Neural network models accurately predict discharge disposition after revision total knee arthroplasty?

PURPOSE: Based on the rising incidence of revision total knee arthroplasty (TKA), bundled payment models may be applied to revision TKA in the near future. Facility discharge represents a significant cost factor for those bundled payment models; however, accurately predicting discharge disposition remains a clinical challenge. The purpose of this study was to develop and validate artificial intelligence algorithms to predict discharge disposition following revision total knee arthroplasty. METHODS: A retrospective review of electronic patient records was conducted to identify patients who underwent revision total knee arthroplasty. Discharge disposition was defined as either home discharge or non-home discharge, which included rehabilitation and skilled nursing facilities. Four artificial intelligence algorithms were developed to predict this outcome and were assessed by discrimination, calibration and decision curve analysis. RESULTS: A total of 2228 patients underwent revision TKA, of which 1405 patients (63.1%) were discharged home, whereas 823 patients (36.9%) were discharged to a non-home facility. The strongest predictors for non-home discharge following revision TKA were American Society of Anesthesiologist (ASA) score, Medicare insurance type and revision surgery for peri-prosthetic joint infection, non-white ethnicity and social status (living alone). The best performing artificial intelligence algorithm was the neural network model which achieved excellent performance across discrimination (AUC = 0.87), calibration and decision curve analysis. CONCLUSION: This study developed four artificial intelligence algorithms for the prediction of non-home discharge disposition for patients following revision total knee arthroplasty. The study findings show excellent performance on discrimination, calibration and decision curve analysis for all four candidate algorithms. Therefore, these models have the potential to guide preoperative patient counselling and improve the value (clinical and functional outcomes divided by costs) of revision total knee arthroplasty patients. LEVEL OF EVIDENCE: IV.

MARS MRI assessment of fatty degeneration of the gluteal muscles in patients with THA: reliability and accuracy of commonly used classification systems.

INTRODUCTION: Fatty degeneration of the gluteal muscles on metal artefact reduction sequence (MARS) MRI has been shown to correlate with poor functional outcomes, particularly in patients with total hip arthroplasty (THA). Standardized, reliable classification systems that permit assessment of fatty gluteal infiltration are needed for clinical decision making. This study aimed to compare the reproducibility and accuracy of commonly used MRI classification systems for fatty gluteal atrophy in THA patients. METHODS: MARS magnetic resonance images of 82 patients with unilateral THA were analysed by three independent trained observers. The readers evaluated fatty degeneration of the gluteus minimus, gluteus medius, and gluteus maximus according to 3 widely used classification systems: Goutallier, Quartile, and Bal and Lowe. Interobserver and intraobserver repeatability were determined using the weighted Kappa test. Quantitative evaluation of the proportion of intramuscular fat based on MR signal intensities was obtained and represented the gold standard. RESULTS: Mean interobserver agreement for the Quartile classification system (0.93) was higher compared with Goutallier classification system (0.87) and the Bal and Lowe classification system (0.83; range 0.79-0.88; p = 0.04). Intraobserver repeatability was significantly higher for the Quartile classification system (weighted kappa 0.91, 0.89, 0.85) compared with the Bal and Lowe classification system (weighted kappa 0.83, 0.77, 0.75; p < 0.01) and Goutallier classification system (weighted kappa 0.83, 0.77, 0.75; p = 0.04). Agreement with the gold standard measurements was significantly higher in the Quartile classification system (0.88, 0.84, 0.81) compared with the Goutallier classification system (0.80, 0.77, 0.78; p = 0.02) and Bal and Lowe classification system (0.76, 0.74, 0.73; p < 0.01). DISCUSSION: This study directly compared three clinically used MRI classification systems for fatty gluteal muscle atrophy in THA patients. Our findings demonstrate that although all three classification systems demonstrate good reproducibility and accuracy, the Quartile classification system is superior to the others in terms of intraobserver reliability and accuracy to quantify fatty gluteal degeneration in THA patients.

