Safety Profile of Seven-Day Intra-articular Antibiotic Irrigation for the Treatment of Chronic Periprosthetic Joint Infection: A Prospective Randomized Phase II Comparative Study.

BACKGROUND: Systemic intravenous antimicrobials yield poor outcomes during treatment of periprosthetic joint infection due to the inability to obtain minimum biofilm eradication concentrations. This study evaluated the safety of a novel method of optimized local delivery of intra-articular antibiotics (IAAs). METHODS: This was a Phase II, multicenter, prospective randomized trial evaluating safety of a rapid (seven-day) two-stage exchange arthroplasty with IAA irrigation compared to standard two-stage exchange. The Experimental Group received irrigation using 80 mg tobramycin daily with a 2-hour soak, followed by hourly irrigation using 125 mg vancomycin with a 30-minute soak via an intramedullary irrigation device. The Control Group received an antibiotic-loaded cement spacer with vancomycin (average 8.4 g) and tobramycin (average 7.1 g, total 16 g antibiotics). Both groups received 12 weeks of systemic antibiotics following Stage 2. Safety measures included adverse events, peak vancomycin/tobramycin serum concentrations (Experimental Group), blood transfusion, and mortality. There were thirty-seven patients randomized to the Experimental Group and 39 to control. There was no difference in baseline demographics or comorbidities. RESULTS: There were no antibiotic medication-related adverse events and 2 serious adverse events related to antibiotic instillation. Of 188 vancomycin peak measurements, 69% had detectable serum level concentrations, with all concentrations well below the maximum acceptable trough threshold of 20 µg/mL. Of the 103 tobramycin peak measurements, 45% had detectable levels, with all below the maximum acceptable peak threshold of 18 to 24 µg/mL. There was no difference in blood transfused per subject (Experimental: 655 mL versus Control: 792 mL; P = .4188). There were two (2) deaths in the Experimental Group and four (4) in the control. CONCLUSIONS: The use of IAA is safe with minimal systemic antibiotic exposure. There was no difference in the rates or severity of serious adverse events between groups. Further research is being conducted to examine treatment efficacy.

Lessons Learned From the Comprehensive Care for Joint Replacement Model at an Academic Tertiary Center: The Good, the Bad, and the Ugly.

BACKGROUND: Our institution participated in the Comprehensive Care for Joint Replacement (CJR) model from 2016 to 2020. Here we review lessons learned from a total joint arthroplasty (TJA) care redesign at a tertiary academic center amid changing: (1) CJR rules; (2) inpatient only rules; and (3) outpatient trends. METHODS: Quality, financial, and patient demographic data from the years prior to and during participation in CJR were obtained from institutional and Medicare reconciled CJR performance data. RESULTS: Despite an increase in true outpatients and new challenges that arose from changing inpatient-only rules, there was significant improvement in quality metrics: decreased length of stay (3.48-1.52 days, P < .001), increased home discharge rate (70.2-85.5%, P < .001), decreased readmission rate (17.7%-5.1%, P < .001), decreased complication rate (6.5%-2.0%, P < .001), and the Centers for Medicare and Medicaid Services (CMS) Composite Quality Score increased from 4.4 to 17.6. Over the five year period, CMS saved an estimated $8.3 million on 1,486 CJR cases, $7.5 million on 1,351 non-CJR cases, and $600,000 from the voluntary classification of 371 short-stay inpatients as outpatient-a total savings of $16.4 million. Despite major physician time and effort leading to marked improvements in efficiency, quality, and large cost savings for CMS, CJR participation resulted in a net penalty of $304,456 to our institution, leading to zero physician gainsharing opportunities. CONCLUSION: The benefits of CJR were tempered by malalignment of incentives among payer, hospital, and physician as well as a lack of transparency. Future payment models should be refined based on the successes and challenges of CJR.

A Physician-led Care Redesign Blunts Predictors of Length of Stay after Total Hip and Knee Arthroplasty.

