Outpatient Total Joint Arthroplasty: A Review of the Current Stance and Future Direction.

INTRODUCTION: The purpose of this review is to outline some of the major considerations when transitioning to performing total hip and knee arthroplasty in the out- patient setting. The review will discuss patient selections, peri-operative management pathways, and outcomes related to outpatient total joint arthroplasty (TJA). PATIENT SELECTION: Appropriate patient selection is key to successful outpatient TJA. Multiple indices have been proposed to estimate patient risk before undergoing outpatient TJA. Perioperative Management: In order to provide a successful outpatient TJA experience, pre-operative education class and physical therapy session can set expectations and prepare the patient for the post-operative recovery at home. Specific anesthesia techniques focus on regional blocks, multi-modal pain control, and reduction of post-operative nausea and vomiting and rapid recovery protocols have been developed to provide early mobilization and physical therapy. OUTCOMES: Nationwide analyses have found improved complication rates ranging from 1.3%-3% in outpatient TJA group compared to 3%-12% in the inpatient TJA group. Financial analyses have found significant cost savings for outpatient TJA mostly related to reduction in surgical floor care. CONCLUSION: Outpatient TJA has the potential to improve patient experience with cost savings and no increased risk of complications in the appropriately selected patient population.

Geographic variation in the treatment of proximal humerus fracture: an update on surgery rates and treatment consensus.

BACKGROUND: Using a larger, more comprehensive sample, and inclusion of the reverse shoulder arthroplasty as a primary surgical approach for proximal humerus fracture, we report on geographic variation in the treatment of proximal humerus fracture in 2011 and comment on whether treatment consensus is being reached. METHODS: This was a retrospective cohort study of Medicare patients with an x-ray-confirmed diagnosis of proximal humerus fracture in 2011. Patients receiving reverse shoulder arthroplasty, hemiarthroplasty, or open reduction internal fixation within 60 days of their diagnosis were classified as surgical management patients. Unadjusted observed surgery rates and area treatment ratios adjusted for patient demographic and clinical characteristics were calculated at the hospital referral region level. RESULTS: Among patients with proximal humerus fracture (N = 77,053), 15.4% received surgery and 84.6% received conservative management. Unadjusted surgery rates varied from 1.7 to 33.3% across hospital referral regions. Among patients receiving surgery, 22.3% received hemiarthroplasty, 65.8% received open reduction internal fixation, and 11.8% received reverse shoulder arthroplasty. Patients that were female, were younger, had fewer medical comorbidities, had a lower frailty index, were white, or were not dual-eligible for Medicaid during the month of their index fracture were more likely to receive surgery (p < .0001). Geographic variation in the treatment of proximal humerus fracture persisted after adjustment for patient demographic and clinical differences across local areas. Average surgery rates ranged from 9.9 to 21.2% across area treatment ratio quintiles. CONCLUSIONS: Persistent geographic variation in surgery rates for proximal humerus fracture across the USA suggests no treatment consensus has been reached.

Trends and Demographics in the Utilization of Total Wrist Arthroplasty.

BACKGROUND: Health disparities exist among many patient populations, with race, payer status, hospital size and access to teaching versus non-teaching hospitals potentially affecting whether certain patients have access to the benefits of total wrist arthroplasty (TWA). METHODS: The National Inpatient Sample Database (NIS) was queried from 2001 to 2013 for TWA using the ICD-9 code 81.73. Patient-level data included age, sex, race, payer status, and year of discharge. Hospital-level data included hospital bed size, location, teaching status, and region. RESULTS: There were 1,213 patients identified who underwent TWA between 2001 and 2013. Total number of procedures decreased from 88 TWAs in 2001 to 65 in 2013. The yearly volume ranged from 33 in 2005 to 128 in 2007. The male-female ratio was 2.5 to 1. The majority of TWA procedures were performed at urban teaching hospitals (60.8%). CONCLUSIONS: The NIS database shows a downward trend of total wrist arthroplasty utilization. The majority of total wrist arthroplasties were performed at urban teaching hospitals indicating treatment occurs most often at academic centers of excellence.

