Why personalized surgery is the future of hip and knee arthroplasty: a statement from the Personalized Arthroplasty Society.

Although hip and knee joint replacements provide excellent clinical results, many patients still do not report the sensation and function of a natural joint. The perception that the joint is artificial may result from the anatomical modifications imposed by the surgical technique and the implant design. Moreover, the joint replacement material may not function similarly to human tissues. To restore native joint kinematics, function, and perception, three key elements play a role: (i) joint morphology (articular surface geometry, bony anatomy, etc.), (ii) lower limb anatomy (alignment, joint orientation), and (iii) soft tissue laxity/tension. To provide a 'forgotten joint' to most patients, it is becoming clear that personalizing joint replacement is the key solution. Performing a personalized joint replacement starts with patient selection and preoperative optimization, followed by using a surgical technique and implant design aimed at restoring the patient's native anatomy, creating optimal implant-to-bone stress transfer, restoring the joint's native articular range of motion without imposed limitations, macro- and micro-stability of the soft tissues, and a bearing whose wear resistance provides lifetime survivorship with unrestricted activities. In addition, the whole perioperative experience should follow enhanced recovery after surgery principles, favoring a rapid and complication-free recovery. As a new concept, some confusion may arise when applying these personalized surgery principles. Therefore, the Personalized Arthroplasty Society was created to help structure and accelerate the adoption of this paradigm change. This statement from the Society on personalized arthroplasty will serve as a reference that will evolve with time.

Unrestricted kinematic alignment corrects fixed flexion contracture in robotically aligned total knees without raising the joint line in extension.

PURPOSE: Mechanically Aligned Total Knee Arthroplasty (MA TKA) typically addresses fixed flexion contractures (FFC) by raising the joint line during extension. However, in unrestricted Kinematically Aligned TKA (KA TKA) utilizing a caliper-based resection technique, the joint line is not raised. This study aims to determine the efficacy of KA TKA in restoring full extension in patients with FFC without increasing distal femoral resection, considering tibial bone resection and sagittal component positioning. METHODS: A retrospective study was conducted by a single surgeon, involving patients who underwent primary robotically assisted cruciate retaining unrestricted KA TKA between June 1, 2021, and December 1, 2022. Complete intraoperative resection and alignment data were recorded, including the thickness of distal femoral and proximal tibial bone cuts. Patients with a preoperative FFC ≥ 5° (study group) were compared to those with FFC < 5° (control group). The impact of variations in tibial resection and sagittal component positioning was assessed by comparing the heights of medial and lateral resections, sagittal femoral component flexion, and tibial slope. Group comparisons were analyzed using the Wilcoxon Signed Rank Test, with a significance level set at p < 0.05. RESULTS: A total of 48 KA TKA procedures met the inclusion criteria, with 24 performed on women. The mean preoperative FFC in the study group was 11.2° (range: 5-25°), while the control group exhibited 1° (range: 0-4°) (p < 0.001). There were no statistically significant differences observed between the study and control groups in terms of distal femoral resections, both medially (p = 0.14) and laterally (p = 0.23), as well as tibial resection heights, both medially (p = 0.66) and laterally (p = 0.74). The alignment of the femoral component flexion and tibial slope was comparable between the two groups (p = 0.31 and p = 0.54, respectively). All patients achieved within 5 degrees of full extension at closure. CONCLUSION: Robotic arm-assisted unrestricted KA TKA effectively restores full extension without raising the joint line during extension for patients with a preoperative fixed flexion contracture. LEVEL OF EVIDENCE: III.

Impact of an automated peri-procedural digital health intervention on rates of emergency department visits and readmissions.

