Parkinson's disease increases the risk of perioperative complications after total knee arthroplasty: a nationwide database study.

PURPOSE: Therefore, the purpose of this study was to evaluate the short-term perioperative outcomes of PD patients who underwent total knee arthroplasty (TKA). We specifically evaluated: (1) perioperative surgical and medical complications; (2) lengths of stay (LOS); and (3) total hospital charges. METHODS: The Nationwide Inpatient Sample was used to identify PD patients who underwent TKA between 2002 and 2013. To control for potential confounders, PD TKA and non-PD TKA patients were propensity score matched (1:3) based on age, sex, ethnicity, Charlson Comorbidity Index, and insurance type. A total of 31,979 PD and 95,596 non-PD TKA patients were included. RESULTS: PD patients had a 44% higher risk of suffering from any complication (OR 1.44; 95% CI 1.35-1.54), a 45% increased risk for any medical complication (OR 1.45; 95% CI 1.36-1.55), and a 9% higher risk for any surgical complication (OR 1.09; 95% CI 0.84-1.41). Compared to the matched cohort, PD patients had a mean LOS that was 6.5% longer (95% CI 5.46-7.54) and mean total hospital charges that were 3.05% higher (95% CI 1.99-4.11). CONCLUSIONS: PD patients are more likely to have postoperative complications, longer LOS, and higher costs after TKA than non-PD TKA patients. Since many of these complications can be prevented, a team-based multi-specialty patient optimization is needed. LEVEL OF EVIDENCE: Level III, therapeutic study.

Operative Time, Length of Stay, Short-Term Readmission, and Complications after Hinged Primary Total Knee Arthroplasty: A Propensity Score Matched Analysis.

Despite the wide utilization of total knee arthroplasty (TKA), it can be technically challenging to perform in patients who have concomitant bone loss, ligamentous laxity, or high-grade deformity, whether in a revision situation or due to a primary pathology. Therefore, hinged knee prostheses have been developed to provide more stable fixation in these situations. The purpose of this study was to compare the short-term peri- and postoperative outcomes of patients undergoing primary TKA with and without hinged prosthesis. Specifically, we compared (1) mean operative times, (2) lengths of stay (LOS), (3) 30-day readmissions, and (4) complications. The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify hinged TKAs and 99 procedures were included. They were matched in a 1:3 ratio to primary TKAs without a hinged prosthesis using propensity score matching. Operative time, LOS, discharge disposition, 30-day readmissions, and complications were compared. Adjusted odds ratios (OR) were also calculated. The operative time was significantly higher in hinged cohort compared with the nonhinged cohort (mean difference [MD] = 22 minutes; range, 10-34 minutes, p < 0.001). There were no significant differences between hinged and nonhinged TKAs with respect to LOS (MD= 0.61 days, range, -0.07-1.30 days, p = 0.080), discharge disposition (OR = 1.09, 95% confidence interval [CI], 0.66-1.84), readmissions (OR = 2.67, 95% CI, 0.84-8.24), and any complications (OR = 1.13, 95% CI, 0.55-2.19). Not surprisingly, primary TKAs with hinged prostheses had increased operative times, but had similar LOS, discharge dispositions, and 30-day rates of readmission and complications when compared with TKAs without a hinged prosthesis. One potential contributing factor to the increased operating time is that patients who receive a hinged implant tend to present with more severe deformities. It is reassuring to know that early outcomes were similar between both cohorts (although we await longer follow-up studies), and that hinged implants can be considered in these difficult to treat patients.

Are We Appropriately Compensated by Relative Value Units for Primary vs Revision Total Hip Arthroplasty?

