Orthopedic surgeons' transition into full-time practice over the last 20 years: an analysis using Ministry of Health billing data.

BACKGROUND: Underemployment is a reality for many new graduates, who accept locum or part-time work as an alternative to unemployment because of lack of opportunities. We sought to analyze orthopedic surgeons' Ontario Health Insurance Program (OHIP) billing data over a 20-year period as a proxy of practice patterns and hypothesized that billing in the first 6 years of practice would be affected by underemployment and locum. METHODS: We analyzed the annual average billing totals of orthopedic surgeons, broken down by year of graduation, year of billings, and number of surgeons billing in that year. We analyzed public census data of the Ontario population size as a proxy of orthopedic demand. RESULTS: A 2019 cross-sectional analysis showed that around 15 surgeons per graduating year were billing in Ontario from the 1995 to 2016 cohorts, while 2017 and 2018 saw an increase to 30 and 36 actively billing surgeons, respectively. The number returned to more historical numbers in 2019, with 20 actively billing surgeons. For those surgeons billing in Ontario, billing trends have been roughly stable, with average billings increasing each year for the first 6 years in practice (p < 0.001). Year of graduation did not have an effect on the first 6 years of billings (p > 0.5). Billings were stable after 6 years in practice (p > 0.09). CONCLUSION: The Ontario health care system has not expanded to support more orthopedic surgeons despite the aging and growing population; despite our growing population, the number of surgeons being trained and retained has not matched this growth. Further research needs to be done to guide optimal health human resource decision-making.

A multimodal assessment of cementless tibial baseplate fixation using radiography, radiostereometric analysis, and magnetic resonance imaging.

Fixation in cementless total knee arthroplasty is provided by osseous integration. Radiography, radiostereometric analysis (RSA), and magnetic resonance imaging (MRI) were used simultaneously to investigate fixation. Relationships between RSA-measured implant micromotions and MRI-evaluated osseous integration at the component-bone interface were assessed in 10 patients up to 6 months postoperation. Supine MRI (using multispectral imaging sequences) and RSA exams were performed to evaluate osseous integration and measure longitudinal migration, respectively. Inducible displacement was measured from standing RSA exams. Radiolucent lines were detected on conventional radiographs. Of 10 patients, 6 had fibrous membranes detected on MRI. No fluid or osteolytic interfaces were found, and no components were scored loose. Of 10 patients, 6 had radiolucent lines detected. Average maximum total point motion (MTPM) for longitudinal migration at 6 months was 0.816 mm (range 0.344-1.462 mm). Average MTPM for inducible displacement at 6 months was 1.083 mm (range 0.553-1.780 mm). Fictive points located in fibrous-classified baseplate quadrants had greater longitudinal migration than fictive points located in baseplate quadrants with normal interfaces at 2 weeks (p = 0.031), 6 weeks (p = 0.046), and 3 months (p = 0.047), and greater inducible displacements at 3 months (p = 0.011) and 6 months (p = 0.045). Greater early micromotion may be associated with the presence of fibrous membranes at the component-bone interface. Clinical significance: This multimodal imaging study contributes knowledge of the fixation of modern cementless TKA, supporting the notion that osseous integration is important for optimal implant fixation.

The cost of outpatient versus inpatient total hip arthroplasty: a randomized trial.

BACKGROUND: One route to mitigate the increasing costs of total hip arthroplasty (THA) is outpatient THA, discharging patients on the same day as their surgery. The purpose of this study was to compare the cost of outpatient THA to standard overnight stay in hospital. METHODS: This was a preliminary analysis of the first group of patients to complete follow-up in a larger randomized controlled trial among patients who underwent primary THA through a direct anterior approach between June 2015 and November 2017. The study was conducted at a single centre among patients of 1 fellowship-trained arthroplasty surgeon. We randomly allocated participants to be discharged either as outpatients or on postsurgery day 1 using a modified Zelen consent model. Adverse events were recorded. Participants completed cost questionnaires 2, 6 and 12 weeks after surgery, and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) before and 12 weeks after surgery. We performed cost analyses from health care payer and societal perspectives. RESULTS: A total of 115 participants completed this study, 49 allocated to the outpatient group and 56 to the inpatient group. The adverse event rate was similar for the 2 groups. The WOMAC total score and function subscale score were higher for the outpatient group than the inpatient group at 12 weeks (mean difference 2.1, 95% confidence interval [CI] 0.0 to 4.1, and 6.5, 95% CI 0.4 to 12.5, respectively). From both a health care payer and a societal perspective, inpatient THA was more costly than outpatient THA (mean difference $1006.86, 95% CI -$2158.92 to $145.21, and $1667.40, 95% CI -$3856.64 to $521.84, respectively). CONCLUSION: Our results suggest that outpatient THA may be a cost-saving procedure compared to inpatient THA from both health care payer and societal perspectives. Further study with larger samples is needed to provide more precision around our estimates. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT03026764.

Health care costs after total knee arthroplasty for satisfied and dissatisfied patients.

