Hospital-Wide Adherence to Postsurgical Opioid Prescribing Guidelines: A Retrospective Cohort Study.

INTRODUCTION: Lowering opioid prescription doses and quantity decreases the risk of chronic opioid usage. A tool was inserted into the brief operative note for the surgeon to assess the severity of pain associated with the procedure. We studied surgeon adherence to current opioid-prescribing recommendations. METHODS: Retrospective cohort study with 5486 patients were included in the study population. Each patient's prescription was scored yes or no for adherence on total morphine milligram equivalents (MMEs) and days prescribed with the selection in the brief operative note. The entire study population was tested for an increase from the null-hypothesis "benchmark" value of 75% using a one-sided exact binomial test of a single proportion with P < 0.05. This procedure was repeated for subgroups, with P < 0.01. RESULTS: Adherence to guidelines was higher than the 75% benchmark for "total MMEs prescribed" (79.5%; P < 0.001), but lower for "number of days prescribed" (63.5%; P > 0.999). Surgeries with severe predicted pain showed the highest adherence toward total MMEs prescribed at 87.1%, followed by moderate (80.5%) and mild (74.5%). Severe cases also showed the highest adherence in number of days prescribed (92.4%). Adherence to total MMEs prescribed was highest among attending physicians (88.1%) and lowest among residents/fellows (76.6%). CONCLUSIONS: Adherence to current guidelines was 79.5% for MMEs prescribed but only 63.5% for days prescribed. Compliance with guidelines was better for severe procedures than mild or moderate. Differences were seen across surgical departments. While an improvement from previous reports, further improvement is needed to reduce the number of days of opioids prescribed and increase compliance with recommended guidelines.

Gluteus Maximus Transfer for Irreparable Hip Abductor Deficiency: A Systematic Review and Meta-Analysis.

BACKGROUND: Gluteus maximus tendon transfer has recently been described as a treatment option for irreparable abductor tendon tears. The purpose of this study was to systematically review outcomes following gluteus maximus tendon transfer for hip abductor deficiency. METHODS: The published literature was queried for outcomes following gluteus maximus transfer in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Outcomes of interest included preoperative and postoperative functional scores, resolution of pain and gait abnormalities, postoperative rehabilitation protocols, surgical complications, reoperation rates, and postoperative magnetic resonance imaging. In total, 10 studies with a total of 125 patients (76% women) with a mean age of 67 years (range, 30 to 87) were identified for inclusion. RESULTS: Modified Harris Hip Score (+30.1 ± 6.6 [95% confidence interval: +15.5 to +46.5]) and Visual Analog Scale for pain (-4.1 ± 1.1 [95% confidence interval: -7.1 to -1.0]) were improved following gluteus maximus transfer, compared to preoperative levels. No significant improvement was noted in abduction strength and 33% of patients demonstrated a residual Trendelenburg gait postoperatively. The overall complication rate was 5.6% (7 of 125), with a reoperation rate of 1.6% (2 of 125). CONCLUSIONS: Gluteus maximus tendon transfer for abductor insufficiency has demonstrated reliable outcomes at 3 years, with improvement in hip function and pain. However, patients demonstrate modest improvements in abduction strength, and a significant subset will continue to demonstrate a Trendelenburg gait postoperatively.

Systemic Inflammatory Response Syndrome and Prosthetic Joint Infection.