BACKGROUND: Relative value units (RVUs) are used to evaluate the effort required for providing a service to patients in order to determine compensation. Thus, more complicated cases, like revision arthroplasty cases, should yield a greater compensation. However, there are limited data comparing RVUs to the time required to complete the service. Therefore, the purpose of this study is to compare the (1) mean RVUs, (2) mean operative times, and (3) mean RVU/minute between primary and revision total hip arthroplasty (THA) and (4) perform an individualized idealized surgeon annual cost difference analysis. METHODS: A total of 103,702 patients who underwent primary (current procedural terminology code 27130) and 7273 patients who underwent revision THA (current procedural terminology code 27134) were identified using the National Surgical Quality Improvement Program database. Mean RVUs, operative times (minutes), and RVU/minute were calculated and compared using Student t-test. Dollar amount per minute, per case, per day, and year was calculated to find an individualized idealized surgeon annual cost difference. RESULTS: The mean RVU was 21.24 ± 0.53 (range, 20.72-21.79) for primary and 30.27 ± 0.03 (range, 30.13-30.28) for revision THA (P < .001). The mean operative time for primary THA was 94 ± 38 minutes (range, 30-480 minutes) and 152 ± 75 minutes (range, 30-475 minutes) for revision THA (P < .001). The mean RVU/minute was 0.260 ± 0.10 (range, 0.04-0.73) for primary and 0.249 ± 0.12 (range, 0.06-1.0) for revision cases (P < .001). The dollar amounts calculated for primary vs revision THA were as follows: per minute ($9.33 vs $8.93), per case ($877.12 vs $1358.32), per day ($6139.84 vs $5433.26), and a projected $113,052.28 annual cost difference for an individual surgeon. CONCLUSION: Maximizing the RVU/minute provides the greatest "hourly rate." The RVU/minute for primary (0.260) being significantly greater than revision THA (0.249) and an annualized $113,052.28 cost difference reveal that although revision THAs are more complex cases requiring longer operative time, greater technical skill, and aftercare, compensation per time is not greater.

Does Multiple Sclerosis Affect the Inpatient Perioperative Outcomes After Total Hip Arthroplasty?

BACKGROUND: There is a paucity of studies evaluating the short-term perioperative outcomes of total hip arthroplasty (THA) in multiple sclerosis (MS) patients. Therefore, this study evaluated (1) patient factors; and (2) patient outcomes in MS THA patients compared to non-MS THA patients. METHODS: The Nationwide Inpatient Sample from 2002 to 2013 identified 5899 MS and 2,723,652 non-MS THA patients. Yearly trends, demographics, and comorbidities were compared, and then non-MS THA patients were matched (3:1) to MS THA patients by age, gender, race, comorbidity score, and surgery year. Regression analyses compared perioperative complications (any, surgical, medical), length of stay (LOS), and discharge dispositions. RESULTS: The annual prevalence of MS in THA patients increased from 1.36 per 1000 THAs in 2002 to 2.54 per 1000 THAs in 2013 (P = .004). MS patients were younger, more likely female, take corticosteroids, have hip osteonecrosis, and have gait abnormalities. Compared to matched cohort, MS patients had a higher risk of any surgical (odds ratio [OR] = 1.18; 95% confidence interval [95% CI], 1.02-1.37) and any medical (OR = 1.55; 95% CI, 1.34-1.81) complications, an 8.24% longer mean LOS (95% CI, 5.61-10.94; <0.0001) and were more likely to be discharged to a care facility (OR = 2.09; 95% CI, 1.82-2.40). CONCLUSION: Orthopedic surgeons should be cognizant of the potential increased risks after THA in MS patients. Neurologists and other practitioners may help optimize and enhance the preoperative care of potential THA candidates, and provide guidance as to the appropriate timing of intervention for hip issues in MS patients.

Description of a technique for vacuum-assisted deep drains in the management of cavitary defects and deep infections in devastating military and civilian trauma.

