The 22-Modifier in Total Hip and Knee Arthroplasty: A Comprehensive Analysis.

BACKGROUND: The 22-modifier requests additional compensation for increased case complexity. Unfortunately, there is little to guide physicians on the application, which may increase successful reimbursement. We sought to evaluate various factors affecting reimbursement of the 22-modifier in primary total joint arthroplasty (TJA) and report which factors contributed to successful utilization. METHODS: In this retrospective study, all cases from a single practice where the 22-modifier was added to Current Procedural Terminology codes: 27130 (total hip arthroplasty) and 27447 (total knee arthroplasty) from October 2018 to March 2022 were evaluated. Out of the 6,869 total cases performed, 816 22-modifier cases were identified (11.9%). Operative reports, demographics, insurance type, billing information, and clinical records were assessed. T-tests were used to determine statistical significance. RESULTS: Of the 816 cases, 221 (27.1%) were successfully reimbursed. Cases justified 22-modifier application with obesity, anatomic variations, or intraoperative factors. Some cases lacked justification, or operative reports were not submitted. Reimbursement was successful for 27.6% of obesity cases, 29.7% of intraoperative complications, and 35.7% of anatomic variations. There was a significantly higher likelihood of Medicare reimbursement than third-party payers or Medicaid (69.6 versus 20.5 and 6.9%) (P < .0001). Additionally, Medicare was more likely to reimburse for obesity (76.6 versus 20.0, and 5.2%), anatomic variations (77.3 versus 22.0%), and intraoperative factors (66.6 versus 21.1, and 1.7%). CONCLUSIONS: Reimbursement for 22-modifier cases in TJA is unlikely. Obesity was cited for most 22-modifier justifications, but anatomic variation justification was successfully reimbursed most often. Medicare was most likely to reimburse compared to third-party payers or Medicaid. These findings should be considered when applying a 22-modifier to TJA procedures.

Orthopedic Hardware Type Impacts Case Complexity in Conversion Total Hip Arthroplasty Surgery.

Background: Conversion total hip arthroplasty (THA) includes a variety of operations and prior implants. The implant present before conversion may influence the outcome and complexity of the procedure. The group hypothesized that conversion arthroplasty for patients with intramedullary nails (IMNs) is more complex from a surgical and resource utilization perspective than for those with screw fixation. Methods: THA conversion cases were reviewed retrospectively from 2012 to 2020 from 6 surgeons across 3 institutions. The included cohort had 106 patients with fixation in the proximal femur for prior traumatic events. Demographics, operative data, outcomes, and implant information were collected from the medical record. The conversion THA group was categorized by preoperative fixation type: closed reduction and percutaneous pinning/screw fixation (CRPP) or IMN. Results: No age or body mass index differences were observed between the cohorts. Prior to conversion THA, IMN patients had undergone more surgeries than CRPP (P < .05). Perioperatively, the IMN cohort sustained increased blood loss (P < .001), had longer surgeries (P < .0001), had longer length of hospital stays (P < .01), necessitated trochanteric plates more often (P < .05), were readmitted more (P < .05), and required additional follow-up surgery (P < .01) than the CRPP cohort. Conclusions: Conversion THA of a prior IMN implant is associated with worse perioperative outcomes than conversion of a CRPP construct. Surgeons, health systems, and payors should consider these differences when caring for these distinct groups of patients.

Modern trunnion designs do not affect clinically significant patient-reported outcomes.