BACKGROUND: The development of systemic inflammatory response syndrome (SIRS) criteria leads to increased mortality. Little is known about development of SIRS in patients who have prosthetic joint infection (PJI). We aimed to determine the incidence, risk factors, clinical outcomes, and causative organisms in patients who develop SIRS with PJI. METHODS: We retrospectively identified 655 patients (321 men, 334 women; 382 total hip, 273 total knee) who have hip or knee PJI at 1 institution between July 1, 2015 and December 31, 2020. We formed 2 groups: patients who have SIRS alert (PJI + SIRS) and patients who do not have SIRS alert (PJI). We analyzed clinical outcomes, comorbidities, and operating room culture results. RESULTS: Of 655 patients, 63 developed SIRS with PJI (9.6%). Intensive care unit (ICU) admission rates (27.0 versus. 6.9%, P < .001) and length of stay (7.7 versus. 5.6 days, P = .003) were greater in PJI + SIRS. At 2 years, reoperation (36.5 versus. 22.3%, P = .01) and mortality rates (17.5 versus. 8.8%, P = .03) were greater in PJI + SIRS. Risk factors included deficiency anemia (P = .001), blood loss anemia (P = .013), uncomplicated diabetes (P = .006), diabetes with complication (P = .001), electrolyte disorder (P < .00001), neurological disorder (P = .0001), paralysis (P = .026), renal failure (P = .005), and peptic ulcer disease (P = .004). Staphylococcus aureus more commonly speciated on tissue cultures in PJI + SIRS (P = .002). CONCLUSION: The incidence of SIRS is 10% among patients who have PJI. Development of PJI + SIRS is associated with increased lengths of stay, ICU admissions, and 2-year reoperation and mortality rates. Identifying certain comorbidities can stratify patients' risk of developing PJI + SIRS.

Do Quality Measures or Hospital Characteristics Predict Readmission Penalties for Hip and Knee Arthroplasty?

BACKGROUND: Quality rating systems exist to grade the value of care provided by hospitals, but the extent to which these rating systems correlate with patient outcomes is unclear. The association of quality rating systems and hospital characteristics with excess readmission penalties for total hip arthroplasty (THA) and total knee arthroplasty (TKA) was studied. METHODS: The fiscal year 2022 Inpatient Prospective Payment System final rule was used to identify 2,286 hospitals subject to the Hospital Readmissions Reduction Program. Overall, 6 hospital quality rating systems and 5 hospital characteristics were obtained. These factors were analyzed to determine the effect on hospital penalties for THA and TKA excess readmissions. RESULTS: Hospitals that achieved a higher Medicare Overall Hospital Quality Star Rating demonstrated a significantly lower likelihood of receiving THA and TKA readmission penalties (Cramer's V = 0.236 and Rp = -0.233; P < .001 for both). Hospitals ranked among the US News & World Report's top 50 best hospitals for orthopaedics were significantly less likely to be penalized (V = 0.042; P = .043). The remaining 4 quality rating systems were not associated with readmission penalties. Penalization was more likely for hospitals with fewer THA and TKA discharges (Rp = -0.142; P < .001), medium-sized institutions (100 to 499 beds; V = 0.075; P = .002), teaching hospitals (V = 0.049; P = .019), and safety net hospitals (V = 0.043; P = .039). Penalization was less likely for West and Midwest hospitals (V = 0.112; P < .001). CONCLUSIONS: A higher Overall Hospital Quality Star Rating and recognition among the US News & World Report's top 50 orthopaedic hospitals were associated with a reduced likelihood of THA and TKA readmission penalties. The other 4 widely accepted quality rating systems did not correlate with readmission penalties. Teaching and safety net hospitals may be biased toward higher readmission rates.

Treatment of Hip and Knee Periprosthetic Joint Infection Requires Extensive Administrative Work.

BACKGROUND: Treatment of periprosthetic joint infections (PJIs) typically requires more resource utilization than primary total joint arthroplasty. This study quantifies the amount of time spent in the electronic medical record (EMR) for patients who have PJI requiring surgical intervention. METHODS: A retrospective analysis of EMR activity for 165 hip and knee PJIs was performed to capture work during the preoperative and postoperative time periods. Independent sample t tests were conducted to compare total time based on procedure, age, insurance, health literacy, sex, race, and ethnicity. RESULTS: The EMR work performed by the orthopaedic team was 338.4 minutes (min) (SD 130.3), with 119.4 minutes (SD 62.8) occurring preoperatively and 219.0 minutes (SD 112.9) postoperatively. Preoperatively, the surgeon's work accounted for 35.7 minutes (SD 25.4), mid-level providers 21.3 minutes (SD 15.9), nurses 38.6 minutes (SD 36.8), and office staff 32.7 minutes (SD 29.9). Infectious disease colleagues independently performed 158.9 minutes (SD 108.5) of postoperative work. Overall, PJI of the knees required more postoperative work. Secondary analysis revealed that patients who have hip PJI and a body mass index <30 and patients <65 years of age required more work when compared to the PJI of heavier and older individuals. There was no difference in total work based on insurance, health literacy, race, or ethnicity. CONCLUSIONS: Over 8 hours of administrative work is required for surgical management of PJI. Surgeons alone performed 451% more work for PJI during the preoperative period (7.9 versus 35.7 min) compared to primary total joint arthroplasty. In efforts to provide best care for our sickest patients, much work is required perioperatively. This work is necessary to consider when assigning value and physician reimbursement.

