Recent Smoking History Is Not Associated with Adverse 30-Day Standardized Postoperative Outcomes following Microsurgical Reconstructive Procedures of the Upper Extremity.

Background: Upper extremity (UE) microsurgical reconstruction relies upon proper wound healing for optimal outcomes. Cigarette smoking is associated with wound healing complications, yet conclusions vary regarding impact on microsurgical outcomes (replantation, revascularization, and free tissue transfer). We investigated how smoking impacted 30-day standardized postoperative outcomes following UE microsurgical reconstruction. Methods: Utilizing the National Surgical Quality Improvement Program, all patients who underwent (1) UE free flap transfer (n = 70) and (2) replantation/revascularization (n = 270) were identified. For each procedure, patients were stratified by recent smoking history (current smoker ≤1-year preoperatively). Baseline demographics and standardized 30-day complications, reoperations, and readmissions were compared between smokers and nonsmokers. Results: Replantation/revascularization patients had no differences in sex, race, or body mass index between smokers (n = 77) and nonsmokers. Smokers had a higher prevalence of congestive heart failure (5.2% vs 1.0%, P = .036) and nonsmokers were more often on hemodialysis (15.6% vs 10.4%, P = .030). Free flap transfer patients had no differences in age, sex, or race between smokers (n = 14) and nonsmokers. Smokers had a longer length of stay (6.6 vs 4.2 days, P = .001) and a greater prevalence of chronic obstructive pulmonary disorder (COPD; 7.1% vs 0%, P = .044). Recent smoking was not associated with increased odds of any 30-day minor and major standardized surgical complications, readmissions, or reoperations following UE microsurgical reconstruction via free flap transfer or replantation/revascularization. Baseline diagnosis of COPD was also not a predictor of adverse 30-day outcomes following free flap transfer. Conclusion: Recent smoking history was not associated with any 30-day adverse outcomes following UE microsurgical reconstruction via replantation/revascularization or free flap transfer. In light of these findings, further investigation is warranted, with particular focus on adverse events specific to free flaps and replantation/revascularization.

Contexte: La reconstruction microchirurgicale du membre supérieur repose sur la bonne guérison de la plaie pour des résultats optimaux. Le tabagisme est associé à des complications pour la guérison des plaies; toutefois, les conclusions concernant ses répercussions sur les résultats microchirurgicaux (réimplantation, revascularisation et transfert de tissu libre) sont variables. Nous avons cherché à savoir quelles étaient les répercussions du tabagisme sur les résultats postopératoires standardisés à 30 jours après reconstruction microchirurgicale du membre supérieur. Méthodes: Utilisant le Programme national d'amélioration de la qualité de la chirurgie, tous les patients ayant subi (1) un transfert de lambeau libre du membre supérieur (n = 70) et (2) une réimplantation/revascularisation (n = 270) ont été identifiés. Pour chaque procédure, les patients ont été classés en fonction de leurs antécédents de tabagisme récent (fumeur actuel ≤ 1 an préopératoire). Les données démographiques initiales et les complications standardisées à 30 jours, les réinterventions et les réhospitalisations ont été comparées entre fumeurs et non-fumeurs. Résultats: Concernant les réimplantations/revascularisations, il n'y a pas eu de différences en termes de sexe, race ou IMC entre les fumeurs (n = 77) et les non-fumeurs. Les fumeurs avaient une plus grande prévalence d'insuffisance cardiaque congestive (5,2 % contre 1,0 %, P = 0,036) et les non-fumeurs étaient plus souvent sous hémodialyse (15,6 % contre 10,4 %, P = 0,030). Concernant les patients ayant eu un transfert de lambeau libre, il n'y a pas eu de différences en termes d'âge, de sexe ou de race entre les fumeurs (n = 14) et les non-fumeurs. La durée d'hospitalisation des fumeurs a été plus longue (6,6 jours contre 4,2 jours, P =0,001) avec une prévalence plus élevée de MPOC (7,1 % contre 0 %, P = 0,044). Le tabagisme récent n'a pas été associé à une augmentation de la probabilité de complications chirurgicales standardisées, majeures ou mineures, à 30 jours, de réhospitalisation ou reprises chirurgicales après reconstruction microchirurgicale du membre supérieur par transfert de lambeau libre ou réimplantation/revascularisation. Le diagnostic de MPOC à l'inclusion dans l'étude n'était pas non plus un facteur prédictif d'événements indésirables à 30 Jours après transfert de lambeau libre. Conclusion: Un antécédent de tabagisme récent n'a pas été associé à des résultats indésirables à 30 jours après reconstruction microchirurgicale du membre supérieur via réimplantation/revascularisation ou transfert de lambeau libre. À la lumière de ces constatations, des études supplémentaires portant particulièrement sur les événements indésirables propres aux procédures de lambeaux libres et de réimplantation/revascularisation sont justifiées.

