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

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

John N. Insall Award: MARCQI's Pain-Control Optimization Pathway (POP): Impact of Registry Data and Education on Opioid Utilization.

BACKGROUND: In 2019, the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) recommended an evidence-based opioid pain pathway to participating physicians and hospitals for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to determine if the education could influence and have lasting effects on the prescribing patterns for TJA patients. METHODS: Using the MARCQI database, the number of oral morphine equivalents (OMEs) prescribed at discharge were collected from January 2018 through December 2019 for all primary arthroplasty procedures. Periods compared included before and after July 2018 Michigan opioid laws as well as before and after the March 2019 MARCQI recommendations. The data compared total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients, opioid-naive vs opioid-tolerant patients, individual surgeons, and MARCQI sites. RESULTS: The data included 84,998 TJAs: 22,774 opioid-naive THAs, 9124 opioid-tolerant THAs, 40,882 opioid-naive TKAs, and 12,218 opioid-tolerant TKAs. In all the groups and at all time periods there were a significant decrease in prescriptions (P < .001). Individual surgeons and participating sites also demonstrated decreased OMEs on discharge after the recommendations. Between the first and last months of collection, this represented an overall decrease of opioid OMEs for THA by 47.1% for opioid-naive patients and 53.4% for opioid-tolerant patients. For TKA patients, the OME decrease was 48.3% for opioid-naive patients, and 48.4% for opioid-tolerant patients. CONCLUSION: The MARCQI pain control optimization pathway (POP) program has been successful in drastically reducing opioid prescribing with lasting effects, which has substantially limited the overall opioid prescription burden for patients undergoing arthroplasty.

Quantifying Patient Engagement in Total Joint Arthroplasty Using Digital Application-Based Technology.

BACKGROUND: Digital patient engagement has been suggested as a mean to increase patient activation and patient satisfaction after total joint arthroplasty. The purpose of this study was to assess patient engagement with application-based educational tools and to explore what content was most useful to patients in the perioperative period surrounding total hip arthroplasty (THA) and total knee arthroplasty (TKA), respectively. METHODS: Patients undergoing THA and TKA between October 2017 and January 2020 were enrolled to use an application-based digital technology. The App provides comprehensive patient education using a series of modules delivered at set intervals preoperatively and postoperatively. Patient engagement was defined as patients viewing at least one time the modules that were sent, or marking them as completed. Patient satisfaction was assessed using an in-application survey. RESULTS: Complete data were available on 207 patients of which 95 (46%) underwent THA and 112 (54%) underwent TKA. The average age was 60 years. 54% with patients invited to the program completed registration. An average compliance rate of 48% (41 modules engaged out of 83) was observed. Of all modules completed, the top three most popular categories included physical therapy/exercise videos, health literacy, and anxiety/stress/pain management. The least viewed category was nutrition planning and education. CONCLUSION: When presented educational material related to THA and TKA, patients had a high rate of compliance. Digital technology platforms provide a scalable, meaningful approach to engaging patients throughout the continuum of joint replacement care and may serve as a cost-effective adjunct to traditional methods.

COVID-19 Impact on Young Arthroplasty Surgeons.

BACKGROUND: The current coronavirus crisis, COVID-19, has affected all orthopedic surgeons. Surgeons at early stages of their career are at risk of being affected differently than their more established counterparts. METHODS: We conducted an online survey for members of the Young Arthroplasty Group to determine what effects this had on their current practice. RESULTS: Nearly 40% of our surveyed group responded ranging from residents, fellows, and early career surgeons. All groups had been affected by the crisis, with different impacts on each subgroup. CONCLUSION: COVID-19 had significant impact on young surgeons affecting their compensation, redeployment, and career advancement. Available resources should be offered to this group, where available, to mitigate the impact of the crisis.

Conversion Total Knee Arthroplasty: Prior Fracture or Osteotomy Around the Knee Leads to Increased Resource Utilization.