Simultaneous Periprosthetic Joint Infection and Infective Endocarditis: Prevalence, Risk Factors, and Clinical Presentation.

BACKGROUND: Infective endocarditis (IE) and periprosthetic joint infections (PJI) occur due to hematogenous bacterial spread, theoretically increasing the risk for concurrent infections. There is a scarcity of literature investigating this specific association. We aimed to assess the prevalence, comorbidities, and clinical presentation of patients who have simultaneous PJI and IE. METHODS: We retrospectively identified 655 patients (321 men, 334 women; 382 total hip arthroplasty, 273 total knee arthroplasty) who developed a PJI from July 1, 2015, to December 31, 2020, at one institution. There were two groups created: patients diagnosed with PJI with IE (PJI + IE) and PJI patients who did not have IE (PJI). We analyzed clinical outcomes and comorbidities. RESULTS: There were nine patients who had PJI with IE (1.4% of PJI patients). The C-reactive protein (170.9 versus 78, P = 0.026), Elixhauser comorbidity score (P = 0.002), length of hospital stay (10.9 versus 5.7 days, P = 0.043), and the 2-year postdischarge mortality rate (55.6 versus 9.0%, P = 0.0007) were significantly greater in the PJI + IE group. Comorbidities such as iron deficiency anemia (P = 0.03), coagulopathy (P = 0.02), complicated diabetes mellitus (P = 0.02), electrolyte disorders (P = 0.01), neurologic disease (P = 0.004), paralysis (P = 0.04), renal failure (P = 0.0001), and valvular disease (P = 0.0008) occurred more frequently in the PJI + IE group. Modified Duke's criteria were met for possible or definite IE in eight of the nine patients. CONCLUSIONS: Concurrent PJIs and IE, although rare, are a potentially devastating disease state with increased length of hospital stay and 2-year mortality rates. This emphasizes the need for appropriate IE workups in patients who have a PJI. The modified Duke's criteria are effective in establishing a diagnosis for IE in this scenario.

Pericapsular Nerve Group Block Did Not Reduce Postoperative Pain or Opioid Use After Total Hip Arthroplasty.

BACKGROUND: The pericapsular nerve group (PENG) block is a newly developed regional anesthesia technique designed to manage postoperative hip pain following a fracture or surgery while also maintaining quadriceps strength and mobility. The goal of our study was to compare postoperative pain scores and opioid usage during the postoperative period before discharge following total hip arthroplasty (THA) using the posterior approach between patients who received a PENG block and those who did not. METHODS: We conducted a retrospective study on patients undergoing elective, posterior approach THA at a single tertiary-care academic center. The 2 groups included a study group (THA with PENG block in 2021; n = 66) and a control group (THA before PENG block implementation in 2019; n = 70). RESULTS: There were no significant differences in pain scores during postoperative minutes 0 to 59 (study group 6.8; control group 6.6; P = .81) or during postoperative minutes 60 to 119 (study group 6.2; control group 5.6; P = .40). There were no significant differences in total postoperative in-hospital morphine milliequivalent opioid consumption (study group 55.8 morphine milligram equivalents; control group 75.0 morphine milligram equivalents; P = .14). The study group was found to have a shorter length of stay (study group 17.0 hours; control group 32.6 hours; P < .0001) and faster mobilization (study group 3.0 hours; control group 4.9 hours; P < .0001) than the control group. CONCLUSIONS: Our results show that use of the PENG block did not result in lower postoperative pain scores or opioid consumption after THA using the posterior surgical approach. The study group had a shorter length of stay and time to mobilization than the control group, though this was likely due to standard hospital procedure shifting to same-day discharge for THA between 2019 and 2021 due to COVID-19.

The Use of General Anesthesia in Revision Joint Arthroplasty.