BACKGROUND: Providing timely peri-procedural education, reminders, and check-ins can improve patient adherence and clinical outcomes. We sought to retrospectively evaluate the impact of a peri-procedural digital health tool on emergency department (ED) visits and readmissions. METHODS: A digital health tool for peri-procedural care engaged patients at scheduled intervals, resulting in an overall engagement score. Multivariate models determined predictors of tool engagement and post-procedural 30- and 90-day rehospitalizations and ED visits. RESULTS: 11,737 unique completed procedures were analyzed from 10,438 patients. Patients of Black and Latinx race/ethnicity (vs White), those with Medicare and Medicaid insurance (vs commercial), and those with non-activated patient portals (vs activated) were less likely to engage. After adjustment for confounders, higher engagement with the tool was associated with lower rates of 30-day hospitalizations (OR 0.64), 90-day hospitalizations (OR 0.65), and 90-day ED visits (OR 0.77). CONCLUSIONS: Highly engaged patients had fewer 30-day and 90-day ED visit and readmissions, even after adjustment for key confounders. Engagement, and thus the resulting benefits, were not equitably distributed.

The Microbiome of Osteoarthritic Hip and Knee Joints: A Prospective Multicenter Investigation.

BACKGROUND: Recent advances in high-throughput DNA sequencing technologies have made it possible to characterize the microbial profile in anatomical sites previously assumed to be sterile. We used this approach to explore the microbial composition within joints of osteoarthritic patients. METHODS: This prospective multicenter study recruited 113 patients undergoing hip or knee arthroplasty between 2017 and 2019. Demographics and prior intra-articular injections were noted. Matched synovial fluid, tissue, and swab specimens were obtained and shipped to a centralized laboratory for testing. Following DNA extraction, microbial 16S-rRNA sequencing was performed. RESULTS: Comparisons of paired specimens indicated that each was a comparable measure for microbiological sampling of the joint. Swab specimens were modestly different in bacterial composition from synovial fluid and tissue. The 5 most abundant genera were Escherichia, Cutibacterium, Staphylococcus, Acinetobacter, and Pseudomonas. Although sample size varied, the hospital of origin explained a significant portion (18.5%) of the variance in the microbial composition of the joint, and corticosteroid injection within 6 months before arthroplasty was associated with elevated abundance of several lineages. CONCLUSIONS: The findings revealed that prior intra-articular injection and the operative hospital environment may influence the microbial composition of the joint. Furthermore, the most common species observed in this study were not among the most common in previous skin microbiome studies, suggesting that the microbial profiles detected are not likely explained solely by skin contamination. Further research is needed to determine the relationship between the hospital and a "closed" microbiome environment. These findings contribute to establishing the baseline microbial signal and identifying contributing variables in the osteoarthritic joint, which will be valuable as a comparator in the contexts of infection and long-term arthroplasty success. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Practical Artificial Intelligence: Realistic Ways It Can Help Orthopaedic Surgeons and the Challenges It Will Face.

Artificial intelligence can improve various orthopaedic subspecialties in the next 5 to 10 years. There are several image recognition applications particularly in orthopedic trauma and orthopedic spine. Specifically, convolutional neural networks have been shown to work well for making diagnoses and recreating more advanced imaging form radiographs. There are many applications of artificial intelligence with predictive in total joint arthroplasty, particularly with shared decision making. And there are many day-to-day applications that can be improved with natural language processing, particularly administrative tasks. This includes several applications in billing and charting. When investigating the landscape of artificial intelligence in healthcare, there are many barriers to their adoption. This includes overcoming bias, incorporating new applications into clinical workflow, regulatory approval, and billing.

Kinematic Alignment of Failed Mechanically Aligned Total Knee Arthroplasty Restored Constitutional Limb Alignment and Improved Clinical Outcomes: A Case Report of 7 Patients.

