Lower Revenue Surplus in Medicare Advantage Versus Private Commercial Insurance for Total Joint Arthroplasty: An Analysis of a Single Payor Source at One Institution.

BACKGROUND: Since the Affordable Care Act was passed in 2010, reductions in Medicare reimbursement have led to larger discrepancies between the relative cost of Medicare patients and privately insured patients. The purpose of this study was to compare reimbursement between Medicare Advantage and other insurance plans in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: Patients of a single commercial payor source who underwent primary unilateral TKA or THA at 1 institution between the dates of January 4 and June 30, 2021, were included (n = 833). Variables included insurance type, medical comorbidities, total costs, and surplus amounts. The primary outcome measure was revenue surplus between Medicare Advantage and Private Commercial plans. t-tests, Analyses of Variance, and Chi-Squared tests were used for analysis. A THA represented 47% of cases and a TKA 53%. Of these patients, 31.5% had Medicare Advantage and 68.5% had Private Commercial insurance. Medicare Advantage patients were older and had higher medical comorbidity risk for both TKA and THA. RESULTS: Significant differences were observed in medical costs between Medicare Advantage and Private Commercial insurance for THA ($17,148 versus $31,260, P < .001) and TKA ($16,723 versus $33,593, P < .001). Additionally, differences were seen in surplus amounts between Medicare Advantage and Private Commercial insurance for THA ($3,504 versus $7,128, P < .001) and TKA ($5,581 versus $10,477, P < .001). Deficits were higher in Private Commercial patients undergoing TKA (15.2 versus 6%, P = .001). CONCLUSION: The lower average surplus associated with Medicare Advantage plans may lead to financial strain on provider groups who care for these patients and face additional overhead costs.

Hip resurfacing: case closed? A bibliometric analysis of the past 10 years.

INTRODUCTION: Hip resurfacing (HR) was introduced as a potential alternative to total hip arthroplasty (THA), indicated predominantly for younger, high demand patients. The modern metal-on-metal implant was popularized in the 1990s and early 2000s and promised greater wear resistance. However, its popularity waned due to increased rates of complications related to metal toxicity including pseudo-tumors as well as the recall of many resurfacing implants. The purpose of this study was to conduct a bibliometric analysis and investigate the current trends in hip resurfacing literature. METHODS: Using the keywords "hip resurfacing," publications between 2012 and 2022 were identified on Web of Science Core Collection of Clarivate Analytics. Results were screened for relevance by three independent reviewers using title, abstract, and full text. The retrieved data were evaluated by the bibliometric method. Included articles were imported into CiteSpace 5.7.R1, 64-bit (Drexel University, Philadelphia, PA, USA), VOSviewer 1.6.15 (Leiden University, Leiden, the Netherlands), and the Online Analysis Platform of Literature Metrology to identify trends in publication. RESULTS: Search terms yielded 1200 results and 724 were included in final analysis. A steady decrease of publications was noted over the past decade with less than 40 articles published in 2020 and 2021. The Journal of Hip Arthroplasty (92), Hip International (74), and Clinical Orthopaedics and Related Research (54) published the most articles. Authors from the United States and the United Kingdom published the most studies. High-frequency keywords in co-occurrence and co-cited cluster analysis were metal-on-metal, metal ions, wear, pseudo-tumor, and revision, demonstrating that long-term concerns have been the focus of most recent studies. CONCLUSION: In conclusion, our bibliometric analysis allowed novel exploration and identification of the current research trends, contributions, and the distribution of publications exploring HR. The understanding of HR and the poor long-term outcomes of some resurfacing implants has improved significantly over the past decade, with the most recent focus on failure rates and long-term complications from metal debris. However, the breadth of literature has steadily declined in the past decade, and ultimately demonstrates the decline of scientific interest and focus on novel areas in hip resurfacing and a potential reached consensus.

Postacute Care Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities After Total Joint Arthroplasty.

