Is the Rise of Medicare Advantage Impacting the Fidelity of Traditional Medicare Claims Data? Implications for Reporting of Long-Term Total Hip Arthroplasty Survivorship.

BACKGROUND: Arthroplasty registries often use traditional Medicare (TM) claims data to report long-term total hip arthroplasty (THA) survivorship. The purpose of this study was to determine whether the large number of patients leaving TM for Medicare Advantage (MA) has compromised the fidelity of TM data. METHODS: We identified 10,962 THAs in 9,333 Medicare-eligible patients who underwent primary THA from 2000 to 2020 at a single institution. Insurance type was analyzed, and 83% of patients had TM at the time of THA. Survivorship free from any revision or reoperation was calculated for patients who have TM. The same survivorship end points were recalculated with censoring performed when a patient transitioned to an MA plan after their primary THA to model the impact of losing patients from the TM dataset. Differences in survivorship were compared. The mean follow-up was 7 years. RESULTS: From 2000 to 2020, there was a decrease in TM insurance (93 to 73%) and a corresponding increase in MA insurance (0 to 19%) among THA patients. Following THA, 23% of TM patients switched to MA. For patients who had TM at the time of surgery, 15-year survivorship free from any reoperation or revision was 90% and 93%, respectively. When censoring patients upon transition from TM to MA, survivorship free from any reoperation became significantly higher (92 versus 90% at 15 years; hazard ratio = 1.16, P = .033), and there was a trend toward higher survivorship free from any revision (95 versus 93% at 15 years; hazard ratio = 1.16, P = .074). CONCLUSIONS: Approximately 1 in 4 patients left TM for MA after primary THA, effectively making them lost to follow-up within TM datasets. The mass exodus of patients out of TM appears to have led to a slight overestimation of survivorship free from any reoperation and trended toward overestimating survivorship free from any revision. If MA continues to grow, efforts to obtain MA data will become even more important.

The INGENIOUS trial: Impact of pharmacogenetic testing on adverse events in a pragmatic clinical trial.

Adverse drug events (ADEs) account for a significant mortality, morbidity, and cost burden. Pharmacogenetic testing has the potential to reduce ADEs and inefficacy. The objective of this INGENIOUS trial (NCT02297126) analysis was to determine whether conducting and reporting pharmacogenetic panel testing impacts ADE frequency. The trial was a pragmatic, randomized controlled clinical trial, adapted as a propensity matched analysis in individuals (N = 2612) receiving a new prescription for one or more of 26 pharmacogenetic-actionable drugs across a community safety-net and academic health system. The intervention was a pharmacogenetic testing panel for 26 drugs with dosage and selection recommendations returned to the health record. The primary outcome was occurrence of ADEs within 1 year, according to modified Common Terminology Criteria for Adverse Events (CTCAE). In the propensity-matched analysis, 16.1% of individuals experienced any ADE within 1-year. Serious ADEs (CTCAE level ≥ 3) occurred in 3.2% of individuals. When combining all 26 drugs, no significant difference was observed between the pharmacogenetic testing and control arms for any ADE (Odds ratio 0.96, 95% CI: 0.78-1.18), serious ADEs (OR: 0.91, 95% CI: 0.58-1.40), or mortality (OR: 0.60, 95% CI: 0.28-1.21). However, sub-group analyses revealed a reduction in serious ADEs and death in individuals who underwent pharmacogenotyping for aripiprazole and serotonin or serotonin-norepinephrine reuptake inhibitors (OR 0.34, 95% CI: 0.12-0.85). In conclusion, no change in overall ADEs was observed after pharmacogenetic testing. However, limitations incurred during INGENIOUS likely affected the results. Future studies may consider preemptive, rather than reactive, pharmacogenetic panel testing.

Comparison of Patient-Reported Outcomes and Functional Assessment Using a Marker-Less Image Capture System in End-Stage Knee Arthritis.