Minority Race and Ethnicity is Associated With Higher Complication Rates After Revision Surgery for Failed Total Hip and Knee Joint Arthroplasty.

BACKGROUND: Racial and ethnic disparities in access to hip and knee total joint arthroplasty (TJA) and postoperative outcomes have wide-reaching implications for patients and the health care system. The aim of this study is to evaluate the effect of ethnicity on clinical outcomes and complications following revision hip and knee TJA. METHODS: A single-institution, retrospective analysis of a consecutive series of 4424 revision hip and knee TJA patients was evaluated. Student's t-test and chi-squared analysis were used to identify significant differences in patient demographics and clinical outcomes between Caucasians and various ethnic minorities, including African Americans, Hispanics, and Asians. RESULTS: When compared with white patients, African American patients demonstrated a significantly higher BMI (P = .04), ASA score (P = .04), length of hospital stay (P = .06), and postoperative infection rates (P = .04). Hispanics demonstrated a significantly higher BMI (P = .04), when compared with white patients, alongside a significantly higher risk for postoperative infection (P < .01). African American demonstrated a significantly higher ASA score (P = .02; P = .03), when compared with Hispanics and Asians, alongside a significantly increased length of stay (P = .01) and higher risk for postoperative infection (P = .02). CONCLUSION: The study findings demonstrate an underutilization of revision TJA by ethnic minority groups, suggesting that disparities in access to orthopedic surgery increase from primary to revision surgery despite higher failure rates of minority ethnic groups reported after primary TJA surgery. In addition, inferior postoperative outcomes were associated with African Americans and Hispanics, when compared to white patients, with African Americans demonstrating the highest risk of postoperative complications.

A Comprehensive Assessment of the Genetic Determinants in Salmonella Typhimurium for Resistance to Hydrogen Peroxide Using Proteogenomics.

Salmonella is an intracellular pathogen infecting a wide range of hosts and can survive in macrophages. An essential mechanism used by macrophages to eradicate Salmonella is production of reactive oxygen species. Here, we used proteogenomics to determine the candidate genes and proteins that have a role in resistance of S. Typhimurium to H2O2. For Tn-seq, a saturated Tn5 insertion library was grown in vitro under either 2.5 (H2O2L) or 3.5 mM H2O2 (H2O2H). We identified two sets of overlapping genes required for resistance of S. Typhimurium to H2O2L and H2O2H, and the results were validated via phenotypic evaluation of 50 selected mutants. The enriched pathways for H2O2 resistance included DNA repair, aromatic amino acid biosynthesis (aroBK), Fe-S cluster biosynthesis, iron homeostasis and a putative iron transporter system (ybbKLM), and H2O2 scavenging enzymes. Proteomics revealed that the majority of essential proteins, including ribosomal proteins, were downregulated upon exposure to H2O2. On the contrary, a subset of conditionally essential proteins identified by Tn-seq were analyzed by targeted proteomics, and 70% of them were upregulated by H2O2. The identified genes will deepen our understanding on S. Typhimurium survival mechanisms in macrophages, and can be exploited to develop new antimicrobial drugs.

Unsuspected Malignancies in Routine Femoral Head Histopathologic Examination During Primary Total Hip Arthroplasty: Cost-Effectiveness Analysis.

