Patient genetic heterogeneities acting as indicators of post-operative pain and opioid requirement in orthopedic surgery: A systematic review.

INTRODUCTION: Orthopedic surgical procedures are expected to increase annually, making it imperative to understand the correlations between patient genetic makeup and post-operative pain levels. METHODS: We performed a systematic literature review using PubMed and Cochrane databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 299 articles were initially selected, 20 articles remained after title and abstract review, and nine articles were selected for inclusion upon full text review. RESULTS: Genetic risk factors identified included the A allele of the 5HT2A gene single nucleotide polymorphism, the AA genotype of the ADRB2 gene, the CG genotype of the IL6 gene, the genotypes CT and TT of the NTRK1 gene, genotypes AA and GA of the OPRM gene, and the AA and GA genotypes of the COMT gene. Additional studies in the review discuss statistical significance of other variants of the COMT gene. CONCLUSION: There have been genetic association studies performed on the patient heterogeneity and its relationship on patient pain levels, but more data need to be collected to understand the clinical utility of stratifying patients based on genomic sequence.

InSpace Balloon for the Management of Massive Irreparable Rotator Cuff Tears: A Systematic Review and Meta-Analysis.

Background: The best course of action for massive irreparable rotator cuff tears (MIRCTs) is not universally agreed upon. Numerous surgical techniques have been discussed. The implantation of a biodegradable spacer into the subacromial area has been documented since 2012 by several authors. The implantation method is touted as being simpler, repeatable, and less invasive than other solutions that are now available. The purpose of this systematic review and meta-analysis, being the first of its kind, was to evaluate the literature to see the efficacy of InSpace balloon (ISB) implantation in the management of MIRCTs. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, and with 2 researchers assessing and analyzing each study separately, an extensive electronic search of the literature was conducted in the PubMed database from 1961 until July 27, 2022. Results: Fourteen studies were included in this systematic review and three in the meta-analysis. Eleven out of fourteen studies favored ISB use for MIRCTs, while only three were against its use. All spacers were arthroscopically implanted in the subacromial space. Three studies were included in the meta-analysis. The differences in the compared outcomes were statistically insignificant. Conclusions: A controversy about the use of ISB remains in patients with MIRCTs. Both good and bad outcomes were reported. However, the majority of patients had good clinical outcomes across several grading scales, radiographic evidence of improved impingement, and self-report that they would redo the procedure in hindsight. To draw more solid conclusions and have statistically significant results in the meta-analysis, more randomized controlled trials and comparative studies comparing this device to other treatments are needed.

Sub-chondroplasty Reduces Pain, Improves Function and Delays the Conversion to Arthroplasty in Patients with Advanced Knee Osteoarthritis: A Stratified Meta-analysis and Quality Assessment.

There is an ongoing interest in alternatives to total knee arthroplasty, as a means to delay inevitable replacement. A possible, minimally invasive, alternative is a sub-chondroplasty, involving interosseous injection of bone substitute materials such as calcium phosphate (CaPo4), platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC) or Injectable demineralized bone matrix (iDBM) into the subchondral bone. Eleven clinical trials were found, investigating the effectiveness of sub-chondroplasties performed using CaPo4, PRP, BMAC, and iDBM. A non-stratified and stratified meta-analysis of the included studies were conducted to test for confounding variables across the trials. Non-stratified analysis, regardless of injectable type, revealed a significant improvement in the average Visual Analog Scale (VAS) score and postoperative Knee Injury and Osteoarthritis Outcome Score (KOOS) in patients post sub-chondroplasty, as compared to baseline. This analysis demonstrates that the sub-chondroplasty procedure reduces pain, improves function, and has lower risk of conversion to arthroplasty. (Journal of Surgical Orthopaedic Advances 32(2):065-074, 2023).

Neuraxial Anesthesia Significantly Reduces 30-Day Venous Thromboembolism Rate and Length of Hospital Stay in Primary Total Hip Arthroplasty: A Stratified Propensity Score-Matched Cohort Analysis.