BACKGROUND: Racial and socioeconomic disparities have been associated with complications and poorer patient-reported outcomes after THA and TKA, but little is known regarding the variation of postacute care resource utilization based on socioeconomic difference in the communities in which patients reside. Hip and knee arthroplasty are among the most common elective orthopaedic procedures. Therefore, understanding social factors provides insight into patients at risk for readmission and the way in which these patients use other postoperative resources. This knowledge can help surgeons better understand which patients are at risk for complications or preventable readmissions and how to anticipate when additional surveillance or intervention might reduce this risk. QUESTIONS/PURPOSES: (1) Do patients from communities with a higher distress level experience higher rates of readmission after THA and TKA? (2) Do patients from distressed communities have increased postoperative resource utilization? METHODS: Demographics, ZIP code of residence, and Charlson comorbidity index (CCI) were recorded for each patient undergoing TKA or THA between 2016 and 2019 at two high-volume hospitals. Patients were classified according to the Distressed Communities Index (DCI) score of their ZIP code of residence. The DCI combines seven metrics of socioeconomic well-being (high school graduation, poverty rate, unemployment, housing vacancy, household income, change in employment, and change in establishment) to create a single score. ZIP codes are then classified by scores into five categories based on national quintiles (prosperous, comfortable, mid-tier, at-risk, and distressed). The DCI was chosen because it provides a single composite measure of multiple important socioeconomic factors. Multivariate analysis with logistic, negative binomial regression, or Poisson was used to investigate the association of DCI category with postoperative resource utilization while controlling forage, gender, BMI, and comorbidities. The primary outcome was 90-day readmissions. Secondary outcomes included postoperative medication prescriptions from the orthopaedic team, patient telephone calls to the surgeon's office, physical therapy sessions attended, follow-up office visits, and emergency department visits. A total of 5077 patients who underwent TKA (mean age 66 ± 9 years, 59% [2983 of 5077] are women, and 69% [3519 of 5077] are White), and 5299 who underwent THA (mean age 63 ± 11 years, 50% [2654 of 5299] are women, and 74% [3903 of 5299] are White) were included. RESULTS: When adjusting for age, gender, race and CCI, readmission risk was higher in distressed communities compared with prosperous communities for patients undergoing TKA (odds ratio 1.6 [95% confidence interval 1.1 to 2.3]; p = 0.02) but not for THA. For secondary outcomes after TKA, at-risk communities had more postoperative prescriptions compared with prosperous communities, but no other differences were found. After THA, no major differences were found in the likelihood to utilize postoperative resources based on DCI category. Race was not associated with readmissions or resource utilization. CONCLUSION: We found that socioeconomic distress was associated with readmission after TKA, but, after controlling for relevant confounding variables, race had no association. Patients from these communities do not demonstrate an increased or decreased use of other resources after post-TKA discharge. Increased awareness of these disparities may allow for closer monitoring and improved patient education and communication, with the goal of reducing the frequency of complications and preventable readmissions. LEVEL OF EVIDENCE: Level III, therapeutic study.

Patients From Distressed Communities Who Undergo Surgery for Hip Fragility Fractures Are Less Likely to Have Advanced Care Planning Documents in Their Electronic Medical Record.

BACKGROUND: Advanced care planning documents provide a patient's healthcare team and loved ones with guidance on patients' treatment preferences when they are unable to advocate for themselves. A substantial proportion of patients will die within a few months of experiencing a hip fracture, but despite the importance of such documents, patients undergoing surgery for hip fracture seldom have discussions documented in the medical records regarding end-of-life care during their surgical admission. To the best of our knowledge, the proportion of patients older than 65 years treated with surgery for hip fractures who have advanced care planning documents in their electronic medical record (EMR) has not been explored, neither has the association between socioeconomic status and the presence of those documents in the EMR. Determining this information can help to identify opportunities to promote advanced care planning. QUESTIONS/PURPOSES: (1) What percentage of patients older than 65 years who undergo hip fracture surgery have completed advanced care planning documents uploaded in the EMR before or during their surgical hospitalization, or at any timepoint (before admission, during admission, and after admission)? (2) Are patients from distressed communities less likely to have advanced care planning documents in the EMR than patients from wealthier communities, after controlling for economic well-being as measured by the Distressed Communities Index? (3) What percentage of patients older than 65 years with hip fractures who died during their hospitalization for hip fracture surgery had advanced care planning documents uploaded in the EMR? METHODS: This was a retrospective, comparative study conducted at two geographically distinct hospitals: one urban Level I trauma center and one suburban Level II trauma center. Between 2017 and 2021, these two centers treated 850 patients for hip fractures. Among those patients, we included patients older than 65 years who were treated with open reduction and internal fixation, intramedullary nailing, hemiarthroplasty, or THA for a fragility fracture of the proximal femur. Based on that, 83% (709 of 850) of patients were eligible; a further 6% (52 of 850) were excluded because they had codes other than ICD-9 820 or ICD-10 S72.0, and another 2% (17 of 850) had incomplete datasets, leaving 75% (640 of 850) for analysis here. Most patients with incomplete datasets were in the prosperous Distressed Communities Index category. Among patients included in this study, the average age was 82 years, 70% (448 of 640) were women, and regarding the Distressed Communities Index, 32% (203 of 640) were in the prosperous category, 25% (159 of 640) were in the comfortable category, 15% (99 of 640) were in the mid-tier category, 5% (31 of 640) were in the at-risk category, and 23% (145 of 640) were in the distressed category. The primary outcome included the presence of advanced care planning documents (advanced directives, healthcare power of attorney, or physician orders for life-sustaining treatment) in the EMR before surgery, during the surgical admission, or at any time. The Distressed Communities Index was used to indicate economic well-being, and patients were identified as being in one of five Distressed Communities Index categories (prosperous, comfortable, mid-tier, at-risk, and distressed) based on ZIP Code. An exploratory analysis was conducted to determine variables associated with the presence of advanced care planning documents in the EMR. A multivariate regression was then performed for patients who did or did not have advanced care planning documents in their medical record at any time. The results are presented as ORs with the associated 95% confidence interval (CI). RESULTS: Nine percent (55 of 640) of patients had advanced care planning documents in the EMR preoperatively or during their surgical admission, and 22% (142 of 640) of patients had them in the EMR at any time. After controlling for potential confounding variables such as age, laterality (left or right hip), hospital type, and American Society of Anesthesiologists (ASA) classification, we found that patients in Distressed Communities Index categories other than prosperous had ORs lower than 0.7, with patients in the distressed category (OR 0.4 [95% CI 0.2 to 0.7]; p < 0.01) and comfortable category (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.01) having a substantially lower odds of having advanced care planning documents in their EMR. Patients aged 86 to 95 years (OR 1.9 [95% CI 1.1 to 3.4]), those 96 years and older (OR 4.0 [95% CI 1.7 to 9.5]), and those with a higher ASA classification (OR 1.6 [95% CI 1.1 to 2.3]) had a higher odds of having advanced care planning documents in the EMR at any time. Among 14 patients who experienced in-hospital mortality, two had advanced care planning documents uploaded into their EMR, whereas 12 of 14 who died in the hospital did not have advanced care planning documents uploaded into their EMR. CONCLUSION: Orthopaedic surgeons should counsel patients regarding the risk for postoperative complications after fragility hip fracture surgery and engage in shared decision-making regarding advanced care planning documents with patients or, if the patients are unable, with their families. Additionally, implementing virtual education about advanced care planning documents and using easy-to-read forms may facilitate the completion of advanced care planning documents by patients older than 65 years, especially patients with low economic well-being. Limitations of this study include having a restricted number of patients in the at-risk and mid-tier Distressed Communities Index categories and a restricted number of patients identifying as non-White races/ethnicities. Future research should evaluate the effect of advanced care document presence in the EMR on end-of-life care intensity in patients treated for fragility hip fractures. LEVEL OF EVIDENCE: Level III, therapeutic study.

