip Arthroplasty Templating.

Work hour restrictions imposed on orthopedic surgery residents since the early 2000s have reduced educational opportunities at the workplace and encouraged alternative strategies for teaching outside the clinical setting. Preoperative templating is essential for safe and effective total hip arthroplasty (THA) and is accurate in predicting final implants. We sought to determine the effectiveness of a video tool for teaching orthopedic residents basic THA templating skills. We developed a video-based teaching tool with instructions on proper THA templating techniques. Ten cases were selected for testing, after excluding patients with severe hip deformities and poor-quality radiographs and only retaining those with concordance between templating by the senior authors and implanted components. The study subjects included three postgraduate year 1 (PGY-1), three PGY-2, and three PGY-5 residents, and three adult reconstruction fellows (PGY-6). Templating skills were assessed before and after watching the instructional video. The evaluation included the size and positioning of femoral and acetabular components, as well as the restoration of leg length. Each templating session was repeated twice. Variance was measured to evaluate consistency in measurements. A linear mixed model and F-test were used for statistical analyses. The number of years in training significantly affected performance prior to exposure to the instructional video. Post-exposure, there was a significant improvement in the accuracy of sizing and positioning of acetabular and femoral components for PGY-1, PGY-2, and PGY-5 residents. The results achieved were comparable to PGY-6 examiners, who did not gain substantial performance benefits from the instructional video. Limb length restoration was less affected by experience or exposure to the video. Component positioning and sizing, as well as leg length discrepancy (LLD), showed a significant decrease in variance after the intervention in all study groups. Video learning is reliable in teaching invaluable skills to orthopedic surgery residents without encroaching on work hours. We conceived a concise video to train orthopedic residents to perform THA templating with proper technique and demonstrated its efficiency and reproducibility.

Systemic Manifestation of Periprosthetic Joint Infection Is Associated With Increased In-Hospital Mortality.

Introduction Periprosthetic joint infection (PJI) is one of the most devastating complications of total joint arthroplasty. Systemic symptoms of infection may indicate a patient who is at a higher risk of serious complications. The goal of this study was to determine if systemic symptoms of infection in the setting of PJI were associated with greater in-hospital mortality. Materials and methods We used our institutional database to identify all patients urgently treated for deep PJI from 2002-2012. Records were reviewed to collect demographics, surgical data, vital signs prior to surgical intervention, blood and intraoperative culture results, preoperative intensive care unit (ICU) admissions, and deaths that occurred during the hospital admission. Patients were classified as having systemic inflammatory response syndrome (SIRS) based on the criteria established by the American College of Chest Physicians and the Society of Critical Care Medicine. Results During the 10-year timeframe of our study, 484 patients were treated emergently for deep infection, with 130 (27%) meeting SIRS criteria preoperatively and 31 (6%) of the patients with SIRS having positive blood cultures. Patients with positive blood cultures and SIRS demonstrated a higher in-hospital mortality rate (p < 0.001). Neither SIRS nor SIRS with positive blood cultures were associated with ICU admission. Discussion Occasionally, PJI can spread beyond the affected joint, showing physical symptoms of systemic illness and bacteremia. This study demonstrates that patients with SIRS and positive blood cultures are at an increased risk of in-hospital mortality. These patients should be monitored closely before definitive treatment in order to minimize their mortality risk.

Complications and Mortality Following Total Hip Arthroplasty in the Octogenarians: An Analysis of a National Database.