Background: Stiffness and mid-flexion instability (MFI) is a recognized complication of mechanically aligned (MA) total knee arthroplasty (TKA). Kinematic alignment (KA) has been proposed as a means by which to restore normal joint motion following TKA and potentially avoid stiffness and MFI. Several studies have documented improved function with KA when compared to MA. The aim of this study was to determine if revising MA TKAs failed for either MFI or stiffness into KA resolves MFI, achieves better range of motion, and improves clinical outcomes. Methods: A retrospective, single surgeon review was performed. All consecutive TKAs revised from MA into KA for MFI (def: >5 mm opening between 10° and 45° of flexion) or stiffness (def: flexion ≤90°) between January 2017 and May 2021 were included. The constitutional limb alignment of the operated knee was "reverse engineered" by measuring the coronal alignment of the contralateral healthy knee or pre-operative x-rays. Femoral Rotation was set at 3 degrees internal to the trans epicondylar axis. All coronal and sagittal angles were digitally measured on pre- and post-operative long leg and maximum flexion radiographs (minimum 12 month follow-up). The Knee Society Score (KSS) and range of motion assessments were collected preoperatively and at final follow-up. Comparisons between groups were done with a paired T test. Significance was set at p < 0.05. Results: Seven patients were included. Two were male, the mean age was 70.1 years (±9.3), mean follow-up was 32 months (±26). Three patients were revised for MFI and 4 for stiffness. Constitutional limb alignment was restored within 2 degrees for all patients. The mean total KSS gain was 65.9 (±18.1). The total KSS was significantly improved in all patients (p < 0.001). The mean maximum flexion gain was 30 deg (±23°) (p = 0.01). MFI was absent in all patients. Conclusion: In a limited series of patients, revision of stiff or unstable TKA from MA to KA resulted in improved range of motion by 30° on averages, resolved instability without the use of constrained liners, improved clinical outcomes with a mean gain of 75 points on the KSS, and restored constitutional limb alignment within 2 degrees in all patients. As these short term results are promising, further study is warranted.

An Enhanced Understanding of Culture-Negative Periprosthetic Joint Infection with Next-Generation Sequencing: A Multicenter Study.

BACKGROUND: The challenges of culture-negative periprosthetic joint infection (PJI) have led to the emergence of molecular methods of pathogen identification, including next-generation sequencing (NGS). While its increased sensitivity compared with traditional culture techniques is well documented, it is not fully known which organisms could be expected to be detected with use of NGS. The aim of this study was to describe the NGS profile of culture-negative PJI. METHODS: Patients undergoing revision hip or knee arthroplasty from June 2016 to August 2020 at 14 institutions were prospectively recruited. Patients meeting International Consensus Meeting (ICM) criteria for PJI were included in this study. Intraoperative samples were obtained and concurrently sent for both routine culture and NGS. Patients for whom NGS was positive and standard culture was negative were included in our analysis. RESULTS: The overall cohort included 301 patients who met the ICM criteria for PJI. Of these patients, 85 (28.2%) were culture-negative. A pathogen could be identified by NGS in 56 (65.9%) of these culture-negative patients. Seventeen species were identified as common based on a study-wide incidence threshold of 5%. NGS revealed a polymicrobial infection in 91.1% of culture-negative PJI cases, with the set of common species contributing to 82.4% of polymicrobial profiles. Escherichia coli, Cutibacterium acnes, Staphylococcus epidermidis, and Staphylococcus aureus ranked highest in terms of incidence and study-wide mean relative abundance and were most frequently the dominant organism when occurring in polymicrobial infections. CONCLUSIONS: NGS provides a more comprehensive picture of the microbial profile of infection that is often missed by traditional culture. Examining the profile of PJI in a multicenter cohort using NGS, this study demonstrated that approximately two-thirds of culture-negative PJIs had identifiable opportunistically pathogenic organisms, and furthermore, the majority of infections were polymicrobial. LEVEL OF EVIDENCE: Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

No Correlation Between Clinical Outcomes and Changes in the Tibia-Metaphyseal Angle Following Total Knee Arthroplasty: A Retrospective Study.

BACKGROUND: Despite numerous advances in the implant design and surgical technique, improvement in patient satisfaction following total knee arthroplasty (TKA) has plateaued. Various TKA alignment strategies have been introduced that impact the coronal positioning of the tibial component relative to the native joint line. This study aims to analyze if postoperative variance of the joint line from preoperative native alignment is correlated with changes in patient-reported outcomes following primary TKA. METHODS: A retrospective review of an academic center's patient population identified all primary TKAs between 2013 and 2021 with full-length, standing radiographs and patient-reported outcome measures (PROMs) data. These measures included the Knee injury and Osteoarthritis Outcome Score for Joint Replacement, Patient-Reported Outcome Measurement Information System, and Veterans RAND 12 scores. Preoperative and postoperative radiographic measurements for hip-knee angle, tibia-metaphyseal angle, tibial-axis orientation angle, and joint-line obliquity angle were recorded. Three-month, 1-year, and 2-year PROM scores were correlated with the change in degrees for each of the angles using a Spearman's correlation. A Mann-Whitney U-test was used to compare angular changes with a change in PROM scores. RESULTS: One hundred and ninety nine patients (204 knees) with a mean age of 67 years were included. Average follow-up was 23 months. Three-month, 1-year, and 2-year follow-up rates were 93%, 64%, and 34%, respectively. Improvements were seen across all PROMs regardless of an angular change. CONCLUSION: There were no clear correlations between PROMs and variation in joint line obliquity in the coronal plane. These data suggest that the magnitude of the variation in coronal tibial alignment from native alignment does not impact PROMs. Further study is indicated to correlate an angular change with functional measures.