Psychosocial factors play a greater role in preoperative symptoms for patients with atraumatic shoulder instability: data from the MOON-Shoulder Instability group.

BACKGROUND: Previous studies have demonstrated that psychosocial factors and comorbid depression are associated with worse preoperative baseline measures, clinical outcomes, and recovery in patients undergoing shoulder surgery. It is unknown whether this potential link would differ between those with traumatic vs. atraumatic shoulder instability, as symptoms may persist longer in atraumatic instability prior to surgical intervention. The purpose of this study was to determine if psychosocial factors and/or comorbid depression more heavily influence preoperative symptoms for patients with traumatic vs. atraumatic shoulder instability. METHODS: Prospective baseline data from 1552 patients in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were analyzed based on mechanism of injury while controlling for age, sex, and direction of instability. Multivariable linear regressions were performed to determine whether psychological factors (RAND 36 Mental Component Score [MCS], depression diagnosis, Personality Assessment Screener-22) were predictive of preoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Western Ontario Shoulder Instability Index (WOSI) scores in the atraumatic group. The same model was repeated for the traumatic instability group, and the model fit was compared between groups, with P < .05 considered statistically significant. RESULTS: Female sex and lower MCS were significantly associated with worse preoperative ASES and WOSI scores for the group with atraumatic instability (ASES R2 = 0.15, P < .001; WOSI R2 = 0.17, P < .001). The same model performed significantly worse (P < .05) for both ASES and WOSI scores in the group with traumatic instability (ASES R2 = 0.07, WOSI R2 = 0.08). CONCLUSIONS: Worse preoperative psychosocial factors were found to be more strongly associated with shoulder-related pain and function for patients with atraumatic instability. Across multiple orthopedic conditions, depression and emotional well-being have been associated with worse preoperative symptoms and inferior postoperative patient-reported outcomes. Despite the stronger and significant association in atraumatic patients, worse psychosocial factors did not have as large an impact as has been seen in other, more chronic conditions such as osteoarthritis or rotator cuff tears. In addition to medically optimizing patients prior to surgery, the current findings identify a subset of shoulder instability patients that may benefit from a behavioral health intervention either prior to surgery or early in the postoperative period to potentially improve postoperative outcomes.

Routine Use of Bladder Scans After Primary Total Joint Arthroplasty is Not Necessary: Results of a Protocol Change.