BACKGROUND: Evidence suggests that up to 21% of patients are dissatisfied after total knee arthroplasty (TKA), but the link between dissatisfaction and use of health care resources is unknown. The objective of this study was to compare costs after TKA between satisfied and dissatisfied patients. METHODS: This was a secondary analysis of a randomized clinical trial among patients who underwent primary TKA at our institution between 2015 and 2018. We estimated rates of satisfaction with pain relief and with return to function 1 year postoperatively. Patients prospectively reported use of health care resources 6 weeks, and 3, 6, 9 and 12 months after surgery. We compared costs between satisfied and dissatisfied patients from a public payer and a societal perspective. RESULTS: We included 156 patients in our analysis, of whom 42 (26.9%) were dissatisfied with pain, and 57 (36.5%) were dissatisfied with function. There was no significant difference in costs between patients dissatisfied with pain or function compared to satisfied patients from a health care payer perspective. From a societal perspective, patients dissatisfied with pain incurred a mean cost of $21 156.18, compared to $13 453.84 for satisfied patients (mean difference $7702.34, 95% confidence interval [CI] -89.43 to 15 494.11). Similarly, patients dissatisfied with function incurred a mean cost of $19 007.70, compared to $13 523.83 for those who were satisfied (mean difference $5483.87, 95% CI -526.34 to 11 494.10). CONCLUSION: Dissatisfied patients incurred greater costs than satisfied patients during the first year after TKA. The results justify further evaluation of factors contributing to patient satisfaction that may help to reduce the economic burden of TKA.

Ultrasound-Guided Motor-Sparing Knee Blocks for Postoperative Analgesia Following Total Knee Arthroplasty: A Cost Analysis.

Background: We recently performed a clinical trial comparing motor sparing blocks (MSB) to periarticular infiltration (PAI) following total knee arthroplasty (TKA). We found that MSBs provided longer analgesia (8.8 hours) than PAI with retention of quadriceps strength, and with similar function, satisfaction, and length hospital stay. However, its potential increased cost could serve as a barrier to its adoption. Therefore, our aim was to compare the costs of MSBs to PAI following TKA. Methods: We conducted a retrospective review of data from our previous RCT. There were 82 patients included in the RCT (n = 41 MSB group, n = 41 PAI group). We compared the mean total costs associated with each group until hospital discharge including intervention costs, health-care professional service fees, intraoperative medications, length of stay, and postoperative opioid use. Results: Seventy patients were included (n = 35 MSB group, n = 35 PAI group). The mean total costs for the MSB group were significantly higher ($1959.46 ± 755.4) compared to the PAI group ($1616.25 ± 488.33), with a mean difference of $343.21 (95% CI = $73.28 to $664.11, p = 0.03). The total perioperative intervention costs for performing the MSB was also significantly higher; however, postoperative inpatient costs including length of stay and total opioid use did not differ significantly. Conclusion: Motor sparing blocks had significantly higher mean total and perioperative costs compared to PAI with no significant difference in postoperative inpatient costs. However, its quadricep sparing nature and previously demonstrated prolonged postoperative analgesia can be used to facilitate an outpatient TKA pathway thereby offsetting its increased costs.

Cost and safety of inpatient versus outpatient open reduction internal fixation of isolated ankle fractures.

BACKGROUND: As health care shifts to value-based models, one strategy within orthopedics has been to transition appropriate cases to outpatient or ambulatory settings to reduce costs; however, there are limited data on the efficacy and safety of this practice for isolated ankle fractures. The purpose of this study was to compare the cost and safety associated with inpatient versus outpatient ankle open reduction internal fixation (ORIF). METHODS: All patients who underwent ORIF of isolated closed ankle fractures at 2 affiliated hospitals between April 2016 and March 2017 were identified retrospectively. Demographic characteristics, including age, gender, comorbidities and injuryspecific variables, were collected. We grouped patients based on whether they underwent ankle ORIF as an inpatient or outpatient. We determined case costing for all patients and analyzed it using multivariate regression analysis. RESULTS: A total of 196 patients (125 inpatient, 71 outpatient) were included for analysis. Inpatients had a significantly longer mean length of stay than outpatients (54.3 h [standard deviation (SD) 36.3 h] v. 7.5 h [SD 1.7 h], p < 0.001). The average cost was significantly higher for the inpatient cohort than the outpatient cohort ($4137 [SD $2285] v. $1834 [SD $421], p < 0.001). There were more unimalleolar ankle fractures in the outpatient group than in the inpatient group (42 [59.2%] v. 41 [32.8%], p < 0.001). Outpatients waited longer for surgery than inpatients (9.6 d [SD 5.6 d] v. 2.0 d [SD 3.3 d], p < 0.001). Fourteen patients (11.2%) in the inpatient group presented to the emergency department or were readmitted to hospital within 30 days of discharge, compared to 5 (7.0%) in the outpatient group (p = 0.3). CONCLUSION: In the treatment of isolated closed ankle fractures, outpatient surgery was associated with a significant reduction in length of hospital stay and overall case cost compared to inpatient surgery, with no significant difference in readmission or reoperation rates. In medically appropriate patients, isolated ankle ORIF can be performed safely in an ambulatory setting and is associated with significant cost savings.