Impact of fatty degeneration on the functional outcomes of 38 patients undergoing surgical repair of gluteal tendon tears.

BACKGROUND: Gluteal tendon tears (GTT) can cause pain and weakness of the hip. We analyze the impact of gluteal muscle fatty degeneration, atrophy and tear morphology on clinical outcomes of surgical repair. METHODS: All sequential patients receiving surgical repair of GTTs via anchor sutures between 1/2015 and 11/2018 were retrospectively identified. MRIs were reviewed by a radiologist for tendon retraction, muscle atrophy and tear size. The Goutallier-Fuchs Classification (GFC) was used to quantify fatty degeneration as < 2° or ≥ 2°. Demographic and clinical variables were abstracted from the electronic records. The surveys HHS Section 1 and HOOS Jr. were obtained at last follow-up. The Pearson correlation and one-way ANOVA tests served for statistical analysis of clinical variance. RESULTS: 38 patients were identified, 29 (76.3%) were female. The average age was 67. Of the 11 (28.9%) patients with a prior hip arthroplasty 87.5% of primary THAs had a direct lateral approach. 29 (76.3%) patients were treated open and 9 (23.7%) arthroscopically. At an average follow-up of 20.9 months, patients reported a significant improvement in pain (97%), analgesic use (85.7%), limp (52.6%) and abduction strength (54.2%) (all: P ≤ 0.01). GFC ≥ 2° were associated with significantly worse outcomes in terms of limp (0.19/3 vs. 1.2/3, P = 0.05), HHS-S1 (58.19 vs. 71.68, P = 0.04) and complication rates (37.5% vs. 0%, P = 0.02). There was a strong correlation between tear retraction (P = 0.005), tear size (P = 0.009) and muscle atrophy (P = 0.001) with GFC ≥ 2° but not with clinical outcomes. GFC ≥ 2° was strongly related to lateral THA exposures (P < 0.001). Surgical approach had no impact on clinical outcomes. CONCLUSION: While fatty degeneration can negatively impact functional outcomes, pain relief is reliably achieved. Tear morphology and muscle atrophy did not correlate with outcomes in this patient cohort. Patients should be counseled to expect a residual limp after surgery if they have GFC ≥ 2° on MRI.

Multicenter Evaluation of Telehealth Utilization in Hip and Knee Arthroplasty Before and for One Year During the COVID-19 Pandemic.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic has led to an increase in telehealth utilization across the health-care sector. It is unknown if telehealth use among hip and knee arthroplasty clinics has remained an important health-care delivery platform. The purpose of the present study was to analyze telehealth utilization before and for 1 year during the pandemic among four varied hip and knee arthroplasty clinics. METHODS: Retrospective data were available from four regionally diverse hip and knee arthroplasty centers. Data on volume of patient visits, demographics, visit types (new visit, follow-up, postoperative visit, other), and visit modality (in-person, telehealth, telephone) were available from January 2020 through April 2021. Data from the centers were analyzed as a total and separately, using chi-squared and Fisher exact tests. RESULTS: Among the four centers, there were 296,540 hip and knee arthroplasty outpatient clinic visits between January 2020 and April 2021. Of those, 15,240 (5%) were telehealth visits. Before March 2020, less than 0.1% of visits across centers occurred over telehealth. The highest utilization of telehealth visits occurred in March 2020 (>55%) and April 2020 (>25%). From August 2020 until April 2021, telehealth visits accounted for 2%-3% of total visits. Younger patients (<50 years old) were most likely to use telehealth. Follow-up and postoperative were the most likely telehealth visits. CONCLUSION: Telehealth utilization peaked during March and April of 2020 and has since reverted to near prepandemic levels. Younger patients and lower complexity visits such as postoperative or follow-up visits are more likely to use telehealth.