BACKGROUND: Several studies have suggested that spinal anesthesia gives superior outcomes for primary total joint arthroplasty (TJA). However, there is a lack of available data regarding contemporary general anesthesia (GA) approaches for revision TJA utilized at high-volume joint arthroplasty centers. METHODS: We retrospectively reviewed a series of 850 consecutive revision TJAs (405 revision total hip arthroplasties and 445 revision total knee arthroplasties) performed over 4 years at a single institution that uses a contemporary GA protocol and reported on the lengths of stay, early recovery rates, perioperative complications, and readmissions. RESULTS: Of the revision arthroplasty patients, 74.4% (632 of 850) were discharged on postoperative day 1 and 68.5% (582 of 850) of subjects were able to participate in physical therapy on the day of surgery. Only 6 patients (0.7%) required an intensive care unit stay postoperatively. The 90-day readmission rate over this time was 11.3% (n = 96), while the reoperation rate was 9.4% (n = 80). CONCLUSIONS: While neuraxial anesthesia is commonly preferred when performing revision TJA, we have demonstrated favorable safety and efficiency metrics utilizing GA in conjunction with contemporary enhanced recovery pathways. Our data support the notion that modern GA techniques can be successfully used in revision TJA.

Suppressive Antibiotic Therapy After Debridement, Antibiotics, and Implant Retention is Well-Tolerated Without Inducing Resistance: A Multicenter Study.

BACKGROUND: Suppressive antibiotic therapy (SAT) after total joint arthroplasty (TJA) debridement, antibiotics, and implant retention (DAIR) maximizes reoperation-free survival. We evaluated SAT after DAIR of acutely infected primary TJA regarding: 1) adverse drug reaction (ADR)/intolerance; 2) reoperation for infection; and 3) antibiotic resistance. METHODS: Patients who underwent total knee arthroplasty (TKA) or total hip arthroplasty (THA) DAIR for acute periprosthetic joint infection at two academic medical centers from 2015 to 2020 were identified (n = 115). Data were collected on patient demographics, infecting organisms, antibiotics, ADR/intolerances, reoperations, and antibiotic resistances. Median SAT duration was 11 months. Stepwise multivariate logistic regressions were used to identify covariates significantly associated with outcomes of interest. RESULTS: There were 11.1 and 16.3% of TKA and THA DAIR patients, respectively, who had ADR/intolerance to SAT. Patients prescribed trimethoprim/sulfamethoxazole (P = .0014) or combination antibiotic therapy (P = .0169) after TKA DAIR had increased risk of ADR/intolerance. There was no difference in reoperation-free survival between TKA (83.3%) and THA (65.1%) DAIR (P = .5900) at mean 2.8-year follow-up. Risk of reoperation for infection was higher among TKA Staphylococcus aureus infections (P = .0004) and lower with increased SAT duration (P < .0450). The optimal duration of SAT was nearly 2 years. No cases of antibiotic resistance developed due to SAT. CONCLUSIONS: Consider SAT after TJA DAIR due to improved reoperation-free survival and favorable safety profile. Prolonged SAT did not induce antibiotic resistance. Use trimethoprim/sulfamethoxazole with caution because of the increased likelihood of ADR/intolerance. LEVEL OF EVIDENCE: Therapeutic Level III.

Does Body Mass Index Affect the Success of Two-Stage Management of Periprosthetic Joint Infection?

INTRODUCTION: Obesity is associated with increased infection risk after primary total joint arthroplasty. In this retrospective cohort analysis, we sought to assess the association between body mass index (BMI) and infection recurrence after two-stage revision total joint arthroplasty (TJA) for periprosthetic joint infection (PJI). METHODS: Patients were grouped by BMI (< 30, 30 to 40, and ≥ 40) as non-obese, obese, and morbidly obese, and assessed for associations and timing of PJI reinfection as well as readmissions and complications. RESULTS: Following the two-stage revision, PJI reinfections increased from 11.5% in non-obese to 19.0% in obese and 25.9% in morbidly obese patients (P = 0.011). As BMI increased across the three groups, 90-day readmission rates following two-stage PJI revision significantly increased (8.6, 19.7, and 16.7%, respectively (P = 0.042)). The average time to reinfection decreased with obesity tercile (restricted-mean times of 4.5, 4.2, and 3.8 years with non-obese, obese, and morbidly obese, respectively (P = 0.023)). DISCUSSION: The success of PJI management with two-stage arthroplasty is significantly impacted by patient BMI, with morbidly obese subjects having the worst outcomes. Attempts to modify BMI before completion of two-stage PJI treatment should be considered in the morbidly obese given high rates of recurrence.