BACKGROUND: Postoperative urinary retention is a common concern after total joint arthroplasty (TJA) and can cause discomfort, incontinence and, if left untreated, myogenic changes to the bladder. However, overdiagnosis of postoperative urinary retention by bladder scans may lead to unnecessary interventions and delayed discharges. The purpose of this study was to compare the safety of two bladder management protocols following TJA. METHODS: From January 3, 2022 to April 29, 2022, 519 consecutive patients operated on by thirteen surgeons underwent routine postoperative bladder scanning (standard protocol). From February 28, 2022 to April 29, 2022, a new protocol was introduced by three surgeons in 209 consecutive patients using a specific algorithm (selective protocol) so that only symptomatic patients had bladder scans. The primary outcome of interest was catheterization rate. Chi-square and Students t-tests were used for analyses. There were 37.7% of patients in the selective group who received scans. RESULTS: Times to catheterization, readmissions, emergency department visits, and straight catheterization rates (15.0 versus 14.8% P = .999) were similar. More scans in the selective group resulted in intervention (39.2 versus 15.0%, P < .001). Prevoid volumes were higher in the selective protocol (608 versus 448 mL, P < .001). Postvoid volumes were similar (233 versus 223 mL, P = .497). There was one readmission for a urinary tract infection in the standard group and no urinary-related readmissions in the selective group. CONCLUSION: The selective protocol had a higher rate of same day discharge, fewer bladder scans, and did not lead to increased rates of urinary-related complications. These findings suggest that selective bladder scanning for symptomatic patients can be safely instituted for TJA patients.

Comparing Risk Assessment Between Payers and Providers: Inconsistent Agreement in Medical Comorbidity Records for Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: The proper risk adjustment for total hip arthroplasty (THA) and total knee arthroplasty (TKA) relies on an accurate assessment of comorbidity profiles by both the payer and the institution. The purpose of this study was to determine how strongly comorbidities tracked by our institution agreed with the same comorbidities reported by payers in patients undergoing THA and TKA. METHODS: All patients of a single payer undergoing primary THA and TKA at a single institution between January 5, 2021 and March 31, 2022 were included (n = 876). There were 8 commonly collected medical comorbidities obtained from institutional medical records and matched with patient records reported by the payer. Fleiss Kappa tests were used to determine agreement of payer data with institutional records. There were 4 medical risk calculations collected from our institutional records and compared with an insurance member risk score reported by the payer. RESULTS: Comorbidities reported by the institution differed significantly from those reported by payers, with Kappa varying between 0.139 and 0.791 for THA, and 0.062 and 0.768 for TKA. Diabetes was the only condition to demonstrate strong agreement for both procedures (THA; k = 0.791, TKA; k = 0.768). The insurance member risk score demonstrates the closest association with total cost and surplus for THA regardless of insurance type and for TKA procedures paid for with private commercial insurance. CONCLUSION: There is a lack of agreement between medical comorbidities within payer and institutional records for both THA and TKA. These differences may put institutions at a disadvantage within value-based care models and when optimizing patients perioperatively.

Surgeons Experience More Physiologic Stress and Strain During Revision Than Primary Total Joint Arthroplasty.

BACKGROUND: Revision total knee arthroplasty (rTKA) and total hip arthroplasty (rTHA) procedures are more complex than primary TKA and THA, but their physiologic burden to the surgeon has not been quantified. While rTKA and rTHA have longer operative times, it is unknown whether differences exist in stress and strain compared to primary TKA and primary THA. The study was conducted to elicit whether differences exist in surgeon physiological response while performing rTKA and rTKA compared to primary TKA and primary THA. METHODS: We evaluated a prospective cohort study of 70 consecutive cases (23 primary TKAs, 12 primary THAs, 16 rTKAs, and 19 rTHAs). Two high-volume fellowship-trained arthroplasty surgeons wore a smart vest that recorded cardiorespiratory data while performing primary THA, primary TKA, rTHA, and rTKA. Heart rate (beats/minute), stress index (correlates with sympathetic activation), respiratory rate (respirations/minute), minute ventilation (L/min), and energy expenditure (Calories) were collected for every case, along with patient body mass index (kilograms/meter2) and working operative time (minutes). T-tests were used to assess for differences between the two groups. RESULTS: Compared to primary TKA, performing rTKAs had a significantly higher surgeon stress index (17 versus 15; P = .035), heart rate (104 versus 99; P = .007), energy expenditure per case (409 versus 297; P = .002), and a significantly lower heart rate variability (11 versus 12; P = .006). Compared to primary THA, performing rTHA had a significantly higher energy expenditure per case (431 versus 307; P = .007) and trended towards having a higher surgeon stress index (16 versus 14; P = .272) and a lower heart rate variability (11 versus 12; P = .185), although it did not reach statistical significance. CONCLUSION: Surgeons experience higher physiological stress and strain when performing rTKA and rTHA compared to primary TKA and primary THA. This study provides objective data on what many surgeons feel and should promote further research on the specific stress and strain felt by surgeons who perform revision arthroplasty procedures.

Mortality and Complications Following Early Conversion Arthroplasty for Failed Hip Fracture Surgery.