BACKGROUND: Routine femoral head histopathology during primary total hip arthroplasty (THA) has been recently reported as a potentially useful screening tool for bone- and bone marrow-associated malignancies. However, cost-effectiveness of routine histopathology during THA remains unclear due to low prevalence of significant medical findings which alter patient management. The aim of this study was to evaluate the cost-effectiveness of routine histopathology in diagnosing unsuspected malignancy in patients undergoing primary THA. METHODS: From 1993 to 2011, we retrospectively analyzed routine histopathologic findings of 3200 femoral head specimens from 2725 patients that underwent primary THA. Preoperative and postoperative diagnoses were classified into concordant (clinical diagnosis concurred with pathologic diagnosis), discrepant (differing diagnosis with no resultant impact on patient management), and discordant (differing diagnosis with subsequent change in patient management). Cost-effectiveness analysis was performed using the incremental cost-utility ratio. RESULTS: A total of 3055 of 3200 pathologic samples were concordant with the preoperative diagnosis (95.4%), 140 of 3200 were discrepant (4.4%), and 5 of 3200 were discordant (0.2%). Routine histopathology revealed 1 unsuspected malignancy out of 640 (5 of 3200) femoral heads. The total cost of histopathologic screening was $614,664.80. The average cost to identify a discrepant case was $4390.46, and the cost to identify a discordant case was $122,932.96. The incremental cost-utility ratio was $49,569.74 per quality-adjusted life year (QALY) gained. CONCLUSION: Our study indicates routine femoral head histopathology may be cost-effective in diagnosing unsuspected malignancy at $49,569.74/QALY gained (less than World Health Organization recommended threshold $159,000/QALY gained), providing useful clinical information for surgeons considering the value of routine femoral head histopathology in patients undergoing THA.

Assessment of accuracy and precision of 3D reconstruction of unicompartmental knee arthroplasty in upright position using biplanar radiography.

This study aimed to evaluate the precision and accuracy of 3D reconstruction of UKA component position, contact location and lower limb alignment in standing position using biplanar radiograph. Two human specimens with 4 medial UKAs were implanted with beads for radiostereometric analysis (RSA). The specimens were frozen in standing position and CT-scanned to obtain relative positions between the beads, bones and UKA components. The specimens were then imaged using biplanar radiograph (EOS). The positions of the femur, tibia, UKA components and UKA contact locations were obtained using RSA- and EOS-based techniques. Intraclass correlation coefficient (ICC) was calculated for inter-observer reliability of the EOS technique. The average (standard deviation) of the differences between two techniques in translations and rotations were less than 0.18 (0.29) mm and 0.39° (0.66°) for UKA components. The root-mean-square-errors (RMSE) of contact location along the anterior/posterior and medial/lateral directions were 0.84mm and 0.30mm. The RMSEs of the knee rotations were less than 1.70°. The ICCs for the EOS-based segmental orientations between two raters were larger than 0.98. The results suggest the EOS-based 3D reconstruction technique can precisely determine component position, contact location and lower limb alignment for UKA patients in weight-bearing standing position.

Assessment of total hip arthroplasty as a predisposing factor for ischiofemoral impingement.

OBJECTIVE: To examine the effect of total hip arthroplasty (THA) on ischiofemoral (IF) and quadratus femoris (QF) spaces with the hypothesis that THA does not affect ischiofemoral relationships. MATERIALS AND METHODS: The study was IRB approved and complied with HIPAA guidelines. We identified consecutive MR examinations (pelvis and/or hip) obtained at our institution in adults (≥18 years old) screened for THA-related complications. Native hips from the same individuals served as controls. We collected medical record data including age, gender, surgical history, and THA designs. Two radiologists independently measured the IF-RAD and IF-MRI (IF space on radiographs and MR imaging, respectively) and QF space (on MR imaging). Groups were compared using ANCOVA controlled for gender. RESULTS: The study group comprised 250 hips (132 subjects; 162 post-THA and 88 native hips). Subjects were aged 59 ± 10 years, with 66 males and 66 females. Comparison of IF-MRI and QF spaces between native and post-THA hips showed no differences (P > 0.12) and IF-RAD was higher in post-THA subjects (P = 0.01). No differences in the IF-MRI and QF spaces were present between native hips and different THA designs (P > 0.4). IF-RAD of metal-on-metal THA was higher than that of native hips (P = 0.01) and trended higher than ceramic-on-polyethylene THA (P = 0.08), with the remaining comparisons showing no significant differences (P > 0.4). CONCLUSIONS: Radiographic- and MRI-based measures in patients with standard THA do not show narrowing of IF and QF spaces.

