Are There Gender Differences Among Leaders of Regional Orthopaedic Societies of the United States?

BACKGROUND: Great efforts are currently being made toward improving gender and racial equity in orthopaedic surgery in the United States. Nonetheless, no research has reported on whether these efforts have increased representation of women and underrepresented minorities in leadership roles in orthopaedic surgery societies. QUESTIONS/PURPOSES: Are women proportionally represented in the leadership of regional orthopaedic societies in the United States? METHODS: The latest version of the American Association of Orthopaedic Surgeons census data was evaluated to determine the numbers (and percentages) of women and men practicing orthopaedic surgery in the United States. We also queried data for regional orthopaedic societies members who held a position of leadership (four societies; n = 53) between 2012 and 2017. Collected data included gender, years of experience, and practice setting. A chi-square analysis was conducted to compare the percentage of women in leadership with the percentage of women in practice in each of four geographic regions (Western Orthopaedic Association [WOA]; Southern Orthopaedic Association [SOA]; Eastern Orthopaedic Association [EOA]; Mid-America Orthopaedic Association [MAOA]) to see if the representation of women was proportional to that of men. RESULTS: With the numbers available, there was no difference in the observed-to-expected proportions between men and women in leadership in any of the regional societies we studied For the eastern region, there were 6% (392 of 6514) versus 0% (0 of 12; p = 0.591) of practicing women orthopaedic surgeons versus women orthopaedic surgeons holding positions in EOA leadership. For the Western region, there were 5% (304 of 5744) versus 7% (1 of 14; p = 0.836) practicing women orthopaedic surgeons versus women orthopaedic surgeons holding positions in WOA leadership. For the Midwest United States region, there were 6% (443 of 6937) versus 0% (0 of 15; p = 0.509) of practicing women orthopaedic surgeons versus women orthopaedic surgeons holding positions in MAOA leadership. For the Southern United States region, there were 4% (443 of 9601) versus 0% (0 of 13; p = 0.662) of practicing women orthopaedic surgeons versus women orthopaedic surgeons holding positions in SOA leadership. CONCLUSIONS: We found that women were represented in leadership roles in the regional societies in the United States in proportion to their overall numbers. However, that overall number was small, and so the percentages of regional society leaders who were women were correspondingly small. CLINICAL RELEVANCE: The low number of women orthopaedic surgeons holding leadership positions in regional societies are most likely a function of the low overall number of women orthopaedic surgeons, but focused efforts to change the status quo may increase the diversity of leadership in these societies.

How Accurate is the Multiplier Method in Predicting the Timing of Angular Correction After Hemiepiphysiodesis?

PURPOSE: The purpose of the study was to validate the accuracy of the Multiplier Method (MM) in predicting the timing of angular correction after hemiepiphysiodesis and to determine the role of using skeletal age when calculating those predictions. METHODS: This retrospective study included 131 physes in 77 patients treated with hemiepiphysiodesis to gradually correct a coronal plane deformity before skeletal maturity. To compare the MM's predictions to the actual treatment duration, the "desired angular correction" was considered the actual achieved angular correction determined from the "endpoint x-ray" (last x-ray before implant removal). We measured the bone length and width of the growth plate from the preoperative x-ray and calculated the MM's prediction of the duration of treatment based on the MM formula. We compared the predicted duration to the observed duration of treatment for each case. The difference was calculated by subtracting the observed duration from the predicted duration. The result was the "absolute difference," which is the number of months over or under predicted by the MM. RESULTS: The mean absolute difference between the MM's predicted duration and the observed duration was 2.31 months, which was highly significant (P≤0.001). The MM's prediction agreed with the observed duration of treatment (ie, zero absolute difference) in 15% of the predictions, 69% were under predicted, and 16% were over predicted. Sixty-eight percent of the absolute differences were within 3 months regardless of the direction of error. The mean difference was relatively less in genu varum cases and was statistically significant (P=0.047). Comparing the mean difference using chronological age and skeletal age in the formula showed no statistically significant difference. CONCLUSIONS: The MM has a tendency to under predict. Therefore, doing a guided growth right before skeletal maturity should be started 2 to 4 months earlier than suggested by the MM. Moreover, our data did not show that the bone age gave more accurate predictions than chronological age. LEVEL OF EVIDENCE: Level IV.

Global Budget Revenue on a Single Institution's Costs, Outcomes, and Patient Quality Metrics in Patients Undergoing Total Knee Arthroplasty.