A Randomized Trial Investigating the Cost-Utility of Patient-Specific Instrumentation in Total Knee Arthroplasty in an Obese Population.

BACKGROUND: Patient-specific instrumentation (PSI) has been introduced in total knee arthroplasty (TKA) with the goal of increased accuracy of component positioning by custom fitting cutting guides to the patient's bony anatomy. A criticism of this technology is the associated cost. The purpose of this randomized controlled trial was to determine the cost-utility of PSI compared with standard of care (SOC) instrumentation for TKA in an obese population. METHODS: Patients with body mass index greater than 30 with osteoarthritis and undergoing primary TKA were randomized to SOC or PSI. Patients completed a health care resource use diary and the EuroQol-5D at three, six, nine, and 12 months and the Western Ontario and McMaster Universities Osteoarthritis Index at three and 12 months postsurgery. We performed cost-utility and cost-effectiveness analyses from public health care payer and societal perspectives. RESULTS: One hundred seventy-three patients were included in the analysis with 86 patients randomized to PSI and 87 to SOC. PSI was dominated (more costly and less effective) by SOC from a health care payer perspective. From a societal perspective, an incremental cost-utility ratio was calculated at $11,230.00 per quality-adjusted life year gained, which is cost-effective at a willingness to pay threshold of $50,000. Net benefit analyses found PSI was not significantly cost-effective at any willingness to pay value from either perspective. CONCLUSION: Our results suggest that widespread adoption of PSI may not be economically attractive or clinically indicated. Future considerations are to compare long-term clinical outcomes and radiographic alignment between the groups.

The economic impact of periprosthetic infection in total knee arthroplasty.

Background: Currently, the gold standard treatment for periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is 2-stage revision, but few studies have looked at the economic impact of PJI on the health care system. The objective of this study was to obtain an accurate estimate of the institutional cost associated with the management of PJI in TKA and to assess the economic impact of PJI after TKA compared to uncomplicated primary TKA. Methods: We identified consecutive patients in our institutional database who had undergone 2-stage revision TKA for PJI between 2010 and 2014 and matched them on age and body mass index with patients who had undergone uncomplicated primary TKA over the same period. We calculated all costs associated with the 2 procedures and compared mean costs, length of stay, clinical visits and readmission rates between the 2 groups. Results: There were 73 patients (mean age 68.8 [range 48-91] yr) in the revision TKA cohort and 73 patients (mean age 65.9 [range 50-86] yr) in the primary TKA cohort. Two-stage revision surgery was associated with a significantly longer hospital stay (mean 22.7 d v. 3.84 d, p < 0.001), more outpatient clinic visits (mean 8 v. 3, p < 0.001), more readmissions (29 v. 0, p < 0.001) and higher overall cost (mean $35 429.97 v. $6809.94, p < 0.001) than primary TKA. Conclusion: Treatment for PJI after TKA has an enormous economic impact on the health care system. Our data suggest a fivefold increase in expenditure in the management of this complication compared to uncomplicated primary TKA.

Contexte: À l'heure actuelle, le traitement par excellence d'une infection de prothèse articulaire (IPA) survenant après une arthroplastie totale du genou (ATG) est l'arthroplastie de révision en 2 étapes. Toutefois, peu d'études se sont penchées sur les répercussions économiques de l'IPA sur le système de santé. La présente étude visait donc à estimer de façon précise le coût de prise en charge de l'IPA par les établissements, ainsi qu'à évaluer les répercussions économiques de l'IPA après une ATG, comparativement à celles d'une ATG primaire sans complications. Méthodes: Nous avons recensé, dans la base de données de notre établissement, tous les patients consécutifs ayant subi une ATG de révision en 2 étapes pour une IPA entre 2010 et 2014, puis les avons jumelés en fonction de l'âge et de l'indice de masse corporelle avec des patients ayant subi une ATG primaire sans complications durant la même période. Nous avons calculé tous les coûts associés aux 2 interventions, et avons comparé la moyenne des coûts, de la durée d'hospitalisation, des visites cliniques et des réadmissions entre les 2 groupes. Résultats: On comptait 73 patients (âge moyen 68,8 ans [plage 48­91 ans]) dans la cohorte d'ATG de révision, et 73 patients (âge moyen 65,9 ans [plage 50­86 ans]) dans la cohorte d'ATG primaire. L'ATG de révision en 2 étapes, comparativement à l'ATG primaire, a été associée à une durée d'hospitalisation significativement plus longue (moyenne 22,7 j c. 3,84 j; p < 0,001), à un plus grand nombre de visites en clinique externe (moyenne 8 visites c. 3 visites; p < 0,001), à un taux plus élevé de réadmission (29 réadmissions c. 0 réadmission; p < 0,001) et à des coûts globaux plus élevés (moyenne 35 429,97 $ c. 6809,94 $; p < 0,001). Conclusion: Le traitement de l'IPA après une ATG a d'énormes répercussions économiques sur le système de santé. Selon nos données, les dépenses liées à la prise en charge de cette complication pourraient être 5 fois plus élevées que celles liées à une ATG primaire sans complications.