Effects of Obesity on Health Related Quality of Life Following Total Hip Arthroplasty.

Obesity is known to negatively impact health related quality of life (HRQoL). Although non-disease specific tools have been used to study HRQoL after THA in obese patients, these do not directly measure health utility improvements. All 435 THA patients in the current study, regardless of BMI, reported improvement in HRQoL as measured by EQ-5D, a universal, standardized, non-disease specific preference-based instrument. These data suggest obese patients value their quality of life improvement following THA as much as non-obese patients. Furthermore, the increased activity level observed following THA in obese patients suggests obese patients may also obtain non-disease specific benefits of a more active lifestyle. This information is important for future assessments of value and cost-effectiveness of THA in the obese population.

Effect of immediate postoperative portable radiographs on reoperation in primary total knee arthroplasty.

Cost-containment strategies are of increasing importance in total knee arthroplasty (TKA). Obtaining immediate postoperative radiographs following primary TKA is common practice, but their usefulness is controversial. The goal of this study was to evaluate the effect of immediate postoperative radiographs on reoperation within 60 days, assess film quality, and determine the cost associated with these radiographs. Using a billing registry at the authors' institution, the number of TKAs performed from 2000 to 2011 was determined. Of those, the authors determined which had undergone reoperation within 60 days. They evaluated those who had immediate postoperative radiographs following their primary TKA, and determined those who had been reoperated on as a result of information obtained from these radiographs. Of 6603 patients who underwent primary TKA from 2000 to 2011, 136 (2%) underwent reoperation within the first 60 days. The causes leading to reoperation were arthrofibrosis, infection, wound-healing complications, and hematoma. Of the 136 who underwent reoperation, 76 had immediate postoperative radiographs. None of them underwent reoperation as a result of findings noted in the radiographs. Of the radiographs reviewed, only 43% were deemed adequate by predetermined criteria. The results of the current study demonstrate that these radiographs do not affect the decision for reoperations that occur within 60 days of the index procedure. Although there may be a benefit to immediate postoperative radiographs in selected clinical situations, the decision for routine use needs to be weighed in light of significant cost and limited clinical usefulness.

Does age or bilateral disease influence the value of hip arthroplasty?

BACKGROUND: Measuring value in medicine is an increasingly important issue as healthcare spending continues to rise and cost containment becomes even more important. However, value assessments can be affected by patient factors and comorbidities. QUESTIONS/PURPOSES: We therefore quantified the approximate value of total hip arthroplasty and determined if patient age and Charnley classification affected the EuroQol5D (EQ5D) after hip arthroplasty. METHODS: Using charge data and an institutional joint registry, we evaluated 1442 patients after hip arthroplasty. Using the Charnley case-mix index to define bilateral disease and age of 65 years to distinguish between elderly and young patients, statistical comparisons were made among all groups. We obtained subspecialty physician charges and hospital charges. RESULTS: Patients with both unilateral and bilateral disease in both age groups had improved EQ5D scores after total hip arthroplasty, and the average change in scores was 0.27. There was no difference in the change in utility scores when patients older than 65 years of age were compared with patients younger than 65 years or when patients with unilateral disease were compared with those with bilateral disease. The average cost per quality-adjusted life-year (QALY) gained was $9773/QALY. CONCLUSIONS: Our data suggest the value of total hip arthroplasty compares favorably with other medical and surgical interventions for other patient groups. No adjustments for patient age or disease status of the contralateral limb are necessary when reporting the value of total hip arthroplasty. LEVEL OF EVIDENCE: Level IV, economic and decision analyses study. See Guidelines for Authors for a complete description of levels of evidence.

Dietary exposure and risk assessment of mercury from the Korean total diet study.