BACKGROUND: Patient self-assessment of knee function in end-stage osteoarthritis (OA) and following total knee arthroplasty (TKA) using patient-reported outcome measures (PROMs) has become standard for defining disability. The relationship of PROMs to functional performance requires a continued investigation. The purpose of this study was to determine correlations between patient demographics, PROMs, and functional performances using a marker-less image capture system (MICS). METHODS: Patients indicated for elective TKA completed the Knee Injury and Osteoarthritis Score for Joint Replacement (KOOS-JR) and an office-based functional assessment using a MICS. Patient age, body mass index (BMI), and gender were collected. A total of 112 patients were enrolled. Their mean age was 65.0 (±9.7) years, mean BMI was 32.5 (±6.6) kg/m2, and mean KOOS-JR was 14.5 (±5.7). The relationships between patient characteristics, KOOS-JR, MICS Alignment (coronal), MICS Mobility (flexion), and composite Total Joint scores were described using Spearman's correlation coefficients. RESULTS: BMI was weakly correlated with KOOS-JR (ρ = -0.22, P = .024), whereas age was not. Age and BMI were not correlated with performance scores. There were weak to no correlations between KOOS-JR and MICS Alignment (ρ = -0.01, P = .951), Mobility (ρ = 0.33, P < .001), and Total Joint scores (ρ = 0.06, P = .504). CONCLUSION: This study found no strong correlation between KOOS-JR and functional performance using a validated MICS for patients with end-stage knee OA. Further study is warranted in determining the relationship between PROMs and performance to optimize outcomes of patients undergoing nonoperative or surgical interventions for knee OA. The use of high-fidelity functional assessment tools that can be integrated into clinical workflow, such as the MICS used in this study, should permit PROM/functional performance comparisons in large populations.

Outcomes Vary Significantly Using a Tiered Approach to Define Success After Total Knee Arthroplasty.

BACKGROUND: Patient-reported outcome measures (PROM) allow assessment of clinical outcomes following primary total knee arthroplasty (TKA). The purpose of this study is to use progressively more stringent definitions of success to examine clinical outcomes of primary TKA at 1 year postoperatively and to determine which demographic variables were associated with achieving clinical success. METHODS: The American Joint Replacement Registry was queried from 2012 to 2020 for primary TKA. Patients who completed the following PROMs preoperatively and 1 year postoperatively were included: Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), and KOOS for Joint Replacement (KOOS JR). Mean PROM scores were determined for each visit and between-visit changes were evaluated using paired t-tests. Rates of achievement of minimal clinically important difference (MCID) by distribution-based and anchor-based criteria, Patient Acceptable Symptom State, and substantial clinical benefit were calculated. Logistic regression was used to evaluate the association between demographic variables and odds of clinical success. RESULTS: In total, 12,341 TKAs were included. Mean improvement in PROM scores were as follows: KOOS JR, 29; WOMAC-Pain, 33; and WOMAC-Function, 31 (P < .0001 for all). Rates of achievement of each metric were the following: distribution-based MCID, 84%-87%; anchor-based MCID, 46%-79%; Patient Acceptable Symptom State, 54%-82%; and substantial clinical benefit, 68%-81%. Patient age and gender were the most influential demographic factors on achievement of clinical success. CONCLUSION: Clinical outcomes at 1 year following TKA vary significantly when using a tiered approach to define success. A tiered approach to interpretation of PROMs should be considered for future research and clinical assessment.

Who Is Still Receiving Blood Transfusions After Primary and Revision Total Joint Arthroplasty?

BACKGROUND: Incidence of blood transfusions after primary and revision total hip and knee arthroplasty (primary total hip arthroplasty [pTHA], revision THA [rTHA], primary total knee arthroplasty [pTKA], and revision TKA [rTKA]) has been decreasing for a multitude of reasons. The purpose of this study was to assess whether transfusion rates have continued to decline and evaluate patient factors associated with transfusions. METHODS: The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing pTHA, pTKA, rTHA, and rTKA between 2011 and 2019. Patients undergoing bilateral procedures and arthroplasty for fracture, infection, or tumor were excluded. Trends in blood transfusions were assessed. Patient factor association with blood transfusions was evaluated using 2018 and 2019 data. RESULTS: Transfusion rates decreased from 21.4% in 2011 to 2.5% in 2019 for pTHA (P < .0001). For pTKA, transfusion rates declined from 17.6% to 0.7% (P < .0001). In rTHA, the transfusion rate decreased from 33.5% to 12.0% from 2011 to 2019 (P < .0001). Transfusion rates declined from 19.4% to 2.6% for rTKA during the study period (P < .0001). Transfusions were more frequent in patients who were older, female, with more comorbidities, with lower hematocrit, receiving nonspinal anesthesia, and with longer operative time. Lower preoperative hematocrit, history of bleeding disorders, and preoperative transfusion were associated with greater odds for postoperative transfusion after multivariate analysis. CONCLUSION: Transfusions after both primary and revision total joint arthroplasty have continued to decrease. Studies of arthroplasty complications should account for decreasing transfusions when assessing overall complication rates. Future studies should consider interventions to further reduce transfusions in revision arthroplasty.

