Cost Analysis of Routine Histopathologic Evaluation of Specimens Following Total Ankle Arthroplasty.

BACKGROUND: Routine histopathologic examination of orthopaedic surgical specimens is a standard practice at many institutions. Previous studies have demonstrated that this practice seldom altered patient management for several orthopaedic procedures. As a result, the value of such practices has come into question. The purpose of this study is to determine the cost-effectiveness of routine histopathologic analysis of specimens obtained during total ankle arthroplasty (TAA). METHODS: A retrospective analysis was performed of patients who underwent uncomplicated primary TAA at a large, academic, health system between January 2015 and December 2021. The postoperative histopathologic diagnoses were compared with the respective patient's preoperative clinical and intraoperative diagnoses. The prevalence of concordant, discrepant, and discordant diagnoses was determined. Cost-effectiveness analysis was conducted to assess the financial implications of obtaining routine specimens for histopathologic examination for TAA. RESULTS: A total of 85 TAAs were identified in 85 individual patients and were included in the present study. A total of 172 specimens were sent for routine histopathologic review. On histopathologic analysis, a final diagnosis was confirmed in 82 (96.5%) of the total specimens reviewed. A discrepant diagnosis was discovered in 3 (3.5%; 2 cases of gout/pseudogout and 1 case of osteonecrosis) cases and 0 (0%) discordant diagnoses were discovered, corresponding to positive and negative predictive values of 97% and 100%, respectively The total estimate of costs incurred for the routine analysis of all specimens included in the study was between $12 299.20 and 17 846.00. The estimated cost to establish each discrepant diagnosis ranged between $4099.73 and $5948.67, and the cost for a discordant diagnosis was unable to be established. CONCLUSION: Routine histopathologic analysis of specimens obtained during TAA rarely revealed a discordant diagnosis and resulted in no alterations to patients' plan of care. Furthermore, the additional costs of routine histopathologic examination are significant. As such, it is recommended that such interventions in TAA should be performed on a per-case basis at the operating surgeon's discretion.

Patient Satisfaction and Risk of Falls with the Use of Intermittent Pneumatic Compression Devices Following Total Joint Arthroplasty.

INTRODUCTION: Patients who undergo total joint arthroplasty (TJA) are at a high risk for the development of thromboembolic complications. The rate at which venous thromboembolism occurs following TJA has been reported to be between 0.5% to 1.0%. As a result, the utilization of prophylactic therapies is considered the standard of care in this patient population. The primary purpose of the current study was to 1. evaluate patient satisfaction with the home use of intermittent pneumatic compression (IPC) devices following TJA and 2. evaluate the risk of self-reported falls secondary to the use of these devices following TJA. METHODS: This is a single institution, prospective study on patients who underwent TJA at an urban, academic orthopedic specialty hospital. Utilizing an electronic patient rehabilitation application (EPRA) that wirelessly pushes digital surveys at predefined time intervals, patients were surveyed regarding their use and satisfaction with their home IPC devices. They were also asked if they experienced any falls or near-falls. Surveys were administered on postoperative day 14, and patients were given 10 days to submit their responses. Using our institutions data warehouse, patient demographics including age, sex, surgery, laterality, insurance type, and length of stay were collected. RESULTS: Survey responses were collected from 424 patients who underwent TJA between August 2018 and January 2019. Of the respondents, 248 were female and 176 were male. Approximately 79% of patients in the cohort were satisfied with their use of their compression devices compared to 21% of patients who were unsatisfied. During this time, 19.3% (82 patients) also reported at least one tripping episode at home while using the device, while 80.7% (342 patients) never had a tripping incident at home. Finally, 1.4% (six patients) had at least one fall at home, while 98.6% (418 patients) did not have any falls at home. CONCLUSION: These results suggest that our patients were significantly dissatisfied with their home intermittent compression devices. There are a significant number of trips or falls following TJA and further study is needed examining the potential causality of these devices and their cords in these falls.

Outcomes with Two Tapered Wedge Femoral Stems in Total Hip Arthroplasty Using an Anterior Approach.