Comparing Relative Value Units among Shoulder Arthroplasty, Hemiarthroplasty, and ORIF for Proximal Humerus Fractures in the Elderly: Which is Most Worth Your Time?

BACKGROUND: Relative value units (RVUs) are assigned to Current Procedural Technology (CPT) codes and give relative economic values to the services physicians provide. This study compared the RVU reimbursements for the surgical options of proximal humerus fractures in the elderly, which include arthroplasty (reverse [RSA] and total [TSA]), hemiarthroplasty (HA), and open reduction and internal fixation (ORIF). METHODS: Using the National Surgical Quality Improvement Program, a total of 1,437 patients of at least 65 years of age with proximal humerus fractures between 2008 and 2016 were identified. Of those, 259 underwent RSA/TSA (CPT code 23472), 418 underwent HA (CPT codes 23470 and 23616), and 760 underwent ORIF (CPT code 23615). Univariate analysis compared RVU per minute, reimbursement rate, and the average annual revenue across cohorts based on respective operative times. RESULTS: RSA/TSA generated a mean RVU per minute of 0.197 (SD 0.078; 95%CI [0.188, 0.207]), which was significantly greater than the mean RVU per minute for 23470 HA (0.156; SD 0.057; 95%CI [0.148, 0.163]), 23616 HA (0.166; SD 0.065; 95%CI [0.005, 0.156]), and ORIF (0.135; SD 0.048; 95%CI [0.132, 0.138]; P<0.001). This converted to respective reimbursement rates of $6.97/min (SD 2.78; 95%CI [6.63, 7.31]), $5.48/min (SD 2.05; 95%CI [5.22, 5.74]), $5.83/min (SD 2.28; 95%CI [5.49, 6.16]) and $4.74/min (SD 1.69; 95%CI [4.62, 4.87]). After extrapolation, respective average annual revenues were $580,386, $456,633, $475,077, and $395,608. CONCLUSION: RSA/TSA provides significantly greater reimbursement rates compared to HA and ORIF. Orthopaedic surgeons can use this information to optimize daily procedural cost-effectiveness in their practices.

Changes in Total Knee Arthroplasty Utilization since the Implementation of ACA: An Analysis of Patient-Hospital Demographics, Costs, and Charges.

The Patient Protection and Affordable Care Act (PPACA) formed the Center for Medicare and Medicaid Innovation Center which has implemented experimental reimbursement models targeted at high-demand procedures to improve care quality. However, the effect of health care reform on total knee arthroplasty (TKA) procedures has not been explored. This study explores patient-hospital level demographics, inpatient costs, and charges related to TKA procedures between 2009 and 2015. The National Inpatient Sample database was utilized to identify patients who received primary TKA between January 2009 and October 2015 (4,283,387 cases). Categorical, continuous, and ordinal data were analyzed using chi-square/Fisher's exact test, t-test/analysis of variance, or Kruskal-Wallis' test, respectively. There was an increase in proportion of TKA recipients belonging to minority groups and the lowest quartile of median income (p < 0.05). There was a 1.9% increase in recipients using Medicaid as a primary payor and volume shifts from urban nonteaching toward urban teaching hospitals. There was a reduction in mean length of stay and mean inpatient costs. There were increases in hospital charges, but reductions in rates of inpatient mortality, and other postoperative complications. TKA procedures remain the most common surgical procedure; therefore, our study assessed national trends to capture the effect of PPACA. We found an increasing proportion of TKA recipients belonging to minority and low-income groups, volume shifts to urban teaching hospitals, and lower costs of care. These findings may be useful in objectively critiquing the effects of PPACA on TKA-related care.

