Allograft or Synthetic Mesh Extensor Mechanism Reconstruction After TKA Carries a High Risk of Infection, Revision, and Extensor Lag.

BACKGROUND: Extensor mechanism disruption is a devastating complication after TKA. Extensor mechanism reconstruction can be performed using an allograft or synthetic mesh. Recent studies have disagreed about the durability of these reconstructions. Evaluating a larger series of reconstructions that use current popular techniques and principles provides information to guide patient and surgeon expectations while bringing to light the potential fate of patients who experience an infection postoperatively. QUESTIONS/PURPOSES: (1) What was the 5-year survival free of repeat revision surgery or persistent extensor lag of more than 30° after allograft or synthetic mesh reconstruction of extensor mechanism disruptions after TKA, and did this differ between techniques? (2) What was the 5-year survival free of infection after allograft or mesh reconstruction, and what proportion of those patients experienced a secondary severe complication (arthrodesis or amputation)? METHODS: Between April 2008 and December 2020, 123 patients underwent extensor mechanism reconstruction after TKA at one center. Of those, 37% (45) were lost to follow-up before 2 years, had not been seen in the past 5 years, did not reach a study endpoint (repeat revision or extensor lag > 30°) before that time, or underwent primary repair and thus could not be analyzed, leaving 63% (78) for analysis here. During the study period, we considered extensor mechanism surgery when acute or chronic disruption of the patellar or quadriceps tendon was present or there was a fracture of the patella resulting in extensor lag. The decision to use either mesh or an allograft largely depended on surgeon experience and familiarity with either technique. We collected patient demographics, operative details (location of disruption and presence of a hinged prosthesis), subsequent periprosthetic joint infection (PJI), and postoperative SF-12 and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, scores. We used Kaplan-Meier survivorship analysis, with endpoints of extensor lag more than 30° or revision of the reconstruction and PJI. The mean follow-up duration was 5.3 ± 3.2 years. RESULTS: Survivorship free from revision or recurrent extensor lag was 54% (95% CI 44% to 66%) at 5 years. There was no difference between those undergoing reconstruction with allografts and those with mesh in terms of survivorship free from those endpoints at that timepoint (52% [95% CI 40% to 68%] versus 57% [95 CI% 41 to 78%]; p = 0.99). Survivorship free from PJI was 81% (95% CI 73% to 90%) at 2 years. There was no difference between those with allografts and those with mesh in terms of survivorship free from PJI at that timepoint (79% [95% CI 69% to 92%] versus 83% [95% CI 71% to 98%]; p = 0.75). Of the 17 patients who experienced PJI, four ultimately underwent arthrodesis and three more underwent transfemoral amputation. CONCLUSION: Allograft and synthetic mesh reconstructions commonly left patients with persistent limb dysfunction, while several patients had PJI and some underwent salvage procedures. Although improvements have been made with regard to treating extensor mechanism disruptions, patients and surgeons should be well aware of the potential adverse outcomes when determining management and use these findings to conduct risk-benefit analyses. There is a need for future studies to identify protocols that improve the durability of reconstructions and to determine whether interventions such as prolonged prophylactic antibiotic therapy have a role in minimizing the risk of PJI. LEVEL OF EVIDENCE: Level III, therapeutic study.

Porous Metal Augments Have Comparable Outcomes to Other Constructs for Severe Acetabular Bone Loss at Mid-Term Follow-up.

BACKGROUND: Acetabular reconstruction options in the setting of severe bone loss remain limited, with few comparative studies published to date. The purpose of this study was to compare the outcomes of revision total hip arthroplasty (THA) for severe bone loss using porous metal augments to cup cage and triflange prostheses. METHODS: We reviewed a consecutive series of 180 patients who had Paprosky 3A or 3B acetabular defects and underwent revision THA. Patients treated with porous augments (n = 141) were compared with those who received cup cages or triflange constructs (n = 39). Failure of the acetabular construct was defined as undergoing acetabular revision surgery or radiographic evidence of loosening. RESULTS: There was no difference in acetabular component survivorship in patients undergoing revision THA with porous augments or a cage or triflange prosthesis (92.2 versus 87.2%, P = .470) at a mean follow-up of 6.6 ± 3.4 years. Overall, survivorship free from any revision surgery was comparable between the 2 groups (78.7 versus 79.5%, P = .720). There was also no difference in dislocation (5.7 versus 10.3%, P = .309) or periprosthetic joint infection rates (7.8 versus 10.3%, P = .623). In a subgroup analysis of patients who had pelvic discontinuity (n = 47), survivorship free from any revision surgery was comparable between the 2 groups (79.5 versus 72.2%, P = .543). CONCLUSIONS: Porous metal augments in the setting of severe acetabular bone loss demonstrated excellent survivorship at intermediate-term (mean 6.6 years follow-up, even in cases of pelvic discontinuity, with comparable outcomes to cup cages and triflanges. Instability and infection remain major causes of failure in this patient population, and long-term follow-up is needed.

