Active Amphetamine Abuse in Total Hip Arthroplasty Carries Increased Risk for Postoperative Surgical and Medical Complications.

Background: The impact of amphetamine abuse on total hip arthroplasty (THA) outcomes has yet to be studied. As the rates of methamphetamine abuse continue to rise, understanding the risk profile of this population is imperative. This study aims to determine the risk of major surgical and medical complications for those with amphetamine abuse undergoing THA, with the hypothesis that amphetamine abuse carries increased risk. Methods: A retrospective review was performed with all-claims data files of a large national database querying International Classification of Disease, tenth revision, procedure codes identifying 333,038 primary THA, and 1027 with active amphetamine abuse. Medical and surgical complications including infection, dislocation, implant failure, periprosthetic fracture, and revision, as well as length of hospital stay and 90-day readmission rate, were identified. Univariate analysis compared rates of dependent outcomes. To account for independent variables, logistic regression was performed using age, Charlson comorbidity index, sex, obesity, tobacco use, and alcohol use. The results were presented as odds ratios (OR) and P values with significance set at <0.05. Results: Patients with active amphetamine abuse carried an increased risk of dislocation (OR 1.82, P ≤ .001), infection (OR 2.37, P ≤ .001), mechanical complications (OR 1.64, P ≤ .001), periprosthetic fracture (OR 1.53, P ≤ .05), revision (OR 1.70, P ≤ .001), 90-day readmission (OR 1.79, P ≤ .001), as well as medical complications (1.43, P = .02) compared to those without documented amphetamine abuse. Conclusions: Patients with amphetamine abuse are at increased risk of postoperative surgical and medical complications following THA. We recommend consideration of these risks prior to primary THA in this patient population.

Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups.

Hip and knee replacement have been marked by racial and ethnic disparities in both utilization and postoperative adverse events among Medicare beneficiaries, but limited knowledge exists regarding racial and ethnic differences in joint replacement care among Medicaid beneficiaries. To close this gap, this study used Medicaid claims in 2018 and described racial and ethnic differences in the utilization and postoperative adverse events of elective joint replacements among Medicaid beneficiaries. Among the 2,260,272 Medicaid beneficiaries, 5987 had an elective joint replacement in 2018. Asian (0.05%, 95% confidence interval [CI]: 0.03%-0.07%) and Hispanic beneficiaries (0.12%, 95% CI: 0.07%-0.18%) received joint replacements less frequently than American Indian and Alaska Native (0.41%, 95% CI: 0.27%-0.55%), Black (0.33%, 95% CI: 0.19%-0.48%), and White (0.37%, 95% CI: 0.25%-0.50%) beneficiaries. Black patients demonstrated the highest probability of 90-day emergency department visits (34.8%, 95% CI: 32.7%-37.0%) among all racial and ethnic groups and a higher probability of 90-day readmission (8.0%, 95% CI: 6.9%-9.0%) than Asian (3.4%, 95% CI: 0.7%-6.0%) and Hispanic patients (4.4%, 95% CI: 3.4%-5.3%). These findings indicate evident disparities in postoperative adverse events across racial and ethnic groups, with Black patients demonstrating the highest probability of 90-day emergency department visits. This study represents an initial exploration of the racial and ethnic differences in joint replacement care among Medicaid beneficiaries and lay the groundwork for further investigation into contributing factors of the observed disparities.

New CMS Merit-Based Incentive Payment System Value Pathway After Total Knee and Hip Arthroplasty: Preparing for Mandatory Reporting.

This article discusses the implementation of a new Merit-Based Incentive Payment System Value Pathway (MVPs) applicable to elective total hip and total knee arthroplasty as created by Medicare and Medicaid Services (CMS) - the Improving Care for Lower Extremity Joint Repair MVP (MVP ID: G0058). We describe specific quality measures, surgeon-hospital collaborations, future developments with Quality Payment Program, and how lessons from early implementation will empower clinicians to participate in the refining of this MVP. The CMS has designed MVPs as a subset of measures relevant to a specialty or medical condition, in an effort to reduce the burden of reporting and improve assessment of care quality. Physicians and payors must be mindful of detrimental effects these measures in their current form may have on surgeons, institutions, and patients, including disincentivizing care for sicker or more vulnerable populations, and increased administrative costs. Early voluntary participation is crucial to gain valuable experience for the orthopedic community and in an effort to work alongside CMS to maximize care while minimizing cost for patients and burden for providers.

