Cash critical care time prices vary substantially by region and hospital ownership: A cross-sectional study.

OBJECTIVES: Emergency department (ED) patients may be billed for critical care time (current procedural terminology codes 99291 and 99292) if they receive at least 30 min of critical care services. We sought to determine the median cash (self-pay) prices for critical care time performed in the ED in the United States and assess for associations between hospital characteristics and prices. METHODS: We performed a cross-sectional analysis of hospital cash prices for critical care time performed in the ED using the first 25 alphabetical states. For each hospital, we recorded hospital characteristics including state, control (nonprofit, governmental, or for-profit), size, teaching status, and system. We then searched for each hospital's cash prices for 99291 and 99292 using Turquoise and hospital websites. We determined the median price for 99291 nationally, regionally, and for large hospital systems. We performed multivariable quantile regression to assess for associations between hospital characteristics and prices for 99291. RESULTS: Of the 2629 eligible hospitals, 2245 (85.4%) and 1893 (72.0%) reported cash prices for 99291 and 99292, respectively. For 99291, the cash price ranged from $45 to $84,775 with a median of $1816 (IQR: $1039-3237). For 99292, the median price was $567 (IQR: $298-1008). On multivariable analysis, hospitals had higher cash prices for 99291 if they were located in the West, for-profit, or part of a large system. In particular, hospitals owned by Tenet Healthcare charged the most for 99291 (median $28,244). CONCLUSION: The cash prices for critical care time vary substantially based on hospital characteristics. In particular, for-profit hospitals and those in the West tend to charge the most. Given that patients who require critical care are unlikely to be able to choose the hospital to which they present, standardization of critical care time fees should be considered.

15-Year Follow-Up of Mobile Bearing Medial Unicompartmental Knee Arthroplasty.

INTRODUCTION: Medial unicompartmental knee arthroplasty (UKA) is a successful treatment for antero-medial osteoarthritis. However, there are few published studies on the long-term survival of this procedure. The purpose of this study was to review the 15-year minimum outcomes and survival of a mobile-bearing medial UKA. METHODS: A retrospective review was performed between July 2004 and December 2006 of all patients who underwent a medial UKA eligible for a minimum of 15-year follow-up. The initial query revealed 299 patients (349 knees). One hundred-seventeen patients died or were lost to follow-up, leaving 182 patients (219 knees) for analyses. Clinical outcomes and survivorship were analyzed. RESULTS: There were 59 implant-related reoperations which occurred at a mean of 10 years (range, 0 to 16 years). The most common reasons for reoperation were arthritic progression (9.1%) and aseptic loosening (9.1%). The 10-year survival with revision to TKA was 89% (95% confidence interval: 86% to 92.4%), and the 15-year survival was 84.1% (95% confidence interval: 80.3% to 88%). There were no statistically significant differences in survival between sex, body mass index, and age. Patients who were not revised had statistically significant improvements in knee range of motion and Knee Society scores. CONCLUSIONS: This study found similar long-term survival of a medial mobile-bearing UKA to published total knee arthroplasty outcomes. The implant evaluated in this study has undergone subsequent improvements in instrumentation and design. Further analyses should be performed on the long-term outcomes of the current implant platform.

Custom Triflange Acetabular Components For Catastrophic Bone Loss: Minimum 5-Year Results.

INTRODUCTION: Custom acetabular components are an increasingly utilized reconstructive option in total hip arthroplasty for catastrophic bone loss and acetabular failure. The purpose of this study was to determine the survivorship of such components for reconstruction due to catastrophic bone loss at a minimum 5-year follow-up. METHODS: From August 2003 to July 2016, 64 patients (66 hips) underwent acetabular reconstruction with custom triflange components. All hips were classified as Paprosky 3B or 3C. Harris hip scores were analyzed. Overall survivorship was determined by survival analysis. RESULTS: Seventeen patients (18 hips) died prior to returning for 5-year follow-up. One presumed living patient was lost to contact, yielding a cohort of 46 patients (47 hips) who had minimum 5-year follow-up. The mean age was 65 years (range, 46 to 85), mean body mass index was 29.4 (range, 18 to 45), and 72% were women. Mean follow-up was 8 years (range, 5 to 16). There were 3 revisions of the triflange device (6.4%) due to infection. Survivorship to end point of triflange removal for any reason was 94.1% (95% confidence interval: ±3.4%) at a mean of 16 years. In the overall series (n = 66), there were 9 (13.6%) additional reoperations as follows: 5 incision and debridements, one open reduction internal fixation, two stem revisions for periprosthetic femoral fracture, and one head revision. Harris hip scores improved significantly from a mean of 41 points preoperatively to 64 points postoperatively. CONCLUSIONS: Custom acetabular triflange components represent a highly effective tool in a surgeon's armamentarium. These devices are extremely helpful in managing catastrophic bone loss and have a good mean 16-year survival.