A Cautionary Tale: Malaligned Incentives in Total Hip and Knee Arthroplasty Payment Model Reforms Threaten Promising Innovation and Access to Care.

Over the past several years, there have been notable changes and controversies involving Medicare reimbursement for total hip (THA) and total knee arthroplasty (TKA). We have seen the development and implementation of experimental bundled payment model pilot programs goals of improving quality and decreasing overall costs of care during the last decade. Many orthopaedic surgeons have embraced these programs and have demonstrated the ability to succeed in these new models by implementing strategies, such as preservice optimization, to shift care away from inpatient or postdischarge settings and reduce postoperative complications. However, these achievements have been met with continual reductions in surgeon reimbursement rates, lower bundle payment target pricings, modest increases in hospital reimbursement rates, and inappropriate valuations of THA and TKA Common Procedural Terminology (CPT) codes. These challenges have led to an organized advocacy movement and spurred research involving the methods by which improvements have been made throughout the entire episode of arthroplasty care. Collectively, these efforts have recently led to a novel application of CPT codes recognized by payers to potentially capture presurgical optimization work. In this paper, we present an overview of contemporary payment models, summarize notable events involved in the review of THA and TKA CPT codes, review recent changes to THA and TKA reimbursement, and discuss future challenges faced by arthroplasty surgeons that threaten access to high-quality THA and TKA care.

AAHKS Surgical Techniques & Technologies Award: Inferior Screw Fixation Decreases Acetabular Component Failure Following Revision Total Hip Arthroplasty.

BACKGROUND: Adjunctive screw fixation has been shown to be reliable in achieving acetabular component stability in revision total hip arthroplasty (THA). The purpose of this study was to assess the effect of inferior screw placement on acetabular component failure following revision THA. We hypothesized that inferior screw fixation would decrease acetabular failure rates. METHODS: We reviewed 250 patients who had Paprosky Type II or III defects who underwent acetabular revision between 2001 and 2021 across three institutions. Demographic factors, the number of screws, location of screw placement (superior versus inferior), use of augments and/or cup-cage constructs, Paprosky classification, and presence of discontinuity were documented. Multivariate regression was performed to identify the independent effect of inferior screw fixation on the primary outcome of aseptic rerevision of the acetabular component. RESULTS: At a mean follow-up of 53.4 months (range, 12 to 261), 16 patients (6.4%) required re-revision for acetabular loosening. There were 140 patients (56.0%) who had inferior screw fixation, all of whom did not have neurovascular complications during screw placement. Patients who had inferior screws had a lower rate of acetabular rerevision than those who only had superior screw fixation (2.1 versus 11.8%, P = .0030). Multivariate regression demonstrates that inferior screw fixation decreased the likelihood of rerevision for acetabular loosening when compared to superior screw fixation alone (odds ratio: 0.1, confidence interval: 0.03 to 0.5; P = .0071). No other risk factors were identified. CONCLUSIONS: Inferior screw fixation is a safe and reliable technique to reduce acetabular component failure following revision THA in cases of severe acetabular bone loss.

Postacute Care Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities After Total Joint Arthroplasty.