BACKGROUND: Prior knee surgery before total knee arthroplasty (TKA) puts patients at higher risk of inferior outcomes and increased care cost. This study compares intraoperative and postoperative variables including procedure duration, components, length of stay, readmission, complications, and reoperations among patients undergoing conversion TKA. METHODS: Primary TKA from a single-surgeon database identified 130 patients with prior knee surgery to form a "conversion" cohort. One-to-one matching identified 130 patients of similar age, American Society of Anesthesiologists score, body mass index, and gender without prior knee surgery for comparison. Perioperative and 90-day postoperative variables were compared between patients with and without prior surgery, within the conversion group based on the type of prior surgery, and whether the prior surgery was bony or soft tissue. RESULTS: The conversion group had longer mean operative time (96.1 vs 90.0 minutes, P = .01), higher revision component utilization (8.5% vs 0.8%, P = .005), and higher calculated blood loss (1440 vs 1249 mL, P = .004). Thirty-eight patients with prior fracture or osteotomy were compared to the remaining 92 patients in the conversion group and showed longer operative time (107.1 vs 91.3 minutes, P < .001), higher 90-day readmissions (18.4% vs 3.3%, P = .003), more complications (23.7% vs 8.7%, P = .021), and greater utilization of revision components (26.3% vs 1.1%, P < .001). CONCLUSION: Patients undergoing conversion TKA required increased resource utilization, particularly patients with a prior osteotomy or fracture. Policymakers should consider these variables, as they did in conversion THA, in adding a code to account for increased case complexity and resource utilization.

Nationwide Organism Susceptibility Patterns to Common Preoperative Prophylactic Antibiotics: What Are We Covering?

BACKGROUND: Many periprosthetic joint infections (PJIs) are caused by organisms not susceptible to first-generation cephalosporins. We sought to evaluate the national susceptibility patterns of organisms to cefazolin and, or oxacillin, clindamycin, and vancomycin using antibiogram data. METHODS: Publically available regional and state antibiograms were evaluated for antibiotic susceptibility patterns to commonly infecting gram-positive organisms. The number of isolates tested in each antibiogram and percent of strains susceptible to oxacillin, clindamycin, and vancomycin were recorded. Oxacillin is used as a surrogate to cefazolin in antibiograms. A comparison of antibiotic susceptibilities was performed. RESULTS: Seven state and 38 regional antibiograms were reviewed. Oxacillin was a sensitive antibiotic in 99.2 ± 4.8% of methicillin-sensitive Staphylococcus aureus (MSSA) isolates, 0 ± 0% of methicillin-resistant Staphylococcus aureus (MRSA) isolates, 44.5 ± 13.7% of coagulase-negative staphylococcus organism isolates (CNS), and 30.6 ± 10.5% of Staphylococcus epidermidis isolates. Clindamycin was a sensitive antibiotic in 75.8 ± 8.4% of MSSA isolates, 60.2 ± 13.2% of MRSA isolates, 60.3 ± 11.4% of CNS isolates, and 56.2 ± 6.5% of S epidermidis isolates. Vancomycin was a sensitive antibiotic in 99.9 ± 0.4% of MSSA isolates, 99.8 ± 0.4% of MRSA isolates, 99.8 ± 0.5% of CNS isolates, and 99.6 ± 0.7% of S epidermidis isolates. Clindamycin was significantly less sensitive in MSSA isolates as compared with oxacillin and vancomycin (P < .0001). Oxacillin was significantly less sensitive in CNS, S epidermidis, and MRSA isolates as compared with clindamycin and vancomycin (P < .0001). CONCLUSION: The national clindamycin susceptibility pattern is limited to MSSA and may not have an optimal susceptibility profile suitable for use as a prophylactic antibiotic. Cefazolin continues to have excellent coverage against MSSA.

Inpatient Versus Outpatient Arthroplasty: A Single-Surgeon, Matched Cohort Analysis of 90-Day Complications.