BACKGROUND: Deep soft-tissue defects often present in high-energy trauma and during the surgical treatment of infection. Injuries caused by high-velocity projectiles can create deep soft-tissue defects that are challenging to manage. Persistent, deep wound cavities have been associated with infection and prolonged wound healing. This article presents a technique that marries vacuum-assisted wound closure technology with traditional drains to allow for management of deep soft-tissue cavities. METHODS: A deep drain was placed in the cavitary lesion with application of a negative-pressure wound therapy sponge in the standard fashion. The deep drain was brought into the sponge and fenestrated as to allow the sponge to evacuate the deep drain. Several illustrative cases are presented. RESULTS: Conversion of deep cavitary defects to superficial defects allowed for delayed primary or secondary closure of the wound defects without the need for increasing the size of the superficial wound to facilitate drainage. Deep infection was also successfully controlled without incurring the additional surgical soft-tissue trauma typical of standard technique. CONCLUSIONS: The use of the active deep suction decreases edema and dead space, theoretically reducing the chance of infection. It also prevents premature walling off of deeper cavities, which can occur with the use of vacuum-assisted closure therapy on superficial defects. Our method of wound management allows for the reduction of the deep cavitary defects without delaying wound closure or creating more tissue damage.

Hemiarthroplasty for proximal humerus fractures in patients with Parkinson's disease.

BACKGROUND: Parkinson's disease is a relatively common problem in geriatric patients with an annual incidence rate of 20.5 per 100,000. These patients are at increased risk for falls and resultant fractures. Several reports suggest total shoulder arthroplasty in patients with fractures has a relatively high rate of complications. Whether hemiarthroplasty reduces the rate of complications or improves pain or function is not known. QUESTIONS/PURPOSES: We therefore determined the ROM, pain, complications, and rate of failure of hemiarthroplasty for management of proximal humerus fractures in patients with Parkinson's disease. PATIENTS AND METHODS: We retrospectively reviewed all eight hemiarthroplasties in patients with Parkinson's disease for fracture of the proximal humerus between 1978 and 2005. Seven patients (seven shoulders) had a minimum of 2 years followup (mean, 9.9 years; range, 2-16 years). RESULTS: Postoperatively, the mean active abduction was 97 degrees , mean external rotation was 38 degrees , and internal rotation was a mean of being able to reach the level of the sacrum. The mean postoperative pain score was 2.5 points (on a scale of 1-5). There was a greater tuberosity nonunion in one patient and a superior malunion of the greater tuberosity in three patients. No patient had revision surgery. CONCLUSIONS: The benefit of hemiarthroplasty for proximal humerus fractures in patients with Parkinson's disease was marginal with three shoulders in seven patients having moderate to severe persistent pain and limited function postoperatively. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Total shoulder arthroplasty in patients with Parkinson's disease.

Currently, there is little information available on the results of total shoulder arthroplasty (TSA) in patients with Parkinson's disease. The purpose of the current study was to determine the results, risk factors for an unsatisfactory outcome, and rates of failure of TSA in patients with Parkinson's disease. Between 1978 and 2005, 49 total shoulder arthroplasties were performed in patients with Parkinson's disease for osteoarthritis of the shoulder. Forty-three shoulders (36 patients) were followed for a minimum of 2 years (mean, 8 years) or until the time of revision surgery. Total shoulder arthroplasty in patients with Parkinson's disease was associated with significant improvement in pain from 4.6 to 1.8 (P < .001), external rotation from 21 degrees to 44 degrees (P < .001), and active abduction from 100 degrees to 119 degrees (P = .0489). There was no significant improvement in internal rotation (P = .09). There was no significant difference in outcome between males and females nor was there an association with stage of Parkinson's disease and outcome (P > .05). Eight shoulders underwent revision arthroplasty. Three of the 8 revisions were performed less than 1 year from the time of surgery due to instability. Total shoulder arthroplasty is associated with significant long-term improvement in pain, external rotation, and abduction in patients with Parkinson's disease. However, early postoperative instability appears to be higher in this patient population. The results of TSA in our patients with Parkinson's disease were marginal, with 20 (47%) achieving unsatisfactory results.