Assessment of Informal Caregiver Assistance and Strain With Total Hip and Knee Arthroplasty.

BACKGROUND: The purpose of our study is to assess which patient-related and caregiver-related factors are predictive of caregiver strain and assistance when caring for total hip and knee arthroplasty (THA and TKA) patients within 2 weeks after surgery. METHODS: We conducted a prospective study of caregivers of participants enrolled in 2 randomized trials. Caregivers provided demographics and completed the Caregiver Strain Index and Caregiver Assistance Scale pre-surgery and post-surgery. We performed backwards stepwise regression with mixed-effects negative binomial models to investigate predictors of caregiver strain and assistance for THA and TKA caregivers. RESULTS: Three hundred six caregiver/patient pairs were included. Our models of caregiver strain found Caregiver Assistance Scale scores and patient age to be predictive for all caregivers. We also found caregiver gender and smoking status to be predictive for THA caregivers and caregiver age to be predictive for TKA caregivers. Our models of assistance provided by caregivers found time (post-surgery vs pre-surgery) was predictive for all caregivers. We also found patient body mass index, and patient and caregiver gender to be predictive for THA caregivers, and patient and caregiver employment status and caregiver education level to be predictive for TKA caregivers. CONCLUSION: Our study identifies patient-related and caregiver-related factors which are associated with caregiver strain and assistance when caring for arthroplasty patients. As this is the first study to assess assistance provided by caregivers, it is important for future research to validate our results and to further explore whether patient-reported outcomes may also be related to assistance and strain.

Perioperative Satisfaction and Health Economic Questionnaires in Patients Undergoing an Elective Hip and Knee Arthroplasty: A Prospective Observational Cohort Study.

Background: Early hospital discharge shifts the recovery burden toward the patient and can leave patients and their caregivers anxious about the recovery process. Postoperative home care must be broadened to include appropriate and adequate support to address recovery at home. In this prospective study, patient and caregiver perspectives on the level of preparation/satisfaction and cost associated with management of recovery in the postoperative period were evaluated. Methods: We designed this prospective study to measure patient-reported outcomes and to inform the design of a postoperative home monitoring system. Patients undergoing inpatient total hip or knee replacements were recruited from a preadmission clinic at a university hospital. Patients and caregivers completed preoperative, postoperative, and health economic questionnaires. Bivariate analyses were conducted to understand factors associated with satisfaction with care. Results: Of 239 patients and caregivers recruited, preoperative questionnaire was completed by 98.8% of patients, the postoperative follow-up questionnaire was completed by 94.2% of patients, 75% of informal caregivers completed the postoperative follow-up questionnaires, and 93.7% completed the health economic questionnaire. The postoperative satisfaction scores were higher than the preoperative needs/expectation scores for both the overall and individual subscales. Patients undergoing hip arthroplasty reported higher satisfaction scores for postoperative pain management than patients undergoing knee arthroplasty (hip arthroplasty vs. knee arthroplasty: 4.07 ± 1.11 vs. 3.37 ± 1.51; P < 0.001). Patients who underwent knee arthroplasty reported better satisfaction scores with regard to having enough information on how to manage leg stiffness at home compared to patients undergoing hip arthroplasty (knee arthroplasty vs. hip arthroplasty: 3.13 ± 1.35 vs. 2.78 ± 1.30; P = 0.04). Conclusion: Overall, patients are generally satisfied with perioperative care, but they have distinct needs and expectations regarding perioperative medication and postoperative pain management. Virtual postoperative monitoring may be a useful tool during postoperative care to address many of patients' concerns.

A protocol for a randomized controlled trial investigating the safety and cost-effectiveness of outpatient total hip arthroplasty.

BACKGROUND: A significant proportion of the overall cost of total hip arthroplasty (THA) results from the inpatient hospital stay following the procedure. Considering the substantial and increasing number of these procedures performed annually, shifting to an outpatient model of care where the patient is discharged home the same day as their surgery represents a potential for significant cost savings. The potential significant impact of an outpatient care model on constrained healthcare budgets and lack of high-quality evidence regarding its effectiveness warrants a rigorous comparative trial. The purpose of this prospective, randomized controlled trial is to evaluate outpatient care pathways for THA. Specifically, our objectives are to compare the rate of serious adverse events and estimate the cost-effectiveness of outpatient compared to standard inpatient THA. METHODS: We will include patients undergoing primary THA whom have an American Society of Anaesthetists status equal to or less than three, live within a 60-min driving distance of the institution and have an adult to accompany them home postoperatively and stay with them overnight. Consenting patients will be randomized to be discharged on the same day as surgery, as outpatients, or as inpatients according to standard of care (minimum of one night in hospital) using a modified Zelen consent model. The primary outcome measure is the incidence of serious adverse events at 30 days postoperative. Participants and their caregivers will complete secondary outcomes measures at each follow-up visit including patient-reported outcome measures and self-reported cost questionnaires. DISCUSSION: This protocol is the first randomized trial to use blinding to evaluate outpatient THA compared to standard overnight stay and first to prospectively perform a full economic evaluation. It is also the first adequately powered trial to prospectively assess the safety of outpatient THA. Successful completion of this study could have the potential to provide clinical evidence for the role of outpatient THA in current practice. TRIAL REGISTRATION: This study was retrospectively registered on ClinicalTrials.gov ( NCT03026764 ) on March 9th, 2016.