BACKGROUND: Racial and socioeconomic disparities have been associated with complications and poorer patient-reported outcomes after THA and TKA, but little is known regarding the variation of postacute care resource utilization based on socioeconomic difference in the communities in which patients reside. Hip and knee arthroplasty are among the most common elective orthopaedic procedures. Therefore, understanding social factors provides insight into patients at risk for readmission and the way in which these patients use other postoperative resources. This knowledge can help surgeons better understand which patients are at risk for complications or preventable readmissions and how to anticipate when additional surveillance or intervention might reduce this risk. QUESTIONS/PURPOSES: (1) Do patients from communities with a higher distress level experience higher rates of readmission after THA and TKA? (2) Do patients from distressed communities have increased postoperative resource utilization? METHODS: Demographics, ZIP code of residence, and Charlson comorbidity index (CCI) were recorded for each patient undergoing TKA or THA between 2016 and 2019 at two high-volume hospitals. Patients were classified according to the Distressed Communities Index (DCI) score of their ZIP code of residence. The DCI combines seven metrics of socioeconomic well-being (high school graduation, poverty rate, unemployment, housing vacancy, household income, change in employment, and change in establishment) to create a single score. ZIP codes are then classified by scores into five categories based on national quintiles (prosperous, comfortable, mid-tier, at-risk, and distressed). The DCI was chosen because it provides a single composite measure of multiple important socioeconomic factors. Multivariate analysis with logistic, negative binomial regression, or Poisson was used to investigate the association of DCI category with postoperative resource utilization while controlling forage, gender, BMI, and comorbidities. The primary outcome was 90-day readmissions. Secondary outcomes included postoperative medication prescriptions from the orthopaedic team, patient telephone calls to the surgeon's office, physical therapy sessions attended, follow-up office visits, and emergency department visits. A total of 5077 patients who underwent TKA (mean age 66 ± 9 years, 59% [2983 of 5077] are women, and 69% [3519 of 5077] are White), and 5299 who underwent THA (mean age 63 ± 11 years, 50% [2654 of 5299] are women, and 74% [3903 of 5299] are White) were included. RESULTS: When adjusting for age, gender, race and CCI, readmission risk was higher in distressed communities compared with prosperous communities for patients undergoing TKA (odds ratio 1.6 [95% confidence interval 1.1 to 2.3]; p = 0.02) but not for THA. For secondary outcomes after TKA, at-risk communities had more postoperative prescriptions compared with prosperous communities, but no other differences were found. After THA, no major differences were found in the likelihood to utilize postoperative resources based on DCI category. Race was not associated with readmissions or resource utilization. CONCLUSION: We found that socioeconomic distress was associated with readmission after TKA, but, after controlling for relevant confounding variables, race had no association. Patients from these communities do not demonstrate an increased or decreased use of other resources after post-TKA discharge. Increased awareness of these disparities may allow for closer monitoring and improved patient education and communication, with the goal of reducing the frequency of complications and preventable readmissions. LEVEL OF EVIDENCE: Level III, therapeutic study.

Dual-Mobility Articulations in Total Hip Arthroplasty: A Durable Game Changer or the Next Cause for Concern?

The use of dual-mobility articulations in total hip arthroplasty (THA) is increasing. The appeal of dual-mobility implants rests in their ability to increase the effective ball head size for a given THA construct compared with conventional bearings, thereby reducing the risk of postoperative instability. Although the concept of dual-mobility articulation in THA is not new and early clinical experience dates back to the 1970s, its widespread use is a relatively recent phenomenon. Furthermore, unlike European surgeons who routinely use monoblock dual-mobility acetabular components in THA, the most common dual-mobility implants used in North America and worldwide are of a modular nature in which a metallic liner is coupled to a multibearing acetabular component and thus creating a metal-on-metal interface. It is important to review the evidence for the indications for dual-mobility implants in both primary and revision THA; present basic science data on the risk of corrosion in modular dual-mobility implants; and highlight the possible ongoing questions and concerns with dual-mobility implants. The goal is to provide a balanced critical review of this technology and define its current place in the hip surgeon's armamentarium.

Health Policy Views and Political Advocacy of Arthroplasty Surgeons: A Survey of the American Association of Hip and Knee Surgeons Members.