BACKGROUND: Maryland was granted a waiver to implement a Global Budget Revenue (GBR) reimbursement model. Statewide results for combined medical and surgical services have been reported for fiscal years 2015 and 2016. A paucity of studies exists exploring the change in care costs and outcomes for total knee arthroplasty (TKA) recipients under GBR. This study aims to assess the effects of GBR on cost of care and resource utilization related to TKA at a single institution before and after GBR. METHODS: The Maryland Center for Medicare and Medicaid Services database was used to find Medicare patients who underwent TKA at a single institution before (2012-2013) and after (2014-2015) GBR. A total of 150 and 161 TKAs were performed in 2012 and 2015. Cost differences were compared for each inpatient care episode, postacute care period, and readmissions. We also evaluated differences in length of stay, discharge disposition, and complication rates. RESULTS: Mean inpatient cost was significantly lower in 2015 vs 2012 (P = .0014); however, analysis of postacute costs showed a nonsignificant increase in price between years (P = .1008). We demonstrated significant increase in home health (P < .0001) and significant decrease in acute rehabilitation (P = .0481). Durable medical equipment costs significantly decreased (P = .0087). CONCLUSION: We demonstrate lower mean inpatient costs since GBR initiation. We reveal increased mean postacute care costs, which may be due to increased acuity for patients needing postacute care. Our results show nonsignificant reductions in length of stay, complications, and increased rate of home discharge, suggesting GBR may be effective in orchestrating reduced costs for TKA at high-volume institutions.

Biologic Therapies for the Treatment of Knee Osteoarthritis.

BACKGROUND: The use of biologic therapies for the management of knee osteoarthritis has increased, despite insufficient evidence of efficacy. Our aim was to complete a systematic review and analysis of reports utilizing the highest level-of-evidence evaluating: (1) platelet-rich plasma injections (PRPs); (2) bone marrow-derived mesenchymal stem cells (BMSCs); (3) adipose-derived mesenchymal stem cells (ADSCs); and (4) amnion-derived mesenchymal stem cells (AMSCs). METHODS: PubMed, Embase, and Cochrane Library databases were queried for studies evaluating PRP injections, BMSCs, ADSCs, and AMSCs in patients with knee osteoarthritis. Of 1009 studies identified within the last 5 years, 123 met inclusion criteria. A comprehensive analysis of all levels-of-evidence was performed, as well as separate analysis on level-of-evidence I studies. Level-of-evidence was determined by the American Academy of Orthopedic Surgeons classification system. RESULTS: Although the majority of PRP reports demonstrated improvements in pain and/or function, others revealed no substantial improvements. Similar findings were noted for BMSCs, ADSCs, and AMSCs. Assessments of BMSC studies yielded majority with positive clinical results, although short-lived. Studies on ADSCs revealed improved clinical outcomes, but equivocal radiographic outcomes. Studies evaluating AMSCs demonstrated improvements in pain and function, and decreased radiographic evidence of osteoarthritis. CONCLUSION: Despite some promising early results for PRP, BMSC, ADSC, and AMSC therapies, the majority of level-of-evidence I studies have multiple problems: small sample sizes, potentially inappropriate control cohorts, short-term follow-up, and so on. Despite the limitations, there still appears to be evidence justifying their use for knee osteoarthritis management. More high-level, larger human studies utilizing standardized protocols are needed.

Treatment of Closed Femoral Shaft Fractures in Children Aged 6 to 10.

BACKGROUND: Management of pediatric femoral shaft fractures remains controversial, particularly in children between the ages of 6 and 10. In the current push toward cost containment, hospital type, and surgeon subspecialization have emerged as important factors influencing this treatment decision. Thus, in the present study, we use a nationwide pediatric inpatient database to compare the: (a) incidence; (b) demographic characteristics; (c) hospital costs; (d) length of stay; and (e) treatment method of pediatric closed femoral shaft fractures admitted to general versus children's hospitals. METHODS: The Kids' Inpatient Database (KID) was queried for all patients aged 6 to 10 who sustained a closed femoral shaft fracture in 2009 or 2012, and patient records were stratified into children's hospitals and general hospitals. Primary outcome measures included method of treatment, total hospital costs, and length of stay. Student/Welch t testing and χ analysis were utilized to compare continuous and categorical outcomes, respectively, between hospital types. RESULTS: The total incidence of closed femoral shaft fractures decreased between 2009 and 2012 (1919 to 1581 patients; P=0.020), as did the proportion of patients treated in children's hospitals (58.6% to 32.3%; P<0.001). In addition, patients treated at general hospitals were more likely to receive open reduction with internal fixation (45.3% vs. 41.1%) or external fixation (4.1% vs. 2.3%), and less likely to be managed with closed reduction with internal fixation (32.0% vs. 39.7%) than those treated at children's hospitals (P<0.001 for all). CONCLUSIONS: The present study demonstrates a decrease in the incidence of closed femoral shaft fractures in 6- to 10-year old patients from 2009 to 2012, as well as decreased definitive management in children's hospitals and increased selection of operative treatment. In addition, treatment in a nonchildren's hospital was associated with decreased total inpatient costs and decreased treatment with closed reduction with internal fixation in favor of open reduction with internal fixation. Future studies should seek to identify the specific surgical procedures performed and match patients more closely based specific fracture pattern. LEVEL OF EVIDENCE: Prognostic level II.

