Does a "July Effect" Exist for Fellowship Training in Total Hip and Knee Arthroplasty?

BACKGROUND: The hypothetical association between health-care errors and the transition of the medical academic year has been termed the "July effect." Data supporting its existence are conflicting, particularly in orthopedic surgery, and prior studies have inappropriately grouped fellows with resident trainees. No studies to date have examined whether a training initiation effect exists among surgical fellows in adult reconstructive orthopedics. METHODS: This is a level IV retrospective cohort study reviewing 15,650 primary hip and knee arthroplasties performed from 2006 to 2016 at a single institution. Forty arthroplasty fellows were trained during this 10-year period. Primary outcome measures included intraoperative complications, additional procedures, revisions, and nonoperative complications within 90 days of surgery. These complication rates were analyzed by quarter of academic year and by temporal progression through three-month fellowship rotations. RESULTS: There were no differences in intraoperative complication, revision, or nonoperative complication rates between any academic quarter. There was a single statistically lower rate of additional procedures in the third quarter (1.2%) than in the fourth quarter (1.8%, P = .04). The most common complication in this subset was wound dehiscence for patients undergoing hip arthroplasty and stiffness for patients undergoing knee arthroplasty. There was no difference in complication rates during the first, second, or third month as fellows progressed through a single rotation. CONCLUSION: This study does not support the existence of a training-initiation effect among fellows in adult hip and knee reconstruction. Graduated autonomy can be safely employed in a fellowship program without negatively impacting patient outcomes, ensuring the continued high-caliber training of future surgeons.

To Cement or Not? Five-Year Results of a Prospective, Randomized Study Comparing Cemented vs Cementless Total Knee Arthroplasty.

BACKGROUND: The optimal mode of fixation in total knee arthroplasty is a continuing subject of debate. METHODS: Previously, we reported 2-year results for this prospective, randomized trial. Knee Society Scores, Oxford scores, and pain visual analog scales were collected pre-operatively and post-operatively. Minimum 5-year follow-up has been obtained with radiographic analysis for 85 patients. RESULTS: Mean Knee Society Scores and Oxford scores and patient-reported outcomes were similar in both groups. Each group had 1 additional revision, but neither was related to implant fixation. Survivorship with revision as an endpoint was equivalent (95.9% and 95.3%, P = .98). There was no significant difference in radiolucencies observed between groups (P = .10), all were non-progressive. CONCLUSION: Cementless and cemented total knee arthroplasty had equivalent patient-reported outcomes and survivorship at midterm follow-up. Updates are planned at 10 and 15-year intervals to observe long-term modes of failure between these 2 methods of fixation.

Effect of Preoperative Dental Extraction on Postoperative Complications After Total Joint Arthroplasty.

BACKGROUND: Poor dental hygiene has historically been considered a potential risk factor for infection in total joint arthroplasty (TJA), which has resulted in the common practice of requiring preoperative dental clearance and often results in dental extractions. However, the association between dental pathology and periprosthetic joint infection (PJI) has recently been called into question. METHODS: A consecutive series of 2457 primary total hip and total knee arthroplasties were retrospectively reviewed. Documented dental evaluation was found in 1944 (79.1%) procedures, 223 (11.5%) of which had extraction of at least 1 tooth. No documented dental evaluation was found in 369 (15.0%) patients. RESULTS: The overall complication rate was 3.87% with an overall PJI rate of 1.51%. There was no statistically significant association between a complication and procedure type, sex, preoperative dental evaluation or extraction, diabetes status, immunosuppression, malnutrition, or age. However, our sample demonstrated a higher complication rate among patients undergoing dental extraction as well as for those with diabetes and immunosuppressed patients. CONCLUSION: Our findings suggest that routine formal dental clearance for all TJA patients may not be necessary. Additionally, patients with poor oral hygiene may not have elevated risk of postoperative PJI, and preoperative tooth extraction may represent an unnecessary step for patients undergoing elective TJA.