INTRODUCTION: Trunnion geometry is known to vary between hip systems. Trunnionosis and the impact of trunnion design on total hip arthroplasty (THA) survival, has gained attention as a failure mechanism. We sought to report the differences in patient-reported outcome measures (PROMs) between the most commonly utilised modern THA trunnions. METHODS: We reviewed primary unilateral THA patients from May 2007 to October 2011. The most frequently used stems were included. LEAS, HOOS subdomains, and SF-12 were obtained pre and post operatively while satisfaction was measured at 2 years after THA. Trunnions were grouped by taper geometry and manufacturer. The 2-year change in PROMs for each trunnion was compared to the pooled 2-year change in HOOS for all other trunnions. RESULTS: 3950 THA patients were studied. 6 trunnion designs were evaluated from 5 manufacturers. The range in differences between the 2-year change in individual PROMs were as follows: HOOS pain (0.6-2.4), HOOS symptoms (0-3.8), HOOS ADL (0.4-4), and HOOS QOL (0.5-3.6). None of the differences in the 2-year change in PROMs reached a minimal clinically important change (MCIC), which we previously determined to be a minimum of 9 points for all HOOS domains. CONCLUSION: All of the trunnions designs utilised in our study cohort demonstrated excellent clinical results. Small differences were well below the known MCIC; and were not clinically relevant. The findings of this study should prompt further investigations into the long-term impact of trunnion design on clinical patient-reported outcomes.

Modular junction fractures in a modern rotating-platform knee arthroplasty system.

In this series, we report the findings from four patients who presented with pain and mechanical symptoms after revision total knee arthroplasty with the DePuy Sigma TC3 RP prosthesis. Plain radiographs for each patient demonstrated failure of the femoral component at the modular junction of the femoral prosthesis. Retrieved implants at the time of surgery revealed fractures occurring exclusively at the femoral adapter bolt and the corresponding adapter. Retrieval analysis was performed on two of the four cases by visual light microscopy. Our findings suggest that the implants had suffered from fatigue fractures likely due to cyclic loading. This is the first case series to describe the failure mechanism and clinical scenarios contributing to failure of the femoral locking bolt and adapter sleeve in this prosthesis.

Distribution of Bone Ongrowth in Metaphyseal Sleeves for Revision Total Knee Arthroplasty: A Retrieval Analysis.

BACKGROUND: The metaphyseal region of the bone has been recognized by its importance to the overall stability of a revision construct. Porous titanium metaphyseal sleeves to enhance biologic fixation can be used to manage bone loss encountered during revision total knee arthroplasty. While clinical results for metaphyseal sleeves are encouraging, there is little information on the extent to which biologic fixation is achievable with metaphyseal sleeves. We examined retrieved metaphyseal sleeves to determine the amount of bone ongrowth. MATERIALS AND METHODS: We studied 14 tibial and 11 femoral retrieved metaphyseal sleeves from 16 typical arthroplasty patients. Prerevision radiographs were reviewed for the presence of biologic fixation to the sleeves and the stem canal fill ratio. Bone ongrowth was assessed regionally in the anterior, posterior, medial, and lateral areas of the retrieved implants. RESULTS: Bone ongrowth covered on average 14.7 ± 3.4% of the entire porous surface of the tibial sleeves. The lateral and anterior surfaces had a significantly greater proportion (P < .05) of bone ongrowth compared with the posterior and medial surfaces of the tibial components. Bone ongrowth covered on average 21.3 ± 2.6% of the entire porous surface of the femoral sleeves. No differences were found in the proportion of bone ongrowth among the posterior, medial, lateral, and anterior surfaces of the femoral. No significant association was found between the clinical, demographic, or radiographic factors and the pattern or quantity of bone ongrowth. DISCUSSION: This study demonstrates that sufficient fixation can be achieved with only limited amounts of bone ongrowth (14.7% in tibial sleeves and 21.3% in femoral sleeves).

Socio-demographic factors impact time to discharge following total knee arthroplasty.