BACKGROUND: The majority of hip arthroplasties in the United States utilize cementless acetabular and femoral components. Despite their similarities, stem geometry can still differ. The purpose of this study is to compare the clinical results of two wedge-type stem designs. METHODS: A retrospective study of patients who underwent primary THA utilizing a direct anterior approach between January 2016 and January 2017. Two cohorts were established based on femoral stem design implanted. Descriptive patient characteristics and surgical and clinical data was extracted which included surgical time, length of stay (LOS), presence of pain (categorized as groin, hip, or thigh pain) at the latest follow-up, and revisions. Immediate postoperative radiographs were compared with the latest follow-up radiographs to assess limb length discrepancies, stem alignment, and stem subsidence. RESULTS: A total of 544 patients were included. 297 patients received the Group A stem (morphometric) and 247 patients received the Group B stem (flat-tapered). A significantly higher proportion of Group B stems subsided ≥3 mm and were in varus alignment than the Group A design. Additionally, a significantly greater number of patients who received the Group B stem reported postoperative hip and thigh pain. The logistic regression found that the Group B stem was 2.32 times more likely to subside ≥3 mm than the Group A stem. CONCLUSION: Our study suggests modestly improved radiographic and clinical outcomes and fewer instances of thigh pain, subsidence, and varus alignment in the patients who received the Group Ahip stem. Further studies are warranted to assess long-term significance.

Clinical and Radiographic Outcomes after Direct Anterior Approach Total Hip Arthroplasty Using Two Specialized Surgical Tables.

BACKGROUND: Specialized tables for direct anterior (DA) approach total hip arthroplasty (THA) have required an unscrubbed assistant for manipulation of the operative limb. A novel surgical table attachment designed for the DA approach is fully surgeon controlled and partially automated. The purpose of this study is to compare the clinical outcomes in patients who underwent THA through a DA approach with an assistant-controlled vs the surgeon-controlled (SC) table. METHODS: This is a retrospective study of 343 patients who underwent primary THA between January 2017 and October 2017. Two cohorts were established based on the surgical table used. Surgical and clinical data included the surgical time, length of stay, presence of pain (groin, hip, or thigh pain) at latest follow-up, and revision for any reason. Immediate postoperative radiographs were compared with latest follow-up radiographs to assess for leg length discrepancy, stem alignment, and stem subsidence. RESULTS: One hundred sixty-seven (48.7%) cases were performed using the assistant-controlled table, and 176 (51.3%) cases were performed using the SC table. The surgical time was significantly greater for surgeries using the SC table (70.2 minutes vs 66.1 minutes, P < .001). Neither group experienced any intraoperative fractures or postoperative dislocations. There were no significant differences in any other clinical or radiographic outcomes. CONCLUSIONS: Although the surgical time with the self-controlled table was longer by approximately 4 minutes, this discrepancy disappeared with progression through the learning curve. In our experience, the SC table allows for greater autonomy for the operating surgeon and eliminates the need for a full-time employee in the operating room workflow.

Arthroplasty Surgeons Do Not Improve Acute Outcomes for Patients With Hip Fracture Relative to Other Subspecialists.

As bundled reimbursement models continue to evolve, there is a continued effort to increase the value of care for patients undergoing arthroplasty. The authors sought to evaluate the effect of surgeon specialization (arthroplasty vs non-arthroplasty) on acute outcomes for patients with hip fracture who underwent total hip arthroplasty (THA), in an effort to determine whether the value of care can be improved by surgeons specializing in these procedures. They performed a multicenter retrospective cohort study of patients who had hip fracture and were treated with THA between June 2013 and February 2018 at 2 academic institutions that were involved in bundled reimbursement initiatives. Patients were stratified based on the subspecialty training of the operative surgeon (fellowship-trained adult reconstruction vs other orthopedic sub-specialty), and 90-day readmissions, length of stay, and discharge disposition were compared between groups. A total of 291 patients were included in the final cohort, with 120 (41.2%) undergoing surgery performed by a fellowship-trained adult reconstruction surgeon. No significant difference was found in age, sex, race, or American Society of Anesthesiologists score between the 2 groups. In addition, no significant difference was found in length of stay, discharge to a facility, or 90-day readmissions on univariable or multivariable analysis when adjusted for age, sex, body mass index, and American Society of Anesthesiologists score. This study showed that the acute outcomes used to assess the value of care for patients undergoing THA were not significantly different when the surgery was performed by an adult reconstruction specialist compared with other orthopedic surgeons at 2 high-volume academic centers with perioperative care pathways. Alternative modalities to significantly improve acute postoperative outcomes in a bundled reimbursement model must be investigated. [Orthopedics. 2020;43(5):e442-e446.].