Trends in Joint Replacement Surgery in Patients with Rheumatoid Arthritis.

OBJECTIVE: This study analyzed trends in large total joint arthroplasties (TJA) and in the proportion of these procedures performed on patients with rheumatoid arthritis (RA). METHODS: The US Nationwide Inpatient Sample (2002-2012) was used to identify the incidences of total shoulder (TSA), elbow (TEA), knee (TKA), hip (THA), and ankle (TAA) arthroplasty and the proportion of these performed with coexisting RA. RESULTS: The prevalence of RA among patients with TJA increased 3.0%. The prevalence of RA among cases of TEA and TSA decreased by 50% (p < 0.0001) and 18% (p = 0.0016), respectively; a 38.0% decrease occurred in the prevalence of RA among TAA (p = 0.06); and nonsignificant increases were seen among THA and TKA. The average age difference between RA and non-RA patients undergoing TJA narrowed by 2 years (p < 0.0001). There was a greater reduction in the proportion of TSA, TEA, and TAA groups among women with RA than men with RA. In the TSA and TEA groups, there was a reduction in the proportion of whites with RA, but not blacks. The proportion of privately insured TSA and TAA patients with RA decreased, while patients with RA undergoing TSA, TEA, or TAA who were receiving Medicaid (government medical insurance) remained relatively stable over time. CONCLUSION: The prevalence of RA has decreased among TSA and TEA patients. A nonsignificant decline occurred among TAA patients. The average age of TJA patients with RA is beginning to mirror those without RA. Sex ratios for TSA, TEA, and TAA patients are following a similar pattern. These results may be evidence of the success of modern RA treatment strategies.

National trends in proximal humerus fracture treatment patterns.

BACKGROUND: The treatment of proximal humerus fractures (PHF) is largely surgeon dependent with no clear guidelines for selecting the optimal method of treatment. AIMS: The aim of this study was to evaluate trends and variations in treatment methods of PHF in the United States from 2004 to 2012 and to determine the regional differences in treatment. METHODS: The National Inpatient Sample was used to identify all patient discharges with diagnosis codes for PHF and the data were classified based on ICD-9 procedure codes. Patient and hospital demographics were also analyzed. Simple linear regression analyses were performed for each treatment modality to evaluate current treatment trends and to extrapolate the future trends of PHF treatment over the next 20 years. RESULTS: A national estimate of 550,116 PHF discharges was identified over the time period. Significant correlations between change over time and treatment modality were found for reverse shoulder arthroplasty (RSA) (r = 0.903, p < 0.001), open reduction internal fixation (r = 0.876, p = 0.002), and closed reduction internal fixation (r = -0.922, p < 0.001). The RSA regression model showed that by the year 2032, PHF treated with RSA will increase 100% from 2012. DISCUSSION: There were significant changes in treatment modalities for PHF from 2004 to 2012; The projected number of RSA used to treat PHF will be about 9115 in 2032, compared to 340 in 2004. CONCLUSION: Overall, there was a growth in proximal humerus fractures treated in an inpatient setting in the United States. RSA had the greatest proportional increase over time, but only accounted for less than 2% of total interventions.

Current Risk Adjustment and Comorbidity Index Underperformance in Predicting Post-Acute Utilization and Hospital Readmissions After Joint Replacements: Implications for Comprehensive Care for Joint Replacement Model.

