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.

Association of race and ethnicity with opioid prescribing for Medicare beneficiaries following total joint replacements.

BACKGROUND: Profound racial and ethnic disparities exist in the use and outcomes of total hip/knee replacements (total joint replacements [TJR]). Whether similar disparities extend to post-TJR pain management remains unknown. Our objective is to examine the association of race and ethnicity with opioid fills following elective TJRs for White, Black, and Hispanic Medicare beneficiaries. METHODS: We used the 2019 national Medicare data to identify beneficiaries who underwent total hip/knee replacements. Primary outcomes were at least one opioid fill in the period from discharge to 30 days post-discharge, and 31-90 days following discharge. Secondary outcomes were morphine milligram equivalent per day and number of opioid fills. Key independent variable was patient race-ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic). We estimated multivariable hierarchical logistic regressions and two-part models with state-level clustering. RESULTS: Among 67,550 patients, 93.36% were White, 3.69% were Black, and 2.95% were Hispanic. Compared to White patients, more Black patients and fewer Hispanic patients filled an opioid script (84.10% [Black] and 80.11% [Hispanic] vs. 80.33% [White], p < 0.001) in the 30-day period. On multivariable analysis, Black patients had 18% higher odds of filling an opioid script in the 30-day period (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.05-1.33, p = 0.004), and 39% higher odds in the 31-90-day period (OR: 1.39, 95% CI: 1.26-1.54, p < 0.001). There were no significant differences in the endpoints between Hispanic and White patients in the 30-day period. However, Hispanic patients had 20% higher odds of filling an opioid script in the 31- to 90-day period (OR: 1.20, 95% CI: 1.07-1.34, p = 0.002). CONCLUSIONS: Important race- and ethnicity-based differences exist in post-TJR pain management with opioids. The mechanisms leading to the higher use of opioids by racial/ethnic minority patients need to be carefully examined.

Is Morbid Obesity a Modifiable Risk Factor in Patients Who Have Severe Knee Osteoarthritis and do Not Have a Formal Perioperative Optimization Program?

BACKGROUND: Obesity is considered a modifiable risk factor prior to total knee arthroplasty (TKA); however, little data support this hypothesis. Our purpose was to evaluate patients who have a body mass index (BMI) >40 presenting for TKA to determine the incidence of: (1) patients who achieved successful weight loss through nutritional modification or bariatric surgery and (2) patients who underwent TKA over the study period without the presence of a formal optimization program. METHODS: This was a retrospective, single-center analysis. Inclusion criteria included: Kellgren and Lawrence grade 3 or 4 knee osteoarthritis, BMI >40 at presentation, and minimum 1-year follow-up (mean 45 months) (N = 624 patients). Demographics, weight loss interventions, pursuit of TKA, maximum BMI change, and Patient-Reported Outcomes Measurement Information System scores were collected. Multivariable logistic and linear regressions evaluated associations of underlying demographic and treatment characteristics with outcomes. RESULTS: There were 11% of patients who ended up pursuing TKA over the study period. Bariatric surgery was 3.7 times more likely to decrease BMI by minimum 10 compared to nonsurgical intervention (95% confidence interval [CI] [1.7, 8.1]; P = .001). Bariatric surgery resulted in mean BMI change of -3.3 (range, 0 to 22) compared to nonsurgical interventions (-2.6 [range, 0 to 12]) and no intervention (0.4 [range, 0 to 15]; P < .0001). Bariatric surgery patients were 3.1 times more likely to undergo TKA (95% CI [1.3, 7.1]; P = .008), and nonsurgical interventions were 2.4 times more likely to undergo TKA (95% CI [1.3, 4.5]; P = .006) compared to no intervention. Non-White patients across all interventions were less likely to experience loss >5 BMI compared to White patients (95% CI [0.2, 0.9]; P = .018). CONCLUSIONS: Most patients were unable to reduce BMI more than 5 to 10 over a mean 4-year period without a formal weight optimization program. Utilization of bariatric surgery was most successful compared to nonsurgical interventions, although ultimate pursuit of TKA remained low in all cohorts.

Demographics and Early Outcomes of Commercial Antibiotic Cement Usage for Infection Prophylaxis During Primary Total Knee Arthroplasty in Patients Older Than 65 Years: An American Joint Replacement Registry Study.