An Analysis of Centers for Medicare & Medicaid Service Payment in Maryland: Can a Global Budget Revenue Model Save Money in Lower Extremity Arthroplasty?

BACKGROUND: Maryland is the only state utilizing the Global Budget Revenue (GBR) model to reduce costs. The purpose of this study is to evaluate whether the GBR payment model effectively reduced the following: (1) costs of inpatient hospital stays; (2) post-acute care costs; (3) lengths of stay (LOS); (4) readmission rates; and (5) discharge disposition in patients who underwent primary total hip and knee arthroplasty (THA and TKA). METHODS: We evaluated the Maryland Centers for Medicare & Medicaid Service database for THAs and TKAs performed at 6 hospitals 1 year prior to (2012) and after the initiation of GBR (2015). We compared differences in costs for each inpatient care episode, post-acute care periods (total costs, acute rehabilitation, short-term nursing facility, home health, durable medical equipment), readmissions, LOS, and discharge disposition. RESULTS: Hospitals had a significant reduction in mean inpatient care costs for THA and TKA (P < .0001). There was a significant reduction in total post-acute care costs following THA (P < .001). Home healthcare had a significant increase in cost following THA and TKA (P < .0001). There was a significant reduction in durable medical equipment costs for THA (P < .0001). There was a significant decrease in LOS for THA and TKA (P < .0001). There was a significant increase in patients discharged home (THA, P = .0262; TKA, P = .0058). CONCLUSION: The Maryland healthcare model may be associated with a reduction in inpatient and post-acute care costs. Furthermore, implementation of GBR may result in reductions in LOS and readmission rates.

Adjunctive Intravenous Diclofenac Decreases Opioid Consumption and Increases Satisfaction in the Primary Total Hip Arthroplasty Population.

Despite the success of total hip arthroplasty (THA), postoperative pain management remains a concern. Although the nonsteroidal anti-inflammatory drug (NSAID) intravenous (IV) diclofenac is a promising addition, its impact on THA outcomes has not been investigated. This study evaluates the effects of adjunctive IV diclofenac on: 1) postoperative pain intensity; 2) opioid consumption; 3) discharge destination; 4) length of stay; and 5) patient satisfaction in primary THA patients. A retrospective study was performed for patients who underwent primary THA by a single surgeon between May 1 and September 31, 2017. Patients of the study group (n=25) were treated postoperatively with IV diclofenac and the standard pain control regimen while the control group (n=88) did not receive diclofenac. Patients receiving adjunctive IV diclofenac were more likely to be discharged home than to inpatient facilities (O.R. 4.02; p=0.049). Patient satisfaction with respect to how well and how often pain was controlled (p= 0.0436 and p=0.0217, respectively) was significantly greater in the IV diclofenac group. Patients who received IV diclofenac had lower opioid consumption on postoperative days one and two (-67.2 and -129.0mg, respectively; p=0.001 for both). The growth of THA as an outpatient procedure has intensified the urgency of improving postoperative pain management. This study demonstrates that THA patients receiving adjunctive IV diclofenac were more likely to be discharged home, had reduced opioid consumption, and experienced greater satisfaction. To further investigate the optimal regimen, future studies comprising a larger cohort and comparing IV diclofenac to other NSAIDs are warranted.

Clostridium difficile infection in the USA: incidence and associated factors in revision total knee arthroplasty patients.

INTRODUCTION: Revision total knee arthroplasty (TKA) procedures performed secondary to periprosthetic joint infection (PJI) are associated with significant morbidity and mortality. These poor outcomes may be further complicated by postoperative infection requiring antibiotics. However, antibiotic overuse may suppress patients' bacterial flora, leading to Clostridium difficile infection (CDI). Therefore, we aimed to study the: (1) incidence; (2) costs; and (3) risk factors associated with CDI in revision TKA patients. METHODS: The National Inpatient Sample database was queried for individuals diagnosed with PJI who underwent revision TKA between 2009 and 2013 (n = 83,806). Patients who developed CDI during their inpatient stay were identified (n = 799). Logistic regression analysis was conducted to assess the association between hospital- and patient-specific characteristics and the development of CDI. RESULTS: The incidence of CDI after revision TKA was 1.0%. These patients were older (mean age 69.05 vs. 65.52 years), had greater LOS (median 11 vs. 5 days) and greater costs ($30,612.93 vs. 18,873.75), and experienced higher in-hospital mortality (3.6 vs. 0.5%; p < 0.001 for all) compared to those without infection. Patients with CDI were more likely to be treated in urban, not-for-profit, medium/large hospitals in the Northeast or Midwest (p < 0.05 for all) and to have underlying depression (OR 4.267; p = 0.007) or fluid/electrolyte disorders (OR 3.48; p = 0.001). CONCLUSION: Although CDI is rare following revision TKA, it can have detrimental consequences. We demonstrate that CDI is associated with longer LOS, higher costs, and greater in-hospital mortality. With increased legislative pressure to lower healthcare expenditures, it is crucial to identify means of preventing costly complications.