Minimum 25-Year Results of a Tapered Titanium Porous Plasma Spray Coated Femoral Component.

BACKGROUND: Previous studies have reported excellent results with tapered, titanium, porous plasma-sprayed components in patients undergoing uncemented primary total hip arthroplasty (THA). The purpose of this study was to examine survival and clinical results at a minimum 25-year follow-up. METHODS: We reviewed all patients who underwent primary THA at our center through 1995 with a specific femoral component that was essentially unchanged since its 1984 introduction, except porous coating was continued circumferentially in 1987, a hydroxyapatite-coated option was offered in 1988, and an offset option was added in 1999. There were 332 patients (396 THA) who had a minimum 25-year follow-up (range, 25 to 37). Mean age at surgery was 48 years (range, 21 to 70 years). Mean follow-up in nonfailed patients was 29 years (range, 25 to 37 years). RESULTS: There were 31 femoral revisions (7.8%): 9 infections, 3 failures of ingrowth, 5 aseptic loosening, 8 osteolysis well-fixed, 2 periprosthetic fractures, 2 polyethylene wear with trochanteric avulsion, 1 component breakage, and 1 malalignment well-fixed. Kaplan-Meier survival with the endpoint of all-cause stem revision was 94.8% (95% confidence interval: ±0.9%) at 37 years, and with the endpoint of aseptic loosening/failure of ingrowth was 98.7% (95% confidence interval: ±0.5) at 37 years. Harris hip scores improved significantly from 43 preoperatively to 76 most recently. CONCLUSION: This tapered, titanium, porous plasma spray-coated femoral component continues to demonstrate high long-term survival with a low rate of femoral component revision for any reason or aseptic loosening/failure of ingrowth.

Use of a Smartphone-Based Care Platform After Primary Partial and Total Knee Arthroplasty: 1-Year Follow-Up of a Prospective Randomized Controlled Trial.

BACKGROUND: The rise in demand of knee arthroplasty has led the industry to develop methods to decrease costs of care, such as novel methods of delivering physiotherapy, including smartphone-based exercise educational platforms. The purpose of this study was to determine the noninferiority of one such system after primary knee arthroplasty as compared to traditional in-person physiotherapy. METHODS: A prospective, multicenter randomized clinical trial was conducted comparing standard of care rehabilitation to a smartphone-based care platform after primary knee arthroplasty from January 2019 to February 2020. One-year patient outcomes, satisfaction scores, and utilizations of health care resources were analyzed. A total of 401 patients was available for analysis-241 in the control and 160 in the treatment group. RESULTS: There were 194 (94.6%) patients in the control group who required 1 or more physiotherapy visits compared to only 97 (60.6%) patients in the treatment group (P < .001). Emergency department visits within 1 year occurred in 13 (5.4%) patients and 2 (1.3%) patients in the control and treatment groups, respectively (P = .03). The change in mean Knee Injury and Osteoarthritis Outcome Score for joint replacement scores at 1 year was similar between both the groups (32.1 ± 1 6.8 versus 30.1 ± 18.1, P = .32). CONCLUSION: Implementation of this smartphone/smart watch care platform showed similar outcomes to traditional care models at 1 year postoperative. Traditional physiotherapy and emergency department visits occurred at much lower rates in this cohort, which could alleviate the need for health care dollars spent by reducing postoperative costs and enhancing communication across the health care system.

Is an "Outpatient Arthroplasty Risk Assessment Score" Needed for Predicting Safe Selection of Outpatient Arthroplasty Candidates?