Neurologic Dysfunction Associated With Mechanically Assisted Crevice Corrosion and Elevated Cobalt Ion Levels After Total Hip Arthroplasty.

Adverse local tissue reactions secondary to mechanically assisted crevice corrosion (MACC) at the trunnion is a complication of total hip arthroplasty known to cause local soft-tissue damage. However, what is not as well appreciated is that MACC in metal-on-polyethylene (MOP) articulations can lead to cobalt ion serum elevations with associated neurological dysfunction just as in metal-on-metal articulations. We report a compelling case for the association of neurologic dysfunction tied to metal ion elevations secondary to MACC at two distinct MOP tapers in a 58-year-old intensive care unit nurse with two hips implanted 3 years apart. This report further raises awareness about the potential of MACC-generated elevated ion levels to produce neurological symptoms that might otherwise be overlooked in patients with MOP articulations.

Tibial Mechanical Axis Is Nonorthogonal to the Floor in Varus Knee Alignment.

BACKGROUND: Classical models of the knee assume the joint line is parallel to the floor and the tibial mechanical axis (TMA) is orthogonal to the floor. Our study characterizes the angle subtended by the TMA and floor during bipedal stance, called the tibial axis orientation angle (TAOA), and tests the assumption that the TMA should be orthogonal to the floor. METHODS: We reviewed the nonoperative knee on full-length, standing radiographs in patients undergoing total knee arthroplasty between 2013 and 2017. Radiographic measurements were obtained for hip-knee-ankle axis, medial proximal tibial angle (MPTA), joint line orientation angle, and TAOA and correlated by regression analysis. The cohort was stratified by hip-knee-ankle axis alignment to determine statistical differences in knee angle values. Demographic data were collected to assess associations with knee angles. RESULTS: Our cohort included 68 patients, with 56% female and average age of 62.3 years. Varus knees comprised 56% of the cohort, with 7% neutral and 37% valgus. The cohort demonstrated an MPTA of 3.06°, TAOA of 2.67°, and joint line orientation angle of 0.36°. Varus knees had a higher MPTA (4.26°) and TAOA (4.74°) than valgus knees (P < .001). MPTA and TAOA were correlated on regression analysis (r2 = 0.465), and all angles were statistically different between sexes. CONCLUSION: The angle between the TMA and floor, called TAOA, is not orthogonal in normal knees, contrary to assumptions in classical biomechanics. Knee angles vary significantly between varus and valgus cohorts, and the distinction between these cohorts should be noted when evaluating normal joint line angles.

Predictive Models for Clinical Outcomes in Total Knee Arthroplasty: A Systematic Analysis.

BACKGROUND: Predictive modeling promises to improve our understanding of what variables influence patient satisfaction after total knee arthroplasty (TKA). The purpose of this article was to systematically review the relevant literature using predictive models of clinical outcomes after TKA. The aim was to identify the predictor strategies used for systematic data collection with the highest likelihood of success in predicting clinical outcomes. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol systematic review was conducted using 3 databases (MEDLINE, EMBASE, and PubMed) to identify all clinical studies that had used predictive models or that assessed predictive features for outcomes after TKA between 1996 and 2020. The ROBINS-I tool was used to evaluate the quality of the studies and the risk of bias. RESULTS: A total of 75 studies were identified of which 48 met our inclusion criteria. Preoperative predictive factors strongly associated with postoperative clinical outcomes were knee pain, knee-specific Patient-Reported Outcome Measure (PROM) scores, and mental health scores. Demographic characteristics, pre-existing comorbidities, and knee alignment had an inconsistent association with outcomes. The outcome measures that correlated best with the predictive models were improvement of PROM scores, pain scores, and patient satisfaction. CONCLUSIONS: Several algorithms, based on PROM improvement, patient satisfaction, or pain after TKA, have been developed to improve decision-making regarding both indications for surgery and surgical strategy. Functional features such as preoperative pain and PROM scores were highly predictive for clinical outcomes after TKA. Some variables such as demographics data or knee alignment were less strongly correlated with TKA outcomes. LEVEL OF EVIDENCE: Systematic review - Level III.