Short-term outcomes with the REDAPT monolithic, tapered, fluted, grit-blasted, forged titanium revision femoral stem.

AIMS: Although good clinical outcomes have been reported for monolithic tapered, fluted, titanium stems (TFTS), early results showed high rates of subsidence. Advances in stem design may mitigate these concerns. This study reports on the use of a current monolithic TFTS for a variety of indications. METHODS: A multi-institutional retrospective study of all consecutive total hip arthroplasty (THA) and revision total hip arthroplasty (rTHA) patients who received the monolithic TFTS was conducted. Surgery was performed by eight fellowship-trained arthroplasty surgeons at four institutions. A total of 157 hips in 153 patients at a mean follow-up of 11.6 months (SD7.8) were included. Mean patient age at the time of surgery was 67.4 years (SD 13.3) and mean body mass index (BMI) was 28.9 kg/m2 (SD 6.5). Outcomes included intraoperative complications, one-year all-cause re-revisions, and subsidence at postoperative time intervals (two weeks, six weeks, six months, nine months, and one year). RESULTS: There were eight intraoperative complications (4.9%), six of which were intraoperative fractures; none occurred during stem insertion. Six hips (3.7%) underwent re-revision within one year; only one procedure involved removal of the prosthesis due to infection. Mean total subsidence at latest follow-up was 1.64 mm (SD 2.47). Overall, 17 of 144 stems (11.8%) on which measurements could be performed had >5 mm of subsidence, and 3/144 (2.1%) had >10 mm of subsidence within one year. A univariate regression analysis found that additional subsidence after three months was minimal. A multivariate regression analysis found that subsidence was not significantly associated with periprosthetic fracture as an indication for surgery, the presence of an extended trochanteric osteotomy (ETO), Paprosky classification of femoral bone loss, stem length, or type of procedure performed (i.e. full revision vs conversion/primary). CONCLUSION: Advances in implant design, improved trials, a range of stem lengths and diameters, and high offset options mitigate concerns of early subsidence and dislocation with monolithic TFTS, making them a valuable option for femoral revision. Cite this article: Bone Joint J 2020;102-B(2):191-197.

Total Hip Arthroplasty for Femoral Neck Fracture: The Economic Implications of Orthopedic Subspecialty Training.

BACKGROUND: Hip fractures have significant economic implications as a result of their associated direct and indirect medical costs. Under alternative payment models, it has become increasingly important for institutions to find avenues by which costs could be reduced while maintaining outcomes in these cases. METHODS: A multi-institutional retrospective analysis of Medicare patients who underwent total hip arthroplasty (THA) for femoral neck fracture was conducted to assess the impact of fellowship training in adult reconstruction (AR) on the total costs of the 90-day episode of care. Patients were divided into 2 cohorts according to fellowship training status of the operating surgeon: (1) AR-trained and (2) other fellowship training (non-AR). The primary outcome was the total cost of the 90-day episode of care converted to a percentage of the bundled payment target price. RESULTS: A total of 291 patients who underwent THA for the treatment of a femoral neck fracture were included. The average total cost percentage of the 90-day episode of care was significantly lower for the AR cohort 70.9% (±36.6%) than the non-AR cohort 82.6% (±36.1%) (P < .01). After controlling for baseline demographics in the multivariable logistic regression, the care episodes in which the operating surgeons were AR fellowship-trained were still found to be significantly lower, at a rate of 0.87 times the costs of the non-AR surgeons (95% confidence interval 0.78-0.97, P = .011). In addition, the non-AR cohort exceeded the bundle target price more frequently than the AR cohort, 49 (28.7%) vs 16 (13.3%) (P = .02). CONCLUSION: In an era of bundled payments, ascertaining factors that may increase the value of care while decreasing the cost is paramount for institutions and policymakers alike. The results presented in this study suggest that in the femoral neck fracture population, surgeons trained in AR achieve lower total costs for the THA episode of care. Furthermore, non-AR fellowship-trained surgeons exceeded the bundled payment target more frequently than the AR surgeons.