Outcomes of Total Knee Arthroplasty Revisions in Obese and Morbidly Obese Patient Populations.

BACKGROUND: The obese population is at higher risk for complications following primary total knee arthroplasty (TKA), but little data is available regarding revision outcomes. This study aimed to investigate the role of body mass index (BMI) in the cause for revision TKA and whether BMI classification is predictive of outcomes. METHODS: A multi-institutional database was generated, including revision TKAs from 2012 to 2019. Data collection included demographics, comorbidities, surgery types (primary revision, repeat revision), reasons for revision, lengths of hospital stay, and surgical times. Patients were compared using 3 BMI categories: nonobese (18.5 to 29.9), obese (30 to 39.9), and morbidly obese (≥40). Categorical and continuous variables were analyzed using chi-square and 1-way analysis of variance tests, respectively. Regression analyses were used to compare reasons for revision among weight classes. RESULTS: Obese and morbidly obese patients showed significant risk for repeat revision surgery in comparison to normal weight patients. Obese patients were at higher risk for primary revision due to stiffness/fibrosis and repeat revision due to malposition. In comparison to the obese population, morbidly obese patients were more likely to require primary revision for dislocation and implant loosening. CONCLUSION: Significant differences in primary and repeat revision etiologies exist among weight classes. Furthermore, obese and morbidly obese patients have a greater risk of requiring repeat revision surgery. These patients should be informed of their risk for multiple operations, and surgeons should be aware of the differences in revision etiologies when anticipating complications following primary TKA.

Surgical Approach Does Not Affect Chronic Opioid Usage After Total Hip Arthroplasty.

BACKGROUND: Three different surgical approaches (the direct anterior, antero-lateral, and posterior) are commonly used for total hip arthroplasty (THA). Due to an internervous and intermuscular approach, the direct anterior approach may result in less postoperative pain and opioid use, although all 3 approaches have similar outcomes 5 years after surgery. Perioperative opioid medication consumption poses a dose-dependent risk of long-term opioid use. We hypothesized that the direct anterior approach is associated with less opioid usage over 180 days after surgery than the antero-lateral or posterior approaches. METHODS: A retrospective cohort study was performed including 508 patients (192 direct anterior, 207 antero-lateral, and 109 posterior approaches). Patient demographics and surgical characteristics were identified from the medical records. The state prescription database was used to determine opioid use 90 days before and 1 year after THA. Regression analyses controlling for sex, race, age, and body mass index were used to determine the effect of surgical approach on opioid use over 180 days after surgery. RESULTS: No difference was seen in the proportion of long-term opioid users based on approach (P = .78). There was no significant difference in the distribution of opioid prescriptions filled between surgical approach groups in the year after surgery (P = .35). Not taking opioids 90 days prior to surgery, regardless of approach, was associated with a 78% decrease in the odds of becoming a chronic opioid user (P < .0001). CONCLUSION: Opioid use prior to surgery, rather than THA surgical approach, was associated with chronic opioid consumption following THA.

Articulating Knee Spacers in the Treatment of Periprosthetic Joint Infection: All Polyethylene Tibia or Tibial Insert?

