Discordance in Published 30-Day Readmission Rates Following Primary Total Hip and Total Knee Arthroplasty: Centers for Medicare and Medicaid Services (CMS) Versus the National Surgical Quality Improvement Program (NSQIP).

Background: 30-day readmission is an important quality metric evaluated following primary total joint arthroplasty (TJA) that has implications for hospital performance and reimbursement. Differences in how 30-day readmissions are defined between Centers for Medicare and Medicaid Services (CMS) and other quality improvement programs (i.e., National Surgical Quality Improvement Program [NSQIP]) may create discordance in published 30-day readmission rates. The purpose of this study was to evaluate 30-day readmission rates following primary TJA using two different temporal definitions. Methods: Patients undergoing primary total hip and primary total knee arthroplasty at a single academic institution from 2015-2020 were identified via common procedural terminology (CPT) codes in the electronic medical record (EMR) and institutional NSQIP data. Readmissions that occurred within 30 days of surgery (consistent with definition of 30-day readmission in NSQIP) and readmissions that occurred within 30 days of hospital discharge (consistent with definition of 30-day readmission from CMS) were identified. Rates of 30-day readmission and the prevalence of readmission during immortal time were calculated. Results: In total, 4,202 primary TJA were included. The mean hospital length of stay (LOS) was 1.79 days. 91% of patients were discharged to home. 30-day readmission rate using the CMS definition was 3.1% (130/4,202). 30-day readmission rate using the NSQIP definition was 2.7% (113/4,202). Eight readmissions captured by the CMS definition (6.1%) occurred during immortal time. Conclusion: Differences in temporal definitions of 30-day readmission following primary TJA between CMS and NSQIP results in discordant rates of 30-day readmission. Level of Evidence: III.

Single-Dose Intravenous Tranexamic Acid Does Not Increase Venous Thromboembolic Rate or Complication Rate During Hip Arthroscopy.

PURPOSE: To determine whether tranexamic acid (TXA) is safe to administer preoperatively in patients undergoing hip arthroscopy by comparing the venous thromboembolic rate and complication rate between patients who did and did not receive TXA preoperatively. METHODS: This was a multicenter consecutive-cohort series of patients who underwent arthroscopic hip surgery between 2014 and 2021. The 2 cohorts comprised patients who did and did not receive TXA preoperatively (single dose of 1-2 g), after a practice change. Data were collected via chart review. Surgical outcomes included days until follow-up, visual analog scale pain score at first follow-up, total operating room (OR) time, number of arthroscopic fluid bags (3 L/bag), and complications and revision operations up to 1 year after surgery. The Mann-Whitney U test was performed for continuous variables, and the χ2 test, for categorical variables. RESULTS: A total of 862 patients were identified: 449 (52%) received TXA and 413 (48%) did not. Patient demographic characteristics including age, sex, height, weight, body mass index, smoking status, and procedures performed, as well as number of anchors used (3.5 anchors for no TXA vs 3.7 anchors for TXA) and traction time (38 minutes for no TXA vs 40 minutes for TXA), did not significantly differ between groups. Significantly more patients underwent prior hip arthroscopy in the TXA group (n = 45; primary, n = 404) than in the group that did not receive TXA (n = 25; primary, n = 388) (P = .03). Visual analog scale pain scores at the first follow-up visit (2.61 for no TXA vs 2.62 for TXA, P = .62) and the need for subsequent revision surgery (24 patients with no TXA vs 18 patients with TXA, P = .68) were not significantly different. TXA use was associated with less arthroscopic fluid utilization (5.9 bags of 3 L of fluid for no TXA vs 5.3 bags of 3 L of fluid for TXA, P < .01) and less total OR time (99.5 minutes for no TXA vs 90.0 minutes for TXA, P < .01). There was a higher overall complication rate in the group that did not receive TXA (n = 27) than in the group that did (n = 10) (P = .01). However, if lateral femoral cutaneous nerve neurapraxia was excluded, then no difference in complication rate was observed (P = .24). CONCLUSIONS: There was no difference in the incidence of venous thromboembolic complications between patients who did and did not receive TXA preoperatively. We observed a lower overall complication rate in patients who received TXA preoperatively; however, this normalized between the 2 groups when lateral femoral cutaneous nerve neuritis was excluded. No difference in early pain control or revision surgery rate was observed between groups. Although there was statistically less arthroscopic fluid utilization and less total OR time in the group that received TXA, further studies are needed to clarify whether this is clinically meaningful. Preoperatively administered TXA is a safe adjunct medication in patients undergoing arthroscopic hip surgery. LEVEL OF EVIDENCE: Level III, retrospective multicenter consecutive series.