OBJECTIVE: To compare the performances of 3 comorbidity indices, the Charlson Comorbidity Index, the Elixhauser Comorbidity Index, and the Centers for Medicare & Medicaid Services (CMS) risk adjustment model, Hierarchical Condition Category (HCC), in predicting post-acute discharge settings and hospital readmission for patients after joint replacement. METHODS: A retrospective study of Medicare beneficiaries with total knee replacement (TKR) or total hip replacement (THR) discharged from hospitals in 2009-2011 (n = 607,349) was performed. Study outcomes were post-acute discharge setting and unplanned 30-, 60-, and 90-day hospital readmissions. Logistic regression models were built to compare the performance of the 3 comorbidity indices using C statistics. The base model included patient demographics and hospital use. Subsequent models included 1 of the 3 comorbidity indices. Additional multivariable logistic regression models were built to identify individual comorbid conditions associated with high risk of hospital readmissions. RESULTS: The 30-, 60-, and 90-day unplanned hospital readmission rates were 5.3%, 7.2%, and 8.5%, respectively. Patients were most frequently discharged to home health (46.3%), followed by skilled nursing facility (40.9%) and inpatient rehabilitation facility (12.7%). The C statistics for the base model in predicting post-acute discharge setting and 30-, 60-, and 90-day readmission in TKR and THR were between 0.63 and 0.67. Adding the Charlson Comorbidity Index, the Elixhauser Comorbidity Index, or HCC increased the C statistic minimally from the base model for predicting both discharge settings and hospital readmission. The health conditions most frequently associated with hospital readmission were diabetes mellitus, pulmonary disease, arrhythmias, and heart disease. CONCLUSION: The comorbidity indices and CMS-HCC demonstrated weak discriminatory ability to predict post-acute discharge settings and hospital readmission following joint replacement.

[Endoprostheses in the elderly : Biomaterials, implant selection and fixation technique]. / Endoprothetik des älteren Menschen : Biomaterialien, Implantatwahl, Verankerungstechnik.

The replacement of hip and knee joints is one of the greatest success stories in orthopedics. Due to continuous improvement of biomaterials and implant design, patient-associated problems are now mostly multifactorial and only rarely caused by the implant. Abrasion was significantly reduced by the introduction of highly cross-linked polyethylene (PE), antioxidant stabilized PE, new ceramics and the development of ceramic and protective surfaces. It is assumed that further reduction of frictional resistance will not lead to a significantly better clinical result: however, the problem of periprosthetic infections and implant-related incompatibility is still unsolved and remains challenging for biomaterial research. For the knee joint PE will be irreplaceable for joint articulation even in the future due to the contact situation. Mobile bearings and fixed bearings are two established successful philosophies, which have shown comparably good clinical results. For the hip joint, it is forecasted that ceramic-on-ceramic will be the system of the future if the correct positioning and mounting of the components can be solved so that the problems, such as development of noise and breakage can be reduced to a minimum. An in-depth understanding and detailed knowledge of the biomaterials by the surgeon can prevent implant-related problems. For elderly patients it is assumed that the economic burden on the public healthcare system will have the strongest impact on implant selection.

Proximal humerus fragility fractures: recent trends in nonoperative and operative treatment in the Medicare population.

BACKGROUND: With an aging population, fragility fractures including injuries to the proximal humerus continue to rise in the United States. The purpose of this study was to investigate recent trends in the incidence and treatment of proximal humerus fractures (PHFs) in a cross-sectional elderly population. METHODS: Medicare data from 2005 to 2012 were queried to identify patients treated for PHF. Associated patient demographics, hospitalization data, treatment, and revision status were obtained. Statistical analyses were performed to identify significant trends in treatment. RESULTS: There were 259,506 PHFs recorded, with 79% occurring in female patients. In all age groups, nonoperative treatment of PHF was the most common method (67%). Within the surgical group, open reduction with internal fixation was most frequently used, and total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA) was the least common (11%). However, although the overall rate of surgical intervention remained constant, there was a significant increase in treatment with TSA from 3% in 2005 to 17% in 2012. In particular, RTSA represented 89% of all TSAs for PHF in 2011. All surgical treatment options demonstrated high 2-year survival rates without revision surgery (97%). CONCLUSION: Recent trends show that in the elderly population, nonoperative management remains the most common treatment for PHFs. Within the surgically treated cohort, there has been an increase in treatment with arthroplasty including RTSA, with a low rate of early revisions. There are excellent survival rates in all surgically treated PHFs, but long-term data will be required to fully evaluate the viability of these surgical options.

Future patient demand for shoulder arthroplasty by younger patients: national projections.