BACKGROUND: The best antibiotic spacer for periprosthetic knee joint infection treatment is unknown. Using a metal-on-polyethylene (MoP) component provides a functional knee and may avoid a second surgery. Our study investigated complication rates, treatment efficacies, durabilities, and costs of MoP articulating spacer constructs using either an all-polyethylene tibia (APT) or a polyethylene insert (PI). We hypothesized that while the PI would cost less, the APT spacer would have lower complication rates and higher efficacies and durabilities. METHODS: A retrospective review evaluated 126 consecutive articulating knee spacer (64 APTs and 62 PIs) cases from 2016 to 2020 was performed. Demographic information, spacer components, complication rates, infection recurrence, spacer longevity, and implant costs were analyzed. Complications were classified as follows: spacer-related; antibiotic-related; infection recurrence; or medical. Spacer longevity was measured for patients who underwent reimplantation and for those who had a retained spacer. RESULTS: There were no significant differences in overall complications (P < .48), spacer-related complications (P = 1.0), infection recurrences (P = 1.0), antibiotic-related complications (P < .24), or medical complications (P < .41). Average time to reimplantation was 19.1 weeks (4.3 to 98.3 weeks) for APT spacers and 14.4 weeks (6.7 to 39.7 weeks) for PI spacers (P = .09). There were 31% (20 of 64) of APT spacers and 30% (19 of 62) of PI spacers that remained intact for an average duration of 26.2 (2.3 to 76.1) and 17.1 weeks (1.7 to 54.7) (P = .25), respectively, for patients who lived for the duration of the study. PI spacers cost less than APT ($1,474.19 versus $2,330.47, respectively; P < .0001). CONCLUSION: APT and PI tibial components have similar results regarding complication profiles and infection recurrence. Both may be durable if spacer retention is elected, with PI constructs being less expensive.

Inconsistency and Ambiguity Within the International Classification of Disease 10 Procedure Coding System for Hip Fractures.

BACKGROUND: The International Statistical Classification of Diseases (ICD), 10th Revision Procedure Coding System (PCS) was created to increase the granularity of procedural coding. These codes are entered by hospital coders from information derived from the medical record. Concern exists that this increase in complexity could lead to inaccurate data. METHODS: Medical records and ICD-10-PCS codes were reviewed for operatively treated geriatric hip fractures from January 2016 through February 2019 at a tertiary referral medical center. Definitions for each of the 7-unit figures from the 2022 American Medical Association's ICD-10-PCS official codebook were compared to the medical, operative, and implant records. RESULTS: There were 56% (135 of 241) of PCS codes that had ambiguous, partially incorrect, or frankly incorrect figures within the code. One or more inaccurate figures were noted in 72% (72 of 100) of fractures treated with arthroplasty compared to 44.7% (63 of 141) treated with fixation (P < .01). There was at least 1 frankly incorrect figure contained in 9.5% (23 of 241) of codes. Approach was coded ambiguously for 24.8% (29 of 117) of pertrochanteric fractures. Device/implant codes were partially incorrect in 34.9% (84 of 241) of all hip fracture PCS codes. Hemi and total hip arthroplasties were partially incorrect in 78.4% (58 of 74) and 30.8% (8/26) of device/implant codes, respectively. Significantly more femoral neck (69.4%, 86 of 124) than pertrochanteric fractures (41.9%, 49 of 117) had 1 or more incorrect or partially correct figures (P < .01). CONCLUSION: Despite the increased granularity of ICD-10-PCS codes, the application of this system is inconsistent and often incorrect when applied to hip fracture treatments. The definitions in the PCS system are difficult to be utilized by coders and do not reflect the operation performed.

Extensor Mechanism Disruption Remains a Challenging Problem.

BACKGROUND: Extensor mechanism disruption (EMD) following total knee arthroplasty (TKA) is a devastating problem commonly treated with allograft or synthetic reconstruction. Understanding of reconstruction success rates and patient recorded outcomes is lacking. METHODS: Patients who have an EMD after TKA undergoing mesh or whole-extensor allograft reconstruction between 2011 and 2019, with minimum 2-year follow-up were reviewed at two tertiary care centers. Functional failure was defined as extensor lag >30 degrees, amputation, or fusion, as well as revision extensor mechanism reconstruction (EMR). Survivorship was assessed using Kaplan-Meier curves, and factors for success were determined with logistic regressions. RESULTS: Of fifty-six EMRs (49 patients), 50.0% (28/56) were functionally successful at 3.2 years of mean follow-up (range, 0.2 to 7.4). In situ survivorship of the reconstructions at 36 months was 75.0% (42 of 58). There were 50.0% (14 of 28) of functionally failed EMRs that retained their reconstruction at last follow-up. Mean extensor lag among successes and failures was 5.4 and 71.0° (P = .01), respectively. Mean Knee Injury and Osteoarthritis Outcome Score, Joint Replacement scores were 67.1 and 48.8 among successes and failures (P = .01). There were 64.0% (16 of 25) of successes and 1 of 19 failures that obtained a Knee Injury and Osteoarthritis Outcome Score, Joint Replacement score above the minimum patient-acceptable symptom state for TKA. Survivorship and success rates were similar between reconstruction methods (P = .86; P = .76). All-cause mortality was 8.2% (4 of 49), each with EMR failure prior to death. All-cause reoperation rate was 42.9% (24 of 56), with a 14.3% (8 of 56) rate of revision EMR and 10.7% (6 of 56) rate of above-knee-amputation or modular fusion. CONCLUSIONS: This multicenter investigation of mesh or allograft EMR demonstrated modest functional success at 3.2 years. Complication and reoperation rates were high, regardless of EMR technique. Therefore, EMD after TKA remains problematic.