Plantar Medial Avulsion Fragment Associated With Tongue-Type Calcaneus Fractures.

BACKGROUND: The plantar fascia attaches to the tuberosity of the calcaneus, which produces a distinct plantar medial avulsion (PMA) fracture fragment in certain calcaneal fractures. We hypothesized that tongue-type fractures, as described by the Essex-Lopresti classification, were more likely to be associated with this PMA fracture than joint depression fractures. METHODS: A retrospective chart review was performed at 2 distinct Level I trauma centers to identify patients sustaining calcaneal fractures. Radiographs were then reviewed to determine the Essex-Lopresti classification, OTA classification, and presence of a PMA fracture. RESULTS: The review yielded 271 total patients with 121 (44.6%) tongue-type (TT), 110 (40.6%) joint depression (JD), and 40 (14.8%) fractures not classifiable by the Essex-Lopresti classification. In the TT group, 73.6% of the patients had the PMA fracture whereas only 8.2% of JD and 15.0% of nonclassifiable fractures demonstrated a PMA fragment ( P < .001). CONCLUSION: Plantar medial avulsion fractures occurred in 38.4% of the calcaneal fractures reviewed with a significantly greater proportion occurring in TT (73.6%) as opposed to JD (8.2%). Given the plantar fascia attachment to the PMA fragment, there may be clinical significance to identifying this fracture and changing treatment management; however, this requires further investigation. LEVEL OF EVIDENCE: Level III, comparative study.

Short-term outcomes for total knee arthroplasty patients with active extension lag.

BACKGROUND: Despite the success of total knee arthroplasty (TKA), quadriceps strength can fail to recover. Active extension lag [quadriceps lag (Q-lag)] is a function of quadriceps weakness. Q-lag presents itself in patients who maintain a full passive range of motion (ROM), but are limited in active extension ROM. Few studies have evaluated the outcomes of post-TKA patients in the presence of post-operative Q-lag. Thus, this study aims to compare: (I) pain scores; and (II) rates of readmission to physical therapy (PT) in TKA patients with Q-lag of ≥15 degrees to patients without Q-lag. METHODS: A retrospective review of primary TKA patients between 2013 and 2015 was performed. A total of 150 patients (mean age 63.0 years) with a mean follow-up of 30.7 months were analyzed. All patients received an evidence-based protocol for PT at our institution. Patient readmission to PT was recorded if the orthopedic surgeon wrote an additional prescription for PT intervention following the standard of care following TKA. An independent samples t-test and chi-square analysis was conducted to assess the continuous and categorical variables, respectively. RESULTS: Fifty-one patients had Q-lag ≥15 degrees and 97 patients had Q-lag <15 degrees. Analysis of mean pain scores between the groups demonstrated a significant difference in mean pain scores (1.9 vs. 3.9; P=0.043). Chi-square analysis demonstrated no significant difference in rates of PT readmission between patients who presented with Q-lag, and patients without Q-lag (23.5% vs. 13.4%; P=0.118). CONCLUSIONS: There was no significant difference in readmission rates; however, patients with Q-lag experienced a clinically significant higher pain level. Since this is the first study of its kind, we suggest further investigations on the effect of Q-lag on patient outcomes following primary TKA.

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.

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.

Decline in allogeneic blood transfusion usage in total hip arthroplasty patients: National Inpatient Sample 2009 to 2013.

INTRODUCTION: Although total hip arthroplasty (THA) is an effective treatment for end-stage arthritis, it is also associated with substantial blood loss that may require allogeneic blood transfusion. However, these transfusions may increase the risk of certain complications. The purpose of our study is to evaluate: (i) the incidence/trends of allogeneic blood transfusion; (ii) the associated risk factors and adverse events; and (iii) the discharge disposition, length of stay (LOS), and costs for these patients between 2009 and 2013. METHODS: The National Inpatient Sample database was used to identify 1,542,366 primary THAs performed between 2009 and 2013. Patients were stratified based on demographics, economic data, hospital characteristics, comorbidities, and whether or not allogeneic transfusion was received. Logistic regression was performed to evaluate the risk factors for transfusion and postoperative complications. RESULTS: From 2009 to 2013, allogeneic transfusions were used in 16.9% of primary THAs, with a declining annual incidence. Except for obesity, all comorbidities were associated with increased likelihood of receiving a transfusion. Allogeneic transfusion patients were more likely to experience surgical site infections or pulmonary complications (p<0.001 for all). These patients were more likely to be discharged to a short-term care facility (p<0.001). Additionally, they had a greater mean LOS (p<0.001) and higher median hospital costs and charges when compared to their non-transfused counterparts. CONCLUSIONS: While the observed decline in allogeneic transfusion usage is encouraging, further efforts should focus on preoperative patient optimisation. Given the projected increase in demand for primary THAs, orthopaedic surgeons must be familiar with safe and effective blood conservation protocols.