Risk Factors and Costs Associated With Clostridium difficile Colitis in Patients With Prosthetic Joint Infection Undergoing Revision Total Hip Arthroplasty.

BACKGROUND: With the increased demand for primary total hip arthroplasty (THA) and corresponding rise in revision procedures, it is imperative to understand the factors contributing to the development of Clostridium difficile colitis. We aimed to provide a detailed analysis of: (1) the incidence of; (2) the demographics, lengths of stay, and total costs for; and (3) the risk factors and mortality associated with the development of C. difficile colitis after revision THA. METHODS: The National Inpatient Sample database was queried for all individuals diagnosed with a periprosthetic joint infection and who underwent all-component revision THA between 2009 and 2013 (n = 40,876). Patients who developed C. difficile colitis during their inpatient hospital stay were identified. Multilevel logistic regression analysis was conducted to assess the association between hospital- and patient-specific characteristics and the development of C. difficile colitis. RESULTS: The overall incidence of C. difficile colitis after revision THA was 1.7%. These patients were significantly older (74 vs 65 years), had greater lengths of hospital stay (19 vs 9 days), accumulated greater costs ($51,641 vs $28,282), and were more often treated in an urban hospital compared to their counterparts who did not develop C. difficile colitis (P < .001 for all). Patients with colitis also had a significantly higher in-hospital mortality compared to those without (5.6% vs 1.4%; P < .001). CONCLUSION: While C. difficile colitis infection is an uncommon event following revision THA, it can have potentially devastating consequences. Our analysis demonstrates that this infection is associated with a longer hospital stay, higher costs, and greater in-hospital mortality.

Does the Amount of Opioid Consumed Influence How Patients Rate Their Experience of Care After Total Knee Arthroplasty?

BACKGROUND: With legislative efforts aimed at optimizing value of care, surgeons performing total knee arthroplasty (TKA) are faced with increased responsibility of optimizing patient perception of care. However, pain after TKA may negatively influence patient perception of care, as measured by Press Ganey (PG) patient satisfaction surveys. While opioid-based medications are best suited for acute pain alleviation, awareness of a growing opioid epidemic has spurred efforts to reduce its administration. Therefore, this study assessed the correlation between postoperative opioid consumption and 7 PG question domains: (1) overall hospital rating; (2) communication with nurses; (3) response time of hospital staff; (4) communication with doctors; (5) hospital environment; (6) pain management and; (7) communication about medication. METHODS: We reviewed our institutional PG database for TKA patients from 2011 to 2014. A total of 406 patients were analyzed (mean age = 66, 73.4%). Opioid consumption was measured using a morphine milliequivalent conversion algorithm. Bivariate correlation analysis assessed the association between opioid consumption and PG domains. Spearman's r was utilized to assess the strength of the association. RESULTS: No association between total opioid consumption and overall hospital rating (r = 0.044), communication with doctors (r = 0.080), communication with nurses (r = 0.072), responsiveness of hospital staff (r = 0.084), pain management (r = 0.100), communication about medicines (r = 0.083), or hospital environment (r = 0.155) were found. DISCUSSION: Our findings demonstrate that PG scores are not influenced by immediate postoperative opioid use. These results suggest opioid-based pain medications should be administered exclusively on the basis of clinical guidelines and patient needs without concern regarding satisfactions scores and reimbursement penalties.

Are Allogeneic Transfusions Decreasing in Total Knee Arthroplasty Patients? National Inpatient Sample 2009-2013.