BACKGROUND: Total joint arthroplasty is rapidly shifting to the outpatient space. One of the challenges of same-day discharge adoption has been determining which patients are suitable candidates. Risk assessment tools have been developed, including the Outpatient Arthroplasty Risk Assessment (OARA) score. The purpose of this study was to assess its predictive utility. METHODS: A retrospective review was performed on all total joint arthroplasties performed at a single ambulatory surgery center in 2018, yielding a cohort of 1,105 patients (1,332 arthroplasties). The institution's outpatient criteria required optimization of all medical conditions; if the patient had no failing organ, they were candidates for same-day discharge. OARA scores were calculated based on preoperative histories and physical examinations. Analyses were performed on the statistical utility of the OARA score in predicting successful same-day discharge. The mean age was 59 years (range, 27-82), the mean body mass index was 33.3 kg/m2 (range, 16-66), and 51.5% were women. A total of 45% of patients had one or more major comorbidity. RESULTS: There were 81.6% of patients who had an acceptable OARA score (<60). In addition, 97% of patients who had an "unacceptable" OARA score were successfully discharged the same day. There were 23 patients who required inpatient observation; of these, 7 (30.4%) had an OARA score ≥60. CONCLUSION: The OARA score was accurate in predicting patients who successfully had same-day discharge but poor at predicting who would not. This system is time consuming and may be too restrictive on which patients are candidates for outpatient arthroplasty. Surgeons may consider a more simplified criteria for outpatient arthroplasty.

Psychophysiology, Cognitive Function, and Musculoskeletal Status Holistically Explain Tactical Performance Readiness and Resilience.

ABSTRACT: Thompson, AG, Ramadan, JH, Alexander, JS, and Galster, SM. Psychophysiology, cognitive function, and musculoskeletal status holistically explain tactical performance readiness and resilience. J Strength Cond Res 37(12): 2443-2456, 2023-This study aimed to advance the techniques used in quantifying holistic readiness and resilience within military personnel. Tactical performers, instructors, and applied human performance scientists designed a weeklong competition to reflect realistic operational demands, test specific underlying performance constructs, and elucidate how modernized assessments could drive programmatic action. By placing first in their installation's local preliminary competition, 34 active-duty Marines earned the opportunity to compete in a series of 7 intense events for the title of champion. All inferential statistics were set to a p ≤ 0.05 level of significance. Morning heart rate variability identified top from bottom quartile finishers before a single competition event. By day 3, morning countermovement jump force production (normalized reactive strength index-modified) and cognitive psychomotor vigilance were significant indicators of performance resilience and final competition group rank. Heart rate variability also tracked performer readiness across time, identifying within-group and between-group differences among top, bottom, and field. Collectively, these holistic assessments proved significant markers of acute and chronic tactical performance capabilities. In summary, the incorporation of psychophysiological monitoring, cognitive performance testing, and musculoskeletal force plate evaluations could help inform selection and support needs, drive workload or recovery modulation, and provide critical metrics for evaluating training efficacy and operational readiness. Defense organizations should consider routinely incorporating and actioning similar holistic status monitoring strategies in training and operational settings. Moreover, leveraging other tactical competitions may provide key opportunities for advancing the standard of practice through additional scientific investigation.

A Reamer by Another Number: What Do They Actually Measure?

Acetabular reamers are a mainstay in the preparation of the acetabulum in total hip arthroplasty. Many surgeons, however, have noticed a discrepancy in the preparation of the socket and the reported size of reamers during this crucial phase of the procedure. A cross-sectional study performed by measuring a variety of sets of acetabular reamers was performed. The results showed that 17 of 21 sizes (81%) measured at least 2mm less than their reported size. Given that these differences beget unintended consequences, the industry may consider replacing or sharpening reamers already in use or even switching to a single-use reamer model.

Influence of Kinematic Alignment on Soft Tissue Releasing and Manipulation Under Anesthesia Rates in Primary Total Knee Arthroplasty.