Meralgia Paresthetica After Spine Surgery on the Jackson Table.

Meralgia paresthetica is a non-life-threatening neurological disorder characterized by numbness, tingling, and burning pain over the anterolateral thigh due to impingement of the lateral femoral cutaneous nerve. This disorder has been seen in patients with diabetes mellitus and obesity, but has also been observed in patients after procedures such as posterior spine surgery, iliac crest bone grafts, lumbar disk surgery, hernia repair, appendectomies, and pelvic osteotomies that ultimately lead to compression or damage to the lateral femoral cutaneous nerve. Overall, permanent sequelae of meralgia paresthetica are rare, however, some cases do require intervention.

Does gender influence how patients rate their patient experience after total hip arthroplasty?

BACKGROUND: Patient satisfaction, as measured by Press Ganey (PG) surveys, partially determines reimbursement rates. Knowing what influences these scores can lead to higher reimbursement for total hip arthroplasty (THA) surgeons. Currently, it is unknown whether gender biases exist in satisfaction surveys post-THA. Therefore, we asked: (i) which PG survey factors most influence hospital ratings among men and women after THA; and (ii) is there a difference in survey element responses and overall hospital ratings between men and women post-THA? METHODS: We queried the PG database for patients who underwent THA from November 2009 to January 2015, which yielded 692 patients (277 men, 415 women). Weighted means were analysed for the scores of PG domains between men and women. A multiple regression analysis was performed for each gender, with overall hospital satisfaction as the dependent variable, in order to assess the influence (ß-weight) of each PG domain. RESULTS: For men, pain management (ß = 0.317, p = 0.021) most influenced overall hospital rating. For women, staff responsiveness (ß = 0.451, p<0.001) most influenced overall hospital rating. This was followed by communication with nurses (ß = 0.373, p<0.001), and doctors (ß = 0.236, p = 0.002). There were no significant differences in mean overall hospital rating between groups. CONCLUSIONS: It is advantageous for orthopaedic surgeons to focus on the PG domains most pertinent to each patient gender post-THA. Focusing efforts based on gender may allow for better patient satisfaction, optimised reimbursements, and improved hospital ratings.

Does Addition of Adductor Canal Blockade to Multimodal Periarticular Analgesia Improve Discharge Status, Pain Levels, Opioid Use, and Length of Stay after Total Knee Arthroplasty?

Total knee arthroplasty (TKA) can be associated with substantial postoperative pain that may affect satisfaction and return to function. Various forms of pain control have been used; however, multimodal periarticular analgesia (MPA) and adductor canal block (ACB) have recently gained popularity. The purpose of this study was to compare (1) discharge status, (2) pain levels, (3) postoperative opioid consumption, and (4) length of stay (LOS) between TKA patients who received MPA only and those who received both MPA and ACB. A single surgeon database was reviewed for TKA patients who received MPA with or without ACB between January 2015 and April 2016. This yielded 110 patients who had a mean age of 62 years. Forty-five patients received MPA alone, while 65 patients received both modalities. Patient records were reviewed to obtain demographic and end-point data (discharge status, pain scores, opioid consumption, and LOS). Student's t-test and chi-squared test were used to compare continuous and categorical variables, respectively. There was no significant difference in discharge status (p = 0.304), pain levels (p = 0.343), and postoperative opioid consumption (p = 0.729) between the two cohorts. When compared with MPA patients, TKA patients who received both MPA and ACB demonstrated shorter LOS (2.44 vs. 1.98 days), a value that trended toward significance (p = 0.061). When comparing TKA patients who received MPA with those who received a combination of MPA and ACB, we were unable to elucidate a significant difference in any of the end points of interest. Therefore, MPA alone is comparable to combined MPA and ACB in managing postoperative pain in TKA patients. However, larger studies may be necessary to verify these findings.

