Is It Getting More Expensive to Treat Patients Who Have a High Comorbidity Burden? Financial Trends in Total Knee Arthroplasty From 2013 to 2021.

BACKGROUND: Utilization of total knee arthroplasty (TKA) continues to rise among patients who have a high comorbidity burden (HCB). With changes in reimbursement models over the past decade, it is essential to assess the financial impact of HCB TKA on healthcare systems. This study aimed to examine trends in revenue and costs associated with TKA in HCB patients over time. METHODS: Of 14,978 TKA performed at a large, urban academic medical center between 2013 and 2021, we retrospectively analyzed HCB patients (Charlson comorbidity index ≥ 5 and American Society of Anesthesiology scores of 3 or 4). A total of 1,156 HCB TKA patients who had complete financial data were identified. Patient demographics, perioperative data, revenue, costs, and contribution margin were collected for each patient. Changes in these financial values over time, as a percentage of 2013 values, were analyzed. Linear regression was performed with a trend analysis to determine significance. RESULTS: From 2013 to 2021, the percentage of HCB TKAs per year increased from 4.2% in 2013 to 16.5% in 2021 (P < .001). The revenue of TKA in HCB patients remained steady (P = .093), while direct costs increased significantly (32.0%; P = .015), resulting in a decline of contribution margin to a low of 82.3% of 2013 margins. There was no significant change in rates of 90-day complications or home discharge following HCB TKA during the study period. CONCLUSIONS: The results of this study indicate a major rise in cost for TKA among HCB patients, without a corresponding rise in revenue. As more patients who have HCB become candidates for TKA, the negative financial impact on institutions should be considered, as payments to institutions do not adequately reflect patient complexity. A re-evaluation of institutional payments for medically complex TKA patients is warranted to maintain patient access among at-need populations.

Factors affecting operating room scheduling accuracy for primary and revision total hip arthroplasty: a retrospective study.

INTRODUCTION: Optimizing operating room (OR) scheduling accuracy is important for OR efficiency, meeting patient expectations, and maximizing value for health systems. However, limited data exist on factors influencing the precision of Total Hip Arthroplasty (THA) OR scheduling. This study aims to identify the factors influencing the accuracy of OR scheduling for THA. METHODS: A retrospective review of 6,072 THA (5,579 primary THA and 493 revision THA) performed between January 2020 and May 2023 at an urban, academic institution was conducted. We collected baseline patient characteristics, surgeon years of experience, and compared actual wheels in to wheels out (WIWO) OR time against scheduled OR time. Significant scheduling inaccuracies were defined as actual OR times deviating by at least 15% from scheduled OR times. Logistic regression analyses were employed to assess the impact of patient, surgeon, and intraoperative factors on OR scheduling accuracy. RESULTS: Using adjusted odds ratios, primary THA patients who had a lower BMI and surgeons who had less than 10 years of experience were associated with overestimation of OR time. Whereas, higher BMI, younger age, general anesthesia, non-primary osteoarthritis indications, and afternoon procedure start times were linked to underestimation of OR time. For revision THA, lower BMI and fewer components revised correlated with overestimated OR time. Men, higher BMI, more components revised, septic indication for surgery, and morning procedure start times were associated with underestimation of OR time. CONCLUSION: This study highlights several critical patient, surgeon, and intraoperative factors influencing OR scheduling accuracy for THA. OR scheduling models should consider these factors to enhance OR efficiency.

Clinical outcomes of patellofemoral arthroplasty: robotic assistance produces superior short and mid-term outcomes.