BACKGROUND: Hip fracture in older patients leads to high morbidity and mortality. Patients who are treated surgically but fail acutely face a more complex operation with conversion total hip arthroplasty (THA). This study investigated mortalities and complications in patients who experienced failure within one year following hip fracture surgery requiring conversion THA. METHODS: Patients aged 60 years or more undergoing conversion THA within one year following intertrochanteric or femoral neck fracture were identified and propensity-matched to patients sustaining hip fractures treated surgically but not requiring conversion within the first year. Patients who had two-year follow-up (91 conversions; 247 comparisons) were analyzed for 6-month, 12-month, and 24-month mortalities, 90-day readmissions, surgical complications, and medical complications. RESULTS: Nonunion and screw cutout were the most common indications for conversion THA. Mortalities were similar between groups at 6 months (7.7% conversion versus 6.1% nonconversion, P = .774), 12 months (11% conversion versus 12% nonconversion, P = .999), and 24 months (14% conversion versus 22% nonconversion, P = .163). Survivorships were similar between groups for the entire cohort and by fracture type. Conversion THA had a higher rate of 90-day readmissions (14% versus 3.2%, P = .001), and medical complications (17% versus 6.1%, P = .006). Inpatient and 90-day orthopaedic complications were similar. CONCLUSION: Conversion THA for failed hip fracture surgery had comparable mortality rates to hip fracture surgery, with higher rates of perioperative medical complications and readmissions. Conversion THA following hip fracture represents a potential "second hit" that both surgeons and patients should be aware of with initial decision-making.

The Ability of Robot-Assisted Total Knee Arthroplasty in Matching the Efficiency of Its Conventional Counterpart at an Orthopaedic Specialty Hospital.

BACKGROUND: Robot-assisted total knee arthroplasty (RA-TKA) has become a popular technology. Studies have investigated the learning curve for surgeons incorporating RA-TKA into practice, but less is known regarding the change in operative efficiency when introducing RA-TKA into a facility. The purpose of this study was to investigate the effects of RA-TKA on operative and turnover time at an orthopaedic specialty hospital. METHODS: A total of 148 cases (74 RA-TKA and 74 conventional TKA [C-TKA]) performed by 2 surgeons with previous robotic experience were identified following the introduction of RA-TKA at our facility. Patient demographics, comorbidities, and operative times (ie, wheels-in to incision, incision to closure, closure to wheels-out, and turnover time) were recorded. Cumulative summation analyses were used to investigate learning curves of factors extraneous to surgeon proficiency with RA-TKA. RESULTS: While RA-TKA had a slightly longer set up (3 minutes; range, 12-45), surgical (5 minutes; range, 33-118), and breakdown time (3 minutes; range, 2-7), there was no difference in turnover time between the groups. The learning curve for surgeon A was 6 robotic cases, whereas surgeon B demonstrated no learning curve. There was no identifiable learning curve for turnover time. CONCLUSION: There was a mean of 8 minutes of increased time required to perform a RA-TKA compared to C-TKA. However, these small increases for the RA-TKA group for set-up, surgical, and breakdown times are not likely to be clinically relevant compared to the C-TKA. It appears that the RA-TKA technology was able to be incorporated into this specialty hospital with minimal changes to surgical efficiency.

Robotic-Assisted Total Knee Arthroplasty: What are Patients' Perspectives, Understanding and Expectations?

BACKGROUND: The rate of using robotic-assisted total knee arthroplasty (RA-TKA) has increased markedly. Understanding how patients view the role of robotics during total knee arthroplasty (TKA) informs shared decision making and facilitate efforts to appropriately educate patients regarding the risks and benefits of robotic assistance. METHODS: A self-administered questionnaire was completed by 440 potential TKA patients at the time of their surgery scheduling. Participants answered 25 questions regarding RA-TKA, socioeconomic factors, and their willingness to pay (WTP) for RA-TKA. Logistic regressions were used to determine if population characteristics and surgeon preferences influenced the patients' perceptions of RA-TKA. RESULTS: There were 39.7% of respondents who said that they had no knowledge regarding RA-TKA. Only 40.7% of participants had expressed a desire for RA-TKA to be used. There were 8.7% who were WTP extra for the use of RA-TKA. Participants believed that the main 3 benefits of RA-TKA compared to conventional methods were: more accurate implant placement (56.2%); better results (49.0%); and faster recovery (32.1%). The main 3 patient concerns were harm from malfunction (55.2%), reduced surgeon role in the procedure (48.1%), and lack of supportive research (28.3%). Surgeon preference of RA-TKA was associated with patient's willingness to have RA-TKA (odds ratio 4.60, confidence interval 2.98-7.81, P < .001), and with WTP extra for RA-TKA (odds ratio 2.05, confidence interval: 1.01-4.26, P = .049). CONCLUSION: Patient knowledge regarding RA-TKA is limited. Nonpeer-reviewed online information may make prospective TKA candidates vulnerable to misinformation and aggressive advertising. The challenge for orthopaedic surgeons is to re-establish control and reliably educate patients about the proven advantages and disadvantages of this emerging technology.