BACKGROUND: The American Association of Hip and Knee Surgeons (AAHKS) is the largest specialty society for arthroplasty surgeons in the United States and is dedicated to education, research, and advocacy. The purpose of this study was to identify the health policy views of AAHKS members and better characterize their advocacy participation. METHODS: A 22 question survey was electronically distributed multiple times via email link to all 3,638 United States members of AAHKS who were in practice or training in 2022. Study results were analyzed using descriptive statistics. RESULTS: There were 311 responses (9%), with 18% of respondents being within 5 years of practice and 38% having more than 20 years of practice. Respondents identified as Republicans (40%), Independents (37%), and Democrats (21%). Top policy issues included preserving physician reimbursement and equitable fee schedule representation (95%), the burden of prior authorization (53%), the impact of Center of Medicare and Medicaid Services regulations (39%), and medical liability and tort reform (39%). Members ranked maintaining appropriate physician reimbursement (44%) and advocating for patients (37%) as the top benefits to participation in advocacy. A majority of respondents (81%) stated that they spend more time on presurgery optimization now than 10 years ago. The most common barrier to advocacy participation was a lack of time (77%). CONCLUSION: Responding AAHKS members are well-informed, politically engaged, patient-oriented, and eager for a voice in policy decisions that affect the professional future of arthroplasty surgeons. These results can be used to help direct strategic efforts of the AAHKS Advocacy Committee to further increase advocacy efforts.

The Appropriateness of Preoperative Patient Reported Outcome Measures as an Indication for Total Hip Arthroplasty.

BACKGROUND: While Medicare requires patient-reported outcome measures (PROMs) for many quality programs, some commercial insurers have begun requiring preoperative PROMs when determining patient eligibility for total hip arthroplasty (THA). Concerns exist these data may be used to deny THA to patients above a specific PROM score, but the optimal threshold is unknown. We aimed to evaluate outcomes following THA based on theoretical PROM thresholds. METHODS: We retrospectively analyzed 18,006 consecutive primary THA patients from 2016-2019. Hypothesized preoperative Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS-JR) cutoffs of 40, 50, 60, and 70 points were used. Preoperative scores below each threshold were considered "approved" surgery. Preoperative scores above each threshold were considered "denied" surgery. In-hospital complications, 90-day readmissions, and discharge disposition were evaluated. HOOS-JR scores were collected preoperatively and 1-year postoperatively. Minimum clinically important difference (MCID) achievement was calculated using previously validated anchor-based methods. RESULTS: Using preoperative HOOS-JR thresholds of 40, 50, 60, and 70 points, the percentage of patients who would have been denied surgery was 70.4%, 43.2%, 20.3%, and 8.3%, respectively. For these denied patients, 1-year MCID achievement was 75.9%, 69.0%, 59.1%, and 42.1%, respectively. In-hospital complication rates for approved patients were 3.3%, 3.0%, 2.8%, and 2.7%, while 90-day readmission rates were 5.1%, 4.4%, 4.2%, and 4.1%, respectively. Approved patients had higher MCID achievement (P < .001) but higher nonhome discharge (P = .01) and 90-day readmissions rates (P = .036) than denied patients. CONCLUSION: Most patients achieved MCID at all theoretical PROM thresholds with low complication and readmission rates. Setting preoperative PROM thresholds for THA eligibility did not guarantee clinically successful outcomes.

Preoperative Patient-Reported Outcome Measure Thresholds Should Not be Used for Indicating Total Knee Arthroplasty.

BACKGROUND: While Medicare requires patient-reported outcome measures (PROMs) for many quality programs, some commercial insurers are requiring preoperative PROMs when determining eligibility for total knee arthroplasty (TKA). Concerns exist that these data may be used to deny TKA to patients above a specific PROM score, but the optimal threshold is unknown. We aimed to evaluate TKA outcomes based on theoretical PROM thresholds. METHODS: We retrospectively analyzed 25,246 consecutive primary TKA patients from 2016 to 2019. Hypothesized preoperative knee injury and osteoarthritis outcome score for joint replacement cutoffs of 40, 50, 60, and 70 points were used. Preoperative scores below each threshold were considered "approved" surgery. Preoperative scores above each threshold were considered "denied" surgery. In-hospital complications, 90-day readmissions, and discharge disposition were evaluated. One-year minimum clinically important difference (MCID) achievement was calculated using previously validated anchor-based methods. RESULTS: For "denied" patients below thresholds 40, 50, 60, and 70 points, 1-year MCID achievement was 88.3%, 85.9%, 79.6%, and 77%, respectively. In-hospital complication rates for approved patients were 2.2%, 2.3%, 2.1%, and 2.1%, while 90-day readmission rates were 4.6%, 4.5%, 4.3%, and 4.3%, respectively. Approved patients had higher MCID achievement rates (P < .001) for all thresholds but higher nonhome discharge rates than denied patients for thresholds 40 (P < .001), 50 (P = .002), and 60 (P = .024). Approved and denied patients had similar in-hospital complication and 90-day readmission rates. CONCLUSION: Most patients achieved MCID at all theoretical PROMs thresholds with low complication and readmission rates. Setting preoperative PROM thresholds for TKA eligibility can help optimize patient improvement, but such a policy can create access to care barriers for some patients who would otherwise benefit from a TKA.