INTRODUCTION: Patellofemoral arthroplasty (PFA) has been shown to provide symptomatic improvement for isolated patellofemoral osteoarthritis (PFOA). The efficacy of robotic-assisted PFA and the most suitable PFA implant design, however, remain ongoing matters of debate. This study sought to compare clinical outcomes between patients who underwent robotic-assisted versus conventional PFAs with inlay and onlay prosthetic designs. METHODS: A single-center retrospective review found 237 knees (211 patients) which underwent PFA between 2011 and 2021. One hundred eighty-four knees were included in the final analysis after cases were excluded for having indications other than osteoarthritis or having less than one year of follow-up. There were 90 conventional PFAs and 94 robotic-assisted PFAs performed. Inlay components were implanted in 89 knees and onlay components were implanted in 95 knees. Propensity score matching was utilized to address demographic differences between groups. RESULTS: Overall, there was a revision-free survivorship rate of 89.7% with an average time to follow-up of 4.6 years (range 1.2 to 11.1). Twenty-nine knees (15.8%) required various non-conversion procedures. The conventional matched cohort exhibited a higher all-cause revision rate, accounting for revision PFAs and conversions to TKA, (18.8 vs. 6.4%, p = 0.014) and a shorter mean time to revision than the robotic-assisted cohort (3.1 vs. 5.8 years, p = 0.026). A Kaplan-Meier survivorship curve showed differences between the conventional and robotics cohorts (p = 0.041). All revisions following robotic-assisted PFA were caused by progression of osteoarthritis, whereas conventional PFAs also required revision due to aseptic loosening and patellar maltracking. The rate of infection resulting in irrigation and debridement was higher for conventional cases (4.3 vs. 0%, p = 0.041). No significant differences in clinical outcomes between the inlay and onlay prosthetic design matched cohorts were identified. CONCLUSION: PFA is an effective treatment for addressing advanced patellofemoral arthritis. Robotic-assisted surgery may lead to improved clinical outcomes. LEVEL OF EVIDENCE: III.

Mid-term outcomes of a kinematically designed cruciate retaining total knee arthroplasty.

BACKGROUND: Advances in implant material and design have allowed for improvements in total knee arthroplasty (TKA) outcomes. A cruciate retaining (CR) TKA provides the least constraint of TKA designs by preserving the native posterior cruciate ligament. Limited research exists that has examined clinical outcomes or patient reported outcome measures (PROMs) of a large cohort of patients undergoing a CR TKA utilizing a kinematically designed implant. It was hypothesized that the studied CR Knee System would demonstrate favorable outcomes and a clinically significant improvement in pain and functional scores. AIM: To assess both short-term and mid-term clinical outcomes and PROMs of a novel CR TKA design. METHODS: A retrospective, multi-surgeon study identified 255 knees undergoing a TKA utilizing a kinematically designed CR Knee System (JOURNEY™ II CR; Smith and Nephew, Inc., Memphis, TN) at an urban, academic medical institution between March 2015 and July 2021 with a minimum of two-years of clinical follow-up with an orthopedic surgeon. Patient demographics, surgical information, clinical outcomes, and PROMs data were collected via query of electronic medical records. The PROMs collected in the present study included the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and Patient-Reported Outcomes Measurement Information System (PROMIS®) scores. The significance of improvements in mean PROM scores from preoperative scores to scores collected at six months and two-years postoperatively was analyzed using Independent Samples t-tests. RESULTS: Of the 255 patients, 65.5% were female, 43.8% were White, and patients had an average age of 60.6 years. Primary osteoarthritis (96.9%) was the most common primary diagnosis. The mean surgical time was 105.3 minutes and mean length of stay was 2.1 d with most patients discharged home (92.5%). There were 18 emergency department (ED) visits within 90 d of surgery resulting in a 90 d ED visit rate of 7.1%, including a 2.4% orthopedic-related ED visit rate and a 4.7% non-orthopedic-related ED visit rate. There were three (1.2%) hospital readmissions within 90 d postoperatively. With a mean time to latest follow-up of 3.3 years, four patients (1.6%) required revision, two for arthrofibrosis, one for aseptic femoral loosening, and one for peri-prosthetic joint infection. There were significant improvements in KOOS JR, PROMIS Pain Intensity, PROMIS Pain Interference, PROMIS Mobility, and PROMIS Physical Health from preoperative scores to six month and two-year postoperative scores. CONCLUSION: The evaluated implant is an effective, novel design offering excellent outcomes and low complication rates. At a mean follow up of 3.3 years, four patients required revisions, three aseptic and one septic, resulting in an overall implant survival rate of 98.4% and an aseptic survival rate of 98.8%. The results of our study demonstrate the utility of this kinematically designed implant in the setting of primary TKA.