Patient-reported outcome scores following patellar instability surgery-high prevalence does not equal high responsiveness: a systematic review.

PURPOSE: The purpose of this study was to determine the utilization and responsiveness of common patient-reported outcomes (PROs) in patients undergoing surgery for patellar instability. METHODS: Using PRISMA guidelines, a systematic review of studies reporting outcomes following surgical intervention for patellar instability was conducted using Pubmed, Cochrane, OVID Medline, and Google Scholar. Subgroup analysis of articles reporting at least two PROs with baseline and follow-up data were used to evaluate responsiveness of instruments using relative efficiency and effect size. RESULTS: From the search, 2,848 unique articles were found, of which 178 were included in final analysis (7,122 patients, mean age 22.6, 63.6% female). The most commonly used PRO was the Kujala score (79.2%), followed by the Lysholm (34.8%), and Tegner (30.9%). Seventy-nine articles were eligible for subgroup analysis. The Kujala had a higher relative efficiency than ten of the 14 instruments to which it was compared but had lower relative efficiency compared to the IKDC and Lysholm scores. The Banff Patella Instability Instrument (BPII) and the Norwich score, condition-specific tools, were unable to be fully assessed due to rarity of use and lack of comparisons. CONCLUSION: The hypothesis that the Kujala score is the most commonly used PRO for patellar instability, although other instruments offer greater efficiency was supported by our results. The IKDC and Lysholm scores had similar effect sizes but higher relative efficiencies than the Kujala, thus suggesting better responsiveness. This analysis adds useful information for surgeons on the effectiveness of the most common PRO's for evaluating patellofemoral instability outcomes. LEVEL OF EVIDENCE: Level III.

A Systematic Review and Meta-Analysis of Non-database Comparative Studies on Cemented Versus Uncemented Femoral Stems in Primary Elective Total Hip Arthroplasty.

BACKGROUND: Cemented and uncemented femoral stems have shown excellent survivorship and outcomes in primary total hip arthroplasty (THA). Cementless stems have become increasingly common in the United States; however, multiple large database studies have suggested that elderly patients may have fewer complications with a cemented stem. As conclusions from large databases may be limited due to variations in data collection, this study investigated femoral stem survivorship and complication rates based on cement status in non-database studies. METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized to identify articles for inclusion up until June 2021. Included articles directly compared outcomes and complications between patients undergoing primary THA without femoral stem cementing to those with cementing. Studies were excluded if they utilized large databases or consisted of patients with a preoperative diagnosis of trauma. RESULTS: Of the 1700 studies, 309 were selected for abstract review and nineteen for full-text review. A total of seven studies were selected. Meta-analyses indicated substantial heterogeneity between studies. There were no differences in revision rates (cementless: 5.53% vs. cemented 8.91%, P = .543), infection rates (cementless: 0.60% vs. cemented: 0.90%, P = .692), or periprosthetic fracture rates (cementless: 0.52% vs. cemented: 0.51%, P = .973) between groups. CONCLUSION: There is scarce literature comparing outcomes and complications between cemented and cementless femoral stems in primary elective THA without utilizing a database methodology. In our study, there were no differences in complications detected on meta-analyses. Given previous findings in database studies, additional high-quality cohort studies are required to determine if selected patients may benefit from a cemented femoral stem.

Life After BPCI: High Quality Total Knee and Hip Arthroplasty Care Can Still Exist Outside of a Bundled Payment Program.

BACKGROUND: Concerns regarding target price methodology and financial penalties have led to withdrawal from Medicare bundled payment programs for total hip (THA) and knee arthroplasty (TKA), despite its early successful results. The purpose of this study was to determine whether there was any difference in patient comorbidities and outcomes following our institution's exit from the Bundled Payments for Care Improvement - Advanced (BPCI-A). METHODS: We reviewed consecutive 2,737 primary TKA and 2,009 primary THA patients following our withdraw from BPCI-A January 1, 2020-March 30, 2021 and compared them to 1,203 TKA and 1,088 THA patients from October 1, 2018-August 2, 2019 enrolled in BPCI-A. We compared patient demographics, comorbidities, discharge disposition, complications, and 90-day readmissions. Multivariate analysis was performed to identify if bundle participation was associated with complications or readmissions. RESULTS: Post-bundle TKA had shorter length of stay (1.4 vs 1.8 days, P < .001). Both TKA and THA patients were significantly less likely to be discharged to a rehabilitation facility (5.6% vs 19.2%, P < .001 and 6.0% vs 10.0%, P < .001, respectively). Controlling for confounders, post-bundle TKA had lower complications (OR = 0.66, 95% CI 0.45-0.98, P = .037) but no difference in 90-day readmission (OR = 0.80, 95% CI 0.55-1.16, P = .224). CONCLUSIONS: Since leaving BPCI-A, we have maintained high quality THA care and improved TKA care with reduced complications and length of stay under a fee-for-service model. Furthermore, we have lowered rehabilitation discharge for both TKA and THA patients. CMS should consider partnering with high performing institutions to develop new models for risk sharing.