Comparing Risk Assessment Between Payers and Providers: Inconsistent Agreement in Medical Comorbidity Records for Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: The proper risk adjustment for total hip arthroplasty (THA) and total knee arthroplasty (TKA) relies on an accurate assessment of comorbidity profiles by both the payer and the institution. The purpose of this study was to determine how strongly comorbidities tracked by our institution agreed with the same comorbidities reported by payers in patients undergoing THA and TKA. METHODS: All patients of a single payer undergoing primary THA and TKA at a single institution between January 5, 2021 and March 31, 2022 were included (n = 876). There were 8 commonly collected medical comorbidities obtained from institutional medical records and matched with patient records reported by the payer. Fleiss Kappa tests were used to determine agreement of payer data with institutional records. There were 4 medical risk calculations collected from our institutional records and compared with an insurance member risk score reported by the payer. RESULTS: Comorbidities reported by the institution differed significantly from those reported by payers, with Kappa varying between 0.139 and 0.791 for THA, and 0.062 and 0.768 for TKA. Diabetes was the only condition to demonstrate strong agreement for both procedures (THA; k = 0.791, TKA; k = 0.768). The insurance member risk score demonstrates the closest association with total cost and surplus for THA regardless of insurance type and for TKA procedures paid for with private commercial insurance. CONCLUSION: There is a lack of agreement between medical comorbidities within payer and institutional records for both THA and TKA. These differences may put institutions at a disadvantage within value-based care models and when optimizing patients perioperatively.

Surgeons Experience More Physiologic Stress and Strain During Revision Than Primary Total Joint Arthroplasty.

BACKGROUND: Revision total knee arthroplasty (rTKA) and total hip arthroplasty (rTHA) procedures are more complex than primary TKA and THA, but their physiologic burden to the surgeon has not been quantified. While rTKA and rTHA have longer operative times, it is unknown whether differences exist in stress and strain compared to primary TKA and primary THA. The study was conducted to elicit whether differences exist in surgeon physiological response while performing rTKA and rTKA compared to primary TKA and primary THA. METHODS: We evaluated a prospective cohort study of 70 consecutive cases (23 primary TKAs, 12 primary THAs, 16 rTKAs, and 19 rTHAs). Two high-volume fellowship-trained arthroplasty surgeons wore a smart vest that recorded cardiorespiratory data while performing primary THA, primary TKA, rTHA, and rTKA. Heart rate (beats/minute), stress index (correlates with sympathetic activation), respiratory rate (respirations/minute), minute ventilation (L/min), and energy expenditure (Calories) were collected for every case, along with patient body mass index (kilograms/meter2) and working operative time (minutes). T-tests were used to assess for differences between the two groups. RESULTS: Compared to primary TKA, performing rTKAs had a significantly higher surgeon stress index (17 versus 15; P = .035), heart rate (104 versus 99; P = .007), energy expenditure per case (409 versus 297; P = .002), and a significantly lower heart rate variability (11 versus 12; P = .006). Compared to primary THA, performing rTHA had a significantly higher energy expenditure per case (431 versus 307; P = .007) and trended towards having a higher surgeon stress index (16 versus 14; P = .272) and a lower heart rate variability (11 versus 12; P = .185), although it did not reach statistical significance. CONCLUSION: Surgeons experience higher physiological stress and strain when performing rTKA and rTHA compared to primary TKA and primary THA. This study provides objective data on what many surgeons feel and should promote further research on the specific stress and strain felt by surgeons who perform revision arthroplasty procedures.

Over Half of All Medicare Total Knee Arthroplasty Patients Are Now Classified as an Outpatient-Three-Year Impact of the Removal From the Inpatient-Only List.

