Hip Fracture Does Not Belong in the Elective Arthroplasty Bundle: Presentation, Outcomes, and Service Utilization Differ in Fracture Arthroplasty Care.

BACKGROUND: Center for Medicare and Medicaid Services reimbursement is the same for hip arthroplasty performed electively for arthritis and urgently for femoral neck fracture. METHODS: An analytic report of hip arthroplasty for a 5-hospital network identified 2362 cases performed from January 2014 to May 2016. Resource utilization was determined using 90-day charges. RESULTS: The fracture population (623 hips) was older (P < .01), had more medical comorbidities (28.3% vs 3.8%, P < .01), and was more likely to be anemic and malnourished (P < .01), and had longer hospital stay (5.7 vs 3.0 days, P < .0001), more frequent intensive care unit admission (4.5% vs 0.5%, P < .01), less frequent discharge to home (16.2% vs 83.6%, P < .01), more emergency department visits (26.5% vs 10.7%, P < .01), and more readmissions after hospital discharge (25.2% vs 12.2%, P < .01). Utilization of services ($50,875 vs $38,705, P < .0001) and the standard deviation of these services ($22,509 vs $9,847, P < .0001), from 90-day charges, were significantly greater in the fracture population. CONCLUSION: This study supports exclusion of fracture care from the Comprehensive Care for Joint Replacement bundled payment program.

Modifiable Risk Factors in Primary Joint Arthroplasty Increase 90-Day Cost of Care.

BACKGROUND: Risk factors in demographics and health status have been identified that increase the risk of complications after joint arthroplasty, necessitating additional care and incurring additional charges. The purpose of this study was to identify the number of patients in a hospital network database who had one or more predefined modifiable risk factors and determine their impact on average length of stay, need for additional care during the 90-day postoperative period, and the 90-day charges for care. METHODS: An electronic hospital record query of 6968 lower extremity joint arthroplasty procedures under Diagnosis-Related Group 469/470 performed in 2014-2015 was reviewed, and total 90-day charges were calculated. The case mean was compared to charges for patients with modifiable risk factors: anemia (Hgb < 10 g/dL), malnutrition (albumin < 3.4 g/dL), obesity (body mass index > 45 kg/m2), uncontrolled diabetes (random glucose >180 mg/dL or A1C > 8), narcotic use (prescription filled), and tobacco use (documented within 30 days before surgery). Length of stay, emergency room visits, and hospital readmission were compared. RESULTS: Mean 90-day charges for Diagnosis-Related Group 469/470 were $36,647. Risk factors were associated with a significant increase in 90-day charges: anemia (+$ 15,869/126 patients), malnutrition (+$9270/592), obesity (+$2048/445), diabetes (+$5074/291), narcotic use (+$1801/1943), and tobacco use (+$2034/1882). Intensive care unit admission rate, emergency department visits, and hospital readmission were significantly increased for patients with each risk factor. Length of stay was higher in patients with anemia, malnutrition, diabetes, and tobacco use. When separated by elective vs fracture admission, 90-day charges were significantly higher for each risk factor. CONCLUSIONS: Medical strategies to optimize patients before joint arthroplasty are warranted to improve postoperative outcomes.

Functional Outcomes After Total Knee Arthroplasty Correlate With Spine Disability.

BACKGROUND: Despite pain resolution in most patients after total knee arthroplasty (TKA), poor function persists in approximately 20% of patients and frequently is associated with patient dissatisfaction. Lumbar spine problems are a leading cause of functional disability. This study sought to determine the association between lower knee function scores and history of spine disability. METHODS: Prospective demographic, health, and knee-specific data were collected for 1156 consecutive TKAs from July 2010 to July 2012. A spine questionnaire and Oswestry Disability Index (ODI) score were obtained from 691 knees. RESULTS: Of 691 patients, 371 (54%) with TKA had daily back pain or back pain that limited activity. Oxford Knee Score was significantly worse in patients with vs without back problems preoperatively (36.9/34.8; P = .0006) and postoperatively (20.2/17.0; P < .0001), but not for improvement (16.7/17.8; P = .10). Knee Society (KS) pain scores were similar regardless of spine history. KS function scores were lower in patients with vs without back problems preoperatively (42.3/47.0; P = .0005), postoperatively (69.0/79.8; P < .0001), and for improvement (25.8/32.9; P < .0001). Lower KS function was associated with female gender, age, health, preoperative function, and ODI. ODI was associated with Oxford Knee Score (R = 0.57) and KS function score (R = 0.54). CONCLUSION: Knee function scores were significantly worse in patients with a history of back problems and directly associated with ODI score. KS function scores indicated that TKA patients with back problems had worse function before and after TKA with less improvement. Poor TKA outcomes and dissatisfaction may reflect poor knee function, spine disability, or both. Awareness of coexisting spine disability should guide patient expectations and evaluation of TKA outcomes.

