Regional Periprosthetic Joint Infection Centers: The Time Has Come for a Paradigm Change in the Treatment of Periprosthetic Joint Infection.

BACKGROUND: Periprosthetic joint infection (PJI) is a rare, yet devastating complication with high mortality rates, unpredictable treatment outcomes, and high costs. The purpose of this study was to determine 90-day and 1-year mortality rates at a specialized PJI center, assess the impact of delayed referral to a PJI center on outcomes, and determine the cost of PJI treatment prior to referral to a PJI center. METHODS: A review of our institution's PJI registry was performed to identify patients who had a chronic PJI treated with a 2-stage exchange arthroplasty at our PJI Center from 2017 to 2021. Patients not referred from an external location were excluded. Mortality at 90 days and 1 year was collected. The date of infection diagnosis until the date of referral was recorded. Outcomes were documented as failure of treatment at the final clinical follow-up. The number and type of prior infection treatments were documented for each patient. The estimated cost was calculated using established PJI literature. RESULTS: There were 172 patients (182 joints) who met inclusion criteria during this timeframe. The 90-day and 1-year mortality rates were 0 and 3.9%, respectively. There was a higher failure rate in patients referred >90 days after the diagnosis of chronic PJI (23 versus 11%, P = 0.031). The total cost of PJI treatment prior to referral for this group of patients was $6.9 million. CONCLUSIONS: Implementation of a specialized PJI referral center leads to lower mortality rates, improved outcomes, and decreased cost for the health-care system.

Nitinol Staple Use in Primary Arthrodesis of Lisfranc Fracture-Dislocations.

BACKGROUND: Primary arthrodesis of Lisfranc fracture-dislocations is a reliable treatment option, yet concerns remain about nonunion. Nitinol staple use has recently proliferated in midfoot arthrodesis. The purpose of this study is to examine the union rate of primary arthrodesis of acute Lisfranc fracture-dislocations treated with nitinol staples compared with traditional plate-and-screw fixation. The secondary objective is to assess the difference in operative times and reoperation rates. METHODS: Midfoot fracture-dislocations treated with primary arthrodesis by 7 foot and ankle orthopaedic surgeons were reviewed. Of 160 eligible patients, 121 patients (305 joints) met the required 4-month minimum radiographic follow-up. Radiographic outcomes were analyzed at the individual joint level. Each joint was classified as either staples alone (45 patients, 154 joints), staples plus plates and screws (hybrid) (45 patients, 40 joints), or plates and screws alone (31 patients, 111 joints). The primary outcome was arthrodesis union at each joint fused. RESULTS: Nonunion was more common (9.0%, 10/111) among joints fixed with plate and screws than with hybrid (2.5%, 1/40) or staples only (1.3%, 2/154) (P = .0085). Multivariable regression demonstrated that autograft use was independent associated with union (P = .0035) and plate-and-screw only fixation was an independent risk factor for nonunion (P = .0407). Median operating room and tourniquet times were shorter for hybrid (92 and 83 minutes) and staple only (67 and 63 minutes) constructs compared to plate-and-screw only fixation (105 and 95 minutes) (P ≤ .0001 and .0003). There was no difference in reoperation rates among patients with different fixation types. CONCLUSION: We found that use of nitinol compression staple and bone autograft in primary arthrodesis of Lisfranc and midfoot fracture-dislocations was associated with both improved union rates and shorter tourniquet and operative times compared to traditional plate-and-screw fixation techniques. LEVEL OF EVIDENCE: Level III, therapeutic.

Prospective Clinical and Computed Tomography Evaluation of Calcaneus Fractures Treated Through Sinus Tarsi Approach.

Background: The traditional lateral extensile approach to the calcaneus allows for excellent visualization but is associated with high wound complication rates. The sinus tarsi approach has been shown to produce similar radiographic outcomes with much lower rates of wound complications. The purpose of this study is to prospectively determine clinical and radiographic outcomes in calcaneus fractures treated with a sinus tarsi approach. Methods: Twenty-nine patients with 30 calcaneus fractures underwent operative fixation through a sinus tarsi approach and were prospectively evaluated. Routine pre- and postoperative radiographs were obtained, in addition to computed tomography (CT) scans at 6 weeks and 12 months after surgery. Patient-reported outcomes including American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) pain score, Veterans Rand 12-Item Health Survey (VR-12), and Foot Functional Index (FFI) were recorded. Patients were followed for a minimum of 1 year postoperation. Results: Twenty-one patients with 22 calcaneus fractures completed 1 year of follow-up. At 12 months postoperation, 20 of 22 patients (91%) had 0 to 2 mm of fracture displacement at the posterior facet on CT scans whereas 2 of 22 patients had 2 to 4 mm of fracture displacement. There was no significant change in posterior facet fracture displacement comparing 6-week and 12-month postoperative CT scans (P > .99). Mean postoperative Bohler angle was 26.1 degrees compared to 13.2 degrees preoperatively. All patients had complete union of fracture site. There were no major wound complications. Four of 22 patients (18.2%) had minor wound complications. AOFAS, FFI, and VAS pain scores improved postoperatively but were not found to correlate with Bohler angle or critical angle of Gissane. Conclusion: We found that in select patients excellent anatomic alignment and good clinical outcomes with low wound complication rates can be achieved when fixing calcaneus fractures through the sinus tarsi approach. Level of Evidence: Level II, prospective cohort study.