INTRODUCTION: Total knee arthroplasty (TKA) is typically performed to restore a neutral mechanical alignment. Recently, there has been increased interest in kinematic alignment to restore the patient's individual alignment. The purpose of this study is to determine if kinematic balancing reduces the need for intraoperative soft tissue releases and rates of manipulation under anesthesia compared to mechanical alignment. MATERIALS AND METHODS: A query was performed between January 2021 and July 2022 to identify all patients who underwent a primary TKA that was performed with kinematic alignment (KA), which revealed 97 patients (107 TKAs). A cohort of consecutive patients from the preceding six months was gathered of patients who underwent primary TKA with mechanical alignment (MA). This cohort consisted of 199 patients (223 TKAs), yielding a total study cohort of 296 patients (330 knees). Mean age was 64.7 years, mean body mass index (BMI) was 33.1 kg/m2, and 57.1% of patients were female. Rates of manipulation under anesthesia and intraoperative release status were analyzed. RESULTS: Average range of motion preoperatively improved from 108.9° to 114.4° in the KA group but decreased from 112.3° to 109.9° in the MA group at six weeks (p<0.0001). Three of 107 knees (2.8%) required an additional pie-crusting of the superficial MCL in the KA group, whereas 58 of 223 knees (26.0%) did in the MA group (p<0.0001). Three of 107 knees (2.8%) in the KA group and 24 of 223 knees (10.8%) in the MA group required MUA (p<0.0001). CONCLUSION: Kinematic alignment significantly reduced the need for intraoperative soft tissue releases and postoperative manipulation under anesthesia. Further studies of the influence of kinematic alignment on these outcomes across multiple surgeons should be performed and/or compared to mechanical alignment.

Isolated Tibial Polyethylene Insert Exchange After Total Knee Arthroplasty for Treatment of Instability and/or Polyethylene Wear.

INTRODUCTION: Isolated tibial polyethylene insert exchange (ITPIE) as a treatment for instability and polyethylene wear after total knee arthroplasty (TKA) remains controversial with studies reporting varied results. The purpose of this study is to evaluate the survival and outcomes of ITPIE performed for treatment of instability with or without polyethylene wear after TKA. MATERIALS AND METHODS: A query of a private practice arthroplasty registry revealed 364 patients (390 knees) treated with ITPIE for instability and/or polyethylene wear after TKA between 1997 and 2019. Mean age was 66.8 years, mean body mass index (BMI) was 33.8 kg/m2, and 59% of patients were female. ITPIE for infection, tibiofemoral aseptic loosening, arthrofibrosis, poor wound healing, and extensor mechanism failure were excluded. All patients had well-fixed and well-aligned components prior to surgery. RESULTS: Mean follow up was 5.9 years. Knee Society Clinical (KSC) scores improved preoperatively from 55 to 76 postoperatively (p <0.001). Thirty knees (7.7%) required re-revision: 15 (3.8%) for ongoing instability, seven aseptic loosening, three infection, two patellofemoral maltracking, one patellar fracture, one metal allergy, and one revised elsewhere for cause unknown. Kaplan-Meier analysis revealed survival of 93.1% (95% CI: ±1.5%) at five years, 84.7% (95% CI: ±3.5%) at 10 years, and 80.5% (95% CI: ±4.4%) at 21 years. CONCLUSIONS: ITPIE is a reliable treatment for instability and/or polyethylene wear after TKA in the presence of well-fixed and well-aligned components with good survival and clinical improvement. The less invasive nature and reduced risk for bone loss make it an attractive option versus full revision.

Use of Ion Beam Enhanced Deposition (IBED) Titanium Nitride for Knee Arthroplasty Implants.

INTRODUCTION: For much of recent history, the metal-bearing surface in total knee arthroplasty has not changed much, with cobalt-chromium being the most widely-used material. However, due to the presence of nickel in its composition, much research has been done to develop alternative metal-bearing surfaces for patients with metal sensitivity. Titanium nitride coatings have shown improved performance and resistance to abrasive wear when compared to their counterparts, thus making this material an ideal alternative to current implant technology. MATERIALS AND METHODS: Rigorous testing was undertaken to analyze the mechanical properties of titanium nitride for use as a coating in orthopedic implants, such as scratch adhesion, hardness, modulus, and wear rates with specialized machinery, including a Tribometer®, Nano Indenter® G200 (KLA Corporation, Milpitas, California), and scratch system. RESULTS: Across all properties tested-abrasive wear resistance, wear resistance, cohesive and adhesive failure load, hardness, and modulus-IBED TiN coatings were shown to be dominant to both uncoated CoCr and uncoated Ti-6Al-4V in a significant manner. CONCLUSION: The use of IBED TiN coatings offers a way to improve the performance of mechanical components, such as orthopedic implants made from Ti-6Al-4V materials. IBED TiN coatings can enable the use of Ti-6Al-4V as an alternative to CoCr for articulating orthopedic implant devices, such as knee arthroplasty.