Bundled Payments for Care Improvement: Health System Experience With Lower Extremity Joint Replacement at Higher and Lower Volume Hospitals.

BACKGROUND: The Bundled Payments for Care Improvement (BPCI) initiative was introduced in 2013 to reduce Medicare healthcare costs while preserving or enhancing quality. We examined data from a metropolitan healthcare system comprised of 1 higher volume hospital and 4 lower volume hospitals that voluntarily elected to participate in the BPCI Major Joint Replacement of the Lower Extremity Model 2, beginning July 1, 2015. Stratifying the data by hospital volume, we determined how costs changed during the 16-month period when all 5 hospitals participated compared to the 1-year period preceding BPCI participation, where savings were achieved, and how the hospitals were rewarded. METHODS: The Medicare data included the 90-day target for each episode and actual part A and part B spending for the anchor hospitalization plus all post-acute payments including inpatient rehabilitation, skilled nursing, home health, outpatient physical therapy, and hospital readmissions. RESULTS: The mean episode of care cost decreased by 11.1% (from $21,324 to $18,953) at the higher volume hospitals and by 8.3% (from $25,724 to $23,584) at the lower volume hospitals during BPCI participation compared to the preceding year. The savings were achieved by reducing the use of inpatient rehabilitation, shortening the length of stay at skilled nursing facilities, and decreasing readmission rates. Although the higher volume hospital achieved an increased mean savings of $230 per episode compared to the lower volume hospitals ($2371 vs $2141), it was penalized $490 per episode after reconciling the actual Medicare expenditures with the BPCI targets while the lower volume hospitals received a mean reward of $315 per episode. CONCLUSION: The BPCI initiative decreased costs and readmissions within our healthcare system. Despite substantial savings compared to the preceding year, the higher volume hospital's low target derived from its 2009-2012 baseline costs was not achieved which resulted in a penalty and led it to withdraw from the BPCI initiative in October 2016.

To Cement or Not? Two-Year Results of a Prospective, Randomized Study Comparing Cemented Vs. Cementless Total Knee Arthroplasty (TKA).

The optimal mode of fixation in total knee arthroplasty (TKA) is a subject of debate. We enrolled 100 TKA patients randomized to cemented or cementless fixation. Knee Society Scores (KSS), Oxford scores and pain visual analog scales (VAS) were collected pre-operatively and post-operatively. Two-year follow-up was obtained for 93 patients. The mean VAS trended higher for the cementless group at 4 months (P=0.06). At 2 years, the KSS functional scores, Oxford scores, and self-reported questions for satisfaction, less pain and better function were similar but the cemented group had higher KSS clinical scores (96.4 vs. 92.3, P=0.03). More radiolucencies were seen in cementless knees (P<0.001). The cementless group had one revision for instability and one cemented knee was revised for infection. Cementless TKA showed equivalent survivorship (revision for any reason as the endpoint) compared to cemented TKA at this early follow-up. Close monitoring of radiolucencies is important with continued follow-up.

Does Powered Femoral Broaching Compromise Patient Safety in Total Hip Arthroplasty?

Background: During manual broaching (MB) in total hip arthroplasty (THA), off-axis forces delivered to the proximal femur and broach malalignment can lead to fractures and cortical perforations. Powered broaching (PB) is a novel alternative that delivers consistent impaction forces and reduces workload. This is the first large-scale study to compare intraoperative and 90-day rates of periprosthetic femur fractures (PFFs) and perforations in THA performed using MB vs PB. Methods: Our institutional database was reviewed for all patients undergoing primary cementless direct anterior THA from 2016 to 2021. Three surgeons performing 2048 THAs (MB = 800; PB = 1248) using the same stem design were included. PFFs and perforations within 90 days of the index procedure were compared. Differences in length of surgery and demographics were assessed. Results: Calcar fractures occurred in <1% of patients (PB [0.96%, 12/1248] vs MB [0.25%, 2/800]; P = .06). Rates of trochanteric fractures did not differ (PB = 0.32% [4/1248] vs MB = 0.38% [3/800]; P = .84). Cortical perforations occurred in 0.24% (3/1248) of the PB cohort and in 0.75% (6/800) of the MB cohort (P = .09). No revisions due to aseptic loosening or PFF occurred within 120 days of surgery. Conclusions: Our single-center experience with powered femoral broaching in THA demonstrates PB is a safe and efficient means of performing direct anterior THA. Low rates (<1%) of PFF, perforation, and revision can be achieved. Given our positive experience with PB, all surgeon authors utilize PB nearly exclusively for elective primary direct anterior THA.