Cold Welding of the Synthes Femoral Neck System Encountered at Conversion to Arthroplasty: A Case Report.

CASE: The Synthes Femoral Neck System (FNS) is a relatively new device available to the market in 2019 designed to reduce complication and revision rates after femoral neck fracture stabilization. We present a 77-year-old man with Parkinson disease and avascular necrosis after femoral neck fracture initially managed with the FNS. Subsequent challenges in device removal occurred because of its propensity for bony integration, plate and locking screw welding, and screw head recess destruction. CONCLUSION: Surgeons must recognize the need for additional available equipment (e.g., burr or broken screw removal set) for successful extraction when FNS removal is required.

The James A. Rand Young Investigator's Award: Increased Revision Risk With Mobile Bearings in Total Knee Arthroplasty: An Analysis of the American Joint Replacement Registry.

BACKGROUND: Mobile-bearing (MB) total knee arthroplasty (TKA) may reduce wear and improve patellar tracking but may increase revision risk due to tibial component design, balance complexity, and bearing dislocation. We utilized the American Joint Replacement Registry to examine risk of revision with MB compared to fixed-bearing (FB) designs. METHODS: An analysis of primary TKA in patients over 65 years was performed with American Joint Replacement Registry data linked to Centers for Medicare and Medicaid Services data from 2012 to 2019. Analyses compared MB to FB designs with a subanalysis of implants from a single company. We identified 485,024 TKAs, with 452,199 (93.2%) FB-TKAs and 32,825 (6.8%) MB-TKAs. Cox proportional hazards regression modeling was used for all-cause revision and revision for infection, adjusting for sex, age, and competing risk of mortality. Event-free survival curves evaluated time to all-cause revision and revision for infection. RESULTS: MB-TKAs were at an increased risk for all-cause revision: hazard ratio (HR) 1.36 ([95% confidence interval (CI) 1.24-1.49], P < .0001) but not revision for infection: HR 1.06 ([95% CI 0.90-1.25], P = .52). When comparing implants within a single company, MB-TKAs were at an increased risk of all-cause revision: HR 1.55 ([95% CI 1.38-1.73], P < .0001). Event-free survival curves demonstrated increased risk for all-cause revision for MB-TKA across all time points, with a greater magnitude of risk up to 8 years. CONCLUSION: Although survivorship of both designs was outstanding, MB-TKA designs demonstrated increased risk for all-cause revision. Additional investigation is needed to determine if this is related to patient selection factors, surgical technique, bearing, or implant design.

The PROMISⓇ-Plus-Osteoarthritis of the Knee (OAK) profile measure integrates generic and condition-specific content to enhance relevance and efficiency.

OBJECTIVE: The Patient-Reported Outcomes Measurement Information System (PROMIS)-Plus-Osteoarthritis of the Knee (OAK) profile integrates universal PROMIS items with knee-specific items across 13 domains. We evaluated the psychometric properties of a subset of six domains associated with quality of life in people with OAK. STUDY DESIGN AND SETTING: In a cross-sectional study of OAK patients (n=600), we estimated reliability using Pearson and Spearman correlations with Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores and known-groups validity with PROMIS Global Health. Measure responsiveness was tested via paired t-tests in a longitudinal study (n=238), pre/post total knee replacement. RESULTS: Across the six domains, internal consistency reliability (Cronbach's alpha) was 0.77-0.95 and test-retest reliability (intraclass correlation coefficients) was ≥0.90. Correlations with Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores and PROMIS Global supported convergent and divergent validity. Known-groups validity testing revealed better scores in all domains for high vs. low global status groups, and knee-specific items added value in physical function and pain. All domains reflected (p<0.001) better health status scores at follow up. CONCLUSION: The six PROMIS-Plus-OAK profile domains demonstrated good psychometric characteristics. The measure integrates universal and knee-specific content to provide enhanced relevance, measurement precision and efficient administration for patient care and clinical research.