We questioned to what extent traditional predictors of care team burden (via increased length of stay [LOS] after total joint arthroplasty [TJA]) were able to be mitigated through alteration of the care pathway. The impact on LOS of traditional patient risk factors, as well as encounter variables, were analyzed for a consecutive set of patients undergoing surgery before and after a physician-initiated arthroplasty care pathway redesign. We analyzed the impact of these variables on LOS, discharge disposition, and 90-day readmission; separate analyses were performed pre- and post-redesign for LOS. Several patient factors (Risk Assessment and Prediction Tool, body mass index, age, insurance type, smoking) predicted longer LOS in the pre-redesign cohort; post-redesign, only ambulation on the day of surgery and anticoagulation type were predictive. The redesign also lessened the aggregate impact of the patient-specific risk factors, resulting in reduced variation in LOS. Physician leadership of care pathways can reduce the impact of factors that have portended longer LOS, thereby reducing variability in LOS and costs for disparate patient populations while driving improvements in value-based care indices. (Journal of Surgical Orthopaedic Advances 32(2):097-101, 2023).

A hybrid implementation-effectiveness randomized trial of CYP2D6-guided postoperative pain management.

PURPOSE: Cytochrome P450 2D6 (CYP2D6) genotype-guided opioid prescribing is limited. The purpose of this type 2 hybrid implementation-effectiveness trial was to evaluate the feasibility of clinically implementing CYP2D6-guided postsurgical pain management and determine that such an approach did not worsen pain control. METHODS: Adults undergoing total joint arthroplasty were randomized 2:1 to genotype-guided or usual pain management. For participants in the genotype-guided arm with a CYP2D6 poor (PM), intermediate (IM), or ultrarapid (UM) metabolizer phenotype, recommendations were to avoid hydrocodone, tramadol, codeine, and oxycodone. The primary endpoints were feasibility metrics and opioid use; pain intensity was a secondary endpoint. Effectiveness outcomes were collected 2 weeks postsurgery. RESULTS: Of 282 patients approached, 260 (92%) agreed to participate. In the genotype-guided arm, 20% had a high-risk (IM/PM/UM) phenotype, of whom 72% received an alternative opioid versus 0% of usual care participants (p < 0.001). In an exploratory analysis, there was less opioid consumption (200 [104-280] vs. 230 [133-350] morphine milligram equivalents; p = 0.047) and similar pain intensity (2.6 ± 0.8 vs. 2.5 ± 0.7; p = 0.638) in the genotype-guided vs. usual care arm, respectively. CONCLUSION: Implementing CYP2D6 to guide postoperative pain management is feasible and may lead to lower opioid use without compromising pain control.

Patient and Procedural Determinants of Postoperative Pain Trajectories.

BACKGROUND: The primary goal of this study was to evaluate patterns in acute postoperative pain in a mixed surgical patient cohort with the hypothesis that there would be heterogeneity in these patterns. METHODS: This study included 360 patients from a mixed surgical cohort whose pain was measured across postoperative days 1 through 7. Pain was characterized using the Brief Pain Inventory. Primary analysis used group-based trajectory modeling to estimate trajectories/patterns of postoperative pain. Secondary analysis examined associations between sociodemographic, clinical, and behavioral patient factors and pain trajectories. RESULTS: Five distinct postoperative pain trajectories were identified. Many patients (167 of 360, 46%) were in the moderate-to-high pain group, followed by the moderate-to-low (88 of 360, 24%), high (58 of 360, 17%), low (25 of 360, 7%), and decreasing (21 of 360, 6%) pain groups. Lower age (odds ratio, 0.94; 95% CI, 0.91 to 0.99), female sex (odds ratio, 6.5; 95% CI, 1.49 to 15.6), higher anxiety (odds ratio, 1.08; 95% CI, 1.01 to 1.14), and more pain behaviors (odds ratio, 1.10; 95% CI, 1.02 to 1.18) were related to increased likelihood of being in the high pain trajectory in multivariable analysis. Preoperative and intraoperative opioids were not associated with postoperative pain trajectories. Pain trajectory group was, however, associated with postoperative opioid use (P < 0.001), with the high pain group (249.5 oral morphine milligram equivalents) requiring four times more opioids than the low pain group (60.0 oral morphine milligram equivalents). CONCLUSIONS: There are multiple distinct acute postoperative pain intensity trajectories, with 63% of patients reporting stable and sustained high or moderate-to-high pain over the first 7 days after surgery. These postoperative pain trajectories were predominantly defined by patient factors and not surgical factors.