BACKGROUND: The outcomes of shoulder arthroplasties in younger patients (55 years or younger) are not as reliable compared with those of the general population. Greater risk of revision and higher complication rates in younger patients present direct costs to the healthcare system and indirect costs to the patient in terms of quality of life. Previous studies have suggested an increased demand for shoulder arthroplasties overall, but to our knowledge, the demand in younger patients has not been explored. QUESTIONS/PURPOSES: We asked: (1) What was the demand for shoulder arthroplasties between 2002 and 2011 in the United States for all patients and a specific subpopulation of patients who were 55 years old or younger? (2) How is the demand for shoulder arthroplasties in younger patients projected to change through 2030? (3) How is procedural demand projected to change in younger patients through 2030, and specifically, what can we anticipate in terms of hemiarthroplasty volume compared with that of total shoulder arthroplasty? METHODS: We used the National Inpatient Sample database to identify primary shoulder arthroplasties performed between 2002 and 2011. A Poisson regression model was developed using the National Inpatient Sample data and United States Census Bureau projections on future population changes to predict estimated national demand for total shoulder arthroplasties and hemiarthroplasties in all patients and in the subpopulation 55 years old or younger. This model was projected until 2030, with associated 95% CIs. We then specifically analyzed the projected demand of hemiarthroplasties and compared this with demand for all arthroplasty procedures in the younger patient population. RESULTS: Demand for shoulder arthroplasties in patients 55 years or younger is increasing at a rate of 8.2% per year (95% CI, 7.06%-9.35%), compared with a growth rate of 12.1% (95% CI, 8.35%-16.02%) per year for patients older than 55 years. In 2002, 15.9% (3587 of 22,617 captured in the National Inpatient Sample) of primary shoulder arthroplasties were performed in patients 55 years old or younger. In 2011, the relative size of the younger patient population had decreased to 11.0% (7001 of 63,784) of all recipients of shoulder arthroplasties. The demand for primary shoulder arthroplasties among younger patients is projected to increase by 333.3% (95% CI, 257.0%-432.5%) from 2011 to 2030. However, in patients older than 55 years demand is projected to increase by 755.4% (95% CI, 380.7%-1511.1%). Therefore, despite the increased predicted demand for shoulder arthroplasties in younger patients, they are predicted to account for only 4% of all recipients by 2030. The rate of hemiarthroplasties in patients 55 years or younger showed a 16.5% decline per year (95% CI, 16.1%-17.1%) from 2002 (53.6% of all arthroplasties) to 2011 (34.2% of all arthroplasties). By 2030, hemiarthroplasties are projected to account for only 23.5% of all shoulder arthroplasties in patients 55 years or younger. CONCLUSIONS: The demand for shoulder arthroplasties in younger patients continues to increase in the United States; however, rates of hemiarthroplasties are declining. The demand has substantial implications for future revision arthroplasties, which include the direct healthcare costs of revision arthroplasty, the indirect societal burden of missed productivity owing to time away from work, and the increased burden of the need for qualified surgeons to meet the demand. Despite the increasing rate of arthroplasties performed in younger patients, current and projected demands remain greater for older patients, indicating a disproportionately greater need for shoulder arthroplasties in older patients. This is in contrast to the trends observed in the literature regarding hip and knee arthroplasties that show projected demands to be greater in younger patients. Factors responsible for the difference in demand require further investigation but may be related to changing indications, reported poorer outcomes in younger patients, the increased popularity of reverse shoulder arthroplasties in the elderly, or the evolution of nonarthroplasty options. LEVEL OF EVIDENCE: Level III, prognostic study.

The incidence of proximal humeral fractures in New York State from 1990 through 2010 with an emphasis on operative management in patients aged 65 years or older.