BACKGROUND: Allogeneic transfusions are commonly used for substantial blood loss in total knee arthroplasty (TKA), but have been associated with adverse effects and increased costs. The purpose of this study is to provide a detailed description of (1) trends of allogeneic blood transfusion; (2) risk factors and adverse events; and (3) discharge disposition, length-of-stay (LOS), and cost/charge analysis for primary TKA patients who received an allogeneic blood transfusion from 2009-2013. METHODS: A cohort of 3,217,056 primary TKA patients was identified from the National Inpatient Sample database from 2009-2013. Demographic, clinical, economic, and discharge data were analyzed for patients who received allogeneic blood products, and for those who did not receive any type of blood transfusion. Other parameters analyzed include risk factors, adverse events, discharge disposition, and costs/charges. RESULTS: There was a significant decline in use of allogeneic transfusion from 2009-2013 incidence (13.9%-7.3%; P < .001). All comorbidities examined were associated with significantly increased risk of receiving allogeneic transfusion with exception of patients with AIDS, metastatic cancer, and peptic ulcer disease. Allogeneic transfusion was associated with worse outcomes during hospitalization. Patients also had a greater likelihood of discharge to short-term care, greater LOS, and greater median costs/charges. Among TKA patients who received an allogeneic transfusion, costs varied based on hospital ownership and characteristics, primary-payer, region, and bed-size. CONCLUSION: Given the poor outcomes and higher costs associated with allogeneic transfusions, efforts must be undertaken to minimize this risky practice. With the projected increase in demand for TKAs, orthopedists must understand effective blood management strategies.

No Correlation Between Press Ganey Survey Responses and Outcomes in Post-Total Hip Arthroplasty Patients.

BACKGROUND: In the era of the online orthopedic market, patients tend to equate publicly available online satisfaction surveys with what they presume their ultimate surgical outcome will be. Therefore, the purpose of this study was to assess whether there is a correlation between Press Ganey (PG) scores and (1) Hip Western Ontario and McMaster Universities Osteoarthritis Index and Harris Hip Score; (2) Short Form-12 and Short Form-36 scores; (3) University of California Los Angeles and Visual Analog Scale scores assessed at a mean of 3 years (range, 1 to 6 years) after surgery. In addition, we assessed whether (4) these correlations persist in patients who were evaluated under 2 years and 3 or more years after surgery. METHODS: Six-hundred ninety-two patients from November 2009 to January 2015 were identified from our institutional PG database. One-hundred ninety (27%) responded to the survey. One-hundred forty-nine (78%) patients were given the total hip arthroplasty assessment tools at a minimum of 2-year follow-up, and 33 patients (17%) completed their survey before 2 years after surgery. We assessed whether overall hospital rating scores correlated with the above assessment tools. RESULTS: Pearson correlation analysis revealed no correlation between the PG survey score and the assessment tools. HHS had the highest correlation coefficient (r = .120; P = .316); however, this was not significant. After removing the patients who had their follow-up survey administered under 2 years after surgery (33 patients), there was still no statistically significant correlation between the above-mentioned outcome scores and PG overall hospital rating (P > .05). CONCLUSION: No statistically significant relationship was found between commonly used total hip arthroplasty assessment tools and the PG overall hospital rating. Based on these results, PG surveys may not be a suitable implementation of the Center for Medicare and Medicaid services. A set of measures that can be widely collected and reported by hospitals for patients to use in order to evaluate hip arthroplasty outcomes needs to be developed. These results are of paramount importance, indicating a necessary reevaluation of PG surveys as a major determinant for reimbursements rendered by orthopedists and their use by patients.

Hip and Knee Arthroplasty Orthopedic Literature in Medical Journals-Is It Negatively Biased?

BACKGROUND: Healthcare policy is often determined by well-designed studies most often published in high-impact medical journals. However, concern about the presence of publication bias against lower-extremity arthroplasty-related studies has called into question some of the validity of certain reports. There are only a few studies investigating the presence of the bias in high-impact medical journals against lower-extremity arthroplasty intervention, particularly in the Journal of American Medical Association (JAMA), New England Journal of Medicine (NEJM), and the Lancet. Thus, the purpose of this study was to assess (1) the distribution of positive, neutral, and negative results; (2) the number of reports focused on lower-extremity arthroplasty complications among these 3 journals; and (3) difference in bias between 2 time periods (1975 to 1990 and 2000 to 2016). METHODS: A review of the literature from 3 major medical journals (NEJM, Lancet, and JAMA) was performed using PubMed electronic databases, which retrieved articles between January 1976 and December 2016. Studies were categorized as being positive, neutral, and negatively biased by 2 reviewers. Studies were categorized as reporting on lower-extremity arthroplasty-related complications if they were based on complications including deep vein thrombosis, infection, metal-related complication, fat embolism, readmission, or mortality. In addition, we have compared the journal bias between 2 different time points (1975 to 1990 and 2000 to 2016). Descriptive analyses were performed to assess frequencies. Chi-squared analysis was conducted for categorical variables, whereas a z-test was performed for dichotomous data. RESULTS: When assessing all 3 journals, there were 46 positive (30.3%), 46 negative (30.3%), and 60 neutral reports (39.5%). There was no statistically significant difference in classification proportions between the 3 groups (P = .905). There was a higher percentage of medical literature reporting on the complications of arthroplasty (55.9%); however, this was not statistically significant (z-score = 1.38; 95% confidence interval, 0.48-0.64; P = .17). There was no difference in overall journal reporting between 1975 to 1990 and 2000 to 2016 (P = .548). CONCLUSION: There was no evidence of publication bias of lower-extremity arthroplasty reports in the major medical journals (JAMA, NEJM, and Lancet). However, there were more published studies reporting on complications of lower-extremity arthroplasty. This may be due to systematic bias among journal editors in these journals, or due to low journal submission reporting noncomplications after arthroplasty intervention. We did not find the time period to be a factor in bias reporting of orthopedic literature in major medical journals. More work is needed to verify the results of this study.