BACKGROUND: In 2018, Centers for Medicare & Medicaid Services removed total knee arthroplasty (TKA) from its inpatient-only list, triggering many unintended consequences. The purpose of this study was to determine how the impact of TKA removal affected the number of outpatient TKA patients, which patients were being labeled outpatient, and how outpatient classification affected discharge location and readmission rates. METHODS: Using a large administrative claims database, we reviewed a consecutive series of 216,365 primary TKA Medicare patients from 2015 to 2020. Patients who had an inpatient status (n = 63,356) were compared to patients who had an outpatient status (n = 38,510) from 2018 to 2020 based on demographics, comorbidities, discharge dispositions, and readmissions. RESULTS: In 2015, only 1.8% of TKA patients were designated as outpatients, but by 2020, 57.2% of Medicare TKA patients were classified as outpatients. A majority of patients (72%) who had an outpatient designation remained in the hospital for >24 hours (average length of stay was 2.7 days). Patients who had an outpatient status were discharged to skilled nursing facilities more frequently than patients who had an inpatient status (3.1 versus 2.0%, P < .001) with increased emergency visits (5.1 versus 3.9%, P < .001) and 90-day readmissions (2.2 versus 0.9%, P < .001). CONCLUSION: Over half of all Medicare TKA patients are being classified as outpatients 3 years following the policy to remove TKA from the inpatient-only list. Patients designated as outpatients had higher readmissions than those designated as inpatients. This policy should be re-evaluated in the context of failure to demonstrate safer discharge of Medicare patients who undergo TKA.

The Ability of Robot-Assisted Total Knee Arthroplasty in Matching the Efficiency of Its Conventional Counterpart at an Orthopaedic Specialty Hospital.

BACKGROUND: Robot-assisted total knee arthroplasty (RA-TKA) has become a popular technology. Studies have investigated the learning curve for surgeons incorporating RA-TKA into practice, but less is known regarding the change in operative efficiency when introducing RA-TKA into a facility. The purpose of this study was to investigate the effects of RA-TKA on operative and turnover time at an orthopaedic specialty hospital. METHODS: A total of 148 cases (74 RA-TKA and 74 conventional TKA [C-TKA]) performed by 2 surgeons with previous robotic experience were identified following the introduction of RA-TKA at our facility. Patient demographics, comorbidities, and operative times (ie, wheels-in to incision, incision to closure, closure to wheels-out, and turnover time) were recorded. Cumulative summation analyses were used to investigate learning curves of factors extraneous to surgeon proficiency with RA-TKA. RESULTS: While RA-TKA had a slightly longer set up (3 minutes; range, 12-45), surgical (5 minutes; range, 33-118), and breakdown time (3 minutes; range, 2-7), there was no difference in turnover time between the groups. The learning curve for surgeon A was 6 robotic cases, whereas surgeon B demonstrated no learning curve. There was no identifiable learning curve for turnover time. CONCLUSION: There was a mean of 8 minutes of increased time required to perform a RA-TKA compared to C-TKA. However, these small increases for the RA-TKA group for set-up, surgical, and breakdown times are not likely to be clinically relevant compared to the C-TKA. It appears that the RA-TKA technology was able to be incorporated into this specialty hospital with minimal changes to surgical efficiency.

Poor Patient Compliance Limits the Attainability of Patient-Reported Outcome Measure Completion Thresholds for the Comprehensive Care for Joint Arthroplasty Model.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) links patient-reported outcome measures (PROMs) with hospital reimbursement in some value-based models for total joint arthroplasty (TJA). This study evaluates PROM reporting compliance and resource utilization using protocol-driven electronic collection of outcomes for commercial and CMS alternative payment models (APMs). METHODS: We analyzed a consecutive series of patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) from 2016 and 2019. Compliance rates were obtained for reporting hip disability and osteoarthritis outcome score for joint replacement (HOOS-JR.), knee disability and osteoarthritis outcome score for joint replacement (KOOS-JR.), and 12-item short form survey (SF-12) surveys preoperatively and postoperatively at 6-months, 1 year, and 2- years. Of 43,252 THA and TKA patients, 25,315 (58%) were Medicare-only. Direct supply and staff labor costs for PROM collection were obtained. Chi-square testing compared compliance rates between Medicare-only and all-arthroplasty groups. Time-driven activity-based costing (TDABC) estimated resource utilization for PROM collection. RESULTS: In the Medicare-only cohort, preoperative HOOS-JR./KOOS-JR. compliance was 66.6%. Postoperative HOOS-JR./KOOS-JR. compliance was 29.9%, 46.1%, and 27.8% at 6 months, 1 year, and 2 years, respectively. Preoperative SF-12 compliance was 70%. Postoperative SF-12 compliance was 35.9%, 49.6%, and 33.4% at 6 months, 1 year, and 2 years, respectively. Medicare patients had lower PROM compliance than the overall cohort (P < .05) at all time points except preoperative KOOS-JR., HOOS-JR., and SF-12 in TKA patients. The estimated annual cost for PROM collection was $273,682 and the total cost for the entire study period was $986,369. CONCLUSION: Despite extensive experience with APMs and a total expenditure near $1,000,000, our center demonstrated low preoperative and postoperative PROM compliance rates. In order for practices to achieve satisfactory compliance, Comprehensive Care for Joint Replacement (CJR) compensation should be adjusted to reflect the costs associated with collecting these PROMs and CJR target compliance rates should be adjusted to reflect more attainable levels consistent with currently published literature.