Transplant Trial Watch.

To keep the transplantation community informed about recently published level 1 evidence in organ transplantation ESOT and the Centre for Evidence in Transplantation have developed the Transplant Trial Watch. The Transplant Trial Watch is a monthly overview of 10 new randomised controlled trials (RCTs) and systematic reviews. This page of Transplant International offers commentaries on methodological issues and clinical implications on 2 articles article of particular interest from the CET Transplant Trial Watch monthly selection. For all high quality evidence in solid organ transplantation, visit the Transplant Library: www.transplantlibrary.com.

Transplant Trial Watch.

To keep the transplantation community informed about recently published level 1 evidence in organ transplantation ESOT (https://esot.org/) and the Centre for Evidence in Transplantation have developed the Transplant Trial Watch (www.transplantevidence.com). The Transplant Trial Watch is a monthly overview of 10 new randomized controlled trials (RCTs) and systematic reviews. This page of Transplant International offers commentaries on methodological issues and clinical implications on two articles of particular interest from the CET Transplant Trial Watch monthly selection. For all high quality evidence in solid organ transplantation, visit the Transplant Library: www.transplantlibrary.com.

TRANSPLANT TRIAL WATCH.

To keep the transplantation community informed about recently published level 1 evidence in organ transplantation ESOT (https://esot.org/) and the Centre for Evidence in Transplantation (www.transplantevidence.com) have developed the Transplant Trial Watch. The Transplant Trial Watch is a monthly overview of 10 new randomized controlled trials (RCTs) and systematic reviews. This page of Transplant International offers commentaries on methodological issues and clinical implications on two articles of particular interest from the CET Transplant Trial Watch monthly selection. For all high quality evidence in solid organ transplantation, visit the Transplant Library: www.transplantlibrary.com.

Transplant Trial Watch.

To keep the transplantation community informed about recently published level 1 evidence in organ transplantation, ESOT (https://esot.org/) and the Centre for Evidence in Transplantation (https://www.transplantevidence.com/) have developed the Transplant Trial Watch. The Transplant Trial Watch is a monthly overview of 10 new randomized controlled trials (RCTs) and systematic reviews. This page of Transplant International offers commentaries on methodological issues and clinical implications on two articles of particular interest from the CET Transplant Trial Watch monthly selection. For all high-quality evidence in solid organ transplantation, visit the Transplant Library (www.transplantlibrary.com).

Allograft nephrectomy versus nonallograft nephrectomy after failed renal transplantation: a systematic review by updated meta-analysis.

There is limited evidence regarding the impact of allograft nephrectomy (AN) on the long-term outcome of subsequent kidney re-transplantation compared with no prior allograft nephrectomy. The aim of the present study was to conduct a systematic review and meta-analysis to estimate the accumulation of evidence over time. Primary outcomes were 5-year graft and patient survival. Cochrane library, Google scholar, PubMed, Medline and Embase were systematically searched. Meta-analysis was conducted using both fixed- and random-effects models. Study quality was assessed in duplicate using the Newcastle-Ottawa scale. Sixteen studies were included, with a total of 2256 patients. All included studies were retrospective and comparative. There was no significant difference in 5-year graft survival (GS) [Hazard Ratio (HR) = 1.11, 95% Confidence Intervals (CI): 0.89, 1.38, P = 0.37, I2  = 10%) or in 5-year patient survival (PS; HR = 0.70, 95% CI: 0.45, 1.10, P = 0.12, I2  = 0%]. Patients in the AN cohort were significantly younger than patients in the nonallograft nephrectomy (NAN) cohort by one year. Prior allograft nephrectomy was associated with a significantly higher risk of delayed graft function (DGF), acute rejection, primary nonfunction (PNF), per cent of panel reactive antibodies (% PRA) and allograft loss of the subsequent transplant. Although, DGF, % PRA, acute rejection and primary nonfunction rates were significantly higher in the AN cohort, allograft nephrectomy prior to re-transplantation had no significant association with five-year graft and patient survival.