AIM: To determine social, logistical and demographic factors that influence time to discharge in a short stay pathway (SSP) by following total knee arthroplasty (TKA). METHODS: The study included primary TKA's performed in a high-volume arthroplasty center from January 2016 through December 2016. Potential variables associated with increased hospital length of stay (LOS) were obtained from patient medical records. These included age, gender, race, zip code, body mass index (BMI), number of pre-operative medications used, number of narcotic medications used, number of patient reported allergies (PRA), simultaneous bilateral surgery, tobacco use, marital status, living arrangements, distance traveled for surgery, employment history, surgical day of the week, procedure end time and whether the surgery was performed during a major holiday week. Multivariate step-wise regression determined the impact of social, logistical and demographic factors on LOS. RESULTS: Eight hundred and six consecutive primary SSP TKA's were included in this study. Patients were discharged at a median of 49 h (post-operative day two). The following factors increased LOS: Simultaneous bilateral TKA [46.1 h longer (P < 0.001)], female gender [4.3 h longer (P = 0.012)], age [3.5 h longer per ten-year increase in age (P < 0.001)], patient-reported allergies [1.1 h longer per allergy reported (P = 0.005)], later procedure end-times [0.8 h longer per hour increase in end-time (P = 0.004)] and Black or African American patients [6.1 h longer (P = 0.047)]. Decreased LOS was found in married patients [4.8 h shorter (P = 0.011)] and TKA's performed during holiday weeks [9.4 h shorter (P = 0.011)]. Non-significant factors included: BMI, median income, patient's living arrangement, smoking status, number of medications taken, use of pre-operative pain medications, distance traveled to hospital, and the day of surgery. CONCLUSION: The cost of TKA is dependent upon LOS, which is affected by multiple factors. The clinical care team should acknowledge socio-demographic factors to optimize LOS.

Long-term Outcomes of Triple Arthrodesis in Cerebral Palsy Patients.

BACKGROUND: Triple arthrodesis in the appropriately indicated cerebral palsy patient with a painful and/or rigid foot deformity can significantly alleviate pain and improve function. Limited data on long-term outcomes of triple arthrodesis in this patient population exist. In addition, there have been concerns about the long-term consequences of altered biomechanics in these patients on the tibiotalar (ankle) joint. METHODS: We retrospectively reviewed 21 cerebral palsy patients who had undergone triple arthrodesis for a painful and/or rigid foot deformity at our institution with at least 10 years of clinical or radiographic follow-up. Preoperative, and the most recent, clinical evaluations and radiographs were reviewed. In addition, all 21 patients and/or caretakers responded to a questionnaire at the time of this study by means of telephone to assess subjective pain, analgesia use, walking aid necessity, walking distance, and satisfaction with the procedure. RESULTS: In this series of 21 cerebral palsy patients, 5 patients had bilateral surgery, resulting in 26 operative feet. The mean age at the time of surgery was 19.4 years and most recent clinical or radiographic follow-up was 22.1 years postoperatively. Preoperative foot deformity was characterized by hindfoot valgus in 66.7% (14/21) and varus in 33.3% (7/21) of patients. Postoperatively, fusion was achieved in 96.2% (25/26) of feet. At final follow-up, 3 feet (11.5%) demonstrated tibiotalar joint arthritis, 1 (3.8%) had midfoot arthritis, and 10 (38.5%) had residual deformity. Of the total patients, 95.2% (20/21) were satisfied with the outcome and 61.9% (13/21) reported pain-free ambulation. There was no association between eventual functional outcome and preoperative diagnosis, preoperative foot deformity, postoperative tibiotalar joint arthritis, or postoperative residual deformity. CONCLUSIONS: Triple arthrodesis is a surgical option in cerebral palsy patients with painful and/or rigid foot deformities. From this series, successful outcomes can be expected as long as bony union is achieved. The incidence of tibiotalar arthritis is relatively low and not associated with long-term functional outcome. In addition, preoperative and residual postoperative foot deformity is not associated with long-term outcome.

Video-assisted thoracoscopic surgery (VATS) lobectomy: catastrophic intraoperative complications.

OBJECTIVE: Large case series have demonstrated that video-assisted thoracoscopic surgery (VATS) lobectomy is feasible and safe. However, catastrophic intraoperative complications during VATS lobectomy requiring thoracotomy can be overlooked and are not reported in the current literature. We reviewed our experience to determine the frequency, management, and outcome of these complications. METHODS: A systematic review of a prospective database was performed after institutional review board approval. All patients who underwent VATS lobectomy or a combination of any VATS procedure plus a thoracotomy were identified. A catastrophic complication was defined as an event that resulted in an additional unplanned major surgical procedure other than the planned lobectomy. RESULTS: From 2002 to 2010, a total of 633 VATS lobectomies were performed and 610 patients had any VATS procedure plus a thoracotomy. Thirteen catastrophic complications were identified in 12 (1%) patients. We included all cases in which a VATS was performed as well as a thoractomy since this would include conversions as well. These cases included 3 main pulmonary arterial and 1 main pulmonary venous transection requiring reanastomosis, 3 unplanned pneumonectomies, 1 unplanned bilobectomy, 1 tracheoesophageal fistula, 1 membranous airway injury to the bronchus intermedius, 1 complete staple line disruption of the inferior pulmonary vein injury to the azygos/superior vena cava junction, and 1 splenectomy. There were no intraoperative deaths. CONCLUSIONS: Catastrophic intraoperative complications of VATS lobectomy are uncommon. However, awareness of the possibility of such injuries is critical to avoid them, and development of specific management strategies is necessary to limit morbidity should they occur.