INTRODUCTION: The use of antibiotic-laden bone cement (ALBC) for infection prophylaxis in the setting of primary total knee arthroplasty (TKA) remains controversial. Using data from the American Joint Replacement Registry (AJRR), (1) we examined the demographics of ALBC usage in the United States and (2) identified the effect of prophylactic commercially available ALBC on early revision and readmission for prosthetic joint infection (PJI) after primary TKA. METHODS: This is a retrospective cohort study of the AJRR from 2017 to 2020. Patients older than 65 years undergoing primary cemented TKA with or without the use of commercially available antibiotic cement were eligible for inclusion (N = 251,506 patients). Data were linked to available Medicare claims to maximize revision outcomes. Demographics including age, sex, race/ethnicity, Charlson Comorbidity Index (CCI), preoperative inflammatory arthritis, region, and body mass index (BMI) class were recorded. Cox proportional hazards regression analysis was used to evaluate the association between the two outcome measures and ALBC usage. RESULTS: Patients undergoing cemented TKA with ALBC were more likely to be Non-Hispanic Black ( P < 0.001), have a CCI of 2 or 3 ( P < 0.001), reside in the South ( P < 0.001), and had a higher mean BMI ( P < 0.001). In the regression models, ALBC usage was associated with increased risk of 90-day revision for PJI (hazards ratio 2.175 [95% confidence interval] 1.698 to 2.787) ( P < 0.001) and was not associated with 90-day all-cause readmissions. Male sex, higher CCI, and BMI >35 were all independently associated with 90-day revision for PJI. DISCUSSION: The use of commercial ALBC in patients older than 65 years for primary TKA in the AJRR was not closely associated with underlying comorbidities suggesting that hospital-level and surgeon-level factors influence its use. In addition, ALBC use did not decrease the risk of 90-day revision for PJI and was not associated with 90-day readmission rates.

Association of Total Knee Replacement Removal From the Inpatient-Only List With Outpatient Surgery Utilization and Outcomes in Medicare Patients.

Importance: Little is known about the association of total knee replacement (TKR) removal from the Medicare inpatient-only (IPO) list in 2018 with outcomes in Medicare patients. Objective: To evaluate (1) patient factors associated with outpatient TKR use and (2) whether the IPO policy was associated with changes in postoperative outcomes for patients undergoing TKR. Design, Setting, and Participants: This cohort study included data from administrative claims from the New York Statewide Planning and Research Cooperative System. Included patients were Medicare fee-for-service beneficiaries undergoing TKRs or total hip replacements (THRs) in New York State from 2016 to 2019. Multivariable generalized linear mixed models were used to identify patient factors associated with outpatient TKR use, and with a difference-in-differences strategy to examine association of the IPO policy with post-TKR outcomes relative to post-THR outcomes in Medicare patients. Data analysis was performed from 2021 to 2022. Exposures: IPO policy implementation in 2018. Main Outcomes and Measures: Use of outpatient or inpatient TKR; secondary outcomes included 30-day and 90-day readmissions, 30-day and 90-day postoperative emergency department visits, non-home discharge, and total cost of the surgical encounter. Results: A total of 37 588 TKR procedures were performed on 18 819 patients from 2016 to 2019, with 1684 outpatient TKR procedures from 2018 to 2019 (mean [SD] age, 73.8 [5.9] years; 12 240 female [65.0%]; 823 Hispanic [4.4%], 982 non-Hispanic Black [5.2%], 15 714 non-Hispanic White [83.5%]). Older (eg, age 75 years vs 65 years: adjusted difference, -1.65%; 95% CI, -2.31% to -0.99%), Black (-1.44%; 95% CI, -2.81% to -0.07%), and female patients (-0.91%; 95% CI, -1.52% to -0.29%), as well as patients treated in safety-net hospitals (disproportionate share hospital payments quartile 4: -18.09%; 95% CI, -31.81% to -4.36%), were less likely to undergo outpatient TKR. After IPO policy implementation in the TKR cohort, there were lower adjusted 30-day readmissions (adjusted difference [AD], -2.11%; 95% CI, -2.73% to -1.48%; P < .001), 90-day readmissions ( -3.23%; 95% CI, -4.04% to -2.42%; P < .001), 30-day ED visits ( -2.45%; 95% CI, -3.17% to -1.72%; P < .001), 90-day ED visits (-4.01%; 95% CI, -4.91% to -3.11%; P < .001) and higher cost per encounter ($2988; 95% CI, $415 to $5561; P = .03). However, these changes did not differ from changes in the THR cohort except for increased TKR cost of $770 per encounter ($770; 95% CI, $83 to $1457; P = .03) relative to THR. Conclusions and Relevance: In this cohort study of patients undergoing TKR and THR, we found that older, Black, and female patients and patients treated in safety-net hospitals may have had lesser access to outpatient TKRs highlighting concerns of disparities. IPO policy was not associated with changes in overall health care use or outcomes after TKR, except for an increase of $770 per TKR encounter.