Slow Dynamics of Acute Postoperative Pain Intensity Time Series Determined via Wavelet Analysis Are Associated With the Risk of Severe Postoperative Day 30 Pain.

BACKGROUND: Evidence suggests that increased early postoperative pain (POP) intensities are associated with increased pain in the weeks following surgery. However, it remains unclear which temporal aspects of this early POP relate to later pain experience. In this prospective cohort study, we used wavelet analysis of clinically captured POP intensity data on postoperative days 1 and 2 to characterize slow/fast dynamics of POP intensities and predict pain outcomes on postoperative day 30. METHODS: The study used clinical POP time series from the first 48 hours following surgery from 218 patients to predict their mean POP on postoperative day 30. We first used wavelet analysis to approximate the POP series and to represent the series at different time scales to characterize the early temporal profile of acute POP in the first 2 postoperative days. We then used the wavelet coefficients alongside demographic parameters as inputs to a neural network to predict the risk of severe pain 30 days after surgery. RESULTS: Slow dynamic approximation components, but not fast dynamic detailed components, were linked to pain intensity on postoperative day 30. Despite imbalanced outcome rates, using wavelet decomposition along with a neural network for classification, the model achieved an F score of 0.79 and area under the receiver operating characteristic curve of 0.74 on test-set data for classifying pain intensities on postoperative day 30. The wavelet-based approach outperformed logistic regression (F score of 0.31) and neural network (F score of 0.22) classifiers that were restricted to sociodemographic variables and linear trajectories of pain intensities. CONCLUSIONS: These findings identify latent mechanistic information within the temporal domain of clinically documented acute POP intensity ratings, which are accessible via wavelet analysis, and demonstrate that such temporal patterns inform pain outcomes at postoperative day 30.

A Randomized Controlled Trial of Music for Pain Relief after Arthroplasty Surgery.

PURPOSE: Effective pain management for patients undergoing orthopedic surgery, using pharmacological and nonpharmacological strategies, is essential. This pilot study evaluated music as an adjuvant therapy with prescribed analgesics to reduce acute pain and analgesic use among patients undergoing arthroplasty surgery. DESIGN: Prospective randomized controlled trial of 50 participants scheduled for arthroplasty surgery at a large university-affiliated hospital. METHODS: Participants were randomly assigned to treatment (music and analgesic medication; n = 25) or control (analgesic medication only; n = 25) groups. The intervention consisted of listening to self-selected music for 30 minutes, three times per day postoperatively in hospital and for 2 days postdischarge at home. Participants rated pain intensity and distress before and after music listening (treatment group) or meals (control group). Analgesic medication use was assessed via medical records in hospital and self-report logs postdischarge. RESULTS: Forty-seven participants completed the study. Participants who listened to music after surgery reported significantly lower pain intensity and distress in hospital and postdischarge at home. There were no statistically significant differences in analgesic medication use after surgery between groups. CONCLUSIONS: Study findings provide further evidence for the effectiveness of music listening, combined with analgesics, for reducing postsurgical pain, and extend the literature by examining music listening postdischarge. Music listening is an effective adjuvant pain management strategy. It is easy to administer, accessible, and affordable. Patient education is needed to encourage patients to continue to use music to reduce pain at home during the postoperative recovery period.