BACKGROUND: Proximal humeral fractures are commonly encountered injuries. The development of locking plate technology and reverse shoulder arthroplasty may have changed the treatment patterns of these fractures. METHODS: We used the Statewide Planning and Research Cooperative System database in New York State to determine the incidence of proximal humeral fractures from 1990 through 2010 and the choice of treatment: closed reduction-internal fixation, open reduction-internal fixation (ORIF), hemiarthroplasty (HA), or total shoulder arthroplasty (TSA). RESULTS: The population-adjusted incidence per 100,000 increased from 15.35 in 1990 to 19.4 in 2010 (P < .0001). In patients aged 65 years or older, the incidence increased from 78.9 in 1990 to 101.0 in 2010 (P < .0001). In 1990, 20.4% of proximal humeral fractures were treated operatively; in 2010, this increased to 28.6% (P < .0001). Closed reduction-internal fixation/ORIF accounted for 58.4% of operative cases in 1990, decreasing to 46.6% in 2001 and increasing to 59.4% in 2010. HA was used in 27.1% of operative cases in 1990, increasing to 41% in 2001 and decreasing to 29.4% in 2010. TSA was used in 6.4% of operative cases in 1990, decreasing to 1.5% in 2001 with an increase to 7.5% in 2010. DISCUSSION: The incidence of proximal humeral fractures in patients aged 65 or older increased by 28% between 1990 and 2010, and operative management increased by more than 40%. The use of ORIF increased between 2001 and 2010, corresponding with the use of locking plate technology. There was an associated decrease in HA. TSA increased between 2006 and 2010, corresponding to the use of reverse shoulder arthroplasty.

Is changing hospitals for revision total joint arthroplasty associated with more complications?

BACKGROUND: Many patients change hospitals for revision total joint arthroplasty (TJA). The implications of changing hospitals must be better understood to inform appropriate utilization strategies. QUESTIONS/PURPOSES: (1) How frequently do patients change hospitals for revision TJA? (2) Which patient, community, and hospital characteristics are associated with changing hospitals? (3) Is there an increased complication risk after changing hospitals? METHODS: We identified 17,018 patients who underwent primary TJA and subsequent same-joint revision in New York or California (1997-2005) from statewide databases. Medicare was the most common payer (56%) followed by private insurance (31%). We identified patients who changed hospitals for revision TJA and those who experienced in-hospital complications. Patient, community, and hospital characteristics were analyzed to determine predictors for changing hospitals for revision TJA and the effect of changing hospitals on subsequent complications. RESULTS: Thirty percent of patients changed hospitals for revision. Older patients were less likely to change hospitals (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.73-0.96); no other patient characteristics were associated with changing hospitals. Patients who had index TJA at the highest-volume hospitals were less likely to change hospitals (OR, 0.52; 95% CI, 0.48-0.57). Overall, changing hospitals was associated with higher complication risk (OR, 1.19; 95% CI, 1.03-1.39). Changing to a lower-volume hospital (6% of patients undergoing revision TJA) was associated with a higher risk of complications (OR, 1.36; 95% CI, 1.05-1.74). A post hoc number needed-to-treat analysis indicates that 234 patients would need to be moved from a lower volume hospital to a higher volume hospital to avoid one overall complication event after revision TJA. CONCLUSIONS: Although the complication risk was higher if changing hospitals, this finding was sensitive to the type of change. Our findings build on the existing evidence of a volume-outcomes benefit for revision TJA by examining the effect of volume in view of potential patient migration. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Trends in treatment of advanced ankle arthropathy by total ankle replacement or ankle fusion.

BACKGROUND: Total ankle replacement (TAR) and ankle fusion (AF) are the 2 major operative options for treatment of advanced ankle arthropathy; there is, however, no large epidemiologic study comparing nationwide trends of these 2 procedures. The current study used a nationwide database to compare epidemiologic profiles of TAR and AF. METHODS: Data collected for the Nationwide Inpatient Sample (NIS) from 2000 to 2010 were reviewed. Procedures were identified by searching for ICD-9-CM codes 81.11 (AF) and 81.56 (TAR). Patients' demographics and comorbidities, geographic distribution, and cost of procedures were compared. RESULTS: The NIS analysis identified 2666 TAR and 16 419 AF cases which was extrapolated to 13 145 TAR and 80 426 AF nationwide. Spearman's ρ showed an increase in the number of AF per year while the number of TAR cases remained relatively flat per year until 2006, after which there was a steady increase in the number of TAR performed. Patients receiving a TAR tended to be older, female, and white. Patients who underwent AF were more likely to be obese or diabetic than TAR patients. Both TAR and AF were performed more frequently in private urban hospitals through 2007. However, in 2010, the number of TAR procedures was greater in academic centers compared to private urban hospitals. CONCLUSIONS: Despite recent increases in the number of TAR implanted, AF was still performed more than 6 times more frequently for advanced ankle arthropathy. A trend was demonstrated toward an increasing number of TAR being implanted in academic centers, and in patients with more underlying comorbidities than was previously seen. LEVEL OF EVIDENCE: Level II, prognostic study.