The economic impact of periprosthetic infection in total hip arthroplasty

Background: Periprosthetic joint infection (PJI) is the third leading cause of total hip arthroplasty (THA) failure. Although controversial, 2-stage revision remains the gold standard treatment for PJI in most situations. To date, there have been few studies describing the economic impact of PJI in today's health care environment. The purpose of the current study was to obtain an accurate estimate of the institutional cost associated with the management of PJI in THA and to assess the economic burden of PJI compared with primary uncomplicated THA. Methods: We conducted a review of primary THA cases and 2-stage revision THA for PJI at our institution. Patients were matched for age and body mass index. All costs associated with each procedure were recorded. Descriptive statistics were used to summarize the collected data. Mean costs, length of stay, clinic visits and readmission rates associated with the 2 cohorts were compared. Results: Fifty consecutive cases of revision THA were matched with 50 cases of uncomplicated primary THA between 2006 and 2014. Compared with the primary THA cohort, PJI was associated with a significant increase in mean length of hospital stay (26.5 v. 2.0 d, p < 0.001), mean number of clinic visits (9.2 v. 3.8, p < 0.001), number of readmissions (12 v. 1, p < 0.001) and average overall cost (Can$38 107 v. Can$6764, t = 8.3, p < 0.001). Conclusion: Treatment of PJI is a tremendous economic burden. Our data suggest a 5-fold increase in hospital expenditure in the management of PJI compared with primary uncomplicated THA.

Contexte: L'infection articulaire périprothétique (IAP) arrive au troisième rang des principales causes d'échec de l'arthroplastie (ou prothèse) totale de la hanche (PTH). Même si elle est controversée, la révision en 2 étapes demeure le traitement standard pour l'IAP dans la plupart des cas. À ce jour, peu d'études ont décrit l'impact économique de l'IAP dans l'environnement actuel des soins de santé. Le but de la présente étude était d'obtenir une estimation précise des coûts institutionnels associés à la prise en charge de l'IAP dans la PTH et d'évaluer le fardeau économique de l'IAP comparativement à une PTH primaire non compliquée. Méthodes: Nous avons passé en revue les cas de PTH primaire et de révision de PTH en 2 étapes pour cause d'IAP dans notre établissement. Les patients ont été assortis selon l'âge et l'indice de masse corporelle. Tous les coûts associés à chaque intervention ont été consignés. Des statistiques descriptives ont servi à résumer les données recueillies. Nous avons comparé les coûts moyens, la durée des séjours, les visites à la clinique et les taux de réadmission associés aux 2 cohortes. Résultats: Cinquante cas consécutifs de révision de PTH ont été assortis à 50 cas de PTH primaire non compliquée entre 2006 et 2014. Comparativement à la cohorte de PTH primaire, les cas d'IAP ont été associés à une augmentation significative de la durée moyenne du séjour hospitalier (26,5 j c. 2,0 j, p < 0,001), du nombre moyen de visites à la clinique (9,2 c. 3,8, p < 0,001), du nombre des réadmissions (12 c. 1, p < 0,001) et du coût global moyen (38 107 $ CA c. 6764 $ CA, t = 8,3, p < 0,001). Conclusion: Le traitement de l'IAP représente un énorme fardeau économique. Selon nos données, les dépenses hospitalières associées à sa prise en charge sont 5 fois plus grandes que pour la PTH primaire non compliquée.

Use of the Corail stem for revision total hip arthroplasty: evaluation of clinical outcomes and cost

Background: With the growing number of total hip arthroplasty (THA) procedures performed, revision surgery is also proportionately increasing, resulting in greater health care expenditures. The purpose of this study was to assess clinical outcomes and cost when using a collared, fully hydroxyapatite-coated primary femoral stem for revision THA compared to commonly used revision femoral stems. Methods: We retrospectively identified patients who underwent revision THA with a primary stem between 2011 and 2016 and matched them on demographic variables and reason for revision to a similar cohort who underwent revision THA. We extracted operative data and information on in-hospital resource use from the patients' charts to calculate average cost per procedure. Patient-reported outcomes were recorded preoperatively and 1 year postoperatively. Results: We included 20 patients in our analysis, of whom 10 received a primary stem and 10, a typical revision stem. There were no significant between-group differences in mean Western Ontario and McMaster Universities Osteoarthritis Index score, Harris Hip Score, 12-Item Short Form Health Survey (SF-12) Mental Composite Scale score or Physical Composite Scale score at 1 year. Operative time was significantly shorter and total cost was significantly lower (mean difference ­3707.64, 95% confidence interval ­5532.85 to ­1882.43) with a primary stem than with other revision femoral stems. Conclusion: We found similar clinical outcomes and significant institutional cost savings with a primary femoral stem in revision THA. This suggests a role for a primary femoral stem such as a collared, fully hydroxyapatite-coated stem for revision THA.