FDA public workshop: Orthopaedic sensing, measuring, and advanced reporting technology (SMART) devices.

Traditional orthopaedic devices do not communicate with physicians or patients post-operatively. After implantation, follow-up of traditional orthopaedic devices is generally limited to episodic monitoring. However, the orthopaedic community may be shifting towards incorporation of smart technology. Smart technology in orthopaedics is a term that encompasses a wide range of potential applications. Smart orthopaedic implants offer the possibility of gathering data and exchanging it with an external reader. They incorporate technology that enables automated sensing, measuring, processing, and reporting of patient or device parameters at or near the implant. While including advanced technology in orthopaedic devices has the potential to benefit patients, physicians, and the scientific community, it may also increase the patient risks associated with the implants. Understanding the benefit-risk profile of new smart orthopaedic devices is critical to ensuring their safety and effectiveness. The 2018 FDA public workshop on orthopaedic sensing, measuring, and advanced reporting technology (SMART) devices was held on April 30, 2018, at the FDA White Oak Campus in Silver Spring, MD with the goal of fostering a collaborative dialogue amongst the orthopaedic community. Workshop attendees discussed four key areas related to smart orthopaedic devices: engineering and technology considerations, clinical and patient perspectives, cybersecurity, and regulatory considerations. The workshop presentations and associated discussions highlighted the need for the orthopaedic community to collectively craft a responsible path for incorporating smart technology in musculoskeletal disease care.

The Effect of the COVID-19 Pandemic on Hip and Knee Arthroplasty Patients in the United States: A Multicenter Update to the Previous Survey.

BACKGROUND: In March 2020, elective total hip and knee arthroplasty (THA and TKA) were suspended across the United States in response to the COVID-19 pandemic. We had previously published the results of a survey to the affected patients from 6 institutions. We now present the results of a larger distribution of this survey, through May and June 2020, to electively scheduled patients representing different regions of the United States. METHODS: Fifteen centers identified through the American Association of Hip and Knee Surgeons Research Committee participated in a survey study of THA and TKA patients. Patients scheduled for primary elective THA or TKA but canceled due to the COVID-19 elective surgery stoppage (3/2020-5/2020) were included in the study. Descriptive statistics along with subgroup analysis with Wilcoxon rank were performed. RESULTS: In total, surveys were distributed to 2135 patients and completed by 848 patients (40%) from 15 institutions. Most patients (728/848, 86%) had their surgery postponed or canceled by the surgeon or hospital. Unknown length of surgical delay remained the highest source of anxiety among survey participants. Male patients were more likely to be willing to proceed with surgery in spite of COVID-19. There were minimal regional differences in responses. Only 61 patients (7%) stated they will continue to delay surgery for fear of contracting COVID-19 while in the hospital. CONCLUSION: Similar to the previous study, the most anxiety-provoking thought was the uncertainty, over if and when the canceled joint replacement surgery could be rescheduled. Patients suffering from the daily pain of hip and knee arthritis who have been scheduled for elective arthroplasty remain eager to have their operation as soon as elective surgery is allowed to resume.

Risk Adjustment in the California Joint Replacement Registry: Is Patient Complexity Accurately Assessed in Academic Versus Nonacademic Hospitals?

