Blood Management Strategies to Reduce Transfusions After Elective Lower-Extremity Joint Arthroplasty Surgeries: One Tertiary Care Hospital's Early Experience With an Alternative Payment Model-a Total Joint "Bundle".

Blood loss associated with lower-extremity total joint arthroplasty (TJA) often results in anemia and the need for red blood cell transfusions (RBCTs). This article reports on a quality improvement initiative aimed at improving blood management strategies in patients undergoing TJA. A multifaceted intervention (preoperative anemia assessment, use of tranexamic acid, discouragement of autologous preoperative blood collection, restrictive RBCT protocols) was implemented. The results were stratified into 3 intervention periods: 1, pre; 2, peri; and 3, post. Fractional logistic regression was used to describe differences between various intervention periods. During the study period, 2511 patients underwent TJA. Compared with the preintervention period, there was 81.8% decrease in total units of RBCT during the postintervention period. Using activity-based costing (~$1000/unit), the annualized saving in RBC expenditure was $480 000. A multidisciplinary approach can be successful and sustainable in reducing RBCT and its associated costs for patients undergoing TJA.

Characterization of Patient Expectations and Satisfaction after Total Hip Arthroplasty.

We conducted a prospective multicenter study in which outcome-related expectations of 236 primary total hip arthroplasty patients were determined. Clinical surveys and radiographs were used to determine the relationship between postoperative level of patient satisfaction and patient-reported and radiographic outcomes. At 1 year, 82.6% of expectations were achieved, most of the time with high satisfaction (89.3%). Younger, lower body-mass index, male patients were more likely to expect the surgery to benefit "return to work" and "sexual function", whereas older, heavier patients, selected "elimination of assistive devices" and "independence in daily activities". The ability of the patient to meet their expectations fully did not correlate directly with level of satisfaction or clinical outcomes, suggesting limitations in current clinical surveys. The characterization of patient expectations is essential in providing patient-centered care.

Experience with Designing and Implementing a Bundled Payment Program for Total Hip Replacement.

BACKGROUND: Bundled payments, also known as episode-based payments, are intended to contain health care costs and promote quality. In 2011 a bundled payment pilot program for total hip replacement was implemented by an integrated health care delivery system in conjunction with a commercial health plan subsidiary. In July 2015 the Centers for Medicare & Medicaid Services (CMS) proposed the Comprehensive Care for Joint Replacement Model to test bundled payment for hip and knee replacement. METHODS: Stakeholders were identified and a structure for program development and implementation was created. An Oversight Committee provided governance over a Clinical Model Subgroup and a Financial Model Subgroup. RESULTS: The pilot program included (1) a clinical model of care encompassing the period from the preoperative evaluation through the third postoperative visit, (2) a pricing model, (3) a program to share savings, and (4) a patient engagement and expectation strategy. Compared to 32 historical controls-patients treated before bundle implementation-45 post-bundle-implementation patients with total hip replacement had a similar length of hospital stay (3.0 versus 3.4 days, p=.24), higher rates of discharge to home or home with services than to a rehabilitation facility (87% versus 63%), similar adjusted median total payments ($22,272 versus $22,567, p=.43), and lower median posthospital payments ($704 versus $1,121, p=.002), and were more likely to receive guideline-consistent care (99% versus 95%, p=.05). DISCUSSION: The bundled payment pilot program was associated with similar total costs, decreased posthospital costs, fewer discharges to rehabilitation facilities, and improved quality. Successful implementation of the program hinged on buy-in from stakeholders and close collaboration between stakeholders and the clinical and financial teams.

Femoral revision with a high offset long stem femoral component.

In this retrospective study, we evaluated the aspetic loosening rate and initial result of an extensively hypoxyapatite-coated high offset (127°) titanium femoral component in 27 consecutive femoral revisions. Fourteen men and 12 women (mean age, 68 years) were followed for 2 to 7 years. Preoperative, 3 month, 6 month, and yearly follow-ups included Harris Hip Scores and radiographic analysis. In this study group, the femoral stem length was 155 to 205 mm and the distal stem diameter was 12 to 20 mm. Extended trochanteric osteotomies were necessary on 7 cases. At a mean 53 months follow-up, there were no loose femoral components (ie, bone ingrown in all cases) and no subsequent femoral stem revisions. Thus far, this high offset stem has demonstrated an excellent rate of stable bone fixation.

Primary total hip arthroplasty using a dual-geometry cup to treat protrusio acetabuli.

This retrospective study examined the results of 29 total hip arthroplasties on patients with protrusio acetabuli, implanted with a dual-geometry shell with a mean follow-up of 48 months (range, 24-110). All surgeries were performed using a conical reamer in addition to a spherical reamer with morsellized autogenous graft packed into the medial acetabular protrusio defect. The Harris Hip Score increased from 41 to 85. There were no cases of aseptic loosening of the acetabular component by radiographic criteria. In 93% of the cases (27 hips), the bone graft appeared incorporated, and in 83% of the cases (24 hips), there were no radiolucent lines present. Using a 2-stage technique of bone preparation to insert a dual-geometry acetabular cup, excellent results were obtained in these 29 hips.

Primary Total Knee Arthroplasty in Morbidly Obese Patients: a 5- to 14-year follow-up study.