Contexte: Avec le nombre croissant d'interventions pour prothèse de hanche (PTH) effectuées, la chirurgie de révision est aussi proportionnellement en hausse, ce qui entraîne des coûts supérieurs pour le système de santé. Le but de cette étude était d'évaluer les résultats cliniques et le coût associés à l'emploi d'une prothèse fémorale primaire à collerette entièrement recouverte d'hydroxyapatite pour la révision de PTH, comparativement à d'autres prothèses d'usage courant utilisées pour les révisions. Méthodes: Nous avons identifié rétrospectivement les patients ayant subi une révision de PTH avec une prothèse primaire entre 2011 et 2016 et nous les avons assortis selon les caractéristiques démographiques et le motif de la révision à une cohorte similaire soumise à une révision de PTH. Nous avons extrait les données sur l'opération et sur l'utilisation des ressources hospitalières à partir des dossiers des patients pour calculer le coût par intervention. Les résultats déclarés par les patients ont été notés avant l'intervention et 1 an après. Résultats: Nous avons inclus 20 patients dans notre analyse, dont 10 ont reçu une prothèse primaire et 10, une révision de prothèse typique. On n'a noté aucune différence significative entre les groupes pour ce qui est du score WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) moyen pour l'arthrose, du score de Harris pour la hanche, ou des sous-échelles santé mentale ou santé physique à 1 an du questionnaire SF-12 (12-Item Short Form Health Survey). L'intervention a duré significativement moins longtemps et le coût a été significativement moindre (différence moyenne ­3707,64, intervalle de confiance de 95 % ­5532,85 à ­1882,43) avec une prothèse primaire qu'avec les autres prothèses de révision. Conclusion: Nous avons observé des résultats cliniques similaires et des économies significatives pour l'établissement avec la prothèse primaire utilisée pour la révision de PTH. Cela donne à penser que la prothèse fémorale primaire, par exemple, à collerette et entièrement recouverte d'hydroxyapatite, aurait un rôle à jouer pour la révision de PTH.

Significant cost savings and similar patient outcomes associated with early discharge following total knee arthroplasty.

BACKGROUND: A substantial portion of the cost of total knee arthroplasty (TKA) results from the postoperative inpatient length of stay (LOS). Considering the annual increase in TKAs, reducing LOS represents a potential for cost savings. We sought to compare in-hospital costs and patient-reported outcomes for an early discharge protocol compared with the standard LOS following TKA. METHODS: We conducted a retrospective matched cohort study, matching patients on age, sex, body mass index and preoperative Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) score. We compared costs associated with time in the operating room, intraoperative pain control and inpatient stay as well as 1-year postoperative patient-reported outcomes between early discharge and standard LOS groups. RESULTS: We included 50 patients in our study (25 per group). The average LOS in the early discharge group was 26.5 hours, compared with 48.9 hours in the standard care group. The early discharge group had higher intraoperative costs associated with pain control (mean difference 26.98, 95% confidence interval 14.41-37.90, p < 0.01); however, this difference was offset by substantial savings associated with the reduced LOS. The mean total cost for the early discharge group was $649.62 ± $281.71 versus $1279.71 ± $515.98 for the standard care group. There were no significant differences in SF12 or WOMAC scores between groups at 1 year postoperative. CONCLUSION: In-hospital costs were significantly lower with a postoperative day 1 discharge protocol than with standard LOS following TKA, with no difference in patient-reported outcomes.