Observed Differences in Patient Comorbidities and Complications Undergoing Primary Total Joint Arthroplasty Between Non-orthopaedic and Orthopaedic Referral Patients.

BACKGROUND: Value-based total joint arthroplasty (TJA) has resulted in decreasing surgeon reimbursement which has created concern that surgeons are being incentivized to avoid medically complex patients. The purpose of this study was to determine if patients who underwent primary total knee (TKA) and total hip arthroplasty (THA) had different comorbidities and complication rates based on referral type: 1) non-orthopaedic referral (NOR), 2) outside orthopaedic referral (OOR) or 3) self-referral (SR). METHODS: At a single tertiary care centre, patients undergoing primary TJA between July 2019 and January 2020 were identified using current procedural codes. Data were abstracted from the Institutional National Surgical Quality Improvement Program (NSQIP) along with electronic medical records which included referral type, primary insurance, demographics, comorbidities, and comorbidity scores, including an American Society of Anesthesiology (ASA) score. Complications and outcomes were tracked for 90 days post-operatively. Referral groups were compared using Chi-square exact tests for categorical variables and t-tests or Wilcoxon Rank Sum tests for continuous variables, as appropriate. RESULTS: Of the 393 patients included in this study, there were 249 (63%) NOR, 104 (26%) OOR, and 40 (10%) SR. The OOR versus NOR group had a significantly greater proportion of patients with obesity (79 vs 64%, p=0.047) and an ASA score ≥3 (59 vs 43%, p=0.007). There was a significantly greater proportion of patients with wound complications (10 vs 4%, p=0.023) and ≥2 complications (14 vs 3%, p<0.001) in OOR versus NOR, respectively. CONCLUSION: Patients who underwent primary TJA and were referred by an orthopaedic surgeon tended to have more comorbid conditions and higher rates of severe complications. The observed difference in referrals may be explained by monetary incentivization in the context of current reimbursement trends. Organizations utilizing bundled payment programs to reimburse surgeons should use a risk-stratification model to mitigate incentivizing surgeons to avoid medically complex patients.

Mind the gap: paramedian approach for coccygectomy.

BACKGROUND CONTEXT: Coccydynia is pain in the coccyx that typically occurs idiopathically or from trauma. Most forms are self-limiting. However, if symptoms persist, nonsurgical treatment options can include offloading, NSAIDs, physical therapy, and steroid injections. If all treatment options fail, a growing body of evidence supports a coccygectomy for symptomatic relief. The standard approach for a coccygectomy involves a midline incision cephalad to the anus along the gluteal cleft. Historically, this method has had high rates of infection. PURPOSE: To improve healing and decrease infection rate, we propose the paramedian approach to a coccygectomy. This approach has the benefit of distancing the surgical site from the anus, diminishing the crevice effect of the incision, and increasing the dermal and subdermal thickness for improved surgical closure. STUDY DESIGN/SETTING: We present a case series study of 41 patients who underwent the paramedian approach coccygectomy using a 4 to 6 cm incision, approximately 0.5 to 1.5 cm lateral to the midline, for coccyx removal. These patients were evaluated postoperatively to determine infection rate and various outcome measures. PATIENT SAMPLE: Forty-one patients suffering from refractory coccydynia had a coccygectomy via the paramedian approach between 2011 and 2022 by the senior author. OUTCOME MEASURES: Outcome measures included self-reported measures (Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) pain scale and satisfaction with procedure), physiologic measures (presence of infection and treatment provided) and functional measures (return to vocation/avocation). METHODS: Data was compiled and transferred to Microsoft Excel and analyzed. Two-tailed T-tests were used to compare the patient improvement in VAS and ODI as appropriate for statistical analysis. RESULTS: The patients' average age was 45.8 years. Patients' average body mass index was 27.9, with 71% of patients overweight or obese. A total of 68% of patients were female. Trauma was the most common precipitating factor (75.6%). Five patients presented with postoperative complications (12.1%), one requiring an incision and drainage, and four others were treated with antibiotics for wound erythema. Postoperative evaluations showed continual improvement, with the most significant improvement reported greater than 1-year postoperatively. The Visual Analogue Scale for pain dropped from 7.5 to 2.3 (p<.001), and the Oswestry Disability Index improved from 30.1 to 9.6 (p<.001). A total of 86.7% of patients reported either a good or excellent result. CONCLUSION: Coccygectomies via the midline approach have a variable infection rate, likely due to proximity of the incision to the anus and due to the crevice effect of the gluteal cleft in terms of aeration. These contributing factors are overcome in the paramedian approach, making it an effective option for treating refractory coccydynia that is nonresponsive to conservative management.

Did Rapid Expansion of Same Day Discharge Hip and Knee Arthroplasty During the COVID-19 Pandemic Increase Early Complications?