BACKGROUND: Although some prior work supports the safety of same-day arthroplasty performed in a hospital, concerns remain when these procedures are performed in a free-standing ambulatory surgery center. The purpose of this study is to compare 90-day complication rates between matched cohorts that underwent inpatient vs outpatient arthroplasty at an ambulatory surgery center. METHODS: A single-surgeon cohort of 243 consecutive patients who underwent outpatient arthroplasty was matched with 243 inpatients who had the same procedure. One-to-one nearest-neighbor matching with respect to gender, age, American Society of Anesthesiologists Score, and body mass index was utilized. The 486 primary arthroplasties included 178 unicondylar knees (36.6%), 146 total hips (30.0%), 92 total knees (18.9%), and 70 hip resurfacings (14.5%). Ninety-day outcomes including reoperation, readmission, unplanned clinic or emergency department visits, and major and minor complications were compared using a 2-sample proportions test. RESULTS: The 2 cohorts were similar in distribution of demographic variables, demonstrating successful matching. The inpatient and outpatient cohorts both had readmission rates of 2.1% (P = 1.0). With the number of subjects studied, there were no statistically significant differences in rates of major complications (2.1% vs 2.5%, P = 1.0), minor complications (7.0% vs 7.8%, P = .86), reoperations (0.4% vs 2.1%, P = .22), emergency department visits (1.6% vs 2.5%, P = .52), or unplanned clinic visits (3.3% vs 5.8%, P = .19). CONCLUSION: This study suggests that arthroplasty procedures can be performed safely in an ambulatory surgery center among appropriately selected patients without an increased risk of complications.

Radiographic Predictors of Screw Cutout for Intertrochanteric Fractures Treated With Cephalomedullary Nails.

The objective of this study was to determine the predictive value of tip-apex distance (TAD) and Parker's ratio for screw cutout after treatment of intertrochanteric hip fractures with a long cephalomedullary nail. A total of 97 patients with AO/OTA 31-A1-A3 intertrochanteric fractures and a minimum follow-up of 8 weeks were included. Increased Parker's ratio on the anteroposterior radiograph (OR = 1.386, p < .003) and lateral radiograph (OR = 1.138, p < .028) was significantly associated with screw cutout. In a multivariable regression analysis, only the Parker's anteroposterior ratio was significantly associated with risk of screw cutout (OR = 1.393, p = .004), but TAD (OR = 0.977, p = .764) and Parker's lateral ratio (OR 1.032, p = .710) were not independent predictors of cutout. The study concluded that Parker's anteroposterior ratio is the most helpful measurement in predicting screw cutout. (Journal of Surgical Orthopaedic Advances 28(2):115-120, 2019).

Improving Value in Total Hip and Knee Arthroplasty: The Role of High Volume Hospitals.

BACKGROUND: Recent healthcare reform efforts have focused on improving the quality of total joint replacement care while reducing overall costs. The purpose of this study is to determine if higher volume centers have lower costs and better outcomes than lower volume hospitals. METHODS: We queried the Centers for Medicare and Medicaid Services (CMS) Inpatient Charge Data and identified 2702 hospitals that performed a total of 458,259 primary arthroplasty procedures in 2014. Centers were defined as low (performing <100 total joint arthroplasty [TJA] per year) or high volume and mean total hospital-specific charges and inpatient payments were obtained. Patient satisfaction scores as well 30-day risk-adjusted complication and readmission scores were obtained from the multiyear CMS Hospital Compare database. RESULTS: Of all the hospitals, 1263 (47%) hospitals were classified as low volume and performed 60,895 (12%) TJA cases. Higher volume hospitals had lower mean total hospital-specific charges ($56,323 vs $60,950, P < .001) and mean Medicare inpatient payments ($12,131 vs $13,289, P < .001). Higher volume facilities had a lower complication score (2.96 vs 3.16, P = .015), and a better CMS hospital star rating (3.14 vs 2.89, P < .001). When controlling for hospital geographic and demographic factors, lower volume hospitals are more likely to be in the upper quartile of inpatient Medicare costs (odds ratio 2.127, 95% confidence interval 1.726-2.621, P < .001). CONCLUSION: Hospitals that perform <100 TJA cases per year may benefit from adopting the practices of higher volume centers in order to improve quality and reduce costs.

Early-Stage Chronic Kidney Disease and Hip Fracture Mortality.

Chronic kidney disease (CKD) is a documented risk factor for hip fracture mortality. CKD represents a spectrum of disease and there is no clear evidence differentiating the risk between patients with early versus end-stage CKD. The purpose of this study was to explore the relationship between the stages of CKD and mortality following operative treatment of hip fractures. Four hundred ninety-eight patients were analyzed; 81 were identified as having CKD. This study followed overall patient mortality at 90 days and at 1 year postoperatively. Patients with CKD had higher mortality at both 90 days and 1 year compared with those without CKD (hazard ratio 1.69 and 1.84, respectively). In a subgroup analysis to determine the effect of CKD stage, only stage 3 CKD was associated with increased mortality. The orthopaedic surgeon can play a key role in identifying at-risk patients and help to facilitate additional management. (Journal of Surgical Orthopaedic Advances 27(3):226-230, 2018).