BACKGROUND: As advances in medicine have increased life expectancy, more octogenarians are undergoing total hip arthroplasty (THA) than ever before. Concerns exist, however, about the safety of performing this elective procedure in this age group. The purpose of this study is to determine the 30-day complications associated with THA patients over 80 years of age and to identify high-risk patients. METHODS: We queried the American College of Surgeons-National Surgical Quality Improvement Program database for all patients who underwent primary THA from 2011 to 2014. Demographic variables, medical comorbidities, and 30-day complication, readmission, and reoperation rates were compared between patients under vs over 80 years of age. A multivariate logistic regression analysis was then performed to identify independent risk factors of poor short-term outcomes. RESULTS: Of the total 66,839 patients who underwent THA, 7198 (11%) patients were 80 years of age or older. Octogenarians had a higher overall complication rate (29% vs 15%, P < .001) and a higher mortality rate (0.9% vs 0.1%, P < .001). When controlling for other comorbidities, age over 80 years is an independent risk factor for mortality (odds ratio 2.02, 95% confidence interval 1.25-3.26, P = .004) and complications (odds ratio 1.41, 95% confidence interval 1.30-1.525, P < .001) following THA. Malnutrition and chronic kidney disease are also independent risk factors for readmission, complications, and mortality (all P < .05). CONCLUSION: THA in patients older than 80 years old are at an increased risk of complications and mortality. Octogenarian patients should be counseled on their risk profile, particularly those with malnutrition and chronic kidney disease.

Preoperative Opiate Use Independently Predicts Narcotic Consumption and Complications After Total Joint Arthroplasty.

BACKGROUND: Multimodal pain protocols have reduced opioid requirements and decreased complications after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, these protocols are not universally effective. The purposes of this study are to determine the risk factors associated with increased opioid requirements and the impact of preoperative narcotic use on the length of stay and inhospital complications after THA or TKA. METHODS: We prospectively evaluated a consecutive series of 802 patients undergoing elective primary THA and TKA over a 9-month period. All patients were managed using a multimodal pain protocol. Data on medical comorbidities and history of preoperative narcotic use were collected and correlated with deviations from the protocol. RESULTS: Of the 802 patients, 266 (33%) required intravenous narcotic rescue. Patients aged <75 years (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.10-3.12; P = .019) and with preoperative narcotic use (OR, 2.74; 95% CI, 2.01-3.75; P < .001) were more likely to require rescue. Multivariate logistic regression analysis demonstrated that preoperative narcotic use (OR, 2.74; 95% CI, 2.01-3.75; P < .001) was the largest independent predictor of increased postoperative opioid requirements. These patients developed more inhospital complications (OR, 1.92; 95% CI, 1.34-2.76; P < .001). This was associated with an increased length of stay (OR, 1.59; 95% CI, 1.06-2.37; P = .025) and a 2.5-times risk of requiring oral narcotics at 3 months postoperatively (OR, 2.48; 95% CI, 1.61-3.82; P < .001). CONCLUSION: Despite the effectiveness of multimodal postoperative pain protocols, younger patients with preoperative history of narcotic use require additional opioids and are at a higher risk for complications and a greater length of stay.

How Many Cultures Are Necessary to Identify Pathogens in the Management of Total Hip and Knee Arthroplasty Infections?

BACKGROUND: Identification of the infecting organism is critical to the successful management of deep prosthetic joint infections about the hip and the knee. However, the number of culture specimens and which culture specimens are best to identify these organisms is unknown. METHODS: We evaluated 113 consecutive patients with infected total hip and total knee arthroplasties and correlated the type of culture specimen and number of specimens taken during surgery to the likelihood of a positive culture result. From these data, we subsequently developed a model to maximize culture yield at the time of surgical intervention. After exclusions, 74 patients meeting the Musculoskeletal Infection Society criteria were left for final analysis. RESULTS: From this cohort, 63 of 74 patients had a positive culture result (85%). The odds of a fluid culture result being positive was 35 of 47 (0.75), whereas the likelihood of tissue cultures yielding a positive result was 164 of 245 (0.67; P = .313). The sample designated "best culture" specimen was the only culture with a positive result in 1 of 48 cases in which a best culture was identified. The optimal number of cultures needed to yield a positive test result was 4 (specificity = 0.61 and sensitivity = 0.63). Increasing the number of samples increases sensitivity but reduces specificity. CONCLUSION: A minimum of 4 tissue cultures from representative areas is necessary to maximize the chance of identifying the infecting organism during management of the infected total hip and total knee arthroplasties. The designation of the best culture specimen for additional testing is arbitrary and may not be clinically efficacious.

Diagnosing Infection in Patients Undergoing Conversion of Prior Internal Fixation to Total Hip Arthroplasty.