Background: The COVID-19 pandemic has had a lasting impact on patients seeking total hip and knee arthroplasty (THA, TKA) including more patients undergoing same day discharge (SDD) following total joint arthroplasty (TJA). The purpose of this study was to assess whether expansion of SDD TJA during the COVID-19 pandemic resulted in more early complications following TJA. We anticipated that as many institutions quickly launched SDD TJA programs there may be an increase in 30-day complications. Methods: We retrospectively queried the ACS-NSQIP database for all patients undergoing primary elective TJA from January 1, 2018, to December 31, 2020. Participants who underwent THA or TKA between January 1, 2018 and March 1, 2020 were grouped into pre-COVID and between March 1, 2020 and December 31, 2020 were grouped into post-COVID categories. Patients with length of stay greater than 0 were excluded. Primary outcome was any complication at 30 days. Secondary outcomes included readmission and re-operation 30 days. Results: A total of 14,438 patients underwent TKA, with 9,580 occurring pre-COVID and 4,858 post-COVID. There was no difference in rates of total complication between the pre-COVID (3.55%) and post-COVID (3.99%) groups (p=0.197). Rates of readmissions for were similar for the pre-COVID (1.75%) and post-COVID (1.98%) groups (p=0.381). There was no statistically significant difference in respiratory complications between the pre-COVID (0.41%) and post-COVID group (0.23%, p=0.03). A total of 12,265 patients underwent THA, with 7,680 occurring pre-COVID and 4,585 post-COVID. There was no difference in rates of total complication between the pre-COVID (3.25%) and post-COVID (3.49%) groups (p=0.52). Rates of readmissions for were similar for the pre-COVID (1.77%) and post-COVID (1.68%) groups (p=0.381). There was no statistically significant difference in respiratory complications between the pre-COVID (0.16%) and post-COVID group (0.07%, p=0.26). Combined data to include THA and TKA patients did not find a statistical difference in the rate of complications or readmission but did note a decrease in the rate of combined respiratory complications in the post-COVID group (0.15% vs. 0.30%, p=0.028). Conclusion: Rapid expansion of SDD TJA during the COVID-19 pandemic did not increase overall complication, readmission, or re-operation rates. Level of Evidence: IV.

Routine Indwelling Urinary Catheterization Is Not Necessary During Total Hip Arthroplasty Performed Under Spinal Anesthesia.

Background: Perioperative indwelling urinary catheterization remains common in patients undergoing total hip arthroplasty. This study sought to examine the effect of routine catheterization following total hip arthroplasty performed under spinal anesthesia on urinary complications. Methods: A total of 991 consecutive patients who underwent primary total hip arthroplasty under spinal anesthesia over a 4-year period were retrospectively reviewed. Major postoperative urinary retention (POUR) was defined as persistent retention following 2 straight catheterizations, which required postoperative indwelling catheter placement. Minor POUR was defined as retention that resolved following 1 or 2 straight catheterizations. Statistical analyses were used to compare outcomes between those who received a routine indwelling catheter and those who did not. Results: Of the 991 patients included, 498 (50.3%) underwent routine indwelling urinary catheter placement preoperatively. Routine indwelling catheterization was associated with a higher rate of urinary tract infection (1.4% vs 0.0%, P = .015), but a lower rate of minor POUR (5.0% vs 10.3%, P = .001). There was no difference with respect to the rate of major POUR or discharge with an indwelling catheter. Multivariate analyses demonstrated indwelling catheterization to be independently associated with a lower rate of minor POUR (P = .021), but there was no association with overall POUR, major POUR, or discharge with a urinary catheter. Conclusion: These data suggest that routine indwelling urinary catheterization is likely unnecessary for patients undergoing total hip arthroplasty in the setting of spinal anesthetic and may even lead to increased risk of complications such as urinary tract infection.

Checklists in Femur Fractures: High Adherence After Implementation of Computer-based Pediatric Femur Guidelines.

INTRODUCTION: The American Academy of Orthopaedic Surgeons (AAOS) created an evidence-based clinical practice guideline for the care of pediatric diaphyseal femur fractures in 2010. Our institution implemented checklists based off these guidelines embedded in a standardized EMR order. The purpose of this study was to describe compliance with checklist completion and to assess safety improvement in a large urban pediatric hospital. METHODS: Retrospective and prospective data were collected from 2 years before and 5 years after checklist implementation. This included the patient safety checklists from August 2011 through August 2016. Patients aged 0 to 18 years with a diaphyseal femur fracture were queried from the EMR and included in this study. Patient charts were reviewed for complications, including nerve injury, pressure sore, leg length discrepancy, loss of reduction, failure of fixation, nonunion, delayed union, and infection. Compliance rates were reported based on the AAOS clinical practice guidelines. RESULTS: A total of 313 patients for the postchecklist period were reviewed in this study. Of 219 patients eligible for inclusion, 198 had checklists completed (group B). This group was compared with 100 patients with diaphyseal femur fractures from the period before implementation of the checklist (group A). We found no statistical difference in the number of patients with complications between groups (12% in both groups, P = 0.988). Postoperative checklists demonstrated that 89.9% of patients (178/198) received age-appropriate treatment consistent with the AAOS guideline recommendations after implementation of the checklist. Before the checklist implementation (group A), 94% (94/100) adhered to the guidelines. CONCLUSION: This study reveals high compliance rates with the AAOS evidence-based clinical practice guideline for the management of pediatric femur fractures. Implementing standardized checklists is possible by embedding them into the EMR. Implementation of checklists did not improve compliance or patient outcomes.