Impact of Injury Severity on the Inflammatory State and Severe Anemia.

BACKGROUND: Severe traumatic injury is a major cause of morbidity and mortality. Our goal was to analyze blunt traumatic injury by injury severity score (ISS) and compare with elective hip repair, as a transient injury, and healthy control with the hypothesis that more severe injury would lead to an increase in neuroendocrine activation, systemic inflammation, and worse anemia. MATERIALS AND METHODS: A prospective observational cohort study was performed at a level 1 trauma center, comparing blunt trauma patients (n = 37), elective hip replacement patients (n = 26), and healthy controls (n = 8). Bone marrow and plasma were assessed for hyperadrenergic state, erythropoiesis, and systemic inflammation. Trauma patient's ISS ranged from 4 to 41 and were broken down into quartiles for analysis. The ISS quartiles were 4-13, 14-20, 21-26, and 27-41. RESULTS: Plasma norepinephrine, interleukin-6, tumor necrosis factor-alpha, and hepcidin increased progressively as ISS increased. Hemoglobin significantly decreased as ISS increased and packed red blood cell (pRBC) transfusion increased as ISS increased. Elective hip replacement patients had an appropriate increase in the bone marrow expression of erythropoietin and the erythropoietin receptor, which was absent in all trauma patient groups. CONCLUSIONS: Increased neuroendocrine activation, systemic inflammation, and anemia correlated with worsening injury severity, lower age, and increased pRBC transfusions. Elective hip replacement patients have only minimal systemic inflammation with an appropriate bone marrow response to anemia. This study demonstrates a link between injury severity, neuroendocrine activation, systemic inflammation, and the bone marrow response to anemia.

AAAPT Diagnostic Criteria for Acute Knee Arthroplasty Pain.

OBJECTIVE: The relationship between preexisting osteoarthritic pain and subsequent post-total knee arthroplasty (TKA) pain is not well defined. This knowledge gap makes diagnosis of post-TKA pain and development of management plans difficult and may impair future investigations on personalized care. Therefore, a set of diagnostic criteria for identification of acute post-TKA pain would inform standardized management and facilitate future research. METHODS: The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the US Food and Drug Administration (FDA), the American Pain Society (APS), and the American Academy of Pain Medicine (AAPM) formed the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) initiative to address this goal. A multidisciplinary work group of pain experts was invited to conceive diagnostic criteria and dimensions of acute post-TKA pain. RESULTS: The working group used contemporary literature combined with expert opinion to generate a five-dimensional taxonomical structure based upon the AAAPT framework (i.e., core diagnostic criteria, common features, modulating factors, impact/functional consequences, and putative mechanisms) that characterizes acute post-TKA pain. CONCLUSIONS: The diagnostic criteria created are proposed to define the nature of acute pain observed in patients following TKA.

Early Polyethylene Failure in a Modern Total Hip Prosthesis: A Note of Caution.

BACKGROUND: Historically, there has been excellent survivorship of total hip arthroplasty with newer implants expected to outperform prior generations. Review of our institutional database identified problems with one particular cross-linked polyethylene liner in mid-term follow-up, which has not been reported in the literature. We report on the technical aspects of this liner, as well as the clinical and radiographic factors associated with early failure of this bearing in our practice. METHODS: A retrospective review of our institutional database was performed from January 2009 to June 2019 of patients who presented with significant osteolysis in the setting of prior total hip arthroplasty with a contemporary polyethylene liner. Demographic and radiographic measures were collected for all patients. RESULTS: Twelve patients were identified, with nine undergoing revision surgery. All patients demonstrated radiographic osteolysis at the time of revision surgery. The average time to diagnosis of failure was 55.9 months (range: 12-120 months). Average cup position preoperatively was 44 degrees inclination (range: 36-53 degrees) and 21 degrees anteversion (range: 10-34 degrees). Nine patients underwent revision of the acetabular component, with two also undergoing femoral component revision. The Manufacturer and User Facility Device Experience database revealed 22 reported cases of wear-related failure from 2009 to 2019. CONCLUSIONS: Considering that no identifiable risk factors related to patient demographics or implant position were identified, the Exactech Connexion GXL liner may be prone to a high rate of early failure from wear and severe secondary osteolysis. We recommend close surveillance of patients with this bearing surface.