Patterns of recurrence and incidence of second primary tumors after lobectomy by means of video-assisted thoracoscopic surgery (VATS) versus thoracotomy for lung cancer.

OBJECTIVE: Reports have questioned the oncologic efficacy of video-assisted thoracoscopic surgery when compared with thoracotomy despite similar survival results. In response, we investigated the pattern of recurrent disease and the incidence of second primary tumors after lobectomy by means of video-assisted thoracoscopic surgery and thoracotomy. METHODS: All patients who underwent lobectomy for clinical stage IA lung cancer determined by means of computed tomographic and positron emission tomographic analysis were identified from a prospective database at a single institution. All patients were selected for video-assisted thoracoscopic surgery or thoracotomy by an individual surgeon. Patients' characteristics, perioperative results, recurrences, and second primary tumors were recorded. Variables were compared by using Student's t test, the Pearson χ(2) test, and Fisher's exact test. A logistic regression model was constructed to identify variables influencing the development of recurrent disease or metachronous tumors. RESULTS: From 2002 to 2009, 520 patients underwent lobectomy by means of video-assisted thoracoscopic surgery, and 652 underwent lobectomy by means of thoracotomy. Final pathological stage was similar in the video-assisted thoracoscopic surgery and thoracotomy groups. Logistic regression demonstrated a lower risk (odds ratio, 0.65; P = .01) of recurrent disease in patients undergoing video-assisted thoracoscopic surgery after adjusting for age, stage, sex, histology, tumor location, and synchronous primary tumors. CONCLUSIONS: Recurrence rates for video-assisted thoracoscopic surgery appear to be at least equivalent to those for thoracotomy. This study supports lobectomy by means of video-assisted thoracoscopic surgery as an oncologically sound technique.

Frequency of use and predictors of cancer-directed surgery in the management of malignant pleural mesothelioma in a community-based (Surveillance, Epidemiology, and End Results [SEER]) population.

INTRODUCTION: Surgical intervention rates for mesothelioma patients treated at specialized tertiary hospitals are well more than 42%. Mesothelioma surgical strategies in the community are less well defined. This study evaluates the frequency of use and predictors of cancer-directed surgical intervention in a nontertiary-based population and the predictors for surgical intervention. METHODS: The Surveillance, Epidemiology, and End Results database was searched from 1990 to 2004. Variables analyzed included age, sex, race, year of diagnosis, region, vital status, stage, surgery, and reasons for no surgery. The association of patient variables on receipt of cancer-directed surgery was evaluated using χ(2) tests and logistic regression. The incidence of mesothelioma was also evaluated over this period of time. RESULTS: Pathologically proven malignant pleural mesothelioma was identified in 1166 women and 4771 men. The rate of cancer-directed surgery was 22% (n = 1317). Significant predictors of receiving cancer-directed surgery included race, age, and stage (all p < 0.0001). A landmark analysis on the effect of cancer-directed surgery on survival after adjusting for patient and disease characteristics demonstrated a hazard ratio of 0.68 (p < 0.0001). The incidence rate of malignant pleural mesothelioma has remained constant. CONCLUSIONS: The rate of surgical intervention in the community is lower compared with tertiary referral centers. Age, stage, and race predict the likelihood of receiving cancer-directed surgery. A lower rate of cancer-directed surgery and worse overall outcome were observed in black patients. As part of quality assurance, referral of patients to centers with multidisciplinary programs that include thoracic surgical expertise should be considered.