Have newer bearing surfaces changed expectations regarding the longevity of total hip arthroplasty?

AIMS: The purpose of this study is to examine six types of bearing surfaces implanted at a single institution over three decades to determine whether the reasons for revision vary among the groups and how long it takes to identify differences in survival. METHODS: We considered six cohorts that included a total of 1,707 primary hips done between 1982 and 2010. These included 223 conventional polyethylene sterilized with γ irradiation in air (CPE-GA), 114 conventional polyethylene sterilized with gas plasma (CPE-GP), 116 crosslinked polyethylene (XLPE), 1,083 metal-on-metal (MOM), 90 ceramic-on-ceramic (COC), and 81 surface arthroplasties (SAs). With the exception of the COC, all other groups used cobalt-chromium (CoCr) femoral heads. The mean follow-up was 10 (0.008 to 35) years. Descriptive statistics with revisions per 100 component years (re/100 yr) and survival analysis with revision for any reason as the endpoint were used to compare bearing surfaces. RESULTS: XLPE liners demonstrated a lower cumulative incidence of revision at 15 years compared to the CPE-GA and CPE-GP groups owing to the absence of wear-related revisions (4% for XLPE vs 18%, p = 0.02, and 15%, p = 0.003, respectively). Revisions for adverse local tissue reactions occurred exclusively among the MOM (0.8 re/100 year) and SA groups (0.1 re/100 year). The revision rate for instability was lower among hips with 36 mm and larger head sizes compared to smaller head sizes (0.2% vs 2%, p < 0.001). CONCLUSION: The introduction of XLPE has eliminated wear-related revisions through 15-year follow-up compared to CPE-GP and CPE-GA. Dislocation incidence has been reduced with the introduction of larger diameter heads but remains a persistent concern. The potential for adverse local tissue reactions with MOM requires continued follow-up. Cite this article: Bone Joint J 2020;102-B(7 Supple B):105-111.

Patient satisfaction with mobile compression devices following total hip arthroplasty.

The goal of this study was to evaluate patient satisfaction with the use of a mobile compression device after anterior total hip arthroplasty. Two hundred forty-seven patients used the mobile compression device for 10 days after surgery with recommended adjunctive 325 mg aspirin therapy. The device has a rechargeable battery pack that weighs 1.65 lb and is attached to compression sleeves worn over the calves of both lower extremities. It delivers sequential compression to the sleeves at a pressure of 50 mm Hg for about 10 seconds at a cycle of 1/min and is synchronized to the patient's venous blood flow pulses. A questionnaire was administered to all patients at 1-month follow-up to gauge patient perception of the device. There were 14 questions about comfort, noise, cost, pain, skin breakdown, rash, and falls related to the device. Overall, 234 of 247 (94.7%) patients stated that they would use the device again. The most common complaint from patients was that the mobile compression device was cumbersome (63.6%). Twenty-five patients (10.1%) reported having a fall while using the device, although no fall-related injuries were documented. Therefore, the authors recommend counseling patients about fall risk and reminding them to use caution while moving about with the device. Despite the limitations described in this study, the data confirmed that patients who used the device had an overall positive response to the system and would choose to use the device again rather than using chemical agents for deep venous thrombosis prophylaxis.