Patient Perception of Orthopedic Surgeon Reimbursement.

Significant attention has been directed at evaluating reimbursement rates to orthopedic surgeons for various surgical procedures. To evaluate patients' understanding of the surgeon reimbursement process, studies using patient surveys have been conducted to determine patients' perceptions of orthopedic surgeon compensation. To date, there has been no systematic review to consolidate the data of these studies. This study aimed to synthesize the findings of these individual studies across multiple subspecialties of orthopedic surgery to evaluate the potential discrepancy between how much patients believe orthopedic surgeons are reimbursed and the actual reimbursement rate. We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies that report findings of patient perceptions of orthopedic surgeon reimbursement for various procedures. Searches were conducted using MEDLINE through PubMed, Embase, and Scopus. Summary estimates of reimbursement discrepancies across subspecialties and overall were reported as unweighted averages of the individual study results within each group. Twelve studies were identified that met inclusion criteria, constituting 4309 surveys. These survey studies measured patients' perceptions of how much orthopedic surgeons are reimbursed for common procedures, including anterior cruciate ligament reconstruction, arthroscopic meniscectomy, carpal tunnel release, rotator cuff repair, multiple spine procedures and total shoulder, hip, and knee arthroplasty. It was found that patients reported reasonable surgeon's fees to be 11.2 times more than actual Medicare reimbursement. Among individual studies, the largest discrepancies were seen in total hip arthroplasty (26 times), whereas the smallest difference was in anterior cruciate ligament reconstruction (1.6 times). On average, patients estimated Medicare reimbursement rates to be 5.9 times higher than the actual surgeon reimbursement. Patients consistently overestimate how much orthopedic surgeons are reimbursed for common orthopedic procedures. The results of this systematic review suggest that patients may value these procedures more than what Medicare reimburses. Such information may help educate the public, direct policy, and increase transparency between orthopedic surgeons and patients.

The Cost Variability of Orthobiologics.

BACKGROUND: Mixed results exist regarding the benefit of orthobiologic injections. The purpose of this study was to assess the variability in costs for platelet-rich plasma (PRP) and stem cell (SC) injections and evaluate for variables that influence pricing. HYPOTHESIS: There will be significant variability in the cost of PRP and SC injections throughout the United States. STUDY DESIGN: Descriptive epidemiology study. LEVEL OF EVIDENCE: Level 3. METHODS: Calls were made to 1345 orthopaedic sports medicine practices across the United States inquiring into the availability of PRP or SC knee injections and associated costs. In addition to pricing, the practice type, number of providers, and population and income demographics were recorded. Univariate statistical analyses were used to identify differences in availability and cost between variables. RESULTS: Of the contacted offices that provided information on both PRP and SC availability (n = 1325), 268 (20.2%) offered both treatments, 550 (41.5%) offered only PRP injections, 20 (1.5%) offered only SC injections, and 487 (36.8%) did not offer either treatment. The mean ± SD cost of a PRP injection was $707 ± $388 (range, $175-$4973), and the mean cost of an SC injection was $2728 ± $1584 (range, $300-$12,000). Practices offering PRP and SC injections tended to be larger (PRP, 12.0 physicians per practice vs. 8.1 [P < 0.001]; SC, 13.6 vs 9.7 [P < 0.001]). Practices that offered PRP injections were located in areas with higher median household income (P = 0.047). Variables associated with higher cost of PRP injections included city population (P < 0.001) and median income of residents (P < 0.001). CONCLUSION: While the majority of sports medicine practices across the United States offer some type of orthobiologic injection, there exists significant variability in the cost of these injections. CLINICAL RELEVANCE: This study demonstrates the significant variability in costs of orthobiologic injections throughout the country, which will allow sports medicine physicians to appreciate the value of these injections when counseling patients on available treatment options.

Determining iron oxide nanoparticle heating efficiency and elucidating local nanoparticle temperature for application in agarose gel-based tumor model.

Magnetic iron oxide nanoparticles (MNPs) have been developed for magnetic fluid hyperthermia (MFH) cancer therapy, where cancer cells are treated through the heat generated by application of a high frequency magnetic field. This heat has also been proposed as a mechanism to trigger release of chemotherapy agents. In each of these cases, MNPs with optimal heating performance can be used to maximize therapeutic effect while minimizing the required dosage of MNPs. In this study, the heating efficiencies (or specific absorption rate, SAR) of two types of MNPs were evaluated experimentally and then predicted from their magnetic properties. MNPs were also incorporated in the core of poly(ethylene glycol-b-caprolactone) micelles, co-localized with rhodamine B fluorescent dye attached to polycaprolactone to monitor local, nanoscale temperatures during magnetic heating. Despite a relatively high SAR produced by these MNPs, no significant temperature rise beyond that observed in the bulk solution was measured by fluorescence in the core of the magnetic micelles. MNPs were also incorporated into a macro-scale agarose gel system that mimicked a tumor targeted by MNPs and surrounded by healthy tissues. The agarose-based tumor models showed that targeted MNPs can reach hyperthermia temperatures inside a tumor with a sufficient MNP concentration, while causing minimal temperature rise in the healthy tissue surrounding the tumor.