Hip Fracture Mortality: Differences Between Intertrochanteric and Femoral Neck Fractures.

The purpose of this study was to identify the specific risk factors that affect mortality in patients with hip fractures and differentiate mortality-associated factors between intertrochanteric (IT) and femoral neck (FN) fractures. A total of 1538 consecutive patients with hip fractures were treated at the authors' institution between January 2005 and October 2013. Ultimately 858 IT and 479 FN fracture patients were included on the basis of age >60 years with an isolated hip fracture. Mortality rate at 90 days was 12.1% for IT and 9.6% for FN fractures. In both IT and FN fractures, variables associated with mortality risk include increased age, greater days to surgery, male gender, decreased body mass index, and increased American Society of Anesthesiologists score. When evaluated independently, the presence of cardiac arrhythmia and chronic kidney disease was strongly associated with greater mortality risk in FN fracture patients. The presence of chronic kidney disease and hypertension correlated with decreased mortality risk among FN fracture patients. (Journal of Surgical Orthopaedic Advances 27(1):64-71, 2018).

Ultrasound findings in asymptomatic patients with modular metal on metal total hip arthroplasty.

OBJECTIVE: The use of metal-on-metal and modular total hip arthroplasty is associated with potentially serious local and systemic complications. The primary aim of this study was to identify the prevalence of a pseudotumor in asymptomatic patients with a particular metal-on-metal hip prosthesis after a minimum follow-up of 5 years using ultrasound evaluation. A secondary purpose was to identify associations between the presence of pseudotumor and serum metal ion levels following implantation. METHODS: We prospectively evaluated data collected from 36 asymptomatic patients who underwent implantation of a Profemur Z metal-on-metal total hip arthroplasty from January 2004 to January 2010. Serum metal ion levels were collected in 2012 and 2015. Hip ultrasounds were performed in 2015. RESULTS: Pseudotumors were found in 7/36 patients (19.4%). The average pseudotumor size measured 38.2 cm3 (range 7.35 cm3-130.81 cm3). Elevated metal ion levels were found in all patients at all time points. No statistical correlation was found between the presence of pseudotumor and patient age, age of the implant, component design, and any of the serum metal ion levels or ratios. CONCLUSIONS: One in every five asymptomatic patients with metal-on-metal implants was found to have a periarticular pseudotumor. There was no dose-dependent relationship found between elevated serum metal ion levels and the development of a pseudotumor. Our findings suggest that in patients with known elevated metal ion levels, continued monitoring of ion levels may not be a reliable predictor of pseudotumor formation, and ultrasound surveillance can and should be routinely used to document the presence and progression of pseudotumor.

Heterotopic Ossification Prophylaxis After Total Hip Arthroplasty: Randomized Trial of 400 vs 700 cGy.

BACKGROUND: Heterotopic ossification (HO) is a known complication following total hip arthroplasty. Radiation is an effective prophylaxis, but an optimal protocol has yet to be determined. We performed a randomized, double-blinded clinical trial in high-risk patients to determine the efficacy of 400 vs 700 cGy doses of radiation. METHODS: One hundred forty-seven patients undergoing total hip arthroplasty and at high risk for HO at an urban medical center were randomized to receive either a single 400 or 700 cGy dose of radiation postoperatively. High risk was defined as a diagnosis of diffuse idiopathic skeletal hyperostosis, hypertrophic osteoarthritis, ankylosing spondylitis, or history of previous HO. Radiation was administered on the first or second postoperative day. A single blinded reviewer graded radiographs taken immediately postoperatively and at a minimum of 6 months postoperatively using the Brooker classification. Progression was defined as an increase in Brooker classification. Operative data including surgical approach, implant fixation, revision surgery, and postoperative range of motion data were also collected. RESULTS: A significantly greater portion of patients who received the 400 cGy dose demonstrated progression of HO than patients who received the 700 cGy dose. There were no wound complications. No preoperative factors were associated with a higher rate of progression. Patients who progressed had less flexion on physical examination than patients who did not progress, but this was not clinically significant. CONCLUSION: Seven hundred centigray was superior to 400 cGy in preventing HO formation following total hip arthroplasty in high-risk patients and may be the more effective treatment in this population. Further studies comparing 700 cGy to dosages between 400 and 700 cGy may help to clarify if a more optimal dose can be identified.