As a national project, obtaining information on the amount of heavy metal exposure of individuals through food intake is an important basic parameter for risk assessment. This study was conducted to evaluate dietary exposure levels and various risks from mercury (Hg) in Korean foods. In total, 342 samples comprising 114 food items were collected and then cooked prior to analysis. As found by Hg analysis, the mean content of metal in the fish and shellfish group was highest among the 15 Korean food groups. The total daily amount of Hg intake from typical Korean foods was 2.40 microg/person/d. The daily amount (microg/person/d) of Hg intake from each food group was 0.155 in grains and cereals, 0.008 potatoes and starch, 0.005 sugars and sweets, 0.0093 pulses, 0.0018 nuts and seeds, 0.203 vegetables, 0.027 fruits, 0.021 meats and poultry, 0.004 eggs, 1.826 fish and shellfish, 0.022 seaweed, 0.043 milk and dairy products, 0.008 oils and fats, 0.042 beverages, and 0.023 seasonings. The fish and shellfish group contributed most to total dietary intake at 76%. For risk assessment, probable daily intake (PDI) was calculated and compared with provisional tolerable weekly intake (PTWI) of the Joint FAO/WHO Expert Committee on Food Additives (JECFA). The level of Hg intake through fish and shellfish of 0.001 mg/kg body weight bw/wk corresponded to 4.54% of the PTWI value of 0.005 mg/kg bw/wk, the safety standard for JECFA. The level of Hg intake through selected foods from the Food list for Koreans was 0.001 mg/kg bw/wk, corresponding to 5.95% of PTWI value. Therefore, overall intake was at levels below the recommended JECFA levels. The relative gender Hg hazard from Korean foods was 6.26% and 5.5% for males and females, respectively. The relative age Hg hazard from Korean foods was, 8.9% in those 3-6 yr old, 6.7% in those 7-12 yr old, 5.2% in those 13-19 yr old, 5.9% in those 20-29 yr old, 6.3% in those 30-49 yr old, 5.6% in those ages 50-64 yr, and 3.7% in the group of those over 65 yr of age. Relative regional Hg hazard from Korean foods was 6.3% in urban versus 5.5% in rural areas. Thus, the amount of Hg intake through consumption of Korean foods was found to be at a relatively safe level. These data may be thus used to establish safety standards for fish and shellfish consumption.

In vitro assessment of a novel polyrotaxane-based drug delivery system integrated with a cell-penetrating peptide.

In the development of anti-cancer drugs, it is important to yield selective cytotoxicity primarily against tumor tissues. To achieve this goal, the use of a polymer-drug conjugate appears to be appealing, simply because it can take the advantage of the so-called enhanced permeability and retention (EPR) effect due to vascular leak in tumors. Among various types of polymers, polyrotaxane (PR) is an interesting candidate and warrants further consideration. It is a self-assembled polymer made entirely of biocompatible components, by threading alpha-cyclodextrin (alpha-CD) molecules with the poly(ethylene glycol) (PEG) chain. The abundance in functional -OH groups on the CD residues renders PR the capability of carrying a large dose of small anti-tumor agents for delivery. Herein, we presented a novel PR-based delivery system using doxorubicin (DOX) as the model anti-cancer drug. Daunorubicin (DNR) was conjugated to the PR polymer via hydrolysable linkages, and upon hydrolysis, doxorubicin was released as the cytotoxic drug. To facilitate an intracellular uptake by the tumor cells of the PR-DOX conjugates, a cell-penetrating low molecular weight protamine (LMWP) peptide was further attached to the two termini of the PR chain. Using an innovative principle established in our laboratory, such as via the inhibition of the cell-penetrating activity by binding with heparin and reversal of this inhibition by subsequent addition of protamine, cellular uptake of the polymer-drug conjugates could be readily regulated. In this paper, we performed in vitro studies to demonstrate the feasibility of this delivery system. The LMWP-PR-DOX conjugates, which yielded a sustained release of DOX over a period of greater than 4 days, were successfully synthesized. Intracellular uptake of these conjugates by A2780 human ovarian cancer cells and regulation of such uptake by heparin and protamine were confirmed by using the MTT assay and also the confocal microscopy method.