Acetabular Insufficiency Fractures in the Setting of Graft vs Host Disease: A Report of Two Cases.

We report a case series of 2 patients with unilateral acetabular insufficiency fractures who received allogeneic peripheral blood stem cell transplantation for hematologic malignancies complicated by chronic graft vs host disease. These were managed with uncemented cup and cage total hip arthroplasty and stabilization of posterior column with plating. Osteonecrosis of the acetabulum is an uncommon musculoskeletal complication of chronic graft vs host disease. The orthopedic impact of this disease should not be overlooked. Surgical intervention with this construct can provide necessary stability to improve patient function.

Spinal anesthesia in a designated block bay for total joint arthroplasty: improving operating room efficiency.

BACKGROUND: Creating highly efficient operating room (OR) protocols for total joint arthroplasty (TJA) is a challenging and multifactorial process. We evaluated whether spinal anesthesia in a designated block bay (BBSA) would reduce time to incision, improve first case start time and decrease conversion to general anesthesia (GA). METHODS: Retrospective cohort study on the first 86 TJA cases with BBSA from April to December 2018, compared with 344 TJA cases with spinal anesthesia performed in the OR (ORSA) during the same period. All TJA cases were included if the anesthetic plan was for spinal anesthesia. Patients were excluded if circumstances delayed start time or time to incision (advanced vascular access, pacemaker interrogation, surgeon availability). Data were extracted and analyzed via a linear mixed effects model to compare time to incision, via a Wilcoxon rank-sum test to compare first case start time, and via a Fisher's exact test to compare conversion to GA between the groups. RESULTS: In the mixed effect model, the BBSA group time to incision was 5.37 min less than the ORSA group (p=0.018). The BBSA group had improved median first case start time (30.0 min) versus the ORSA group (40.5 min, p<0.0001). There was lower conversion to GA 2/86 (2.33%) in the BBSA group versus 36/344 (10.47%) in the ORSA group (p=0.018). No serious adverse events were noted in either group. CONCLUSIONS: BBSA had limited impact on time to incision for TJA, with a small decrease for single OR days and no improvement on OR days with two rooms. BBSA was associated with improved first case start time and decreased rate of conversion to GA. Further research is needed to identify how BBSA affects the efficiency of TJA.

Angiotensin II blockade had no effect on range of motion after total knee arthroplasty: a retrospective review.

BACKGROUND: Stiffness and pain from arthrofibrosis following total knee arthroplasty (TKA) is a challenging problem, and investigating methods to prevent or reduce the incidence of postoperative arthrofibrosis is critical. Studies have shown that angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are efficacious at preventing fibrotic disorders in the lungs, liver, kidneys, and eyes. Our aim was to determine if ACEI or ARB use postoperatively reduces the incidence of arthrofibrosis in TKA patients. METHODS: In a retrospective review, we analyzed 141 consecutive TKAs performed at a single institution by a single surgeon from December 2010 to December 2014. Range of motion (ROM) in patients already taking ACEI, ARB, or neither medication was compared. Independent variables recorded were gender, age, BMI, presence of diabetes or preoperative opioid or statin use, preoperative ROM, and use of ACEIs or ARBs. Dependent variables recorded were postoperative knee flexion, extension, and total arc of motion. The primary outcome variable was success or failure of achieving 118o total arc of motion postoperatively, based on a study that found significant compromise of function in TKA patients who failed to obtain this goal. Secondary endpoints were postoperative knee flexion, extension, and total arc of motion. RESULTS: The use of neither ACEIs nor ARBs showed a significant difference in attaining greater than 118° of motion postoperatively compared to controls at 6 months. Significant predictors of obtaining > 118° motion were BMI (p < 0.05), preoperative flexion (p < 0.001), and preoperative total arc of motion (p < 0.002). Significant predictors of secondary ROM outcomes were preoperative ROM and BMI. CONCLUSIONS: Our study demonstrated that the principle predictor of postoperative ROM is BMI and preoperative ROM. The use of ACEIs or ARBs did not result in a greater likelihood of obtaining satisfactory ROM postoperatively.

Oncology Patients Are High Cost Outliers in Total Joint Replacement Bundled Payment Systems.