BACKGROUND: General anesthesia (GA) has been the commonly used protocol for total hip arthroplasty (THA); however, neuraxial anesthesia (NA) has been increasingly performed. Our purpose was to compare NA and GA for 30-day postoperative outcomes in United States veterans undergoing primary THA. METHODS: A large veteran's database was utilized to identify patients undergoing primary THA between 1999 and 2019. A total of 6,244 patients had undergone THA and were included in our study. Of these, 44,780 (79.6%) had received GA, and 10,788 (19.2%) had received NA. Patients receiving NA or GA were compared for 30-day mortalities, cardiovascular, respiratory, and renal complications, and wound infections and hospital lengths of stay (LOS). Propensity score matching, multivariate regression analyses, and subgroup analyses by American Society of Anesthesiology classification were performed to control for selection bias and patient baseline characteristics. RESULTS: Upon propensity-adjusted multivariate analyses, NA was associated with decreased risks for deep venous thrombosis (odds ratio [OR] = 0.63; 95% CI = 0.4-0.9; P = .02), any respiratory complication (OR = 0.63; 95% CI = 0.5-0.9; P = .003), unplanned reintubation (OR = 0.51; 95% CI = 0.3-0.9; P = .009), and prolonged LOS (OR = 0.78; 95% CI = 0.72-0.84; P < .001). Subgroup analyses by American Society of Anesthesiology classes showed NA decreased 30-day venous thromboembolism rate in low-risk (class I/II) patients and decreased respiratory complications in high-risk (class III/IV) patients. CONCLUSION: Using a patient cohort obtained from a large national database, NA was associated with reduced risk of 30-day adverse events compared to GA in patients undergoing THA. Postoperative adverse events were decreased with NA administration with similar decreases observed across all patient preoperative risk levels. NA was also associated with a significant decrease in hospital LOS.

The risk of hospital readmission, revision, and intra- and postoperative complications between direct anterior versus posterior approaches in primary total hip arthroplasty: a stratified meta-analysis and a probability based cost projection.

INTRODUCTION: This study presents stratified meta-analysis and projected cost per case analysis of direct anterior approach (DAA) versus posterior approach (PA) in total hip arthroplasty (THA) to determine the best surgical approach and guarantee hip joint longevity. METHODS: Several online databases were searched for clinical trials comparing DAA and PA in primary THA. The stratified analysis was conducted to test for confounding and biases across the different types of included trials. The average cost and probability were used to determine projected added costs of medical and surgical management for complications. RESULTS: 30 clinical trials included 11,562 patients who underwent THA. Almost 50% of these patients performed DAA. As compared to PA, both non-stratified and stratified analyses demonstrated that DAA has a significant higher incidence of the overall intra- and postoperative complications (non-stratified, OR 1.64; p = 0.003) (stratified, OR 4.12; p = 0.005), nerve injury (non-stratified, OR 22.0; p < 0.00001) (stratified, OR 0.28; p < 0.00001), higher rate of revision surgery (non-stratified; OR 1.54; p = 0.01) (stratified, OR 7.37; p = 0.006), and higher incidence of surgical wound complications (non-stratified; OR 1.67; p = 0.002) as compared to PA following primary THA. In addition, DAA demonstrated higher trends of incidence (non-statistically significant) of femur fracture (Non-stratified, OR 1.32, p = 0.10) and thrombo-embolic complications (Retrospective studies, OR 1.39, p = 0.69). However, PA demonstrated higher trends of incidence (non-statistically significant) of hip joint dislocation, as compared to DAA. (Stratified RCTs, OR 0.63, p = 0.65]. Collectively, this amounts a $421,068.68 surplus in DAA complication costs. CONCLUSIONS: PA may provide a more lucrative, safer approach to those undergoing THA given its comparable postoperative outcomes, reduced complication rates, and lower overall cost relative to DAA.

Opioid-Related Genetic Polymorphisms of Cytochrome P450 Enzymes after Total Joint Arthroplasty: A Focus on Drug-Drug-Gene Interaction with Commonly Coprescribed Medications.