BACKGROUND: We sought to report on the differences in observed versus expected arthroplasty outcomes between academic and nonacademic hospitals in a large joint registry. We utilized the California Joint Replacement Registry's data and risk adjustment model. METHODS: Observed versus expected hip and knee arthroplasty complications were utilized to assess hospital and surgeon risk-adjusted complication rates (RACRs). Based on a hospital and surgeon RACR, each was assigned a performance rating ("worse," "expected," "better"). Associations between academic status and performance ratings, rates of individual complications, prevalence of risk factors associated with increased complication rates, and differences in complication rates were calculated. RESULTS: A higher percentage of academic providers had "worse" than expected ratings, whereas a higher percentage of nonacademic providers had "expected" and "better" than expected ratings (P = .011) based on the observed versus expected complication rates. There was a higher incidence of patients with congestive heart failure and an elevated American Society of Anesthesiologists classification in academic institutions (P = .0001). The complication rate was higher in academic institutions for all total knee arthroplasties (P < .0016). CONCLUSIONS: We identified disparities in RACRs between nonacademic and academic institutions. This may reflect the difficulty of fully adjusting for medical risk and surgical complexity in a large arthroplasty database.

Risk-Adjusted Cost Performance for 90-Day Total Hip Arthroplasty Episodes: Comparing US Hospitals Nationwide Before CJR.

BACKGROUND: We characterize variation in total hip arthroplasty (THA) episode payments in the United States. Medicare population immediately preceding implementation of the comprehensive care for joint replacement (CJR) bundled care model and propose a model for ongoing evaluation of hospital performance. METHODS: We identified THA episodes in Medicare part A 2014-2016 (n = 366,380) and compared 90-day episode payments across years and geographic regions. We fit hierarchical models that regressed episode payments on patient-level fixed and region-level and hospital-level random effects. Random effects estimates were used to characterize risk-adjusted hospital cost performance. We ranked hospitals (n = 3218) in each region by their cost performance estimate and constructed 95% confidence intervals to visualize high-performing and low-performing hospitals. RESULTS: Mean part A episode payments declined from 2014 to 2016 throughout the United States ($19,925-$17,775; P < .001), primarily attributable to decreased postacute care payments. Ninety-day readmission rates fell by a percentage point (from 7.9% to 6.8%; P < .001). We found significant variation in risk-adjusted episode payments, postacute care utilization, and readmission rates across regions, and ever greater variation at the hospital level. CONCLUSION: Medicare part A payments decreased for THA episodes between 2014 and 2016. The time frame for this decrease is notable for preceding full implementation of CJR, thus suggesting a more universal embrace of value-based care principles before the start date of CJR. These decreases were primarily because of decreased postacute care utilization and possibly related to falling readmission rates. Yet, significant variation in hospital cost performance remains, even after risk adjustment.

Data for registry and quality review can be retrospectively collected using natural language processing from unstructured charts of arthroplasty patients.

AIMS: Natural Language Processing (NLP) offers an automated method to extract data from unstructured free text fields for arthroplasty registry participation. Our objective was to investigate how accurately NLP can be used to extract structured clinical data from unstructured clinical notes when compared with manual data extraction. METHODS: A group of 1,000 randomly selected clinical and hospital notes from eight different surgeons were collected for patients undergoing primary arthroplasty between 2012 and 2018. In all, 19 preoperative, 17 operative, and two postoperative variables of interest were manually extracted from these notes. A NLP algorithm was created to automatically extract these variables from a training sample of these notes, and the algorithm was tested on a random test sample of notes. Performance of the NLP algorithm was measured in Statistical Analysis System (SAS) by calculating the accuracy of the variables collected, the ability of the algorithm to collect the correct information when it was indeed in the note (sensitivity), and the ability of the algorithm to not collect a certain data element when it was not in the note (specificity). RESULTS: The NLP algorithm performed well at extracting variables from unstructured data in our random test dataset (accuracy = 96.3%, sensitivity = 95.2%, and specificity = 97.4%). It performed better at extracting data that were in a structured, templated format such as range of movement (ROM) (accuracy = 98%) and implant brand (accuracy = 98%) than data that were entered with variation depending on the author of the note such as the presence of deep-vein thrombosis (DVT) (accuracy = 90%). CONCLUSION: The NLP algorithm used in this study was able to identify a subset of variables from randomly selected unstructured notes in arthroplasty with an accuracy above 90%. For some variables, such as objective exam data, the accuracy was very high. Our findings suggest that automated algorithms using NLP can help orthopaedic practices retrospectively collect information for registries and quality improvement (QI) efforts. Cite this article: Bone Joint J 2020;102-B(7 Supple B):99-104.