BACKGROUND: In 2016, the Centers for Medicare and Medicaid Services began its first mandatory bundled payment program, the Comprehensive Care for Joint Replacement (CJR) model, which covers a 90-day episode of care. This study determined whether oncology patients enrolled in the CJR bundle incur higher hospital costs than patients with osteoarthritis (OA). METHODS: A retrospective review of all patients enrolled in the CJR bundled payments system from April 1, 2016 to June 31, 2018 at a single academic medical center was conducted. To determine whether tumor patients had higher total episode costs, this group was compared to patients diagnosed with OA using a 2-tailed t-test. To adjust for moderators of total hospital costs, we used generalized linear regression with a log-link, including multiple variables abstracted from chart review. RESULTS: Three hundred fourteen patients met inclusion criteria (12 primary or metastatic tumors, 302 OA). Fifty-eight percent of tumor patients were over the target price vs 16% of OA patients. The mean tumor patient had $40,862 for total internal hospital costs compared to $16,356 in the OA group (P < .001). Length of stay was greater in the tumor group (6.75 vs 2.0 days, P < .001). A greater percentage of tumor patients were discharged to a skilled nursing facility (67% vs 27%, P = .006) with significantly higher skilled nursing facility episode costs ($18,852 vs $7731, P = .04). With adjustment for fracture status, tumor patients were 5.36 times more likely to exceed the CJR target price than OA patients (risk ratio 5.36, confidence interval 3.44-8.35, P < .001) and 50 times more likely to be outliers over the regional threshold than OA patients (risk ratio 50.33, confidence interval 16.33-155.19, P < .001). CONCLUSION: Oncology patients enrolled in the CJR bundled payment model incur significantly higher costs and have higher cost variability than patients with OA. We recommend that oncology patients be excluded from the CJR bundle.

The Epidemiology of Primary and Revision Total Hip Arthroplasty in Teaching and Nonteaching Hospitals in the United States.

INTRODUCTION: The purpose of this study was to examine the epidemiology of primary and revision total hip arthroplasty (THA) in teaching and nonteaching hospitals. METHODS: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample was queried from 2006 to 2010 to identify primary and revision THAs at teaching and nonteaching hospitals. RESULTS: A total of 1,336,396 primary and 223,520 revision procedures were identified. Forty-six percent of all primary and 54% of all revision procedures were performed at teaching hospitals. Teaching hospitals performed 17% of their THAs as revisions; nonteaching hospitals performed 12% as revisions. For primary and revision THAs, teaching hospitals had fewer patients aged >65 years, fewer Medicare patients, similar gender rates, more nonwhite patients, and more patients in the highest income quartile compared with nonteaching hospitals. Costs, length of stay, and Charlson Comorbidity Index scores were similar; however, the mortality rate was lower at teaching hospitals. CONCLUSIONS: This study found small but significant differences in key epidemiologic and outcome variables in examining primary and revision THA at teaching and nonteaching hospitals. LEVEL OF EVIDENCE: Level III.

Multiple cultures and extended incubation for hip and knee arthroplasty revision: impact on clinical care.

The impact on patient care of introducing a protocol of obtaining 5 or more intra-operative separate tissue biopsies that were cultured for 10 days was assessed for hip and knee arthroplasty revision. The charts of seventy-three patients undergoing 77 cases of revision arthroplasty were reviewed one year post-operatively. When compared to the prior standard of obtaining only one intra-operative culture, the protocol changed the microbiological diagnosis in 26/77 cases (34%, 95% Confidence Interval (CI): 23-45%) and antibiotic treatment in 23/77 cases (30%, 95% CI: 20-41%). In addition, the protocol had a predictive value of joint sterility in culture negative cases of 95% (95% CI: 85-99%). This data demonstrated the new protocol significantly changed patient care, and suggests that 1 or 2 cultures are insufficient. Adopting a similar protocol should be considered by surgeons and institutions as a new minimum standard for management of prosthetic joint infections.

Open treatment of femoroacetabular impingement is associated with clinical improvement and low complication rate at short-term followup.