Management of Injuries to the Medial Patellofemoral Ligament: A Review.

The medial patellofemoral ligament (MPFL) is thought to be the most important medial structure providing restraint to lateral subluxation of the patella. After an initial patellar dislocation, the MPFL is frequently injured and can usually be treated with conservative measures. However, these patients often suffer from recurrent dislocations, which thereby necessitate operative intervention. In the setting of normal anatomy and kinematics, isolated reconstruction of the MPFL is an effective treatment for preventing recurrent dislocations. Various surgical techniques have been described, with differences in fixation and graft selection. The treatment of MPFL injuries should aim to provide patellar stabilization and restore normal kinematics throughout the joint. This review will discuss the following: (1) anatomy of the MPFL, (2) presentation and assessment of MPFL injuries, (3) management of patients with MPFL injuries, and (4) complications following MPFL reconstruction.

Factors Influencing Patients' Hospital Rating After Total Joint Arthroplasty.

Patient satisfaction assessments, such as the Press Ganey surveys, have been adopted by the Centers for Medicare & Medicaid Services to help determine reimbursements. It is uncertain what facets most affect survey scores among patients who have received total joint arthroplasty (TJA). This study explored which factors guide scores for TJA patients. Specifically, the authors assessed (1) which Press Ganey survey features affected the patients' overall hospital rating and (2) whether survey scores were disparate between patients who did and patient who did not have complications. The authors' institutional Press Ganey database was queried for lower-extremity TJAs that occurred between November 2009 and January 2015. This yielded 1454 patients with a mean age of 63 years (range, 15-92 years; 60% women and 40% men). The database contains information related to American Society of Anesthesiologists scores, Press Ganey question responses, and demographics. Multiple regression analysis was performed to assess the association (beta weight) between Press Ganey domains and overall hospital rating. The weighted mean for each domain was calculated. The authors' analysis revealed that overall hospital rating was significantly influenced by communication with nurses (beta weight=0.434, P<.001), responsiveness of hospital staff (beta weight=0.181, P=.001), communication with doctors (beta weight=0.115, P=.014), and hospital environment (beta weight=0.100, P=.039). No significant differences were found when comparing the Press Ganey scores of patients with and without complications. By recognizing these elements, physicians can direct measures appropriately, which may help avoid financial penalties and possibly increase patient satisfaction after TJA. [Orthopedics. 2017; 40(6):377-380.].

The Effect of Preoperative Physical Status on Pain Management in Total Knee Arthroplasty Patients Receiving Adductor Canal Blockade.

INTRODUCTION: Managing postoperative pain can be challenging for arthroplasty surgeons. While pain control modalities, such as adductor canal blockade (ACB), have been proven effective, the multifactorial nature of pain perception may serve as an obstacle for optimizing pain control. This study assesses the effect of patient pre-operative physical status on patient perception of pain. Specifically, we compared 1) lengths of hospital stay (LOS), 2) pain levels, and 3) opioid consumption in patients receiving total knee arthroplasty (TKA) who presented with an American Society of Anesthesiologists physical status score (ASA) of 2 and 3. MATERIALS AND METHODS: A single hospital, single surgeon database was reviewed for patients who had TKA between January 2015 and April 2016. Only patients with an ASA class of 2 or 3 who received ACB were analyzed. This yielded 106 patients with a mean age of 63 years, comprised of 36 men and 70 women. Patients were stratified into those with an ASA class of 2 (n= 58) and those with an ASA class of 3 (n= 48). Electronic medical records were reviewed to obtain demographic and endpoint data. Pain was quantified using Visual Analog Scale (VAS). Continuous variables were compared using the student' s t-test and analysis of variance, while categorical variables were compared using chi-square analysis. RESULTS: There was no significant difference found between the two groups in LOS (2.25 days vs. 2.19 days; p=0.805), VAS scores (4.95 vs. 5.75; p=0.306), and opioid consumption on day 0 (17.77 morphine eq vs. 23.49 morphine eq; p=0.233) and day 3 (9.11 morphine eq vs. 19.87 morphine eq; p=0.100). However, patients with an ASA score of 2 had a significantly lower opioid consumption on day 1 (32.20 morphine eq vs. 52.70 morphine eq; p=0.049), day 2 (19.21 morphine eq vs. 40.71 morphine eq; p=0.018), and overall (78.30 morphine eq vs. 135.77 morphine eq; p=0.024). CONCLUSION: Despite the effectiveness of ACB in controlling pain, patient pre-operative status may affect perception of pain. This study demonstrates that patients with a higher ASA physical status classification consumed more opioid medication postoperatively, despite having similar pain scores and lengths of stay to those with a lower classification. Future studies should assess all ASA classifications and stratify for preoperative opioid consumption and tolerance as a possible confounder.

