Effects of Hospital and Surgeon Volume on Patient Outcomes After Total Joint Arthroplasty: Reported From the American Joint Replacement Registry.

BACKGROUND: The purpose of this study was to evaluate outcomes and complications because it relates to surgeon and hospital volume for patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) using the American Joint Replacement Registry from 2012 to 2017. METHODS: A retrospective study was conducted on Medicare-eligible cases of primary elective THAs and TKAs reported to the American Joint Replacement Registry database and was linked with the available Centers of Medicaid and Medicare Services claims and the National Death Index data from 2012 to 2017. Surgeon and hospital volume were defined separately based on the median annual number of anatomic-specific total arthroplasty procedures performed on patients of any age per surgeon and per hospital. Values were aggregated into separate surgeon and hospital volume tertile groupings and combined to create pairwise comparison surgeon/hospital volume groupings for hip and knee. RESULTS: Adjusted multivariable logistic regression analysis found low surgeon/low hospital volume to have the greatest association with all-cause revisions after THA (odds ratio [OR], 1.63, 95% confidence interval [CI], 1.41-1.89, P < 0.0001) and TKA (OR, 1.72, 95% CI, 1.44-2.06, P < 0.0001), early revisions because of periprosthetic joint infection after THA (OR, 2.50, 95% CI, 1.53-3.15, P < 0.0001) and TKA (OR, 2.18, 95% CI, 1.64-2.89, P < 0.0001), risk of early THA instability and dislocation (OR, 2.47, 95% CI, 1.77-3.46, P < 0.0001), and 90-day mortality after THA (OR, 1.72, 95% CI, 1.27-2.35, P = 0.0005) and TKA (OR, 1.47, 95% CI, 1.15-1.86, P = 0.002). CONCLUSION: Our findings demonstrate considerably greater THA and TKA complications when performed at low-volume hospitals by low-volume surgeons. Given the data from previous literature including this study, a continued push through healthcare policies and healthcare systems is warranted to direct THA and TKA procedures to high-volume centers by high-volume surgeons because of the evident decrease in complications and considerable costs associated with all-cause revisions, periprosthetic joint infection, instability, and 90-day mortality. LEVEL OF EVIDENCE: III.

Cementless Fixation Is Associated With Increased Risk of Early and All-Time Revision After Hemiarthroplasty But Not After THA for Femoral Neck Fracture: Results From the American Joint Replacement Registry.

BACKGROUND: Despite ample evidence supporting cemented femoral fixation for both hemiarthroplasty and THA for surgical treatment of displaced femoral neck fractures, cementless fixation is the preferred fixation method in the United States. To our knowledge, no nationally representative registry from the United States has compared revision rates by fixation for this surgical treatment. QUESTION/PURPOSE: After controlling for relevant confounding variables, is femoral fixation method (cemented or cementless) in hemiarthroplasty or THA for femoral neck fracture associated with a greater risk of (1) all-cause revision or (2) revision for periprosthetic fracture? METHODS: Patients with Medicare insurance who had femoral neck fractures treated with hemiarthroplasty or THA reported in the American Joint Replacement Registry database from 2012 to 2017 and Centers for Medicare and Medicaid Services claims data from 2012 to 2017 were analyzed in this retrospective, large-database study. Of the 37,201 hemiarthroplasties, 42% (15,748) used cemented fixation and 58% (21,453) used cementless fixation. Of the 7732 THAs, 20% (1511) used cemented stem fixation and 80% (6221) used cementless stem fixation. For both the hemiarthroplasty and THA cohorts, most patients were women and had cementless femoral fixation. Early revision was defined as a procedure that occurred less than 90 days from the index procedure. All patients submitted to the registry were included in the analysis. Patient follow-up was limited to the study period. No patients were lost to follow-up. Due to inherent limitations with the registry, we did not compare medical complications, including deaths attributed directly to cemented fixation. A logistic regression model including the index arthroplasty, age, gender, stem fixation method, hospital size, hospital teaching affiliation, and Charlson comorbidity index score was used to determine associations between the index procedure and revision rates. RESULTS: For the hemiarthroplasty cohort, risk factors for any revision were cementless stem fixation (odds ratio 1.42 [95% confidence interval 1.20 to 1.68]; p < 0.001), younger age (OR 0.96 [95% CI 0.95 to 0.97]; p < 0.001), and higher Charlson comorbidity index (OR 1.06 [95% CI 1.02 to 1.11]; p = 0.004). Risk factors for early revision were cementless stem fixation (OR 1.77 [95% CI 1.43 to 2.20]; p < 0.001), younger age (OR 0.98 [95% CI 0.97 to 0.99]; p < 0.001), and higher Charlson comorbidity index (OR 1.09 [95% CI 1.04 to 1.15]; p < 0.001). Risk factors for revision due to periprosthetic fracture were cementless fixation (OR 6.19 [95% CI 3.08 to 12.42]; p < 0.001) and higher Charlson comorbidity index (OR 1.16 [95% CI 1.06 to 1.28]; p = 0.002). Risk factors for early revision due to periprosthetic fracture were cementless fixation (OR 7.38 [95% CI 3.17 to 17.17]; p < 0.001), major teaching hospital (OR 2.10 [95% CI 1.08 to 4.10]; p = 0.03), and higher Charlson comorbidity index (OR 1.20 [95% CI 1.09 to 1.33]; p < 0.001). For the THA cohort, there were no associations. CONCLUSION: These data suggest that cemented fixation should be the preferred technique for most patients with displaced femoral neck fractures treated with hemiarthroplasty. The fact that stem fixation method did not affect revision rates for those patients with displaced femoral neck fractures treated with THA may be due to current practice patterns in the United States. LEVEL OF EVIDENCE: Level III, therapeutic study.