Comparison of Payment Margins Between the Bundled Payments for Care Improvement Initiative and the Comprehensive Care for Joint Replacement Model Shows a Marked Reduction for a Successful Program.

BACKGROUND: The Comprehensive Care for Joint Replacement (CJR) model was implemented to address the 2 most commonly billed inpatient surgical procedures, total hip arthroplasty and total knee arthroplasty. The primary purpose of this study was to review the economic implications of 1 institution's mandatory involvement in the CJR in comparison with prior involvement in the Bundled Payments for Care Improvement (BPCI) initiative. METHODS: The mean cost per episode of care was calculated using our institution's historical data. The target prices, projected savings or losses per episode of care, and projected annual savings for both BPCI and CJR were established and were comparatively analyzed. RESULTS: The CJR target prices will decrease in comparison with BPCI target prices by 24.0% for Medicare Severity-Diagnosis Related Group (MS-DRG) 469 without fracture, 22.8% for MS-DRG 469 with fracture, 26.1% for MS-DRG 470 without fracture, and 27.7% for MS-DRG 470 with fracture, resulting in a reduction in savings per episode of care by 92.8% for MS-DRG 469 without fracture, 166.0% for MS-DRG 469 with fracture, 94.9% for MS-DRG 470 without fracture, and 61.7% for MS-DRG 470 with fracture. Our institution's projected annual savings under CJR will decrease by 83.3%. CONCLUSIONS: These results suggest that the margin for savings in the CJR will be substantially reduced compared with the margin for savings in the BPCI. In hospitals that had previously devoted resources, these will have far less impact in the CJR, and hospitals new to the CJR that have not made these investments previously will require even greater resources for developing cost reduction and quality control strategies to remain financially solvent. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A Novel Opioid-Sparing Pain Management Protocol Following Total Hip Arthroplasty: Effects on Opioid Consumption, Pain Severity, and Patient-Reported Outcomes.

BACKGROUND: Opioid prescriptions and subsequent opioid-related deaths have increased substantially in the past several decades. Orthopedic surgery ranks among the highest of all specialties with respect to the amount of opioids prescribed. We present here the outcomes of our opioid-sparing pain management pilot protocol for total hip arthroplasty (THA). METHODS: A retrospective study was conducted to assess outcomes before and after the implementation of an opioid-sparing pain management protocol for THA. Patients were divided into 2 cohorts for comparison: (1) traditional pain management protocol and (2) opioid-sparing pain management protocol. The Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, pain severity using a Visual Analog Scale, and inpatient morphine milligram equivalents (MMEs) per day were compared between the 2 cohorts. RESULTS: No statistically significant difference was observed in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement between the 2 cohorts at any time point (P > .05). Although there was a significant decrease in pain scores over time (P < .01), there was no statistically significant difference in the rates of change between the 2 pain management protocols at any time point (P = .463). Inpatient opioid consumption was significantly lower for the opioid-sparing cohort in comparison to the traditional cohort (14.6 ± 16.7 vs 25.7 ± 18.8 MME/d, P < .001). Similarly, the opioid-sparing cohort received significantly less opioids than the traditional cohort during the post discharge period (13.9 ± 24.2 vs 80.1 ± 55.9 MME, P < .001). CONCLUSION: The results of this study suggest that an opioid-sparing protocol reduces opioid consumption and provides equivalent pain management and patient-reported outcomes during the 90-day THA episode of care relative to a traditional opioid-based regimen. These findings may help decrease the risk of adverse events associated with postoperative opioid use and provide a means of decreasing the opioid footprint in clinical practice.

Cost-Effectiveness of Dual Mobility and a Value-Based Algorithm of Utilization.