Outpatient Total Knee Arthroplasty Shows Decreasing Complication Burden From 2010 to 2020.

BACKGROUND: The number of total knee arthroplasties (TKAs) performed on an outpatient basis continues to increase. The purpose of this study was to compare complication rates over the last decade to evaluate trends in the safety of outpatient TKA. METHODS: Patients who underwent TKA from 2010 to 2020 from a large administrative claims database were retrospectively identified and stratified based on the year of surgery. Propensity-score matching was performed to match patients who were discharged within 24 hours of surgery to inpatients based on age, sex, comorbidity index, and year of surgery. Linear regression analyses were used to compare trends from 2010 to 2020. The 90-day adverse events in the early cohort (2010-2012) were compared to those in the late cohort (2018-2020) using multivariable regression analyses. Of the 547,137 patients in the sample, 28,951 outpatients (5.3%) were propensity matched to inpatients. RESULTS: The incidence of outpatient TKA increased from 2010 to 2018 (1.9 versus 13.8%, P < .001). Despite a similar complication rate early (24.1 versus 22.6%, P = .164), outpatient TKA had fewer complications at the end of the study period (13.7 versus 16.7%, P < .001). Multivariate analyses demonstrated that the risk of any complication after outpatient TKA was lower than inpatient from 2018 to 2020 (odds ratio, 0.78; 95% confidence interval, 0.71-0.84). CONCLUSIONS: Complications in both cohorts declined dramatically suggesting improvements in quality of care over time, with the greatest decline in patients undergoing outpatient surgery. These results suggest that outpatient TKA today is not higher risk for the patient than inpatient TKA. LEVEL OF EVIDENCE: Level III.

Dual-Mobility versus Large Femoral Heads in Revision Total Hip Arthroplasty: Interim Analysis of a Randomized Controlled Trial.

BACKGROUND: This multicenter randomized controlled trial evaluated if dual-mobility bearings (DM) lower the risk of dislocation compared to large femoral heads (≥36 mm) for patients undergoing revision total hip arthroplasty (THA) via a posterior approach. METHODS: A total of 146 patients were randomized to a DM (n = 76; 46 mm median effective head size, range 36 to 59 mm) or a large femoral head (n = 70; twenty-five 36 mm heads [35.7%], forty-one 40 mm heads [58.6%], and four 44 mm heads [5.7%]). There were 71 single-component revisions (48.6%), 39 both-component revisions (26.7%), 24 reimplantations of THA after 2-stage revision (16.4%), seven isolated head and liner exchanges (4.8%), four conversions of hemiarthroplasty (2.7%), and 1 revision of a hip resurfacing (0.7%). Power analysis determined that 161 patients were required in each group to lower the dislocation rate from 8.4 to 2.2% (power = 0.8, alpha = 0.05). RESULTS: At a mean of 18.2 months (range, 1.4 to 48.2), there were three dislocations in the large femoral head group compared to two in the DM cohort (4.3 versus 2.6%; P = .67). One patient in the large head group and none in the DM group were successfully treated with closed reduction without subsequent revision. CONCLUSION: Interim analysis of this randomized controlled trial found no difference in the risk of dislocation between DM and large femoral heads in revision THA, although the rate of dislocation was lower than anticipated and continued follow-up is needed.

Prior Authorization in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership.