Opioids Consumed in the Immediate Post-Operative Period Do Not Influence How Patients Rate Their Experience of Care After Total Hip Arthroplasty.

BACKGROUND: Patient perception of care, commonly measured with Press Ganey (PG) surveys, is an important metric used to determine hospital and provider reimbursement. However, post-operative pain following total hip arthroplasty (THA) may negatively affect patient satisfaction. As a result, over-administration of opioids may occur, even without marked evidence of pain. Therefore, this study evaluated whether opioid consumption in the immediate postoperative period bears any influence on satisfaction scores after THA. Specifically, this study assessed the correlation between post-operative opioid consumption and 7 PG domains: (1) Overall hospital rating; (2) Communication with nurses; (3) Responsiveness of hospital staff; (4) Communication with doctors; (5) Hospital environment; (6) Pain Management; and (7) Communication about medicines. METHODS: Our institutional PG database was reviewed for patients who received THA from 2011 to 2014. A total of 322 patients (mean age = 65 years; 61% female) were analyzed. Patient's opioid consumption was measured using a morphine milli-equivalent conversion algorithm. Bivariate correlation analysis assessed the association between opioid consumption and Press-Ganey survey elements. Pearson's r assessed the strength of the association. RESULTS: No correlation was found between total opioid consumption and Overall hospital rating (r = 0.004; P = .710), Communication with nurses (r = 0.093; P = .425), Responsiveness of hospital staff (r = 0.104; P = .381), Communication with doctors (r = 0.009; P = .940), Hospital environment (r = 0.081; P = .485), and Pain management (r = 0.075; P = .536). However, there was a positive correlation between total opioid consumption and "Communication about medicines" (r = 0.262; P = .043). CONCLUSIONS: Our report demonstrates that PG patient satisfaction scores are not influenced by post-operative opioid use, with the exception of PG domain, "Communication about medications." These results suggest that opioid medications should be administered based solely on patient requirements without concern about patient satisfaction survey results.

Patients With Major Depressive Disorder Experience Increased Perception of Pain and Opioid Consumption Following Total Joint Arthroplasty.

BACKGROUND: Pain in the immediate postoperative period following total joint arthroplasty is influenced by various patient factors, including major depressive disorder (MDD). Therefore, this study aimed to compare the patient perception of pain and opioid consumption between patients with and without MDD who received either a total knee arthroplasty (TKA) or total hip arthroplasty (THA). Specifically, we compared (1) pain intensity, (2) lengths of stay, (3) opioid consumption, and (4) patient perception of pain control. METHODS: We reviewed our institutional Press Ganey database to identify patients with a diagnosis of MDD who received a THA (n = 48) and TKA (n = 68) between 2012 and 2016. An independent samples t-test and chi-square analyses were conducted to assess continuous and categorical variables, respectively. Analysis of covariance assessed the effects of depression on postoperative pain intensity. Mixed-design analysis of variance assessed the difference in opioid consumption between groups. RESULTS: Patients with MDD who received THA or TKA demonstrated a higher mean pain intensity score when compared to those without MDD; however, this was not statistically different (235.6 vs 207.7; P = .264 and 214.8 vs 185.1; P = .055, respectively). Patients with MDD who received THA or TKA consumed more opioids when compared to those without MDD (P = .048 and P = .038, respectively). CONCLUSION: Patients with MDD undergoing total joint arthroplasty consume more opioids compared to their matched cohort during the immediate postoperative period. Identifying patient-specific factors, such as MDD, could help arthroplasty surgeons modulate patients' course of recovery. These findings warrant more cooperation between arthroplasty surgeons and primary care providers to optimize outcome.

Global Budget Revenue on a Single Institution's Costs and Outcomes in Patients Undergoing Total Hip Arthroplasty.