The Risk Assessment and Prediction Tool Accurately Predicts Discharge Destination After Revision Hip and Knee Arthroplasty.

BACKGROUND: The Risk Assessment and Prediction Tool (RAPT) was developed and validated to predict discharge disposition after primary total hip and knee arthroplasty (THA/TKA). To date, there are no studies evaluating the applicability and accuracy of RAPT for revision THA/TKA. This study aims to determine the predictive accuracy of the RAPT for revision THA/TKA. METHODS: Prospectively collected data from a single tertiary academic medical center were retrospectively analyzed for patients undergoing revision THA/TKA between January 2016 and July 2019. RAPT score was used to predict their postoperative discharge destination and its predictive accuracy was calculated. Patient risk (low, intermediate, and high) for postoperative inpatient rehabilitation facilities or skilled nursing facilities were determined based on the predictive accuracy of each RAPT score. Other factors evaluated included patient-reported discharge expectation, body mass index, and American Society of Anesthesiologists scores. RESULTS: A total of 716 consecutive revision THA/TKA episodes were analyzed. Overall, predictive accuracy of RAPT for discharge disposition was 83%. RAPT scores <3 and >8 were deemed high and low risk of discharge to a post-acute care facility, respectively. RAPT scores of 4 to 7 were still accurate 65%-71% of the time and were deemed to be intermediate-risk. RAPT score and patient-reported discharge expectation had the strongest correlation with actual discharge disposition. CONCLUSION: The RAPT has high predictive accuracy for discharge planning in revision THA/TKA patients. Patient-expected discharge destination is a powerful modulator of the RAPT score and we suggest that it be taken into consideration for preoperative discharge planning.

Revision Arthroplasty Does Not Require More Opioids Than Primaries: A Review of Prescribing Practices After Implementation of a Structured Perioperative Pain Management Strategy.

BACKGROUND: There is a growing body of literature on opioid mitigation strategies following total joint arthroplasty. However, these have almost exclusively been studied in populations undergoing primary procedures, with revision arthroplasty historically thought to be more resistant due to procedural variability and complexity. We report on opioid utilization for revision arthroplasty following implementation of a structured, standardized opioid reduction strategy. METHODS: Beginning January 2015, a comprehensive multidisciplinary pain protocol was developed and applied universally to all patients undergoing hip and knee arthroplasty, including revisions, without exclusion. We performed a retrospective review of opioid prescription trends for the revision arthroplasty subgroup between January 2014 and July 2018, with the first year serving as a baseline for comparison. Inpatient and outpatient opioid prescription data, inpatient satisfaction scores, and quality metrics were also reviewed. RESULTS: We identified 1273 revision arthroplasty cases in the study period. There was a significant reduction in average oral morphine equivalents utilized per procedure when comparing preintervention and postimplementation values. Overall, inpatient prescriptions decreased 24.1% and outpatient utilization decreased 62.4% over the study period. Significant reductions were seen in both the total hip (60.6%) and total knee (64.0%) subgroups. Although revision arthroplasty patients were prescribed 32.5% more oral morphine equivalents at baseline, at year 5 there was no significant difference in outpatient prescriptions between primary and revision subgroups. CONCLUSION: At our institution, a standardized opioid reduction strategy has resulted in marked reduction in opioid prescriptions for revision arthroplasty patients in line with generally successful reductions for primary arthroplasty. More importantly, with this approach, revision arthroplasty patients required no more outpatient opioids than their primary counterparts. LEVEL OF EVIDENCE: Level III, Retrospective cohort study.