BACKGROUND: This study surveyed the impact that prior authorization has on the practices of total joint arthroplasty (TJA) members of the American Association of Hip and Knee Surgeons (AAHKS). METHODS: A 24-question survey was approved by the AAHKS Advocacy Committee and distributed to all 2,802 board-certified members of AAHKS. RESULTS: There were 353 survey responses (13%). Ninety-five percent of surgeons noted a 5-year increase in prior authorization. A majority (71%) of practices employ at least 1 staff member to exclusively work on prior authorization. Average time spent on prior authorization was 15 h/wk (range, 1 to 125) and average number of claims peer week was 18 (range, 1 to 250). Surgeries (99%) were the most common denial. These were denied because nonoperative treatment had not been tried (71%) or had not been attempted for enough time (67%). Most (57%) prior authorization processes rarely/never changed the treatment provided. Most (56%) indicated that prior authorization rarely/never followed evidence-based guidelines. A majority (93%) expressed high administrative burden as well as negative clinical outcomes (87%) due to prior authorization including delays to access care (96%) at least sometimes. DISCUSSION: Prior authorization has increased in the past 5 years resulting in high administrative burden. Prior authorizations were most common for TJA surgeries because certain nonoperative treatments were not attempted or not attempted for enough time. Surgeons indicated that prior authorization may be detrimental to high-value care and lead to potentially harmful delays in care without ultimately changing the management of the patient.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective.

OBJECTIVE: To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS: We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS: The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION: This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

Machine learning algorithms predict within one size of the final implant ultimately used in total knee arthroplasty with good-to-excellent accuracy.

PURPOSE: To develop a novel machine learning algorithm capable of predicting TKA implant sizes using a large, multicenter database. METHODS: A consecutive series of primary TKA patients from two independent large academic and three community medical centers between 2012 and 2020 was identified. The primary outcomes were final tibial and femoral implant sizes obtained from an automated inventory system. Five machine learning algorithms were trained using six routinely collected preoperative features (age, sex, height, weight, and body mass index). Algorithms were validated on an independent set of patients and evaluated through accuracy, mean absolute error (MAE), and root mean-squared error (RMSE). RESULTS: A total of 11,777 patients were included. The support vector machine (SVM) algorithm had the best performance for femoral component size(MAE = 0.73, RMSE = 1.06) with accuracies of 42.2%, 88.3%, and 97.6% for predicting exact size, ± one size, and ± two sizes, respectively. The elastic-net penalized linear regression (ENPLR) algorithm had the best performance for tibial component size (MAE 0.70, RMSE = 1.03) with accuracies of 43.8%, 90.0%, and 97.7% for predicting exact size, ± one size, and ± two sizes, respectively. CONCLUSION: Machine learning algorithms demonstrated good-to-excellent accuracy for predicting within one size of the final tibial and femoral components used for TKA. Patient height and sex were the most important factors for predicting femoral and tibial component size, respectively. External validation of these algorithms is imperative prior to use in clinical settings. LEVEL OF EVIDENCE: Case-control, III.

Home Health Care in Medicare-Aged Patients is Associated With Increased Early Emergency Visits, Readmissions, and Costs Following Total Knee Arthroplasty.

BACKGROUND: Home health services are utilized in order to provide at-home care following total knee arthroplasty (TKA). The purpose of this study is to determine whether patients receiving home health services post-operatively had lower rates of complications, emergency room visits, and readmissions as well as to determine if home health provided value by reducing total episode-of-care costs. METHODS: The PearlDiver database was retrospectively reviewed to identify all primary TKA patients over 65 years old from 2010 to 2018. Patients who received home health services were matched using a propensity score algorithm to a set of similar patients who were discharged home under self-care. We compared complication rates, emergency room visits, readmissions, and 90-day episode-of-care claims costs between the groups. Multivariate regression analysis was performed to determine the independent effect of home health services on emergency department (ED) visits and hospital readmissions. RESULTS: Of the 185,444 TKA patients discharged home, 15,849 (8.5%) received home health services. Patients who received home health services had higher rates of ED visits at 2 weeks (3.3% vs 2.8%, P = .014) and 3 months (7.1% vs 6.5%, P = .038) as well as increased readmissions at 2 weeks (0.9% vs 0.7%, P = .028); complication rates were similar between groups (11.4% vs 10.9%, P = .159). Episode-of-care costs for home health patients were higher than those discharged under self-care ($24,266 vs $22,539, P < .001). CONCLUSION: Home health services do not appear to provide value as they are associated with significantly increased costs and do not lower the rates of complications, ED visits, or readmissions following TKA.