Pharmacogenomic testing, together with the early detection of drug-drug-gene interactions (DDGI) before initiating opioids, can improve the selection of dosage and reduce the risk of adverse drug interactions and therapeutic failures following Total Joint Arthroplasty. The variants of CYP genes can mediate DDGI. Orthopedic surgeons should become familiar with the genetic aspect of opioid use and abuse, as well as the influence of the patient genetic makeup in opioid selection and response, and polymorphic variants in pain modulation.

Genetic Polymorphisms Associated with Perioperative Joint Infection following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.

The number of orthopedic procedures, especially prosthesis implantation, continues to increase annually, making it imperative to understand the risks of perioperative complications. These risks include a variety of patient-specific factors, including genetic profiles. This review assessed the current literature for associations between patient-specific genetic risk factors and perioperative infection. The PRISMA guidelines were used to conduct a literature review using the PubMed and Cochrane databases. Following title and abstract review and full-text screening, eight articles remained to be reviewed­all of which compared single nucleotide polymorphisms (SNPs) to periprosthetic joint infection (PJI) in total joint arthroplasty (TJA). The following cytokine-related genes were found to have polymorphisms associated with PJI: TNFα (p < 0.006), IL-6 (p < 0.035), GCSF3R (p < 0.02), IL-1 RN-VNTR (p = 0.002), and IL-1B (p = 0.037). Protein- and enzyme-related genes that were found to be associated with PJI included: MBL (p < 0.01, p < 0.05) and MBL2 (p < 0.01, p < 0.016). The only receptor-related gene found to be associated with PJI was VDR (p < 0.007, p < 0.028). This review compiled a variety of genetic polymorphisms that were associated with periprosthetic joint infections. However, the power of these studies is low. More research must be conducted to further understand the genetic risk factors for this serious outcome.

Coronavirus pandemic in the Nordic countries: Health policy and economy trade-off.

Background: Countries making up the Nordic region - Denmark, Finland, Iceland, Norway, and Sweden - have minimal socioeconomic, cultural, and geographical differences between them, allowing for a fair comparative analysis of the health policy and economy trade-off in their national approaches towards mitigating the impact of the COVID-19 pandemic. Methods: This study utilized publicly available COVID-19 data of the Nordic countries from January 2020 to January 3, 2021. COVID-19 epidemiology, public health and health policy, health system capacity, and macroeconomic data were analysed for each Nordic country. Joinpoint regression analysis was performed to identify changes in temporal trends using average monthly percent change (AMPC) and average weekly percent change (AWPC). Results: Sweden's health policy, being by far the most relaxed response to COVID-19, was found to have the largest COVID-19 incidence and mortality, and the highest AWPC increases for both indicators (13.5, 95% CI = 5.6, 22.0, P < 0.001; 6.3, 95% CI = 3.5, 9.1, P < 0.001). Denmark had the highest number of COVID-19 tests per capita, consistent with their approach of increased testing as a preventive strategy for disease transmission. Iceland had the second-highest number of tests per capita due to their mass-testing, contact tracing, quarantine and isolation response. Only Norway had a significant increase in unemployment (AMPC = 2.8%, 95% CI = 0.7-4.9, P < 0.009) while the percentage change in real Gross Domestic Product (GDP) was insignificant for all countries. Conclusions: There was no trade-off between public health policy and economy during the COVID-19 pandemic in the Nordic region. Sweden's relaxed and delayed COVID-19 health policy response did not benefit the economy in the short term, while leading to disproportionate COVID-19 hospitalizations and mortality.

Current Guidelines and Practice Recommendations to Prevent Hospital-Acquired Conditions After Major Orthopaedic Surgeries.

¼: In 2016, a total of 48,771 hospital-acquired conditions (HACs) were reported in U.S. hospitals. These incidents resulted in an excess cost of >$2 billion, which translates to roughly $40,000 per patient with an HAC. ¼: Current guidelines for the prevention of venous thromboembolism and surgical site infection consist primarily of antithrombotic prophylaxis and antiseptic technique, respectively. ¼: The prevention of catheter-associated urinary tract infection (CA-UTI) and in-hospital falls and trauma is done best via education. In the case of CA-UTI, this consists of training staff about the indications for catheters and their timely removal when they are no longer necessary, and in the case of in-hospital falls and trauma, advising the patient and family about the patient's fall risk and communicating the fall risk to the health-care team. ¼: Blood incompatibility is best prevented by implementation of a pretransfusion testing protocol. Pressure ulcers can be prevented via patient positioning, especially during surgery, and via postoperative skin checks.