Does Extended-Release Liposomal Bupivacaine Better Control Pain Than Bupivacaine After Total Knee Arthroplasty (TKA)? A Prospective, Randomized Clinical Trial.

Liposomal bupivacaine periarticular injection (PAI) offers sustained bupivacaine release after TKA, but few prospective independent studies exist. In this prospective, blinded study, liposomal bupivacaine was randomized against bupivacaine and incorporated into a comprehensive multimodal pain management protocol. 111 primary TKAs were randomized to receive PAI: 58 patients received 266 mg (20cc) liposomal bupivacaine mixed with 75 mg (30cc) 0.25% bupivacaine, and 53 patients received 150 mg (60cc) 0.25% bupivacaine. Visual analog pain scores and narcotic use were determined. No pain score differences occurred between study and control patients: Day 1: 4.5/4.6 (P=0.73); Day 2: 4.4/4.8 (P=0.27); or Day 3: 3.5/3.7 (P=0.58). Narcotic use was similar during hospitalization, 51.8/54.2 (P=0.34). The study medication costs $285, and the control medication costs $2.80. This finding does not justify the routine use of liposomal bupivacaine.

Benefits of prolonged postoperative cyclooxygenase-2 inhibitor administration on total knee arthroplasty recovery: a double-blind, placebo-controlled study.

A double-blind, placebo-controlled study of a selective cyclooxygenase (COX)-2 inhibitor administered in 107 patients for 6 weeks after total knee arthroplasty was done to determine any benefits. All patients received celecoxib preoperatively and during hospitalization. At hospital discharge, patients were randomized to receive celecoxib or placebo for 6 weeks. Narcotic use, knee flexion, Knee Society Score, Oxford Knee Score, and Short-Form 12 scores were determined preoperatively and at postoperative intervals to 1 year. Visual analog scale scores documented pain at rest, at night, and with activities. The celecoxib group used fewer narcotics and had significantly better visual analog scale scores, knee flexion, Knee Society Score scores, Oxford Knee Score scores, and Short-Form 12 physical composite scores than the placebo group. Knee flexion remained significantly improved through 1 year. These results demonstrate that patients who took celecoxib for 6 weeks after total knee arthroplasty had a less painful and more rapid recovery.

Isokinetic strength testing of minimally invasive total knee arthroplasty recovery.

Fifty patients underwent isokinetic muscle strength testing before surgery and at 6 weeks, 3 months, 6 months, and 1 year after unilateral total knee arthroplasty using the minisubvastus surgical technique. Quadriceps muscle strength returned to preoperative levels by 3 months postoperatively and was 17% stronger at 6 months and 30% stronger at 1 year than preoperative levels (P < .05). At 1 year, the quadriceps strength of the involved knee was equivalent to that of the uninvolved knee (P = .81). When the entire study population was subdivided by age, weight, sex, and the presence of arthritis in the uninvolved knee, each subgroup still had equivalent quadriceps strength between the involved and uninvolved knees. This prospective study demonstrated that the minisubvastus total knee arthroplasty technique led to a more rapid and more complete recovery of muscle strength than has been previously demonstrated after total knee arthroplasty with a medial parapatellar arthrotomy.

Association of increased knee flexion and patella clunk syndrome after mini-subvastus total knee arthroplasty.

This study reviewed 747 consecutive posterior stabilized total knee arthroplasty (TKA) to explain the increased incidence of patella clunk syndrome that occurred when the surgeon switched from a medial parapatellar arthrotomy to a mini-subvastus (MIS) TKA technique. The incidence of patella clunk syndrome increased with increased postoperative knee flexion. Six weeks after surgery, knees that developed patella clunk had a mean flexion of 124 degrees vs 117 degrees for knees that did not develop this syndrome (P = .016). As the MIS approach resulted in increased knee flexion, this approach was indirectly associated with the increased incidence of patella clunk. Knee flexion at 6 weeks postoperatively was 117 degrees for the MIS knees vs 108 degrees for traditional medial parapatellar arthrotomy knees (P < .001). The effect of increased knee flexion achieved with the MIS approach, which resulted in an increase in patella clunk, was mitigated by using a new posterior stabilized femoral component designed to minimize soft tissue entrapment.