BACKGROUND: The state of Maryland was granted a waiver by the Center for Medicare and Medicaid Services to implement a Global Budget Revenue (GBR) reimbursement model. This study aims to compare (1) costs of inpatient hospital stays; (2) postacute care costs; (3) lengths of stay (LOS); and (4) discharge disposition who underwent primary total hip arthroplasty at a single Maryland-based orthopedic institution before and after the implementation of GBR. METHODS: The Maryland Center for Medicare and Medicaid Services database was queried to obtain all Medicare patients who underwent total hip arthroplasty at a single institution before and after the implementation of GBR. We compared the differences in costs for the following: inpatient care, the postacute care period, and readmissions. In addition, we evaluated differences in LOS, discharge disposition, and complication rates. RESULTS: There was a significant decrease in inpatient costs ($26,575 vs $23,712), an increase in mean home health costs ($627 vs 1608), and a decrease in mean durable medical equipment costs ($604 vs $82) and LOS (2.92 days vs 2.33 days). There was an increase in discharge to home rates (72.3% vs 78.9%) and a decrease in discharge to acute rehabilitation (4.3% vs 1.8%) CONCLUSION: Under the GBR model, our institution experienced significant cost savings during the inpatient and postacute care episodes. Thus, GBR may serve as a viable solution to reducing costs to Medicare for high-volume arthroplasty institutions with a large Medicare population. Multicentered studies are needed to verify our results.

Articulating Spacers as a Modified One-Stage Revision Total Knee Arthroplasty: A Preliminary Analysis.

INTRODUCTION: Periprosthetic joint infection (PJI) following primary total knee arthroplasty (TKA) is a challenging complication for surgeons and patients alike. Although two-stage revision arthroplasty remains the gold standard PJI management in the United States, one-stage revision has had success in many parts of Europe. The aim of this study was to retrospectively review: 1) ultimate treatment success; 2) necessary antibiotic duration; 3) change in knee range of motion (ROM); and 4) final Knee Society Scores (KSS) in a case series of patients managed with retention of articulating antibiotic spacers following PJI. MATERIALS AND METHODS: A retrospective review was performed on all patients treated for chronic PJI after primary TKA with retention of articulating antibiotic spacers at a minimum of one-year follow-up. Descriptive analysis was utilized to evaluate demographic characteristics, discharge destination, follow-up and antibiotic durations, Knee Society Score (KSS), and rates of treatment failure. Paired-Samples t-Tests were utilized to evaluate mean changes in flexion and extension between the preoperative and postoperative time periods. RESULTS: Our final cohort included 29 patients who were managed with articulating spacer retention at a mean follow-up of 16.8 (range, 12.0 to 23.1) months, with 21 patients (72.4%) medically unfit for multiple surgeons and eight patients (27.6%) satisfied with their function. Mean age was 61.3 (range, 41 to 85) years and mean Charlson Comorbidity Index (CCI) was 6.1 (mean, 0 to 12). The predominant infecting organism was Methicillin-Resistant Staphylococcus aureus (MRSA), which was involved in eight patients (27.6%). There was a significant increase in postoperative knee flexion (+14.7°; p<0.001) and no decrease in postoperative knee extension (+2.3°; p=0.361). Treatment success in our cohort was 79.3% (23 patients), with four patients (13.8%) having chronic wound drainage and two patients (6.9%) requiring multiple spacer exchanges. Sixteen patients (55.2%) were able to complete their antibiotic regimen, with the remaining patients unable to discontinue their antibiotics by latest clinic follow-up. DISCUSSION: One-stage exchange arthroplasty offers the advantage of a single procedure with analogous failure rates compared to two-stage exchange, decreases hospitalization, and improves cost-effectiveness, which is paramount in today's healthcare environment. To our knowledge, this is the first study in the United States to evaluate outcome scores, function, and success rate of a modified one-stage revision TKA technique. Although we are unable to make definitive conclusions based on the small sample size, the outcomes in this study are encouraging.

Use of Neuromuscular Electrical Stimulation During Physical Therapy May Reduce the Incidence of Arthrofibrosis After Total Knee Arthroplasty.