BACKGROUND: Since the modern description of femoroacetabular impingement (FAI) a decade ago, surgical treatment has become increasingly common. Although the ability of open treatment of FAI to relieve pain and improve function has been demonstrated in a number of retrospective studies, questions remain regarding predictability of clinical outcome, the factors associated with clinical failure, and the complications associated with treatment. QUESTIONS/PURPOSES: We therefore described the change in clinical pain and function after open treatment, determined whether failure of treatment and progression of osteoarthritis was associated with Outerbridge Grade IV hyaline cartilage injury, and described the associated complications. METHODS: We retrospectively reviewed all 94 patients (96 hips) (55 males and 39 females; mean age, 28 years) who underwent surgical dislocation for femoroacetabular impingement between 2000 and 2008. Seventy-two of the 96 hips had acetabular articular cartilage lesions treated with a variety of methods, most commonly resection of damaged hyaline cartilage and labral advancement. Patients were followed for a minimum of 18 months (mean, 26 months; range, 18-96 months). RESULTS: Mean Harris hip scores improved from 67 to 91 at final followup. Six of the 96 hips (6%) were converted to arthroplasty or had worse Harris hip score after surgical recovery. Four of these six had Outerbridge Grade IV acetabular cartilage lesions and two had Legg-Calvé-Perthes disease or slipped capital epiphysis deformities. Two hips (2%) had refixation of the greater trochanter. CONCLUSIONS: At short-term followup, open treatment for femoroacetabular impingement in hips without substantial acetabular hyaline cartilage damage reduced pain and improved function with a low complication rate. Treatment of Outerbridge Grade IV acetabular cartilage delamination remains the major challenge. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The economic impact of reprocessing external fixation components.

BACKGROUND: The trend toward temporizing external fixation of complex fractures has resulted in increased expenditures for these devices. Increasing pressure to reduce health-care expenditures has led to exploration of reuse of equipment intended for single use. Devices must be tested and recertified prior to redeployment in hospital stock. We report the rate of manufacturer recertification and institutional cost savings associated with a reuse program approved by the United States Food and Drug Administration. METHODS: All Hoffmann-II external fixation components that had been removed at our institution during the study period were submitted to the manufacturer for visual inspection and mechanical testing. Pass rates for original components and previously recycled components were determined. With use of a conservative pass rate and the assumption of a maximum of three recertifications of each component, the total potential hospital savings on external fixation were calculated. RESULTS: The first pass rate was 76%. The second pass rate (i.e., the rate for components that had already been recertified once and had been sent for a second recertification) was 83%, but that rate was derived from a limited sample. On the basis of a conservative pass-rate estimate of 75%, the predicted average number of uses of a recyclable component was 2.7. The recertified components were sold back to our hospital at 50% of the original price. Because carbon-fiber bars and half-pins are not recycled, 85% of the charges expended on a new external fixation component are spent on portions of the system that are recyclable. The potential total savings on reusable components was found to be 32%, with a total savings of 27% for the whole external fixation system. No recertified components failed in clinical use over the course of the study. CONCLUSIONS: With the expansion of cost-control efforts, the recycling of medical devices appears inevitable. Previous data have demonstrated the safety of reuse of external fixation devices, and this study confirms that finding. Our paper demonstrates the real cost savings associated with a manufacturer-based testing and recertification program. Issues of voluntary participation in reuse programs, component ownership, and the impact of savings on patient charges are yet to be worked out by individual institutions.

Diagnosis and management of synovial sarcoma.

Synovial sarcoma is a unique tumor with substantial promise for biologically targeted therapy. Although it demonstrates moderate chemosensitivity, with approximately 50% response rates to ifosfamide- and doxorubicin-containing regimens, it has a diagnostic translocation and a potentially informative chimeric protein product. Although surgical management remains the cornerstone to effect local control, therapeutic advancements are unlikely to occur by continuing to include advanced cases of synovial sarcomas in trials with other soft tissue sarcomas. Rather, attention should be turned toward prospective molecular targets and development of novel agents to exploit them. Research should be directed at understanding the fusion protein of the X,18 translocation and further validating the role of overexpressed proteins in synovial sarcoma. Meanwhile, carefully designed clinical trials of these agents, with translational correlates, will provide in vivo data to complement the preclinical experience.