Hip dislocation remains a major concern following total hip arthroplasty due to its high frequency and economic burden. This article evaluates the cost-effectiveness regarding dual mobility as an alternative to standard implant designs. A review of literature analyzing the PubMed Central database was undertaken using the following terms in the primary query: dual mobility, cost-effectiveness, cost-analysis, or economic analysis. Dual mobility systems may be a cost-effective alternative when the price of the implant does not exceed the traditional system by $1023. Dual mobility cups may be an essential component for the future success of value-based total hip arthroplasty.

Modifying Patient Expectations Can Enhance Total Hip Arthroplasty Postoperative Satisfaction.

BACKGROUND: A better understanding of patient expectations within the perioperative setting will enable clinicians to better tailor care to the needs of the total hip arthroplasty (THA) recipient. Such an approach will promote patient-centered decision-making and optimize recovery times while enhancing mandated hospital quality metrics. In the present study, we preoperatively and postoperatively surveyed THA candidates to elucidate the relationship between patient expectations and length of stay (LOS). METHODS: This is a multi-institutional prospective study among THA candidates. Patients were surveyed regarding discharge planning 1 week preoperatively and postoperatively to capture perioperative patient expectations and correlate with inpatient LOS. RESULTS: In total, 93 THAs performed by 6 high-volume orthopedic surgeons at 2 medical centers. Our results demonstrated that patients of male gender and commercial insurance had significantly (P < .05) shorter LOS. Shorter LOS patients demonstrated significantly higher levels of LOS acceptance ("very comfortable" rate in same-day discharge: 75.0% and next-day discharge: 63.8%; 2 days: 40.7%; 3+ days: 42.9%; P < .05) and a higher likelihood to participate in SDD programs. Postoperatively, patients with a shorter LOS had more acceptance to their LOS, albeit not statistically significant (P = .20). CONCLUSION: Our results suggest that guiding patient expectations within the perioperative setting is an essential component for successful and timely discharge after THA. Having clear and transparent discussion with the surgical team regarding the perioperative course can improve a THA candidate's understanding and buy-in with the postoperative plan, regardless of LOS. Finally, inpatient LOS does not appear to affect patient satisfaction. LEVEL OF EVIDENCE: Level II, prospective observational study.

The learning curve following adoption of a novel short-stem prosthesis in total hip arthroplasty: implications on short-term patient outcomes.

BACKGROUND: Short-stem (SS) hip prostheses for total hip arthroplasty (THA) have gained popularity as surgeons strive to reproduce physiological stress distributions at the proximal femur. Additionally, as THA indications continue to target younger populations, preservation of femoral bone stock for potential revision surgeries is particularly appealing. However, little is known regarding the short-term complications of each variety of short stem during the learning curve period. The purpose of this study is to evaluate the short-term complications among the THA recipients with the use of a novel SS hip prosthesis. METHODS: A retrospective chart review was performed of all patients undergoing primary THA utilizing an Echo Bi-Metric Microplasty hip stem. Patient demographics, surgical factors, complications and quality outcomes were collected utilizing our institution's data warehouse and verified by chart review. RESULTS: In total, 182 SSs were implanted in 168 patients undergoing primary THA. Of these, 5 (2.9%) patients sustained a periprosthetic fracture. Two fractures occurred during the index hospital admission, and 3 occurred in the post-discharge period. Subset analysis demonstrated that 4 (80%) fractures had occurred during the initial learning curve period, within the first 30 surgical cases with a SS. CONCLUSION: Short-stem hip prostheses are a safe alternative for THA. The results of the present study demonstrate a fracture incidence of 2.9% among patients. However, surgeons should remain cautious when utilizing new implant system and expect a learning curve. In this study, 80% of periprosthetic fractures following SS THA occurred within the first 30 cases for experienced arthroplasty-trained surgeons.

Relationship Between the Patient-Reported Outcome Measurement Information System and Traditional Patient-Reported Outcomes for Osteoarthritis.