Home Discharge Has Increased After Total Hip Arthroplasty, However Rates Vary Between Large Databases.

BACKGROUND: There have been significant advancements in perioperative total hip arthroplasty (THA) care and it is essential to quantify efforts made to better optimize patients and improve outcomes. The purpose of this study is to assess trends in discharge destination, length of stay (LOS), reoperations, and readmissions following THA. METHODS: Patients undergoing primary THA were identified using International Statistical Classification of Diseases and Current Procedural Terminology codes in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Humana claims databases. Discharge destinations were assessed and categorized as home or not home. Trends in discharge destination, LOS, readmissions, reoperation, and comorbidity burden were assessed. RESULTS: In ACS NSQIP, 155,637 patients underwent THA and the percentage of patients discharging home increased from 72.2% in 2011 to 87.0% in 2017 (P < .0001). In Humana, 84,832 THA patients were identified, with an increase in home discharge from 56.6% to 72.8% (P < .0001). LOS decreased and proportion of patients with an American Society of Anesthesiologists score ≥3 or Charlson Comorbidity Index ≥2 increased significantly for both home and nonhome going patients. Patients discharged home had a decrease in readmissions in both databases. CONCLUSION: Patients undergoing THA more often discharged home and had shorter hospital LOS with lower readmission rates, despite an increasingly comorbid patient population. It is likely these changes in disposition and LOS have resulted in significant cost savings for both payers and hospitals. The efforts necessary to maintain improvements should be considered when changes to reimbursement are being evaluated. ACS NSQIP hospitals had a larger proportion of patients discharged home and the source of data used to benchmark hospitals should be considered as findings may differ.

More Patients Are Being Discharged Home After Total Knee Arthroplasty, However Rates Vary Between Large Databases.

BACKGROUND: There have been significant advancements in perioperative care for total knee arthroplasty (TKA). It is essential to quantify the impact of efforts to better optimize patients and deliver care. The purpose of this study is to assess trends in discharge destination, length of stay (LOS), and complications. METHODS: Patients undergoing primary TKA were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Humana claims databases using procedural codes. Patients were classified as being discharged home or not home (skilled nursing facility, acute rehab, other non-home destinations). Changes in discharge destination, LOS, comorbidity burden, readmissions, and reoperation were assessed. RESULTS: In total, 254,195 ACS NSQIP patients underwent TKA, with an increase in home discharge from 67.2% in 2011 to 85.3% in 2017 (P < .0001). There were 178,071 TKA patients in the Humana database and home discharge increased from 62.1% in 2007 to 74.7% in 2016 (P < .0001). LOS decreased and proportion of patients with an American Society of Anesthesiologists score ≥3 or Charlson Comorbidity Index ≥2 increased significantly for both home and non-home going patients. Home going patients had a decrease in 30-day readmissions (ACS NSQIP: 2011: 3.6%, 2017: 2.7%, P = .001; Humana: 2007: 4.0%, 2016: 2.4%, P < .0001). CONCLUSION: Patients undergoing TKA were discharged home more often, had shorter LOS, and had significantly lower readmission rates, despite an increasingly comorbid patient population. It is likely that these improvements in postoperative care have resulted in significant cost savings, for both payers and hospitals. The efforts necessary to create and maintain such improvements, as well as the source of data, should be considered when changes to reimbursement are being evaluated. The metrics studied in this paper should provide a comparison for further improvement with continued transition to bundle payments and transition to outpatient surgery with removal of TKA from the inpatient-only list.

Clinical and Administrative Databases Used in Lower Extremity Arthroplasty Research.