Distal Phalangeal Replacement Using a Patient-Specific 3D-Printed Prosthesis: A Case Report.

CASE: A 38-year-old man developed a nonunion of a comminuted distal phalanx fracture, which resulted in gross instability of the fingertip. To restore stability, a patient-specific 3D-printed distal phalangeal prosthesis was implanted, and the patient was able to return to his occupation with excellent 2-year outcomes. CONCLUSION: This case highlights the application of 3D printing technology in the development of a patient-specific solution and discusses 6 important considerations for the design and planning process: Patient, Priorities, Point of fixation, Procedure, Problems, and People.

Pseudo-dense Hair Transplantation: Strategy of "Less Inside, More Outside" and Central Bulking with Curled Chest Hairs as Treatment for Scalp Scars.

Hair transplantation in areas of scalp scars is a clinical challenge. However, by creating the visual illusion of central bulking with the use of peripherally transplanted curled chest hairs, cicatricial alopecia can perhaps be cosmetically improved. In a case of a 34-year-old affected man, this strategic procedure was implemented with positive results, as the transplantation was successful, the scar was far less noticeable, and the patient was satisfied with the results. The "pseudo-dense hair transplantation" method can be applied to similar patients, noting that a more succinct procedure will need to be elucidated for the varying etiologies of cicatricial alopecia.

When VSEPR fails: experimental and theoretical investigations of the behavior of alkaline-earth-metal acetylides.

The synthesis, structural, and spectral characterization as well as a theoretical study of a family of alkaline-earth-metal acetylides provides insights into synthetic access and the structural and bonding characteristics of this group of highly reactive compounds. Based on our earlier communication that reported unusual geometry for a family of triphenylsilyl-substituted alkaline-earth-metal acetylides, we herein present our studies on an expanded family of target derivatives, providing experimental and theoretical data to offer new insights into the intensively debated theme of structural chemistry in heavy alkaline-earth-metal chemistry.

Barium Triphenylmethanide: An Examination of Anion Basicity.

Differences in anion basicity seem to be key for the formation of the first charge-separated barium triphenylmethanide versus a novel heteroleptic vinyl ether which results from cleavage of the attendant [18]crown-6. Ba: green; O: red; P: yellow; N: blue.

Alkali metal diphenylmethanides: synthetic, computational and structural studies.

In search of new synthetic precursors for the preparation of alkaline earth organometallic compounds, we investigated the application of a powerful desilylation reaction to cleanly afford a variety of contact and charge-separated alkali metal derivatives without the difficulties commonly encountered in other methods. The resulting diphenylmethanides display both contact molecules and separated ion pairs. Analysis of the structural data demonstrates that simple electrostatic models are insufficient for predicting and explaining the solid-state structures of these complexes. Detailed computational investigations were performed to probe the nature of the metal-anion and metal-donor interactions and determine the contributions of each to the observed solid-state structures.

Distinctive structural features of hydroxyamino-1,3,5-triazine ligands leading to enhanced hydrolytic stability of their titanium complexes.

Three bis(homoleptic) titanium complexes of hydroxyamino-1,3,5-triazine ligands were synthesized and characterized, and their kinetic behavior in THF-water solutions was studied at various pH conditions using UV-vis, based on the characteristic Ti-O band at 380 nm. One of these complexes, , was analyzed by X-ray crystallography. Due to the characteristic electronic structure of the triazine rings, high electron density on the nitrogen atoms leads to strong N-Ti bonds, as indicative by the 2.0 A coordinative bond lengths in the X-ray structure. Consequently, these complexes exhibit high hydrolytic stability over a wide pH range, where hydrolysis was observed to be promoted by basic conditions. At neutral pH, t(1/2) was estimated to be >200 h, whereas at pH = 5.5, no hydrolysis was observed for a period of at least three days.

More arrows in the quiver: new pathways and old problems with heavy alkaline earth metal diphenylmethanides.

Progress in the field of sigma-bonded alkaline earth organometallics has been handicapped by numerous complications, such as high reactivity, low solubility, and the limited availability of suitable starting materials. Here we present two synthetic methods, hydrocarbon elimination and desilylation, as alternative routes into this chemistry. A novel barium diphenylmethanide was prepared using these routes delineating that both methods provide a powerful, versatile synthetic access route to an extended library of organometallic alkaline earth derivatives.