INTRODUCTION: Arthrofibrosis remains a major complication following total knee arthroplasty (TKA) that negatively impacts patient outcomes and exhausts healthcare resources. The use of neuromuscular electrical stimulation (NMES) has demonstrated the ability to facilitate quadriceps muscle recovery and reduce pain. Therefore, the purpose of this study was to compare TKA patients who received physical therapy (PT) and adjuvant NMES therapy versus physical therapy alone in terms of: 1) rates of manipulation under anesthesia (MUA) to treat arthrofibrosis; and 2) post-therapy range of motion (ROM). MATERIALS AND METHODS: This was a retrospective review of TKA patients from multiple institutions who underwent physical therapy versus physical therapy and adjuvant NMES therapy following primary TKA. A total of 206 patients were reviewed in the two cohorts that either received PT alone (n=86) or PT and adjuvant NMES therapy (n=120). Data regarding the requirement of MUA postoperatively for treatment of arthrofibrosis were collected for every patient. Additionally, pre- and post-therapy knee ROM data was also collected. Outcomes in both cohorts were then compared and analyzed. RESULTS: Lower rates of arthrofibrosis requiring MUA were recorded in patients who used NMES therapy and PT when compared to PT alone (7.5% vs. 19.8%; p=0.009). Log regression analysis revealed lower odds of needing MUA in patients who utilized NMES therapy in adjunct with PT (odds ratio [OR]=0.36; 95% CI: 0.115 to 0.875; p=0.023). Patients who received the NMES therapy were shown to have a statistically greater mean improvement in ROM when compared to those patients who did not receive NMES (+2.63, p=0.04). Log regression analysis also demonstrated that post-PT ROM decreased the odds of receiving MUA with a larger ROM (OR=92; 95% CI: 0.824 to 0.9855; p<0.001). CONCLUSION: This study demonstrated that the use of NMES during PT may reduce the incidence of arthrofibrosis and improve patient ROM. Prospective, randomized controlled, and larger-scale studies are needed to validate these results. Nevertheless, this novel report demonstrated the positive outcomes for a new application of the NMES therapy.

Decreased Time to Return to Work Using Robotic-Assisted Unicompartmental Knee Arthroplasty Compared to Conventional Techniques.

INTRODUCTION: Unicompartmental knee arthroplasty (UKA) is a commonly used procedure for patients suffering from debilitating unicompartmental knee arthritis. For UKA recipients, robotic-assisted surgery has served as an aid in improving surgical accuracy and precision. While studies exist detailing outcomes of robotic UKA, to our knowledge, there are no studies assessing time to return to work using robotic-assisted UKA. Thus, the purpose of this study was to prospectively assess the time to return to work and to achieve the level of work activity following robotic-assisted UKA to create recommendations for patients preoperatively. We hypothesized that the return to work time would be shorter for robotic-assisted UKAs compared with TKAs and manual UKAs, due to more accurate ligament balancing and precise implementation of the operative plan. MATERIALS AND METHODS: Thirty consecutive patients scheduled to undergo a robotic-assisted UKA at an academic teaching hospital were prospectively enrolled in the study. Inclusion criteria included employment at the time of surgery, with the intent on returning to the same occupation following surgery and having end-stage knee degenerative joint disease (DJD) limited to the medial compartment. Patients were contacted via email, letter, or phone at two, four, six, and 12 weeks following surgery until they returned to work. The Baecke physical activity questionnaire (BQ) was administered to assess patients' level of activity at work pre- and postoperatively. Statistical analysis was performed using SAS Enterprise Guide (SAS Institute Inc., Cary, North Carolina) and Excel® (Microsoft Corporation, Redmond, Washington). Descriptive statistics were calculated to assess the demographics of the patient population. Boxplots were generated using an Excel® spreadsheet to visualize the BQ scores and a two-tailed t-test was used to assess for differences between pre- and postoperative scores with alpha 0.05. RESULTS: The mean time to return to work was 6.4 weeks (SD=3.4, range 2-12 weeks), with a median time of six weeks. There was no difference seen in the mean pre- and postoperative BQ scores (2.70 vs. 2.69, respectively; p=0.87). CONCLUSION: The findings of the current study suggest that most patients can return to work six weeks following robotic-assisted UKA which appears to be shorter than conventional UKA and TKA. Future level I studies are needed to verify our study findings.

Do Press Ganey Scores Correlate With Total Knee Arthroplasty-Specific Outcome Questionnaires in Postsurgical Patients?

BACKGROUND: The purpose of this study was to assess whether Center for Medicaid and Medicare services-implemented satisfaction (Press Ganey [PG]) survey results correlate with established total knee arthroplasty (TKA) assessment tools. METHODS: Data from 736 patients who underwent TKA and received a PG survey between November 2009 and January 2015 were analyzed. The PG survey overall hospital rating scores were correlated with standardized validated outcome assessment tools for TKA (Short form-12 and 36 Health Survey; Knee Society Score; Western Ontario and McMaster Universities Arthritis Index; University of California, Los Angeles; and visual analog scale) at a mean follow-up of 1154 days post-TKA. RESULTS: There was no correlation between PG survey overall hospital rating score and the above-mentioned outcome assessment tools. CONCLUSION: Our study shows that there is no statistically significant relationship between established arthroplasty assessment tools and the PG overall hospital rating. Therefore, PG surveys may not be an appropriate tool to determine reimbursement for orthopedists performing TKAs.