BACKGROUND: Criteria for diagnosis of infected internal fixation implants at the time of conversion to total hip arthroplasty (THA) are not clear. The purpose of this study is to identify risk factors for infection in patients undergoing conversion to THA. METHODS: We retrospectively reviewed patients at a single institution who underwent conversion to THA from 2009 to 2014. Patients were diagnosed with infection preoperatively using Musculoskeletal Infection Society criteria or postoperatively if they were found to have positive cultures intraoperatively at the time of conversion surgery. Medical comorbidities and preoperative inflammatory markers were compared between infected and noninfected groups. Univariate and multivariate logistic regression analysis were performed to identify independent risk factors for infection. Receiver operating characteristic curves were generated to determine test performance of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). A post hoc power analysis was performed. RESULTS: Thirty-three patients were included in the study. Six patients (18%) were diagnosed with infection. We found no association between comorbidities and infection in this cohort. The mean ESR and CRP were higher in infected (ESR = 41.6 mm/h, CRP = 2.0 mg/dL) vs noninfected (ESR = 19.3 mm/h, CRP = 1.3 mg/dL) groups (both P < .01). ESR >30 mm/h (odds ratio 28.8, 95% confidence interval 2.6-315.4, P = .001) and CRP >1.0 mg/dL (odds ratio 11.5, 95% confidence interval 1.6-85.2, P = .01) were strongly associated with infection. Receiver operating characteristic curves for ESR (area under the curve [AUC] = 0.89) and CRP (AUC = 0.89) demonstrated good fit. CONCLUSION: We report a high incidence of infection in patients who underwent conversion to THA. Preoperative ESR and CRP are effective screening tools though occult infections may still be missed. Patients with borderline or elevated inflammatory markers should raise strong suspicion for infection.

Single-component revisions are associated with dislocation after revision total hip arthroplasty at intermediate-term follow-up.

PURPOSE: Dislocation is the most frequent complication following revision total hip arthroplasty (THA). Although several risk factors for dislocation in revision THA have been described, many cannot be modified at the time of surgery. Identifying modifiable risk factors for subsequent dislocation after revision THA provides opportunity for orthopedic surgeons to decrease instability. METHODS: A retrospective analysis of 203 consecutive revision THA procedures performed by a single surgeon with a minimum 2-year follow-up between May 2003 and June 2012 was performed. 2 (1.0%) died and 14 (6.9%) were lost to follow-up leaving 187 (92%) revision procedures in 123 men and 64 women. Univariate and multivariate logistic regression was used to identify risk factors for dislocation. RESULTS: 9 (4.8%) of all patients reviewed experienced a dislocation episode. Of those, 8 (89%) had a single component revised, 6 (67%) were women, and 4 (44%) had a history of recurrent dislocation. 2 of 14 (14%) patients with a constrained liner dislocated. Univariate analysis demonstrated that single-component revisions were at higher risk for dislocation after the surgery (p value = 0.033). CONCLUSIONS: Identifying modifiable risk factors for dislocation after revision THA provide opportunity to decrease rates of instability. Based on our data, single-component revision THA is a risk factor for subsequent dislocation.

Should All Patients Be Included in Alternative Payment Models for Primary Total Hip Arthroplasty and Total Knee Arthroplasty?

BACKGROUND: Alternative payment models in total joint replacement incentivize cost effective health care delivery and reward reductions in length of stay (LOS), complications, and readmissions. If not adjusted for patient comorbidities, they may encourage restrictive access to health care. METHODS: We prospectively evaluated 802 consecutive primary total hip arthroplasty and total knee arthroplasty patients evaluating comorbidities associated with increased LOS and readmissions. RESULTS: During this 9-month period, 115 patients (14.3%) required hospitalization >3 days and 16 (1.99%) were readmitted within 90 days. Univariate analysis demonstrated that preoperative narcotic use, heart failure, stroke, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and liver disease were more likely to require hospitalization >3 days. In multivariate analysis, CKD and COPD were independent risk factors for LOS >3 days. A Charlson comorbidity index >5 points was associated with increased LOS and readmissions. CONCLUSION: Patients with CKD, COPD, and Charlson comorbidity index >5 points should not be included in alternative payment model for THA and TKA.