Clock Drawing Performance Slows for Older Adults After Total Knee Replacement Surgery.

BACKGROUND: Clock drawing is a neurocognitive screening tool used in preoperative settings. This study examined hypothesized changes in clock drawing to command and copy test conditions 3 weeks and 3 months after total knee arthroplasty (TKA) with general anesthesia. METHODS: Participants included 67 surgery and 66 nonsurgery individuals >60 years who completed the digital clock drawing test before TKA (or a pseudosurgery date), and 3 weeks and 3 months postsurgery. Generalized linear mixed models assessed digital clock drawing test latency (ie, total time to completion, seconds between digit placement) and graphomotor output (ie, total number of strokes, clock size). Reliable change analyses examined the percent of participants showing change beyond differences found in nonsurgery peers. RESULTS: After adjusting for age, education, and baseline cognition, both digital clock drawing test latency measures were significantly different for surgery and nonsurgery groups, where the surgery group performed slower on both command and copy test conditions. Reliable change analyses 3 weeks after surgery found that total time to completion was slower among 25% of command and 21% of copy constructions in the surgery group. At 3 months, 18% of surgery participants were slower than nonsurgery peers. Neither graphomotor measure significantly changed over time. CONCLUSIONS: Clock drawing construction slowed for nearly one-quarter of patients after TKA surgery, whereas nonsurgery peers showed the expected practice effect, ie, speed increased from baseline to follow-up time points. Future research should investigate the neurobiological basis for these changes after TKA.

The Postinjury Inflammatory State and the Bone Marrow Response to Anemia.

RATIONALE: The pathophysiology of persistent injury-associated anemia is incompletely understood, and human data are sparse. OBJECTIVES: To characterize persistent injury-associated anemia among critically ill trauma patients with the hypothesis that severe trauma would be associated with neuroendocrine activation, erythropoietin dysfunction, iron dysregulation, and decreased erythropoiesis. METHODS: A translational prospective observational cohort study comparing severely injured, blunt trauma patients who had operative fixation of a hip or femur fracture (n = 17) with elective hip repair patients (n = 22). Bone marrow and plasma obtained at the index operation were assessed for circulating catecholamines, systemic inflammation, erythropoietin, iron trafficking pathways, and erythroid progenitor growth. Bone marrow was also obtained from healthy donors from a commercial source (n = 8). MEASUREMENTS AND MAIN RESULTS: During admission, trauma patients had a median of 625 ml operative blood loss and 5 units of red blood cell transfusions, and Hb decreased from 10.5 to 9.3 g/dl. Compared with hip repair, trauma patients had higher median plasma norepinephrine (21.9 vs. 8.9 ng/ml) and hepcidin (56.3 vs. 12.2 ng/ml) concentrations (both P < 0.05). Bone marrow erythropoietin and erythropoietin receptor expression were significantly increased among patients undergoing hip repair (23% and 14% increases, respectively; both P < 0.05), but not in trauma patients (3% and 5% increases, respectively), compared with healthy control subjects. Trauma patients had lower bone marrow transferrin receptor expression than did hip repair patients (57% decrease; P < 0.05). Erythroid progenitor growth was decreased in trauma patients (39.0 colonies per plate; P < 0.05) compared with those with hip repair (57.0 colonies per plate; P < 0.05 compared with healthy control subjects) and healthy control subjects (66.5 colonies per plate). CONCLUSIONS: Severe blunt trauma was associated with neuroendocrine activation, erythropoietin dysfunction, iron dysregulation, erythroid progenitor growth suppression, and persistent injury-associated anemia. Clinical trial registered with www.clinicaltrials.gov (NCT 02577731).

The Role of Social Support and Psychological Distress in Predicting Discharge: A Pilot Study for Hip and Knee Arthroplasty Patients.