This retrospective study examined the results of 39 total knee arthroplasties in morbidly obese patients with 5- to 14-year follow-up compared with a case-controlled group of nonobese patients. All surgeries were performed by the 2 authors in a single institution using similar techniques. Although we found a somewhat higher rate of minor wound complications, suboptimal alignment, and late revision (5%) in the morbidly obese group compared with the case-controlled group, overall, the problems in morbidly obese patients have been relatively few thus far. The substantial improvement in scores and high rate of patient satisfaction (85%) suggests that total knee arthroplasty should continue to be offered to morbidly obese patients. Techniques that can increase the accuracy of alignment may be especially useful in this group of patients.

Donepezil in the prevention and treatment of post-surgical delirium.

OBJECTIVE: Delirium is a frequent complication of major surgery in older persons. The authors evaluated the possible benefit of donepezil versus placebo in the prevention and treatment of postoperative delirium in an older population without dementia undergoing elective total joint-replacement surgery. METHODS: A sample of 80 patients participated in this randomized, double-blind, placebo-controlled trial of donepezil. Each participant was evaluated before surgery and then received donepezil or placebo for 14 days before surgery and 14 days afterward. Postoperative delirium was assessed with the Delirium Symptom Interview, Confusion Assessment Method, daily medical record, nurse-observation reviews, and DSM-IV diagnostic criteria for delirium. Subsyndromal delirium was also assessed for each participant. RESULTS: Delirium, diagnosed by DSM-IV criteria, was found on at least 1 postoperative day in 18.8% of subjects, but there were no significant differences between the donepezil and placebo groups. When delirium was present, it lasted only 1 day, and there was no difference between the groups. Subsyndromal delirium was found on at least 1 postoperative day for 68.8% of subjects, and, when this occurred, lasted 2 days or less, on average. There was no difference between the groups in the occurrence or duration of subsyndromal delirium. There was no difference between the groups in disposition to home or to another facility. CONCLUSIONS: This pilot study was unable to demonstrate a benefit for donepezil in preventing or treating delirium in a relatively young and cognitively-intact group of elderly patients undergoing elective orthopedic surgery. Furthermore, postoperative delirium was not a major problem in this population.

Early femoral head penetration of a highly cross-linked polyethylene liner vs a conventional polyethylene liner: a case-controlled study.

Forty highly cross-linked, polyethylene-liner primary total hip arthroplasties were matched by sex, age, and body mass index with 40 conventional polyethylene primary total hip arthroplasties to compare femoral head penetration rates. Both inserts were 10 degrees liners manufactured by the same company and packaged in a nitrogen/vacuum atmosphere. Identical acetabular components and a 28-mm cobalt chrome femoral head were used in all cases. The mean femoral head penetration rate for the highly cross-linked and conventional polyethylene was 0.05 (range, 0.01-0.09) and 0.12 (range, 0.02-0.29) mm/y, respectively, a 58.33% reduction in femoral head penetration (P < .001). In this short-term follow-up study (mean, 47.73 months), both reduced "bedding-in" and reduced wear may contribute to the observed decrease in femoral head penetration.

Age-Related Differences in Predictors of Adherence to Rehabilitation After Anterior Cruciate Ligament Reconstruction.

OBJECTIVE: To examine whether the relationships between psychological factors and rehabilitation adherence after knee surgery differ as a function of age. DESIGN AND SETTING: Participants completed inventories of self-motivation, social support, athletic identity, and psychological distress before anterior cruciate ligament (ACL) reconstruction. After surgery, participants recorded their completion of home rehabilitation exercises and cryotherapy, and the sport rehabilitation professionals providing their treatment reported on the patients' attendance at, and adherence during, rehabilitation sessions. SUBJECTS: Sixty-one individuals with acute ACL tears. MEASUREMENTS: The Self-Motivation Inventory, Social Support Inventory, Athletic Identity Measurement Scale, Brief Symptom Inventory, and Sport Injury Rehabilitation Adherence Scale were used to measure self-motivation, social support, athletic identity, psychological distress, and adherence, respectively, during rehabilitation sessions. RESULTS: Hierarchic regression analyses indicated that age moderated the relationships between (1) self-motivation and home exercise completion, (2) social support and home exercise completion, (3) athletic identity and home exercise completion, and (4) athletic identity and home cryotherapy completion. CONCLUSIONS: The prospective moderating relationships for between psychological factors and indices of adherence to home-based rehabilitation activities indicate the need to consider developmental issues when examining psychological aspects of sport-injury rehabilitation.

Evaluation of the safety and efficacy of the perioperative administration of rofecoxib for total knee arthroplasty.

Nonsteroidal anti-inflammatory drugs (NSAIDs) frequently are discontinued before elective total knee arthroplasty (TKA) because of the increased incidence of perioperative bleeding. Rofecoxib, a selective cyclooxygenase 2 inhibitor, does not interfere with the coagulation system and may be a safer NSAID for patients undergoing TKA. In this study, 100 patients undergoing elective TKA discontinued their use of NSAIDs 10 days before surgery and were assigned randomly to receive either placebo (n = 50) or rofecoxib (n = 50), 25 mg daily for 5 consecutive days starting 3 days before surgery. The administration of rofecoxib resulted in improved preoperative pain scores and no significant increase in the incidence of perioperative bleeding or international normalized ratio compared with placebo. Rofecoxib does not need to be discontinued before elective TKA.