Closed-incision negative pressure therapy at -125 mmHg significantly reduces surgical site complications following total hip and knee arthroplasties: A stratified meta-analysis of randomized controlled trials.

BACKGROUND: Closed-incision negative pressure wound therapy (ciNPT) has shown promising effects for managing infected wounds. This meta-analysis explores the current state of knowledge on ciNPT in orthopedics and addresses whether ciNPT at -125 mmHg or -80 mmHg or conventional dressing reduces the incidence of surgical site complications in hip and knee arthroplasty. METHODS: This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines and Cochrane Handbook. Prospective randomized controlled trials (RCTs) with ciNPT use compared to conventional dressings following hip and knee surgeries were considered for inclusion. Non-stratified and stratified meta-analyses of six RCTs were conducted to test for confounding and biases. A P value less than .05 was considered statistically significant. RESULTS: The included six RCTs have 611 patients. Total hip and knee arthroplasties were performed for 51.7% and 48.2% of the included population, respectively. Of 611 patients, conventional dressings were applied in 315 patients and 296 patients received ciNPT. Two ciNPT systems have been used across the six RCTs; PREVENA Incision Management System (-125 mmHg) (63.1%) and PICO dressing (-80 mmHg) (36.8%). The non-stratified analysis showed that the ciNPT system had a statistically significant, lower risk of persistent wound drainage as compared to conventional dressing following total hip and knee arthroplasties (OR = 0.28; P = .002). There was no difference between ciNPT and conventional dressings in terms of wound hematoma, blistering, seroma, and dehiscence. The stratified meta-analysis indicated that patients undergoing treatment with high-pressure ciNPT (120 mmHg) displayed significantly fewer overall complications and persistent wound drainage (P = .00001 and P = .002, respectively) when compared to low-pressure ciNPT (80 mmHg) and conventional dressings. In addition, ciNPT is associated with shorter hospital stays. (P = .005). CONCLUSION: When compared to conventional wound dressing and -80 mmHg ciNPT, the use of -125 mmHg ciNPT is recommended in patients undergoing total joint arthroplasty.

The Implementation of Lean Six Sigma Principles to Improve the Value of Care Delivery for Total Joint Arthroplasty Patients: The Perioperative Institute of Surgical Excellence Experience.

BACKGROUND: With the projected increase in the volume of total joint arthroplasty (TJA), minimizing variations in surgery times, hospital length of stay (LOS), discharge dispositions, and inhospital complication rates would help reduce costs and improve the quality of care. As the move toward bundle payment models gains further traction, providers will be reimbursed based on the quality and cost associated with the surgical episode. As such, it remains critical to design and implement high-quality cost-effective perioperative delivery care models. Lean Six Sigma (LSS) methodology has been well described in the healthcare field as a superior strategy in designing processes aimed at reducing waste while minimizing error rates. We present an institutional experience with the design and implementation of a LSS quality improvement process specific to the TJA pathway, with a hypothesis of expected decrease in case cancellation rate, inhospital LOS, 30-day readmissions, and inpatient rehabilitation utilization after program implementation. METHODS: In 2017, the Perioperative Institute of Surgical Excellence (PISE) program for lower limb TJA was designed and implemented at our institution over a 4-month duration. The program was designed following LSS principles as a low-cost easily adoptable model with a goal to reduce hospital LOS, case cancellation rate, 30-day readmissions, and inpatient rehabilitation utilization. RESULTS: A total of 328 patients (128 total hip arthroplasty and 200 total knee arthroplasty) were included in PISE compared with a total of 255 patients (106 total hip arthroplasty and 149 total knee arthroplasty) for the preimplementation cohort. After implementation of the model, and compared with a similar 4-month preimplementation duration, the pilot results revealed an increase in monthly case load by 28.6%, decrease in the 30-day readmission rate by 1.16%, inpatient rehabilitation utilization by 60%, a reduction of the average LOS by 0.8 days, and a case cancellations decrease by 51%. CONCLUSION: The implementation of the pilot protocol for PISE within our institution was successful in decreasing LOS, inpatient rehabilitation utilization, 30-day readmission, and case cancellation. Further assessment is needed to ascertain sustainability of the protocol over a longer duration and generalizability of the results at different institutions and surgeons.