BACKGROUND: The use of national databases in lower extremity arthroplasty research has grown rapidly in recent years. We aimed to better characterize available databases by: (1) quantifying the number of these studies in the highest impact arthroplasty journals; (2) comparing respective sample sizes; and (3) contrasting their measured variables/outcomes. METHODS: An extensive literature search was conducted to identify all database studies in the top 12 highest impact factor journals that published arthroplasty research between January 1, 2018 and December 31, 2019. A total of 5070 publications were identified. These studies were sorted by both database utilized and journal published. Tables were constructed to compare/contrast databases by metrics and measured outcome parameters including coding, patient sample size, preoperative comorbidities, postoperative complications, and limitations/barriers to their use. RESULTS: Four hundred twenty-six database studies (8.4%, range 0.4%-29.7% per journal) were identified, of which 139 were from non-English-speaking arthroplasty databases. Among English-speaking arthroplasty databases, the 5 most common sources were National Surgical Quality Improvement Project (n = 72), Medicare (n = 62, 39 from Medicare Claims and 23 from PearlDiver), Nationwide Inpatient Sample (n = 35), PearlDiver non-Medicare private insurance (n = 18), and Statewide Planning and Research Cooperative System (n = 18). Metrics, outcome parameters, and features of commonly used registries were reviewed. CONCLUSION: Database studies constitute an important part of arthroplasty-specific orthopedic research. Their use will continue to grow in the future, and it would be beneficial for clinicians/researchers to be aware of and familiarize themselves with their features to understand which are most appropriate for their work.

The Impact of Transitioning From International Classification of Diseases, Ninth Revision to International Classification of Diseases, Tenth Revision on Reported Complication Rates Following Primary Total Knee Arthroplasty.

BACKGROUND: In 2015, the healthcare system transitioned from International Classification of Diseases, Ninth Revision (ICD-9) coding to the Tenth Revision (ICD-10). We sought to determine the effect of this change on the reported incidence of complications following total knee arthroplasty (TKA). METHODS: The Humana administrative claims database was queried from 2 years prior to October 1, 2015 (ICD-9 cohort) and for 1 year after this date (ICD-10 cohort) to identify all TKA procedures. Complications occurring within 6 months of surgery were captured using the respective coding systems. Incidence of each complication was compared between cohorts using risk ratios (RR) and 95% confidence intervals. RESULTS: There were 19,009 TKAs in the ICD-10 cohort and 38,172 TKAs in the ICD-9 cohort. The incidence of each complication analyzed was significantly higher in the ICD-9 cohort relative to the ICD-10 cohort. Periprosthetic joint infection occurred in 1.9% vs 1.3% (RR 1.5, 1.3-1.9), loosening in 0.3% vs 0.1% (RR 2.7, 1.8-4.9), periprosthetic fracture in 0.3% vs 0.1% (RR 3.0, 1.6-4.5), and other mechanical complications in 0.7% vs 0.4% (RR 2.0, 1.5-2.5) (P < .05 for all). CONCLUSION: The transition from ICD-9 to ICD-10 coding has altered the reported incidence of complications following TKA. These results are likely due to the added complexity of ICD-10 which is joint and laterality specific. It is important to understand the differences between coding systems as this data is used for quality initiatives, risk adjustment models, and clinical research. Thoughtful methodology will be necessary when ICD-9 and ICD-10 data are being analyzed simultaneously.

Has Removal From the Inpatient-Only List Increased Complications After Outpatient Total Knee Arthroplasty?

BACKGROUND: On 1/1/2018, the Centers for Medicare and Medicaid Services removed total knee arthroplasty (TKA) from the Inpatient-Only (IPO) list. This change allowed expansion of outpatient TKA, potentially to include older, more frail patients at greater risk for perioperative complications. The purpose of this study was to evaluate the impact of removing TKA from the IPO list on early complications. METHODS: Patients undergoing TKA in the National Surgical Quality Improvement Program database were identified using CPT code 27447. Only cases with length of stay of zero days were included. Rates of 30-day complications, readmissions, and reoperation were compared before and after TKA was removed from the IPO list (2015-2017 vs 2018). The analysis was performed both with and without propensity score matching. RESULTS: 212,313 patients underwent TKA during the study period. 2466 (1.5%) were outpatient TKA in 2015-2017 and 3189 (5.6%) in 2018. After propensity matching, there were 2458 patients in each cohort. Rates of total 30-day complications were significantly lower in 2018 (3.7%) than the years TKA remained on the IPO (4.5%, P = .04). Similarly, rates of any reoperation decreased from 1.2% during 2015-2017 to 0.6% in 2018 (P = .03). There were no significant changes in rates of readmission (2.5% vs 2.2%, P = .5) or wound complications (0.8% vs 0.8%, P = 1.0). CONCLUSION: Removal of TKA from the IPO list did not result in an increase in complications or readmissions. These data suggest, despite the regulatory change, surgeons have continued to exercise sound judgment as to what patients can safely undergo outpatient TKA.