The COVID-19 Pandemic and Centers of Medicaid and Medicare Services Regulatory Reform Impact on Total Hip Arthroplasty Metrics.

BACKGROUND: Shifts in demand, capacity, and site of service have impacted total hip arthroplasty (THA) volumes and revenues over the 2019-2021 time period. Moving THA off the inpatient-only (IPO) list and the COVID-19 pandemic has caused a shift in delivery away from inpatient services and a decrease in demand. METHODS: Medicare claims data were surveyed for the latest period available (April 1, 2020 to September 2020) and compared with a similar period in 2019 prior to THA removal from the IPO list and before the COVID-19 pandemic. Length of stay (LOS), admission status, site of service, discharge status, cost to CMS (Centers of Medicaid and Medicare Services), and racial disparities were analyzed. RESULTS: From 2019 to 2020, changes in primary THA metrics occurred (overall change in total joint arthroplasty [THA plus total knee arthroplasty metrics]): CMS THA volume decreased from 78,691 to 65,360, -16% (-22%); THA performed as an outpatient increased from 0% to 51% (141%); THA performed as same-day discharge increased from 3% to 12%, 325% (221%); overall LOS decreased from 1.91 to 1.46, -23% (-11%); inpatient LOS increased from 1.92 to 2.05, 7% (16%); outpatient LOS increased from 0.92 to 0.93, 1% (-12%); discharge home increased from 82% to 91%, 12.8% (11%); and CMS spending decreased from $1,033 million to $751 million, -27% (-27%). CONCLUSION: Medicare payments, LOS, discharge to facilities, and volume declined from 2019 to 2020 and were accelerated by IPO list changes and COVID-19 issues. Same-day discharge and hospital outpatient department cases also increased. THA metrics were not affected by race.

Worsening Arthroplasty Utilization With Widening Racial Variance During the COVID-19 Pandemic.

BACKGROUND: Elective arthroplasty surgery in the United States came to a near-complete halt in the spring of 2019 as a response to the COVID-19 pandemic. Racial disparity has been a long-term concern in healthcare with increased focus during the pandemic. The purpose of this study is to evaluate the effects of COVID-19 and race on arthroplasty utilization trends during the pandemic. METHODS: We used 2019 and 2020 Center for Medicare and Medicaid Service fee-for-service claims data to compare arthroplasty volumes prior to and during the COVID-19 pandemic. We compared overall arthroplasty utilization rates between 2019 and 2020 and then sought to determine the effect of race and COVID-19, both independently and combined. RESULTS: There was a decrease in primary total knee arthroplasty (-28%), primary total hip arthroplasty (-14%), primary total hip arthroplasty for fracture (-2%), and revision arthroplasty (-14%) utilization between 2019 and 2020. The highest decrease in overall arthroplasty utilization was in the Hispanic population (34% decrease vs 19% decrease in the White population). We found that a non-White patient was 39.9% (P < .001) less likely to receive a total joint arthroplasty prior to COVID-19. The COVID-19 pandemic further exacerbated the pre-existing racial differences in arthroplasty utilization by decreasing the probability of receiving a total joint arthroplasty for non-White patient by another 12.9% (P < .001). CONCLUSION: We found an overall decreased utilization rate of arthroplasty during the COVID-19 pandemic with further decrease noted in all non-White populations. This raises significant concern for worsening racial disparity in arthroplasty caused by the ongoing pandemic.