Orthopedic Specialty Hospital Reasons for Transfer and Subsequent Outcomes.

BACKGROUND: Surgical specialty hospitals provide patients, surgeons, and staff with a streamlined approach to elective surgery but may not be equipped to handle all complications arising postoperatively. The purpose of this study is to evaluate the immediate postoperative and 90-day outcomes of patients who were transferred from a high-volume specialty hospital following primary total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS: All patients who were admitted to one orthopedic specialty hospital for primary THA or TKA between January 2015 and December 2019, and subsequently transferred to a tertiary care hospital, were identified and propensity matched to nontransferred patients. Emergency department visits, complications, readmissions, mortality, and revisions within 90 days of surgery were identified for each group. RESULTS: There were 26 TKAs (0.78%) and 20 THAs (0.48%) transferred, representing 0.62% of all primary THAs and TKAs performed over the study duration. Arrhythmia and chest pain were the most common reasons for transfer. Ninety-day readmissions were significantly higher in the transfer group (15.2% vs 4.3%, P = .020) with an odds ratio for readmission after transfer of 3.9 (95% confidence interval 1.3-12.4). Overall complications and orthopedic complications did not differ significantly, although transferred patients had a higher rate of medical complications (13.0% vs 2.2%, P = .008) with an odds ratio of 6.7 (95% confidence interval 1.6-28.2). CONCLUSION: Transfer from a specialty hospital is rarely required following primary TKA and THA. Although not at increased risk for orthopedic complications, these transferred patients are at increased risk for readmissions and medical complications within the first 90 days of their care, necessitating increased vigilance.

Stress and Strain During Total Joint Arthroplasty Are Not Impacted by Hand Dominance or Operative Laterality in Orthopedic Surgeons.

BACKGROUND: Orthopedic surgeons experience significant musculoskeletal pain and work-related injuries while performing total joint arthroplasty (TJA). We sought to investigate the impact of operative extremity and surgeon limb dominance on surgeon physiologic stress and energy expenditure during TJA. METHODS: This was a prospective cohort study conducted at a tertiary academic practice. Cardiorespiratory data was recorded continuously in 3 high-volume arthroplasty surgeons using a smart garment that measured heart rate (HR), HR variability, respiratory rate, minute ventilation, and energy expenditure (calories) during conventional total knee (TKA) and total hip arthroplasty (THA). RESULTS: Surgeon 1 and 2 (right-handed) performed 21 right TKAs, 10 left TKAs, 13 right THAs, and 10 left THAs. Surgeon 3 (left-handed) performed 6 right TKAs, 9 left TKAs, 16 right THAs, and 10 left THAs. While performing TKA or THA, limb laterality had no significant impact on operative time and no significant differences existed in HR, HR variability, respiratory rate, minute ventilation, or energy expenditure for any right-handed or left-handed surgeons, regardless of the operative limb laterality. While performing TKA, consistently standing on the side of hand dominance was associated with decreased strain and stress, compared to always standing on the operative side. CONCLUSION: This study suggests that surgeon hand dominance and operative limb laterality do not impact energy expenditure or physiologic strain during TJA. However, consistently standing on the side of hand dominance in TKA may lead to decreased physiologic strain and stress during surgery. Further study utilizing wearable technology during TJA may provide orthopedic surgeons with information about modifiable factors that contribute to differences in physiological parameters during surgery.

Surgeons Experience Greater Cardiorespiratory Strain and Stress During Total Hip Arthroplasty Than Total Knee Arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are physically demanding, with a high prevalence of work-related injuries among arthroplasty surgeons. It is unknown whether there are differences in cardiorespiratory output for surgeons while performing THA and TKA. The objective of this study is to characterize whether differences in surgeon physiological response exist while performing primary THA vs TKA. METHODS: This is a prospective cohort study including 3 high-volume, fellowship-trained arthroplasty surgeons who wore a smart garment that recorded cardiorespiratory data on operative days during which they were performing primary conventional TKA and THA. Variables collected included patient body mass index (BMI), operative time (minutes), heart rate, heart rate variability, respiratory rate, minute ventilation, and energy expenditure (calories). RESULTS: Seventy-six consecutive cases (49 THAs and 27 TKAs) were studied. Patient BMI was similar between the 2 cohorts (P > .05), while operative time was significantly longer in TKAs (60.4 ± 12.0 vs 53.6 ± 11.8; P = .029). During THA, surgeons had a significantly higher heart rate (95.7 ± 9.1 vs 90.2 ± 8.9; P = .012), energy expenditure per minute (4.6 ± 1.23 vs 3.8 ± 1.2; P = .007), and minute ventilation (19.0 ± 3.0 vs 15.5 ± 3.3; P < .001) compared to TKA. CONCLUSION: Surgeons experience significantly higher physiological strain and stress while performing THA. While scheduling THAs and TKAs, surgeons should consider the higher physical demand associated with THAs and ensure adequate personal preparation and sequence of cases.