CONTEXTE: Une portion substantielle du coût de l'arthroplastie pour prothèse totale du genou (PTG) est liée à la durée du séjour postopératoire. Compte tenu de l'augmentation annuelle des cas de PTG, abréger les séjours représente une source potentielle d'économies. Nous avons comparé les coûts hospitaliers et les résultats signalés par les patients avec un protocole de congé rapide et avec le séjour de durée standard après la PTG. MÉTHODES: Nous avons procédé à une étude de cohorte rétrospective appariée, où les patients étaient assortis selon le l'âge, le sexe, l'indice de masse corporelle et le score WOMAC (Western Ontario & McMaster Universities Osteoarthritis) préopératoire. Nous avons comparé les coûts associés au temps passé au bloc opératoire, au contrôle de la douleur peropératoire et au séjour hospitalier, de même que les résultats signalés par les patients 1 an après l'intervention entre les 2 groupes (congé rapide c. durée de séjour standard). RÉSULTATS: Nous avons inclus 50 patients dans notre étude (25 par groupe). Le séjour moyen du groupe soumis au congé rapide a été de 26,5 heures, contre 48,9 heures pour le séjour standard. Le groupe soumis au congé rapide a présenté des coûts peropératoires plus élevés associés au contrôle de la douleur (différence moyenne 26,98, intervalle de confiance de 95 % 14,41-37,90, p < 0,01); par contre, cette différence a été compensée par d'importantes économies associées à des séjours plus courts. Le coût total moyen pour le groupe soumis au congé rapide a été de 649,62 $ ± 281,71 $ contre 1279,71 $ ± 515,98 $ pour le séjour standard. On n'a noté aucune différence significative pour ce qui est des scores SF12 ou WOMAC entre les groupes 1 an après l'intervention. CONCLUSION: Les coûts perhospitaliers ont été significativement moindres avec le protocole de congé postopératoire rapide (après 1 jour), comparativement au séjour standard après la PTG, sans différence en ce qui concerne les résultats signalés par les patients.

Synthetic Graft Compared With Allograft Reconstruction for Extensor Mechanism Disruption in Total Knee Arthroplasty: A Multicenter Cohort Study.

BACKGROUND: Extensor mechanism disruption after total knee arthroplasty is a serious complication leading to notable patient morbidity. The purpose of this study is to compare the outcomes of extensor mechanism allograft with synthetic graft reconstruction. METHODS: We retrospectively identified all patients who underwent extensor mechanism reconstruction using either allograft or synthetic graft from two high-volume academic arthroplasty institutions between 2006 and 2017. We collected extensor lag, need for ambulatory aids, and patient-reported outcome measures, as well as the incidence of postoperative complications and revision surgeries. We evaluated cost differences, considering both material cost and the need for revision surgery. RESULTS: We identified 27 cases. A significantly greater postoperative extensor lag was found in the allograft group (P = 0.05). Graft failure after synthetic reconstruction was zero, with an overall revision surgery rate of 15%. Graft failure was 21%, and the revision surgery rate was 43% after allograft reconstruction. The allograft cost was significantly higher compared with the synthetic graft cost (P = 0.001). The mean total cost was 4,733.08 CAD for the synthetic group and 24,050.40 CAD for the allograft group (P = 0.17). DISCUSSION: Synthetic reconstruction for extensor mechanism disruption shows benefit in postoperative extensor lag, graft failure, revision surgery, and cost when compared with allograft. LEVEL OF EVIDENCE: Level III.

Damage Assessment of Retrieved Birmingham Monoblock Cups: Is Conversion to Dual-Mobility Head a Viable Revision Option?

BACKGROUND: A novel revision technique for failed hip resurfacings involves retention of the acetabular cup, if well-fixed, which is mated to dual-mobility (DM) prosthesis in a traditional hip replacement configuration. It is unknown whether existing damage on the retained cup will result in unacceptable wear of the DM prosthesis. METHODS: Thirty retrieved Birmingham (Smith & Nephew) monoblock cups were visually scored for damage features and area of coverage. Surface roughness measurements were obtained within each damage feature as well as reference points on each cup. Analysis of prior metal-on-metal wear was also performed to determine the maximum change in diameter of the cup. RESULTS: Scratching and grooving (deep, singular scratches) were the most common damage features. Overall bearing surface roughness was estimated as 0.059 µm (±0.030 µm) based on percent area coverage of each damage feature. Dimensional change of the bearing surface was negligible for most cups (18 of 30) but ranged from 0.20 to 0.38 mm for the most severely worn samples (5 of 30). CONCLUSION: Average surface roughness of the retrieved Birmingham cups was low, suggesting an expected 10%-20% increase in DM prosthesis wear. Similarly, dimensional change of the cup due to prior wear is not believed to significantly affect wear. Our findings support the use of a DM head in appropriate scenarios but suggest caution when applied to younger, more active patients whom may be adversely affected by increased prosthesis wear in the long term.

Is There a Role for Preoperative Iron Supplementation in Patients Preparing for a Total Hip or Total Knee Arthroplasty?