How Accurate Is ICD-10 Coding for Revision Total Knee Arthroplasty?

BACKGROUND: The International Classification of Diseases-10 (ICD-10) came into effect in October 2015. The new procedural codes (ICD-10-PCS) were designed to specify granular aspects of the procedure, including laterality and revised components. This specificity could improve data collection in institutional databases, large registries, and administrative claims data. Given these possible applications, this study's purpose was to assess the accuracy of ICD-10-PCS coding for revision total knee arthroplasty (rTKA). METHODS: This multicenter retrospective analysis utilized the rTKA databases at four academic medical centers for all aseptic rTKAs between October 1, 2015 and July 3, 2019. Operative reports were reviewed to determine laterality and revised components (tibial, femoral, liner, and patellar component), which were then compared with the ICD-10-PCS codes associated with the billing records. Proper coding required both component removal and replacement codes. The correct series of removal and replacement codes was determined using the American Joint Replacement Registry's guidelines. RESULTS: In total, 1906 rTKAs were examined, and 98.0% had at least one proper ICD-10-PCS code, indicating an rTKA had occurred. Coding for components replaced was correct in 76.3% of cases. When examining both removal and replacement codes, accuracy dropped to 57.0%. CONCLUSION: Nearly 25% of rTKA procedures were incorrectly coded for replaced components, and over 40% were incorrectly coded for removed and replaced components. ICD-10-PCS codes can accurately identify that an rTKA has occurred; however, the inaccuracy in identifying which specific components were revised should prompt further evaluation of the coding process before utilizing ICD-10-PCS codes to report granular rTKA data. LEVEL OF EVIDENCE: III, retrospective observational analysis.

The Modern Total Knee Arthroplasty: What to Make of All of These Options?

Total knee arthroplasty (TKA) continues to grow in number each year with over three million procedures anticipated to be performed by 2030. The success and prevalence of the procedure has led to expansion in the types of implants available for surgeons to choose from. Shifts in biomaterials, bearing surfaces, and porous surfaces have occurred recently. It is difficult to find a source to make heads or tails of the available options and what they mean for patient outcomes and satisfaction. This instructional course lecture is focused on helping surgeons decide what to make of all the options available for the modern TKA.

Opioid Use After Total Knee Arthroplasty: Does Tramadol Have Lower Risk Than Traditional Opioids?

BACKGROUND: Preoperative opioid use has been shown to increase postoperative opioid use following total knee arthroplasty (TKA). Tramadol is recommended for symptomatic treatment of osteoarthritis; however, it acts on opioid receptors and may confer similar adverse effects. The purpose of this study is to assess postoperative opioid use with preoperative opioid and tramadol use. METHODS: Patients undergoing primary TKA were identified in the Humana administrative claims database. Patients were stratified by whether they filled a prescription for an opioid, tramadol, either, or neither within 3 months of TKA. Prescription claims were tracked for 12 months postoperatively and relative risk for each group was calculated. RESULTS: In total, 107,973 patients undergoing TKA were identified. Preoperatively, 29,890 (27.7%) patients filled a prescription for opioids, 8049 (7.5%) for tramadol, 44,403 (41.1%) for tramadol or opioids, and 63,570 (58.9%) did not fill a prescription for either. At 12 months postoperatively, an opioid prescription was filled by 6.0% of preoperative narcotic-free patients, 35.2% opioid users (relative risk [RR] 5.83 [5.63-6.03]), 9.2% tramadol users (RR 1.52 [1.40-1.63]), and 29.5% opioid or tramadol users (RR 4.88 [4.72-5.05]). Opioid or tramadol prescriptions were filled by 7.7% of preoperative narcotic-free patients, 37.3% opioid users (RR 4.84 [4.70-4.99]), 26.2% tramadol users (RR 3.40 [3.26-3.57]), and 35.7% opioid or tramadol users (RR 4.64 [4.50-4.78]) at 12 months. CONCLUSION: Patients taking tramadol preoperatively were found to be at lower risk for prolonged postoperative opioid use following TKA. Patients taking either narcotics preoperatively continued use of these medications at a higher rate than those who were not.

Total Joint Arthroplasty in the Morbidly Obese: How Body Mass Index ≥40 Influences Patient Retention, Treatment Decisions, and Treatment Outcomes.