BACKGROUND: Bundled payment initiatives for joint replacement have prompted re-evaluation of the continuum of care with emphasis on anticipating disposition needs. The purpose of this study is to investigate the role of social support and psychological distress in patient optimization after lower joint replacement. METHODS: Two hundred thirty-one patients undergoing elective joint replacement completed the Risk Assessment and Predictive Tool (RAPT) (social support assessment) and modified STarT Back Tool (mSBT) (assessment of pain-related psychological distress). Outcomes of interest were length of stay (LOS) and discharge location (home vs facility). RESULTS: No significant differences in mSBT scores were observed across RAPT levels when comparing individuals by discharge location (P > .05). There was significant indirect effect (0.07; P < .001) between mSBT and LOS. Therefore, the mSBT does not predict discharge location as a standalone metric for this sample. Mediation analysis for LOS indicates that higher psychological distress was predictive of longer LOS. Higher psychological distress and lower social support are associated with longer LOS. Despite higher psychological distress scores, higher social support scores are associated with shorter LOS. CONCLUSION: Analysis of this cohort suggests that pre-operative assessments of social and psychological constructs may provide preparatory information for patient discharge status. The RAPT is important for predicting LOS and discharge location. The mSBT may be important for predicting LOS for individuals with low to moderate social support.

Clinical Evaluation of Alpha Defensin Test Following Staged Treatment of Prosthetic Joint Infections.

BACKGROUND: Diagnosing persistent infection following staged treatment of prosthetic joint infection (PJI) is challenging. The alpha defensin (AD) test has been shown to be an accurate diagnostic test for the primary diagnosis PJI but has limited evaluation for use following a staged treatment of PJI. The goal of this study was to evaluate the diagnostic accuracy of AD testing following staged treatment of PJI before reimplantation surgery and to determine if negative AD test predicted success following reimplantation using Delphi Criteria at time of last follow-up. METHODS: Patients who underwent AD testing prior to reimplantation after staged treatment of PJI (n = 52) were reviewed. Preoperative data (AD result, synovial fluid [SF], C-reactive protein level [mg/L], SF culture, SF white blood cell count, % of polymorphonuclear lymphocytes, serum C-reactive protein/erythrocyte sedimentation rate) and intraoperative data (purulence and tissue culture) were reviewed and used to classify patients using 2018 Musculoskeletal Infectious Disease Society criteria for infection, which was then used as a gold standard test to calculate diagnostic accuracy. Chart review was used to determine if patients who underwent reimplantation surgery would go on to treatment failure as defined by Delphi Criteria. RESULTS: The sensitivity and specificity of AD test result as compared with Musculoskeletal Infectious Disease Society criteria in diagnosing PJI was calculated to be 71% and 97.78%. Positive predictive value was calculated to be 83.3%, and negative predictive value was calculated to be 95.65%. Patients who underwent reimplantation (46/52 patients) all had negative AD test results, and 9/46 or 19.5% would have treatment failure as defined by the Delphi Criteria with an average follow-up of 588 days. CONCLUSION: AD demonstrates high specificity and negative predictive value, with low sensitivity when utilized after staged treatment of PJI. Further investigation of this and other diagnostic tests following staged treatment of PJI is needed. Additionally, validated criteria used to identify persistent infection following staged treatment of PJI are required.

Bundled Payment "Creep": Institutional Redesign for Primary Arthroplasty Positively Affects Revision Arthroplasty.