Intravenous Acetaminophen May Be Associated with Reduced Odds of 30-Day Readmission after Total Knee Arthroplasty.

The purpose of this study was (1) to evaluate 30-day readmission rates in total knee arthroplasty (TKA) patients who either received intravenous (IV) or oral (PO) acetaminophen (APAP) perioperatively and (2) to extrapolate the potential annual cost savings on the national level. This was a review of 190,691 TKA recipients between the years 2012 and 2015 who received either IV (n = 56,475) or PO APAP (n = 134,216). All-cause readmissions that occurred between patient discharge and 30 days postdischarge were recorded. Continuous and categorical variables were evaluated using t-test and chi-square test, respectively. A logistic regression analysis was conducted to assess the effect of IV APAP on 30-day readmission. We also performed a literature review on 30-day readmission rates and risk prediction tools for TKA and correlated these with our findings. In addition, we extrapolated potential cost savings on the national level. The readmission rate was 0.04% in the IV and 0.14% in the PO APAP cohort (69% decreased risk; odds ratio = 0.31; 95% confidence interval = 0.20-0.47; p < 0.001). The readmission rate in this patient population appears to be markedly lower, when compared with previous reports. This reduction in readmissions may potentially result in $160 million savings per year. The use of IV APAP in TKA patients resulted in lower readmission rates, which may be valuable in clinical decision making by surgeons and health care administrators looking to lower costs of care.

The Role of Barbed Sutures in Wound Closure Following Knee and Hip Arthroplasty: A Review.

Lower extremity joint arthroplasty procedures often require a large incision to have an adequate exposure, which subsequently leads to lengthy wounds that may contribute to long closure, anesthesia, and overall operative times. The recently introduced knotless barbed suture may provide better outcomes, faster closure time, and decreased material utilization. Therefore, the aim of this study was to review the impact of barbed sutures on: (1) wound-related complications; (2) closure and operative time; (3) patient outcomes (range of motion and Knee Society Scores [KSS]); and (4) effects on cosmesis and patients' satisfaction. A literature search was performed using up to February 2017. Barbed sutures were associated with shorter closure times, shorter operative times, and larger cost savings per procedure as well as comparable wound complication rates after total joint arthroplasty. Although the current review is limited by the number of studies included, it demonstrates that overall, barbed sutures contribute to surgical efficiency when compared with conventional skin closure modalities.

Liposomal Bupivacaine in Total Knee Arthroplasty for Better Postoperative Analgesic Outcome and Economic Benefits.

When orthopedists consider which analgesia to use after total knee arthroplasty (TKA), the primary objective is to relieve pain with fewer adverse side effects. Over the last decade, substantial efforts have been made to improve pain control following TKA, but it is still very challenging to obtain optimal control. Current modalities in use, such as opioids, epidurals, and nerve blocks, provide substantial pain relief, but they are associated with substantial side effects and serious complications. Recently, bupivacaine, a commonly used nonopioid analgesic, has been formulated into an aqueous suspension of multivesicular liposomes that provide long-lasting analgesia, while avoiding significant adverse effects of opioids. The purpose of this review is to analyze the use of traditional postsurgical pain management and the potential contribution of a long-acting liposomal formulation of bupivacaine as part of the analgesic regimen in TKA, including its mode of action, injection technique, efficacy on pain, and health care costs.

Efficacy of Periarticular Injection With a Long-Acting Local Analgesic in Joint Arthroplasty.

Attention to patient satisfaction is critical in today's health care environment-satisfaction surveys inform the development of hospital performance standards and can influence an institution's rankings and reimbursement. The effectiveness of postoperative pain management can affect clinical outcomes and also influence the patient's perception of the overall surgical experience. Ample clinical- trial data now exist that demonstrate the benefits of periarticular injections as part of a multimodal regimen in patients undergoing joint arthroplasty. One option that surgeons now use widely is bupivacaine liposome injectable suspension (EXPAREL®, Pacira Pharmaceuticals, Inc), a long-acting local analgesic that the orthopedic surgeon can administer intraoperatively. The US Food and Drug Administration has approved liposomal bupivacaine for injection into the surgical site to produce postsurgical analgesia. The safety and efficacy of liposomal bupivacaine has been demonstrated in clinical studies in multiple types of surgical procedure, including double-blind, randomized, controlled clinical trials that involved over 1300 patients. In a case-control study comparing clinical and economic parameters before and after the introduction of liposomal bupivacaine as a component of the multimodal perioperative pain regimen for total joint arthroplasty, liposomal bupivacaine provided improved overall pain scores, an increase in patients reporting a pain score of 0, increased patient satisfaction, decreased length of stay, and a decrease in overall costs.