Hospital-Acquired Conditions: A Review of Classical and Novel Risk Factors Following Total Hip and Knee Arthroplasties.

¼: In 2016, a total of 48,771 hospital-acquired conditions (HACs) were reported in U.S. hospitals. These incidents resulted in an excess cost of >$2 billion, which translates to roughly $41,000 per patient per HAC. ¼: In the settings of total hip arthroplasty (THA) and total knee arthroplasty (TKA), increased age, a body mass index of >35 kg/m2, male sex, diabetes mellitus, electrolyte disturbances, and a history of anemia increase the likelihood of surgical site infections. ¼: Institution-specific (surgical) risk factors such as increased tourniquet time, an operative time of >130 minutes, bilateral procedures, a femoral nerve block, and general anesthesia increase the risk of HACs in the settings of THA and TKA.

Direct anterior approach has short-term functional benefit and higher resource requirements compared with the posterior approach in primary total hip arthroplasty : a meta-analysis of functional outcomes and cost.

AIMS: It has been suggested that the direct anterior approach (DAA) should be used for total hip arthroplasty (THA) instead of the posterior approach (PA) for better early functional outcomes. We conducted a value-based analysis of the functional outcome and associated perioperative costs, to determine which surgical approach gives the better short-term outcomes and lower costs. METHODS: This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and the Cochrane Handbook. Several online databases were searched. Non-stratified and stratified meta-analyses were conducted to test the confounding biases in the studies which were included. The mean cost and probability were used to determine the added costs of perioperative services. RESULTS: The DAA group had significantly longer operating times (p < 0.001), reduced length of hospital stay by a mean of 13.4 hours (95% confidence interval (CI) 9.12 to 18; p < 0.001), and greater blood loss (p = 0.030). The DAA group had significantly better functional outcome at three (p < 0.001) and six weeks (p = 0.006) postoperatively according to the Harris Hip Score (HHS). However, there was no significant difference between the groups for the HHS at six to eight weeks (p = 0.230), 12 weeks (p = 0.470), six months (p = 0.740), and one year (p = 0.610), the 12-Item Short Form Survey (SF-12) physical score at six weeks (p = 0.580) and one year (p = 0.360), SF-12 mental score at six weeks (p = 0.170) and one year (p = 0.960), and University of California and Los Angeles (UCLA) activity scale at 12 weeks (p = 0.250). The mean non-stratified and stratified difference in costs for the operating theatre time and blood transfusion were $587.57 (95% CI 263.83 to 1,010.29) to $887.04 (95% CI 574.20 to 1,298.88) and $248.38 (95% CI 1,003.40 to 1,539.90) to $1,162.41 (95% CI 645.78 to 7,441.30), respectively, more for the DAA group. However, the mean differences in costs for the time in hospital were $218.23 and $192.05, respectively, less for the DAA group. CONCLUSION: The use of the DAA, rather than the PA, in THA has earlier benefits for function and pain. However, these are short-lasting, with no significant differences seen at later intervals. In addition the limited benefits were obtained with higher cumulative costs for DAA. Cite this article: Bone Joint J 2021;103-B(6):1078-1087.

Postoperative outcomes of ventral hernia repair in veterans.