Limited Treatment Options in Primary Hyperoxaluria with Renal Failure.

Primary hyperoxaluria (PH) is a rare autosomal recessive metabolic disorder where serum oxalate levels rise due to overproduction. The kidney tubule is a main target for oxalate deposition, resulting in damage to the organ. Kidney failure is rare in these patients. We present a 67-year-old female with hemodialysis-dependent end-stage renal disease likely due to PH type 2 or 3. With extremely high levels of serum oxalate (60.4 µmol/L), this patient had minimal treatment options for her rare disease. This report details a unique presentation of a rare disease where kidney biopsy was instrumental.

Renal Cell Carcinoma as an Incidental Finding in Firefighters: A Case Series.

The link between cancer, including cancers of the kidney, and occupational exposure in firefighters has been well established. Renal cell carcinoma has a tendency to present incidentally on imaging rather than with the classic symptoms of flank pain and hematuria. In this case series, we identify four firefighter patients, all of whom initially presented with a kidney tumor as an incidental finding. We examine the absence of other risk factors in these patients along with current screening guidelines. This report aims to detail how these tumors present incidentally as well as evaluate the current screening guidelines in an effort to build awareness within this population. Patient demographics, risk factors, length of firefighting career, final pathology, and postoperative recurrence were evaluated. Four males underwent successful partial or total nephrectomy. All who have had follow-up have been tumor free with renal function intact. None are dialysis dependent. The role of routine renal imaging of this population is explored.

Traumatic hangman's fracture after cervical disk arthroplasty with device in-tact: A case report and literature review.

BACKGROUND CONTEXT: Cervical disk arthroplasty (CDA) has been demonstrated to be a safe and effective method to treat myelopathy with the added benefit of preserving neck mobility compared to anterior cervical discectomy and fusion (ACDF). Few studies describe complications of trauma after CDA, and to our knowledge this is the only study describing a grossly intact artificial cervical disk (ACD) without extrusion after high energy trauma. Based on our case and a review of literature, we hypothesize that, given adequate osseous integration (OI), CDA may be a safe intervention despite their risk for higher energy trauma. PURPOSE: To present a rare case of high-energy trauma after CDA resulting in a Hangman's fracture and grossly in-tact ACD and to engage a biomechanical discussion of trauma after CDA and ACDF utilizing a literature review. STUDY DESIGN/SETTING: Case-report with literature review and discussion. PATIENT SAMPLE: Electronic medical record data. OUTCOME MEASURES: Computed Tomography, Magnetic Resonance Imaging, and X-Ray physiologic measures. METHODS: We report the case of a 44-year-old woman who received a C5-C6 level CDA with a (Synthes Prodisc-C©, Synthes Spine Company, L.P., West Chester, PA) and was subsequently involved in a high-speed motorcycle accident one-and-a-half years later resulting in a Hangman's fracture. RESULTS: Radiographic evidence after the motorcycle wreck demonstrated a minimally displaced Hangman's fracture at the C2 vertebrae through the pedicles on both sides, partially involving the transverse foramina with approximately 5 mm of displacement. The ACD at C5-C6 was grossly intact and no malalignment was noted. Three years later the patient elected to have an ACDF due to recurrence of facet pain that appeared by way of selective medial branch block injections to originate posteriorly in the facets of C5-6. A literature review revealed reports of trauma induced adjacent disk herniation, metallosis, and implant extrusion after CDA. No accounts of intact hardware, or concomitant Hangman's fracture after CDA were found following high-energy trauma. CONCLUSIONS: Our case reveals the first reported occurrence of a traumatic Hangman's fracture with intact fusion hardware after CDA. We hypothesize that the preserved mobility in the affected spinal level after the CDA exerted a protective effect compared to an ACDF following the high-speed trauma, particularly on the adjacent segments. This case and included literature review, reveal the need for future research efforts to guide decision making in whether ACDF or CDA is superior in younger patients at higher risk for trauma.