BACKGROUND: Several treatment modalities exist for the treatment of perioperative anemia. We determined the effect of oral iron supplementation on preoperative anemia, and the use of blood-conserving interventions before total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: A total of 3435 total joint arthroplasties (1461 THAs and 1974 TKAs) were analyzed during 2 phases of a blood conservation program. The first phase used erythropoietin alfa (EPO) or intravenous (IV) iron for patients at risk for perioperative anemia. The second phase included these interventions, as well as preoperative iron supplementation. The effect on preoperative hemoglobin (Hb) and serum ferritin, as well as EPO and IV iron utilization, was determined. RESULTS: Oral iron therapy increased preoperative Hb level by 6 g/L (P < .001) and 7 g/L (P < .001) in the hip and knee cohorts, respectively. Serum ferritin level rose by 80 µg/L (P < .001) and 52 µg/L (P < .001) in the hip and knee cohorts, respectively. The number of patients with an Hb level <130 g/L was significantly reduced (P < .001 for both cohorts), as were patients with serum ferritin levels <35 µg/L (P = .002 for hip and P < .001 for knee cohorts). Utilization of EPO reduced from 16% to 6% (P < .001) and 18% to 6% (P < .001) in the hip and knee cohorts, respectively. Utilization of IV iron reduced from 4% to 2% (P = .05) and 5% to 2% (P < .001) in the hip and knee cohorts, respectively. CONCLUSION: Oral iron therapy reduced the burden of perioperative anemia and reduced utilization of other blood-conserving therapies before THA and TKA. Future research should delineate the cost-effectiveness of oral iron therapy.

Outcomes of Surgical Management of Supracondylar Periprosthetic Femur Fractures.

BACKGROUND: Fracture location is an important consideration in managing supracondylar periprosthetic femur fractures. The outcomes of locked plating and intramedullary (IM) nail fixation were therefore compared based on fracture location, being above or at/below the total knee arthroplasty (TKA) flange. METHODS: Fifty-seven patients were identified from surgical records as being treated for supracondylar periprosthetic femur fracture with either a locking plate (n = 38) or IM nail (n = 19). Based on fracture location, either above or at/below the TKA flange, both groups were assessed for time to full weight bearing, time to radiographic union, number of postoperative complications, subsequent surgery, transfusion requirements, as well as range of motion, pain, and instability at most recent follow-up. Radiographs were reviewed to assess fracture alignment with comparisons made immediately postoperative to most recent. RESULTS: Mean follow-up for IM nail and locking plate fixation was 13.9 and 15.6 months, respectively. There was no statistical difference between groups in the mean time to fully weight bear, the incidence of postoperative pain, range of motion, use of gait aids, time to full radiographic union, or the overall radiographic alignment of a healed fracture (P > .05). Comparison based on fracture location yielded similar outcomes. Nonunion was only demonstrated in the IM nail cohort, particularly for fractures below the TKA flange (n = 2). CONCLUSION: The use of either IM nail or locking plate fixation for supracondylar periprosthetic fractures provides comparable clinical outcomes. Caution is recommended in using IM nails for fractures below the flange where limited fixation may increase the risk of nonunion.

A cost analysis of single-stage bilateral versus two-stage direct anterior total hip arthroplasty.

PURPOSE: The potential cost savings of single-stage bilateral total hip arthroplasty (THA) are unclear, and the risks associated with it are not well defined. We sought to compare the costs and perioperative complications of single-stage bilateral THA via the direct anterior approach (DAA) to a two-stage bilateral protocol. METHODS: We retrospectively reviewed patients who underwent a single- stage bilateral DAA THA and compared them to a two-stage THA group. We conducted a cost analysis from both the hospital perspective and the Ministry of Health (MOH) perspective. RESULTS: 24 patients were included in this study. The 2 groups were similar in age (58.9 vs 63.9 yrs), height (169.2 vs 170.9 cm), weight (80.2 vs 78.6 kg), BMI (27.9 vs 26.3 kg/m2), ASA score (2.2 vs 2.2), and CCI score (2.3 vs 2.9). The mean cost per patient from the hospital perspective for the single-stage group was $10,728.13 (SD = 621.46) compared to $12,670.63 (SD = 519.72) for the two-stage group (Mean Difference = $1,942.50, 95% CI = $1,457.49 to $2,427.51, p<0.001). Similarly, from the MOH perspective, the cost for the single-stage group was $12,552.34 (SD = 644.93) compared to $14,740.58 (SD = 598.07) for the two-stage group (Mean Difference = $2,188.24, 95% CI = $1,661.67 to $2,714.81, p<0.001). There were no significant differences in complication rate between groups. The largest percent of total cost savings from a hospital perspective was attributed to cost of operating room staff and OR set-up (55%). CONCLUSIONS: Our results suggest that single-stage bilateral DAA THA results in significant cost savings compared to two-stage DAA THA.

In-Hospital Cost Analysis of Total Hip Arthroplasty: Does Surgical Approach Matter?

The purposes of this study were to determine the impact of surgical approach on costs of total hip arthroplasty (THA) from a hospital perspective and to provide an updated cost estimation of THA. A prospective, microcosting analysis was performed on 118 patients undergoing a THA through an anterior, lateral, or posterior approach. We determined that overall costs (intraoperative costs and hospital stay) were significantly less for the anterior ($7300.22; 95% confidence interval [CI], 7064.49-7535.95) vs lateral ($7853.10; 95% CI, 7577.29-8128.91; P = .031) and anterior vs posterior approach ($8287.46; 95% CI, 7906.42-8668.51; P < .001). A reduction in hospital length of stay when THA was performed through an anterior approach contributed significantly to an overall reduction in costs from a hospital perspective.