BACKGROUND: Revision total joint arthroplasty (TJA) is associated with increased readmissions, complications, and expense compared to primary TJA. Bundled payment methods have been used to improve value of care in primary TJA, but little is known of their impact in revision TJA patients. The purpose of this study is to evaluate the impact of a care redesign for a bundled payment model for primary TJA on quality metrics for revision patients, despite absence of a targeted intervention for revisions. METHODS: We compared quality metrics for all revision TJA patients including readmission rate, use of post-acute care facility after discharge, length of stay, and cost, between the year leading up to the redesign and the 2 years following its implementation. Changes in the primary TJA group over the same time period were also assessed for comparison. RESULTS: Despite a volume increase of 37% over the study period, readmissions declined from 8.9% to 5.8%. Use of post-acute care facilities decreased from 42% to 24%. Length of stay went from 4.84 to 3.92 days. Cost of the hospital episode declined by 5%. CONCLUSION: Our health system experienced a halo effect from our bundled payment-influenced care redesign, with revision TJA patients experiencing notable improvements in several quality metrics, though not as pronounced as in the primary TJA population. These changes benefitted the patients, the health system, and the payers. We attribute these positive changes to an altered institutional mindset, resulting from an invested and aligned care team, with active physician oversight over the care episode.

Arthroplasty Care Redesign Impacts the Predictive Accuracy of the Risk Assessment and Prediction Tool.

BACKGROUND: The Risk Assessment and Prediction Tool (RAPT) is used to predict patient discharge disposition after total joint arthroplasty. Following a comprehensive, multidisciplinary redesign, our institution noticed a trend toward home discharge in patients with RAPT scores that historically predicted discharge to acute care facilities, presenting an opportunity to redefine the predictive ranges for RAPT. METHODS: Retrospectively collected data were analyzed from a single institution in patients undergoing elective primary total joint arthroplasty from January 2016 to April 2017. Predictive accuracy (PA) was calculated for each RAPT score (1-12), RAPT score risk ranges (low, intermediate, and high), as well as overall. Other factors evaluated included patient-reported discharge expectation, body mass index, and American Society of Anesthesiologists scores as related to discharge disposition and the PA of RAPT. RESULTS: Overall PA of RAPT was 88% (n = 1024 patients). Patients were high risk for acute care facility with a RAPT score of 1 to 3 (PA ≥ 83%), intermediate risk 4 to 7 (PA, 52%-79%), and low risk 8 to 12 (PA ≥ 89%). In multivariable analysis, RAPT score and patient-reported discharge expectation had the strongest correlation with actual discharge disposition. CONCLUSION: Our multidisciplinary redesign has impacted the PA of RAPT. The original predictive ranges should be modified to reflect the increasing proportion of patients being discharged home following elective arthroplasty procedures. We have identified patient-expected discharge destination as a powerful modulator of the RAPT score and suggest that it be taken into consideration for discharge planning.

Early Experience with Bilateral Continuous Femoral Nerve Block and Single-Injection Spinal Anesthesia for Bilateral Total Knee Arthroplasty: A Case Series.

Objective: Total knee arthroplasty (TKA) is a commonly performed surgery in the United States, with demand for unilateral and simultaneous bilateral TKAs (BTKAs) expected to increase significantly over the coming decades. This study reports the authors' early experience in a consecutive series of simultaneous BTKAs performed under regional anesthesia and mild sedation. Methods: In this retrospective case series, the authors examined all simultaneous BTKAs performed over two years by a single surgeon. Only patients receiving bilateral continuous femoral nerve blockade (CFNB) and single-injection sciatic nerve blockade in combination with single-injection subarachnoid block were included in the study. Of the 32 patients who underwent BTKAs during this period, 25 met the inclusion criteria. The patient's anesthesia records, physician notes, nursing notes, pharmacy records, and physical therapy records were then reviewed systematically to create a database of information. Results: Only one of 25 patients required conversion to general anesthesia during surgery. There were no major perioperative complications. The average Defense and Veterans Pain Rating Scale score immediately postoperation was 0.6/10, and the average daily score remained below 3.5/10 throughout the hospital stay. The use of bilateral CFNB did not prevent patients from ambulating during physiotherapy. Conclusions: This early retrospective case series suggests that it is feasible to effectively manage the postoperative pain associated with BTKA with staged bilateral CFNB and single-injection sciatic nerve blockage in combination with single-injection subarachnoid block as the sole anesthetic technique without negatively influencing early ambulation.