The Effect of Impact Location on Force Transmission to the Modular Junctions of Dual-Taper Modular Hip Implants.

BACKGROUND: The purpose of this study was to investigate the effect that off-axis impaction has on stability of dual-taper modular implants as measured by forces delivered to and transmitted through the head-neck and neck-stem tapers, respectively. METHODS: One hundred forty-four impact tests were performed using 6 different directions: one on-axis and five 10° off-axes. Four different simulations were performed measuring the head-neck only and 3 different neck angulations: 0°, 8°, and 15°. A drop tower impactor delivered both on- and off-axis impaction from a constant height. Load cells positioned in the drop mass and at the head-neck (HN) or neck-stem (NS) junction measured the impact and joint forces, respectively. RESULTS: Impact force of the hammer on the head ranged from 3800-4500 N. Greatest impact force delivered to the head was typically with axial impact. However, greatest force transmission to the neck-stem junction was not necessarily with axial impacts. There was limited variability in the force measured at the NS junction for all impaction directions seen in the 8° neck, whereas the 15° neck had greater forces transmitted to the NS junction with off-axes impactions directed in the proximal and posterior-proximal directions. CONCLUSION: The location of the impact significantly influences the force transmitted to the head-neck and neck-stem junctions in dual-taper modular hip implants. Although axial impacts proved superior to off-axis impacts for the straight 0° neck, greater force transmission with off-axis impacts for the angled necks suggests that off-axis impacts may potentially compromise the stability of dual-taper components.

Rivaroxaban Versus Enoxaparin for Venous Thromboembolism Prophylaxis after Hip and Knee Arthroplasty.

The oral Factor Xa inhibitor rivaroxaban (Xarelto) has been the pharmacologic agent used for venous thromboembolism (VTE) prophylaxis after primary hip and knee arthroplasty (THA/TKA) at our institution since February 2012. The purpose of our study was to compare rates of VTE and major bleeding between rivaroxaban and our previous protocol of enoxaparin after THA/TKA. A retrospective cohort study was performed including 2406 consecutive patients at our institution between 1/1/11 and 9/30/13. Patients who did not have unilateral primary THA/TKA or who received other anticoagulants were excluded. Of the 1762 patients included, 1113 patients (63.2%) received enoxaparin and 649 patients (36.8%) received rivaroxaban. This study found no demonstrable differences between these two anticoagulants in rates of VTE, infection, reoperation, transfusion, or major bleeding. Therapeutic, Retrospective comparative study, Level III.

Intraoperative Periprosthetic Femur Fracture: A Biomechanical Analysis of Cerclage Fixation.

Intraoperative periprosthetic femur fracture is a known complication of total hip arthroplasty (THA) and a variety of cerclage systems are available to manage these fractures. The purpose of this study was to examine the in situ biomechanical response of cerclage systems for fixation of periprosthetic femur fractures that occur during cementless THA. We compared cobalt chrome (CoCr) cables, synthetic cables, monofilament wires and hose clamps under axial compressive and torsional loading. Metallic constructs with a positive locking system performed the best, supporting the highest loads with minimal implant subsidence (both axial and angular) after loading. Overall, the CoCr cable and hose clamp had the highest construct stiffness and least reduction in stiffness with increased loading. They were not demonstrably different from each other.

Predictors and complications of blood transfusion in total hip and knee arthroplasty.

Perioperative patient optimization can minimize the need for blood transfusions in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of this study was to determine predictors and complications of transfusions. This retrospective review analyzed 1795 patients who underwent primary THA and TKA at our institution between January 2011 and December 2012. Of the 1573 patients ultimately included the rates of transfusion were 9.27% in TKA and 26.6% in THA. Significant predictors for transfusion include: preoperative hemoglobin, age, female gender, body mass index, creatinine, TKA, operating room time, operative blood loss, and intra-operative fluids. The DVT rate was comparable, but deep surgical site infection rate among transfused patients was 2.4% compared to 0.5% in non-transfused patients (P = 0.0065).