Effects of increased surgical volume on total knee arthroplasty complications.

The effect of increased total knee arthroplasty (TKA) surgical volume on the incidence of knee complications within a single surgeon's practice was determined. Data were collected prospectively on 600 primary TKAs. Major complications required knee reoperation. Minor complications were wound concerns requiring increased surveillance or oral antibiotics. Twelve major (2.0%) and 40 minor (6.7%) complications occurred at minimum 2-year follow-up. Surgical volume increased from 57 to 150 procedures per 6 months through the course of the study. Multivariate analysis determined that increased surgical volume was associated with lower rates of both major and minor complications, adjusted odds ratio 0.62 (95% confidence interval [CI], 0.40-0.96) and 0.56 (95% CI, 0.43-0.73), respectively. For each additional 50 procedures performed within a 6-month interval, major complications were reduced by 38% (P = .03), and minor complications were reduced by 44% (P < .0001). All complications were significantly decreased when the surgeon was performing 112 +/- 44 TKAs compared with 85 +/- 49 TKAs per 6-month interval.

Applicability of the mini-subvastus total knee arthroplasty technique: an analysis of 725 cases with mean 2-year follow-up.

Recent total knee arthroplasty (TKA) studies suggest a more rapid functional recovery with minimally invasive surgical (MIS) techniques. These studies often fail to disclose the percentage of primary TKA that underwent the MIS technique, raising the concern that positive clinical outcomes are a result of patient selection. This study evaluates the applicability of the mini-subvastus technique in one surgeon's consecutive primary TKA patients. The applicability was determined utilizing a computer record review to determine the percentage of primary TKA patients in which the surgeon utilized a MIS surgical technique. The mini-subvastus approach was applied to 99% of 732 consecutive primary TKA. There was no patient selection based on age or weight. Traditional TKA, utilizing a medial parapatellar arthrotomy, was more likely to be performed on patients with a diagnosis of traumatic arthritis and in knees that required stems or augments. Preoperative tibiofemoral angle and mean knee deformity were not predictors of which procedure would be utilized. Despite employing this new surgical approach in nearly all primary TKAs, there was no increase in the complication rate. This high applicability rate with the mini-subvastus technique obviates concerns that the positive clinical outcomes in these patients are a result of patient selection.

Surgical accuracy with the mini-subvastus total knee arthroplasty a computer tomography scan analysis of postoperative implant alignment.

A total of 50 total knee arthroplasty (TKA) patients, 25 traditional and 25 minimally invasive surgical (MIS), underwent computed tomography scans to determine if a loss of accuracy in implant alignment occurred when a surgeon switched from a traditional medial parapatellar arthrotomy to a mini-subvastus surgical technique. Surgical accuracy was determined by comparing the computed tomography measured implant alignment with the surgical alignment goals. There was no loss in accuracy in the implantation of the tibial component with the mini-subvastus technique. The mean variance for the tibial coronal alignment was 1.03 degrees for the traditional TKA and 1.00 degrees for the MIS TKA (P = .183). Similarly, there was no difference in the mean variance for the posterior tibial slope (P = .054). Femoral coronal alignment was less accurate with the MIS procedure, mean variance of 1.04 degrees and 1.71 degrees for the traditional and MIS TKA, respectively (P = .045). Instrumentation and surgical technique concerns that led to this loss in accuracy were determined.

Mini-subvastus approach for total knee arthroplasty.

The mini-subvastus surgical technique avoids both quadriceps arthrotomy and patella eversion. Since March 2003, this quad-sparing minimally invasive surgical (MIS) technique has been applied to more than 98% of our primary total knee arthroplasty (TKA) patients. This study compares our first 150 MIS TKA patients to our previous 150 traditional TKA patients. Quadriceps recovery was rapid in the MIS group with 83% able to do a straight leg raise the day after surgery. Hospital length of stay was decreased in the MIS group, 3.4 days, vs the traditional group, 4.1 days (P = .00013). Fewer MIS patients required skilled nursing or rehabilitation center admission. Increased knee flexion was seen for the MIS patients throughout the first 2 years of follow-up. Mean knee flexion at 1 year was 127 degrees for the MIS patients vs 114 degrees in the traditional TKA patients (P < .0001). Comparison between the MIS and traditional techniques demonstrated no increase in the number or severity of complications and no difference in operating room time.