BACKGROUND: Ventral hernia repair is a common procedure with reported 15% to 37% morbidity and 0.3% to 1.4% mortality rates. This study examines the 30-day morbidity and mortality of open and laparoscopic ventral hernia repair in veterans, along with the impact of body mass index on these outcomes. METHODS: The Veterans Affairs Surgical Quality Improvement Program was queried for all ventral hernia repairs during the period 2008 to 2015. In this retrospective analysis, we compared outcomes of open ventral hernia repair versus laparoscopic ventral hernia repair and among different body mass index classes. RESULTS: A total of 19,883 patients were identified (92.6% male, mean age 59.7, 53.1% obese, and 71.6% with American Society of Anesthesiologists class ≥III). There were 95 (0.5%) mortalities, and complications occurred in 1,289 (6.5%) patients. Open ventral hernia repair was performed in 60.2%; 14.5% were recurrent, and 3.3% were performed as an emergency operation. When compared with open ventral hernia repair, the laparoscopic ventral hernia repair group had higher mean body mass index, less patients with American Society of Anesthesiologists class ≥III, fewer emergency operations, longer operative time, less complications, decreased mortality, and shorter duration of stay. Body mass index 35.00 to 49.99 was predictive of overall complications in the open ventral hernia repair group. CONCLUSION: Ventral hernia repair can be performed in the veteran population with outcomes comparable to those in the private sector. Morbid obesity has a negative impact on ventral hernia repair outcomes that is most prominent following open surgery. Laparoscopic ventral hernia repair may offer superior outcomes when compared to open ventral hernia repair and may be considered.

Recent trends in cholecystectomy in US veterans.

INTRODUCTION: We hypothesize that the recent trend in performing cholecystectomy in US Veterans shows wide adoption of the laparoscopic technique and improvement in the outcome following both laparoscopic (LC) and open cholecystectomy (OC). This study utilizes the Veterans Affairs Surgical Quality Improvement Program database to examine the status and outcome of cholecystectomy. METHODS: A retrospective review of veterans who underwent cholecystectomy between 2008 and 2015 was performed. Data analysis included patient demographics, operations, and postoperative outcomes. Cochran-Armitage trend analysis was used to assess significant changes in outcome over the study period. p ≤ 0.05 was considered significant. RESULTS: A total of 40,722 patients (average age of 61 years) were included in the study (males 85.6%). LC was performed in the majority of patients (86.4%). Patients in the OC group (13.6%) were more likely to have advanced age (≥ 65 years) (47.6% vs 32.0%, p < 0.001) and higher ASA class (III-V) (81.9% vs 65.4%, p < 0.001) than those in the LC group. Compared with LC, OC had higher mortality rates at 30 days (1.3% vs 0.3%; OR = 1.6, p = 0.03), 3 months (2.6% vs 0.7%; OR = 1.7, p < 0.001), 6 months (3.9% vs 1.1%; OR = 1.5, p < 0.001) and 1 year (5.7% vs 2.0%; OR = 1.5, p < 0.001); higher rates of morbidity, including pneumonia (OR = 1.9, p < 0.001), deep venous thrombosis (OR = 2.4, p = 0.02), reoperation (OR = 1.8, p < 0.001), and superficial (OR = 4.9, p < 0.001) and deep (OR = 1.5, p = 0.01) surgical site infections; and a longer length of stay (6.5 days vs 2.6 days, p < 0.001). Trend analysis showed a significant decrease in both mortality (p = 0.02) and morbidity (p < 0.001) for LC over the study period, but no improvement in mortality (p = 0.35) and a only a minimal improvement in morbidity (p = 0.04) for OC. CONCLUSION: In the recent era, LC has been widely performed in the VA with significant improvement in outcome. Efforts are needed to adopt alternative approaches to planned OC and to improve postoperative outcomes.

Outcomes of cholecystectomy in US veterans with cirrhosis: Predicting outcomes using nomogram.

BACKGROUND: This study examines the outcomes of open and laparoscopic cholecystectomy (OC/LC) in veterans with cirrhosis and develops a nomogram to predict outcomes. METHODS: We analyzed the Veterans Affairs Surgical Quality Improvement Program to identify all patients with cirrhosis and ascites who underwent cholecystectomy from 2008 to 2015. Univariate and multivariate regression were used to identify predictors of morbidity and mortality. A predictive nomogram was constructed and internally validated. RESULTS: A total of 349 patients were identified. Overall, complications occurred in 18.7% of patients, and mortality was 3.8%. LC was performed in 58.9%, and 19.2% were preformed emergently. Overall, Model for End-Stage Liver Disease score was an independent factor of morbidity and mortality, while laparoscopic approach had a protective effect on morbidity. CONCLUSIONS: Although cholecystectomy is a high-risk operation in cirrhotic veterans, LC may have favorable outcomes than OC in selected patients. An easy-to-use nomogram to predict morbidity and mortality for cirrhotic patients undergoing cholecystectomy is proposed.