Trends in the use of total ankle replacement and ankle arthrodesis in the United States Medicare population.

BACKGROUND: Total ankle replacement (TAR) has gained acceptance as an alternative to traditional ankle arthrodesis (AA) for end-stage ankle arthritis. Little is known about long-term trends in volume, utilization, and patient characteristics. The objective of this study was to use longitudinal data to examine temporal trends in TAR and AA. METHODS: We identified all United States fee-for-service Medicare beneficiaries who underwent TAR and AA between 1991 and 2010 (n = 5871 and 29 532, respectively). We examined changes in patient demographics and comorbidity, nationwide and hospital volume, per capita utilization, and length of stay (LOS). RESULTS: Between 1991 and 2010, both TAR and AA patients had modest shifts in characteristics, with higher rates of diabetes and obesity. Overall, TAR Medicare volume increased by more than 1000% from 72 procedures in 1991 to 888 in 2010, while per-capita standardized utilization increased 670.8% (P < .001). AA volume increased 35.8% from 1167 procedures in 1991 to 1585 in 2010, while per-capita standardized utilization declined 15.6% (P < .001). The percentage of all US hospitals performing TAR increased nearly 4-fold from 3.1% in 1991 to 12.6% in 2010, while the proportion performing AA remained relatively unchanged. LOS decreased dramatically from 8.7 days in 1991 to 2.3 days in 2010 in TAR and from 5.5 days to 3.2 days in AA (P < .001). CONCLUSION: Between 1991 and 2010, Medicare beneficiaries undergoing either TAR or AA became more medically complex. Both volume and per-capita utilization of TAR increased dramatically but remained nearly constant for AA. At the same time, mean hospital volume for both procedures remained low. Further research should be directed toward determining design, surgeon, and hospital variables that relate to optimal outcomes following TAR, which has become increasingly used for the treatment of ankle arthritis. LEVEL OF EVIDENCE: Level III, comparative series.

Decreased need of large joint replacement in patients with rheumatoid arthritis in a specialized Brazilian center.

Disease-modifying antirheumatic biological and non-biological therapies are associated with reduced disease progression and joint destruction. Suggestions have been made that total knee and hip joint arthroplasty indications are decreasing as a beneficial effect of the new forms of therapy for rheumatoid arthritis. We present findings of our institution on the incidence of joint arthroplasty in the past few years in patients with rheumatoid arthritis and the increase in the numbers of procedures not associated with inflammatory arthritis.

The economics of new age arthroplasty: can we afford it?

New technology in joint replacement design and materials adds cost that must be documented by improved outcomes. This is not always the case as the recent metal/metal data has shown. The current economics of arthroplasty have put increasing financial pressure on hospitals and will progress under new health care legislation. New technology must be cost-effective and this will be increasingly difficult in an era of outstanding long-term results with current designs. Cost may necessitate less expensive alternatives, eg, generic implants, in arthroplasty patients. Joint replacement surgery has evolved over the past 4 decades into a highly successful surgical procedure. Earlier designs and materials that demonstrated inferior functional and long-term results have disappeared in a Darwinian fashion. Through this evolutionary process many of the current designs have proven efficacy and durability. Current outcome data indicates that hip and knee designs demonstrate 90% to 95% success rates at 15-year follow-up. Technologic advances are necessary to improve implant design and materials, however, only in an environment of reduced reimbursement to hospitals can the increase cost be justified.