Extensive Preoperative Work Is Required for Revision Hip and Knee Arthroplasty.

BACKGROUND: Determining the clinical effort associated with preparing for revision total hip and knee arthroplasty is necessary to maintain the appropriate work relative value unit rating. We have investigated the work done by the orthopedic surgical team in the days and weeks prior to revision hip and knee arthroplasty using a count of time by team members in the electronic medical record (EMR). METHODS: EMR audit logs were generated, and preoperative work (POW) was calculated for members of the surgical team for 200 sequential revision cases. Independent samples t-tests were conducted to compare total POW for procedure, age, gender, insurance, and health literacy; significance threshold was set at P = .05. RESULTS: POW was 97.7 minutes (standard deviation [SD] 53.1). Surgeon POW accounted for 10.5 minutes (SD 9.3), nurses for 29.9 minutes (SD 34.2), mid-level providers for 22.1 minutes (SD 17.0), and office technicians for 34.1 minutes (SD 35.2). There was no difference in total POW based on procedure (hip vs knee), age, gender, insurance type, or health literacy. CONCLUSION: Revision arthroplasty requires substantial preoperative preparation from the surgical team. Most of this is by nurses, mid-level providers, and office staff. This does not seem to be different for hip or knee revisions or by age and gender. EMR audit logs capture the bare minimum POW required to prepare a patient for revision arthroplasty.

Price Transparency for Primary Hip & Knee Arthroplasty: An Overview of the Top 50 US News and World Report Orthopedic Hospitals.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) has mandated all hospitals to publish the charges of 300 common procedures to provide price transparency. The aims of our study are to evaluate 50 top orthopedic hospitals to determine compliance with this mandate and to assess the ease of finding cost information for arthroplasty procedures. METHODS: The websites of the top 50 US News and World Report (USNWR) orthopedic hospitals were searched to find publicly accessible procedural charges. Data included the number of clicks to locate pricing documents, number of files provided, and number of data rows pertaining to arthroplasty. Charge data was queried based on Diagnosis related group (DRG) codes (469, 470), Current Procedural Technology (CPT) codes (27130, 27477), and keyword searches ("arthroplasty", "total hip", and "total knee"). RESULTS: Forty-four (88%) of the top 50 USNWR Orthopedic institutions had publicly accessible files containing cost information. Thirty three of the 44 institutions provided results with DRG search while less than 10 institutions used CPT and keyword searches. There was an average of 226,190 (range 304-1,121,876) rows of data per file. Average charges varied depending on the use of DRG, CPT or keyword searches ($6,663-$117,072). CONCLUSION: The majority of compliant hospitals published large data files requiring the use of DRG codes to find cost information with extreme variation in resultant charges provided. These findings underscore the lack of direct patient benefit afforded by the current mandate, as pricing determinations require expert knowledge in medical coding and have a high variability in the reported charges.

The Efficacy and Safety of Regional Nerve Blocks in Total Knee Arthroplasty: Systematic Review and Direct Meta-Analysis.

BACKGROUND: Regional nerve blocks are widely used in primary total knee arthroplasty (TKA) to reduce postoperative pain and opioid consumption. The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after TKA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management. METHODS: We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published before March 24, 2020 on femoral nerve block, adductor canal block, and infiltration between Popliteal Artery and Capsule of Knee in primary TKA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks compared to a control, local peri-articular anesthetic infiltration (PAI), or between regional nerve blocks. RESULTS: Critical appraisal of 1,673 publications yielded 56 publications representing the best available evidence for analysis. Femoral nerve and adductor canal blocks are effective at reducing postoperative pain and opioid consumption, but femoral nerve blocks are associated with quadriceps weakness. Use of a continuous compared to single shot adductor canal block can improve postoperative analgesia. No difference was noted between an adductor canal block or PAI regarding postoperative pain and opioid consumption, but the combination of both may be more effective. CONCLUSION: Single shot adductor canal block or PAI should be used to reduce postoperative pain and opioid consumption following TKA. Use of a continuous adductor canal block or a combination of single shot adductor canal block and PAI may improve postoperative analgesia in patients with concern of poor postoperative pain control.