Are the Affordable Care Act Restrictions Warranted? A Contemporary Statewide Analysis of Physician-Owned Hospitals.

BACKGROUND: The Affordable Care Act placed a moratorium on physician-owned hospital (POH) expansion. Concern exists that POHs increase costs and target healthier patients. However, limited historical data support these claims and are not weighed against contemporary measures of quality and patient satisfaction. The purpose of this study was to investigate the quality, costs, and efficiency across hospital types. METHODS: One hundred forty-five hospitals in a single state were analyzed: 8 POHs; 16 proprietary hospitals (PHs); and 121 general, full-service acute care hospitals (ACHs). Multiyear data from the Centers for Medicare and Medicaid Services Medicare Cost Report and the statewide Health Care Cost Containment Council were analyzed. RESULTS: ACHs had a higher percentage of Medicare patients as a share of net patient revenue, with similar Medicare volume. POHs garnered significantly higher patient satisfaction: mean Hospital Consumer Assessment of Healthcare Providers and Systems summary rating was 4.86 (vs PHs: 2.88, ACHs: 3.10; P = .002). POHs had higher average total episode spending ($22,799 vs PHs: $18,284, ACHs: $18,856), with only $1435 of total spending on post-acute care (vs PHs: $3867, ACHs: $3378). Medicare spending per beneficiary and Medicare spending per beneficiary performance rates were similar across all hospital types, as were complication and readmission rates related to hip or knee surgery. CONCLUSION: POHs had better patient satisfaction, with higher total costs compared to PHs and ACHs. A focus on efficiency, patient satisfaction, and ratio of inpatient-to-post-acute care spending should be weighted carefully in policy decisions that might impact access to quality health care.

Bundled Payment in Total Joint Care: Survey of AAHKS Membership Attitudes and Experience with Alternative Payment Models.

The goal of alternative payment models (APMs), particularly bundling of payments in total joint arthroplasty (TJA), is to incentivize physicians, hospitals, and payers to deliver quality care at lower cost. To study the effect of APMs on the field of adult reconstruction, we conducted a survey of AAHKS members using an electronic questionnaire format. Of the respondents, 61% are planning to or participate in an APM. 45% of respondents feel that a bundled payment system will be the most effective model to improve quality and to reduce costs. Common concerns were disincentives to operate on high-risk patients (94%) and uncertainty about revenue sharing (79%). While many members feel that APMs may improve value in TJA, surgeons continue to have reservations about implementation.

Revision THA in obese patients is associated with high re-operation rates at short-term follow-up.

We performed a retrospective review of 309 consecutive revision THAs from 2005 to 2009. We identified a subgroup of patients with BMI >35 and compared the operative time, rate of complications, ICU admissions, re-admissions, and re-operations to patients with BMI <35 undergoing revision THA. At a mean follow-up of 36.3 months, there was no significant difference in operative time, perioperative complications, or re-admission rate between the two groups. However, a significantly higher rate of re-operation was observed in the obese group (46% vs. 28%, P=0.015). Obese patients were more likely to undergo reoperation for infection (P=0.017). Patients with high BMI contemplating primary THA should be aware of the potential subsequent complications associated with revision surgery should it become necessary.

One-week staged bilateral total knee arthroplasty protocol: a safety comparison of intended and completed surgeries.

The number of patients requiring bilateral total knee arthroplasty (TKA) is expected to grow rapidly. While some trials have compared staged with simultaneous TKA, no literature characterizes the subset of staged TKA patients who cancel their second surgery. In this study, we report on the safety and utility of a one-week staged TKA protocol in a series of 145 patients who registered to undergo staged bilateral total knee arthroplasty one week apart. Among these patients, we identify a significantly higher complication rate and comorbidity status among patients who do not proceed to a second TKA. This finding identifies a potential advantage of a staged protocol over simultaneous bilateral TKA in not subjecting higher-risk patients to a second physiologic insult of a contralateral TKA.