What Influences How Patients with Depression Rate Hospital Stay After Total Joint Arthroplasty?

BACKGROUND: Recent healthcare reform has spurred important changes to provider reimbursement. With the implementation of the Value Based Purchasing program, significant weight is placed on patient experience of care. The Press Ganey (PG) survey is currently used by over 10,000 hospitals, as it serves to help optimize patient satisfaction. However, confounding factors, such as clinical depression, are not screened against by PG. Thus, arthroplasty surgeons performing lower extremity total joint arthroplasty (TJA) may have difficulty optimizing patient satisfaction while caring for patients with clinical depression. Therefore, we asked: 1) What Press Ganey elements affect the overall hospital rating in patients who suffer from clinical depression? and 2) Are survey responses different between patients who do and do not have clinical depression? MATERIALS AND METHODS: We queried our institutional PG database for patients who underwent a TJA from November 2009 to January 2015. Our search yielded 1,454 patients, of which 204 suffered from depression and 1,250 did not. Multiple regression analysis was performed to determine the influence (b weight) of selected PG survey domains on overall hospital rating. The weighted mean for domain was also calculated. RESULTS: Multiple regression analyses showed that overall hospital ratings were significantly influenced by communication with nurses (b-weight = 0.881, p< 0.001) in post-TJA patients with depression. The remaining domains were not statistically significant. There were no significant differences in individual PG elements for patients who did and did not have depression. CONCLUSION: Overall patient satisfaction among patients with depression was greatly influenced by communication with nurses. Understanding these challenges may encourage care coordination across disciplines for the management of patients with depression before and after surgery. As a result, this could optimize orthopedic surgery outcomes, but, more importantly, patient health and satisfaction, while reducing costs of care.

Current Epidemiology of Revision Total Knee Arthroplasty in the United States.

BACKGROUND: Revision surgery for failed total knee arthroplasty (TKA) continues to pose a substantial burden for the United States healthcare system. The predominant etiology of TKA failure has changed over time and may vary between studies. This report aims to update the current literature on this topic by using a large national database. Specifically, we analyzed: (1) etiologies for revision TKA; (2) frequencies of revision TKA procedures; (3) various demographics including payer type and region; and (4) the length of stay (LOS) and total charges based on type of revision TKA procedure. METHODS: The Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) database was used to identify all revision TKA procedures performed between 2009 and 2013. Clinical, economic, and demographic data were collected and analyzed for 337,597 procedures. Patients were stratified according to etiology of failure, age, sex, race, US census region, and primary payor class. The mean LOS and total charges were also calculated. RESULTS: Infection was the most common etiology for revision TKA (20.4%), closely followed by mechanical loosening (20.3%). The most common revision TKA procedure performed was all component revision (31.3%). Medicare was the primary payor for the greatest proportion of revisions (57.7%). The South census region performed the most revision TKAs (33.2%). The overall mean LOS was 4.5 days, with arthrotomy for removal of prosthesis without replacement procedures accounting for the longest stays (7.8 days). The mean total charge for revision TKAs was $75,028.07. CONCLUSION: Without appropriate measures in place, the burden of revision TKAs may become overwhelming and pose a strain on providers and institutions. Continued insight into the etiology and epidemiology of revision TKAs may be the principle step towards improving outcomes and mitigating the need for future revisions.