Male Sex, Western Ontario Shoulder Instability Index Score, and Sport as Predictors of Large Labral Tears of the Shoulder: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study.

PURPOSE: To identify factors predictive of a large labral tear at the time of shoulder instability surgery. METHODS: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Patients with >270° tears were defined as having large labral tears. To build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm was used to add significant interaction effects. RESULTS: After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort, with an average age of 24.7 years (range 12 to 66). The prevalence of large tears was 4.6% (n = 57), with the average tear size being 141.9°. Males accounted for significantly more of the large tears seen in the cohort (94.7%, P = .01). Racquet sports (P = .01), swimming (P = .02), softball (P = .05), skiing (P = .04), and golf (P = .04) were all associated with large labral tears, as was a higher Western Ontario Shoulder Instability Index (WOSI; P = .01). Age, race, history of dislocation, and injury during sport were not associated with having a larger tear. Using our predictive logistic regression model for large tears, patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (P = .007). CONCLUSIONS: Multiple factors were identified as being associated with large labral tears at the time of surgery, including male sex, preoperative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf. LEVEL OF EVIDENCE: I, prognostic study.

Responsiveness of patient-reported outcomes in shoulder arthroplasty: what are we actually measuring?

HYPOTHESIS: The purpose of this study was to determine the prevalence and responsiveness of common patient-reported outcome (PRO) tools in patients undergoing primary total shoulder arthroplasty (TSA) for glenohumeral arthritis. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of anatomic and reverse TSA studies from PubMed, SportDiscus, Cochrane, and CINAHL was performed. Studies on primary TSA for glenohumeral arthritis that reported at least 1 PRO tool were included in the final analysis. A subgroup analysis of studies that reported preoperative and postoperative PRO scores with at least 2-year follow-up data was evaluated to compare the responsiveness between the different PRO instruments. RESULTS: After full-text review of 490 articles, 74 articles met all inclusion criteria and were included in the final analysis. Anatomic TSA was evaluated in 35 studies, reverse TSA in 32 studies, and both anatomic and reverse in 7 studies. There were a total of 7624 patients, and 25 different PRO tools were used. The most commonly reported PRO tools were the American Shoulder and Elbow Surgeons (44 studies), Constant (42 studies), the visual analog scale for pain (23 studies), and the Simple Shoulder Test (17 studies). A median of 3.0 PRO instruments were used in each study. All instruments had large effect sizes. The University of California at Los Angeles (UCLA) score was found to be the most responsive instrument, and the Single Assessment Numeric Evaluation score was least responsive. The American Shoulder and Elbow Surgeons score was the most responsive instrument that required only patient-reported data. CONCLUSION: Overall, the UCLA score was found to be the most responsive followed by the Adjusted Constant. However, both the UCLA and Adjusted Constant scores require strength and range of motion assessment that may limit their widespread clinical use. The increased responsiveness of these measures, which include objective clinical testing, speaks to the predicted increases in strength and range of motion after shoulder arthroplasty. Of the measures that can be administered without in-person clinical evaluation, the American Shoulder and Elbow Surgeons score and Western Ontario Osteoarthritis of the Shoulder index were the most responsive.

Reporting and Analyzing Demographics in the Journal of Arthroplasty: Are We Making Progress?

BACKGROUND: Demographic factors, including age, sex, body mass index (BMI), race, and ethnicity have great effects on the outcomes of patients undergoing total joint arthroplasty. A portion of this data is included in nearly every study, but the completeness with which it is reported is variable. The purpose of this study is to investigate the frequency at which demographic information is reported and analyzed through formal statistical methods in randomized controlled trials (RCTs) published in the Journal of Arthroplasty (JOA). METHODS: A systematic review was conducted of RCTs published in JOA between 2015 and 2019. For each study, we determined if age, sex, weight, height, BMI, race, and ethnicity were reported and/or analyzed. The overall frequency was assessed, along with the rates of reporting by individual year. Studies were evaluated using Cochrane risk-of-bias tool. RESULTS: Age (96.7%), sex (96.7%), and BMI (80.4%) were reported by the majority of studies. There was very little information provided regarding race (6.2%) and ethnicity (3.8%); although both were reported at the highest frequency in 2019, the final year of articles reviewed. Sex was the most frequently analyzed variable at 11.5%. Only 1 study (0.5%) analyzed ethnicity and no studies analyzed race. CONCLUSION: Although age, sex, and BMI are reported at a high rate, RCTs published in JOA rarely reported information on patient race and ethnicity. Demographics were infrequently included as part of statistical analysis. The importance of this information should be recognized and included in the analysis and interpretation of future studies.