BACKGROUND: The United States is in an obesity epidemic. Obesity has multiple common comorbid conditions, including lower extremity arthritis. We sought to examine the course of treatment for a population with body mass index (BMI) ≥40 kg/m2 and osteoarthritis (OA) of the hip or knee. We investigated decision criteria that influenced arthroplasty surgeons to recommend nonoperative management vs total joint arthroplasty (TJA). For those patients who ultimately received TJA, we compared outcomes in this population to those with BMI <40 kg/m2. METHODS: This study retrospectively reviewed 158 new patients with BMI ≥40 kg/m2 and moderate/severe OA of the hip or knee. Demographics, comorbidity profiles, and weight loss were compared between groups that underwent TJA and those that did not. The arthroplasty database was used to identify patients who underwent TJA during 2016-2018 (N = 1473). Comorbidities, readmissions, surgical site infections, and overall complications were compared between those with BMI ≥40 kg/m2 and BMI <40 kg/m2. RESULTS: About 51.3% of new patients with BMI ≥40 kg/m2 and moderate/severe OA did not return for a second clinic visit. Of those who did return, 42.9% eventually underwent surgery. BMI was higher in single visit patients vs those with multiple visits (49.5 vs 46.3 kg/m2, P < .001), no difference in those scheduled on an "as-needed" basis vs a specific return date (P = .18), and did not change significantly during the 2-year follow-up (P = .41). Patients who underwent TJA had a lower mean BMI at presentation than their nonoperative counterparts (44.5 vs 47.6 kg/m2, P < .01) and demonstrated significant weight loss prior to surgery (44.5 vs 42.6 kg/m2, P < .05). When comparing patients with BMI ≥40 kg/m2 vs BMI <40 kg/m2, overall complications were not higher in the BMI ≥40 kg/m2 group, although surgical site infections were higher in those undergoing total hip arthroplasty with BMI ≥40 kg/m2 (0.3% vs 3.1%, P < .05). CONCLUSION: A majority of patients with BMI ≥40 kg/m2 and moderate/advanced OA will be lost to orthopedic follow-up. A relatively lower BMI indicates a greater chance of retention in care, and ultimately surgery, but does not influence surgeons' recommendations to continue orthopedic management. Patients who persist in seeking treatment, lose significant weight, and exhaust nonoperative alternatives may be suitable for TJA despite a BMI ≥40 kg/m2, with an overall complication rate of 4.3%. However, only 9% of patients at 2-year follow-up achieved BMI <40 kg/m2 and only 20% of surgeries were performed on patients who had achieved this proposed cutoff.

The Inaccuracy of ICD-10 Coding in Revision Total Hip Arthroplasty and Its Implication on Revision Data.

BACKGROUND: The International Statistical Classification of Diseases, 10th Revision (ICD-10), was adopted by the United States on October 1, 2015 and expanded coding from 3800 codes with the International Statistical Classification of Diseases, Ninth Revision, procedure code system (ICD-9-PCS) to 73,000. The increase in number of codes was designed to create more accurate representations of procedures like revision total hip arthroplasties (rTHAs). However, many worry that the increased complexity leads to more inaccurate coding. The purpose of this study is to determine the accuracy of ICD-10-PCS coding for rTHA and discuss the implications on registry data. METHODS: The rTHA databases at 2 large, academic medical centers were retrospectively reviewed for all rTHAs between October 1, 2015 and July 3, 2019. The laterality and specific revised components were recorded and compared with the ICD-10-PCS codes used for each procedure. The accuracy of ICD-10-PCS codes relative to the surgical record was determined using coding guidelines published by the American Joint Replacement Registry (AJRR). RESULTS: Overall, 895 cases were reviewed. Replacement coding was 22% accurate (195 of 895). For removal and replacement coding, accuracy dropped to 17% (152 of 895). All procedures had at least 1 rTHA trigger code that would signify correctly to AJRR that an rTHA occurred. CONCLUSION: In this study, the percent of correctly coded rTHA was low. All rTHA procedures had at least 1 AJRR trigger code; therefore, an rTHA would have been appropriately captured by AJRR. But these inaccuracies should make one pause when using ICD-10-PCS procedural data to try to evaluate specific rTHA details from administrative claims databases and ward against expanding ICD-10-PCS as a means to collect implant survival and registry data.