Review article: Patient characteristics that act as risk factors for intraoperative complications in hip, knee, and shoulder arthroplasties.

The number of annual THA's, TKA's, and TSA's is set to increase significantly by the year 2030, making it imperative to understand the risks for negative outcomes in these procedures. While research has studied the patient risk factors for perioperative and postoperative complications, there has been relatively little research for intraoperative complications. After a thorough literature review, the most supported finding was that patients with a BMI >30 had significantly more intraoperative blood loss than those with a BMI <30. All other relationships between patient risk factors and intraoperative complications of interest were inadequately studied.

The Joint Utilization Management Program-Implementation of a Bundle Payment Model and Comparison Between Year 1 and 2 Results.

BACKGROUND: Health care spending is projected to increase throughout the next decade alongside the number of total joint arthroplasties (TJAs) performed. Such growth places significant financial burden on the economic system. To address these concerns, Bundled Payments for Care Improvement (BPCI) is becoming a favorable reimbursement model. The aim of this study is to present the outcomes with BPCI model focused on the post-acute care (PAC) phase and compare the outcomes between years 1 and 2 of implementation. METHODS: The Joint Utilization Management Program (JUMP) was implemented in January 2014. Inclusion criteria were Medicare patients undergoing primary unilateral in-patient TJA procedures, outpatient procedures that resulted in an in-hospital admission, and trauma episodes that required TJA. Scorecards monitoring surgeons' performance and tracking length of stay (LOS) in the PAC setting were established. The data generated from these scorecards guided percentage sum-allocation from the total gain-shared sum among the participating providers. RESULTS: A total of 683 JUMP patients were assessed over two years. PAC utilization decreased between 2014 and 2015. The average LOS was longer in year 1 than year 2 (4.50 vs 3.19 days). In-patient rehabilitation (IPR) decreased from 6.45% to 3.22%, with a decrease in IPR average LOS of 1.47 days. The rate of 30-day readmission was lower for JUMP patients in 2015 than 2014 (8.77% vs 10.56%), with day of readmission being earlier (11.91 days vs 13.71 days) in 2014. CONCLUSION: Under the BPCI program, our experience with the JUMP model demonstrates higher efficiency of care in the PAC setting through reduced LOS, IPR admission rates, and 30-day readmission rate.

Improvement of Orthopedic Residency Programs and Diversity: Dilemmas and Challenges, an International Perspective.

BACKGROUND: To date, little has been published comparing the structure and requirements of orthopedic training programs across multiple countries. The goal of this study was to summarize and compare the characteristics of orthopedic training programs in the U.S.A., U.K., Canada, Australia, Germany, India, China, Saudi Arabia, Russia and Iran. METHODS: We communicated with responders using a predetermined questionnaire regarding the national orthopedic training program requirements in each respondent's home country. Specific items of interest included the following: the structure of the residency program, the time required to become an orthopedic surgeon, whether there is a log book, whether there is a final examination prior to becoming an orthopedic surgeon, the type and extent of faculty supervision, and the nature of national in-training written exams and assessment methods. Questionnaire data were augmented by reviewing each country's publicly accessible residency training documents that are available on the web and visiting the official website of the main orthopedic association of each country. RESULTS: The syllabi consist of three elements: clinical knowledge, clinical skills, and professional skills. The skill of today's trainees predicts the quality of future orthopedic surgeons. The European Board of Orthopedics and Traumatology (EBOT) exam throughout the European Union countries should function as the European board examination in orthopedics. We must standardize many educational procedures worldwide in the same way we standardized patient safety. CONCLUSION: Considering the world's cultural and political diversity, the world is nearly unified in regards to orthopedics. The procedures (structure of the residency programs, duration of the residency programs, selection procedures, using a log book, continuous assessment and final examination) must be standardized worldwide, as implemented for patient safety. To achieve this goal, we must access and evaluate more information on the residency programs in different countries and their needs by questioning them regarding what they need and what we can do for them to make a difference.