BACKGROUND: Incorporating patient-reported outcomes (PROs) is paramount to the creation of a value-based healthcare system that prioritizes patient-centered care in total joint arthroplasty. The relationship between global assessment PROs such as Patient-Reported Outcome Measurement Information System (PROMIS) and joint-specific PROs for hip and knee, such as short form variations of Knee Injury and Osteoarthritis Outcome Score (KOOS-JR) and Hip Injury and Osteoarthritis Outcome Score (HOOS-JR), has yet to be assessed. METHODS: A retrospective analysis was conducted to assess PRO measurements for knee-related and hip-related complaints. The KOOS-JR and HOOS-JR were compared to the PROMIS computerized adaptive test (CAT) short forms (physical function, pain interference, and pain intensity) to assess their relationship. RESULTS: A total of 3644 patients completed 4609 questionnaires. A modest to strong correlation was observed between the KOOS-JR and the PROMIS CAT (ranging from r = 0.56 to -0.71, P < .05). A modest to strong correlation was also found between the HOOS-JR and the PROMIS CAT (r = 0.59 to -0.79, P < .05). CONCLUSION: PROMIS CATs demonstrated a modest to strong correlation with KOOS-JR or HOOS-JR. Future studies should further investigate the limitations of global assessment health surveys in capturing disease-specific changes following total joint arthroplasty.

Imaging of the varicella zoster virion in the viral highways: comparison with herpes simplex viruses 1 and 2, cytomegalovirus, pseudorabies virus, and human herpes viruses 6 and 7.

Imaging by scanning electron microscopy (SEM) can provide insight into viral egress. At a low magnification level, varicella zoster virions (VZV) emerge from an infected cell surface in a distinctive pattern previously described as "viral highways." Viral highways consist of thousands of particles arranged in linear pathways across the syncytial surface. This egress pattern has not been described with other herpesviruses, but a systematic analysis has not been performed. Therefore, the characteristic arrangement of VZV egress was compared with that of six other members of the herpes virus family, including herpes simplex virus (HSV) types 1 and 2, human cytomegalovirus (CMV), pseudorabies virus (PRV), and human herpesvirus types 6 and 7 (HHV-6 and HHV-7). Only VZV-infected cells exhibited viral highways. Subsequent SEM examination of VZ virions at an ultra high-resolution revealed that more than 70% were aberrant. Further imaging of the other herpesviruses demonstrated that VZV structure was more closely related to PRV than HSV-1 or HSV-2. Finally, it is noted that the individual members of the herpesvirus family have distinguishable SEM profiles.

Tropism of varicella-zoster virus for human tonsillar CD4(+) T lymphocytes that express activation, memory, and skin homing markers.

Varicella-zoster virus (VZV) is an alphaherpesvirus with the characteristic neurotropism of this group, but VZV also infects T cells productively and downregulates major histocompatibility complex (MHC) class I expression on infected T cells, as shown in the SCID-hu mouse model. T-cell tropism is likely to be critical for the cell-associated viremia associated with primary VZV infection. In these experiments, we found that VZV infects human tonsillar CD4(+) T cells in culture, with 15 to 25% being positive for VZV proteins as detected by polyclonal anti-VZV immunoglobulin G (IgG) staining and monitored by flow cytometry analysis. RNA transcripts for VZV gE, a late gene product, were detected in T-cell populations that expressed VZV surface proteins, but not in the VZV-negative cell fraction. Exposure to phorbol myristate acetate resulted in an increase in VZV-positive T cells, indicating that viral DNA was present within these cells and that VZV gene expression could be induced by T-cell activation. By immune scanning electron microscopy, VZV virions were detected in abundance on the surfaces of infected tonsillar T cells. The predominant CD4(+) T-lymphocyte subpopulations that became infected were activated CD69(+) T cells with the CD45RA(-) memory phenotype. Subsets of CD4(+) T cells that expressed skin homing markers, cutaneous leukocyte antigen, and chemokine receptor 4 were also infected with VZV. By chemotaxis assay, VZV-infected T cells migrated to SDF-1, demonstrating that skin migratory function was intact despite VZV infection. The susceptibility of tonsil T cells to VZV suggests that these cells may be important targets during the initial VZV infection of upper respiratory tract sites. Viral transfer to migrating T cells in the tonsils may facilitate cell-associated viremia, and preferential infection of CD4 T cells that express skin homing markers may enhance VZV transport to cutaneous sites of replication.