Disparities in the Epidemiology and Management of Fragility Hip Fractures.

PURPOSE OF REVIEW: The purpose of this review is to synthesize the recently published scientific evidence on disparities in epidemiology and management of fragility hip fractures. RECENT FINDINGS: There have been a number of investigations focusing on the presence of disparities in the epidemiology and management of fragility hip fractures. Race-, sex-, geographic-, socioeconomic-, and comorbidity-based disparities have been the primary focus of these investigations. Comparatively fewer studies have focused on why these disparities may exist and interventions to reduce disparities. There are widespread and profound disparities in the epidemiology and management of fragility hip fractures. More studies are needed to understand why these disparities exist and how they can be addressed.

Association of Medicare Mandatory Bundled Payment Reform With Joint Replacement Surgery Use for Beneficiaries With Alzheimer Disease and Related Dementias.

Importance: Medicare beneficiaries with Alzheimer disease and related dementias (ADRD) are a particularly vulnerable group in whom arthritis is a frequently occurring comorbidity. Medicare's mandatory bundled payment reform-the Comprehensive Care for Joint Replacement (CJR) model-was intended to improve quality and reduce spending in beneficiaries undergoing joint replacement surgical procedures for arthritis. In the absence of adjustment for clinical risk, hospitals may avoid performing elective joint replacements for beneficiaries with ADRD. Objective: To evaluate the association of the CJR model with utilization of joint replacements for Medicare beneficiaries with ADRD. Design Setting and Participants: This cohort study used national Medicare data from 2013 to 2017 and multivariable linear probability models and a triple differences estimation approach. Medicare beneficiaries with a diagnosis of arthritis were identified from 67 metropolitan statistical areas (MSAs) mandated to participate in CJR and 104 control MSAs. Data were analyzed from July 2020 to July 2021. Exposures: Implementation of the CJR model in 2016. Main Outcomes and Measures: Outcomes were separate binary indicators for whether or not a beneficiary underwent hip or knee replacement. Key independent variables were the MSA group, before-CJR and after-CJR phase, ADRD diagnosis, and their interactions. The linear probability models controlled for beneficiary characteristics, MSA fixed effects, and time trends. Results: The study included 24 598 729 beneficiary-year observations for 9 624 461 unique beneficiaries, of which 250 168 beneficiaries underwent hip and 474 751 underwent knee replacements. The mean (SD) age of the 2013 cohort was 77.1 (7.9) years, 3 110 922 (66.4%) were women, 3 928 432 (83.8%) were non-Hispanic White, 792 707 (16.9%) were dually eligible for Medicaid, and 885 432 (18.9%) had an ADRD diagnosis. Before CJR implementation, joint replacement rates were lower among beneficiaries with ADRD (hip replacements: 0.38% vs 1.17% for beneficiaries with and without ADRD, respectively; P < .001; knee replacements: 0.70% vs 2.25%; P < .001). After controlling for relevant covariates, CJR was associated with a 0.07-percentage-point decline in hip replacements for beneficiaries with ADRD (95% CI, -0.13 to -0.001; P = .046) and a 0.07-percentage-point decline for beneficiaries without ADRD (95% CI, -0.12 to -0.02; P = .01) residing in CJR MSAs compared with beneficiaries in control MSAs. However, this change in hip replacement rates for beneficiaries with ADRD was not statistically significantly different from the change for beneficiaries without ADRD (percentage point difference: 0.01; 95% CI, -0.08 to 0.09; P = .88). No statistically significant changes in knee replacement rates were noted for beneficiaries with ADRD compared with those without ADRD with CJR implementation (percentage point difference: -0.03, 95% CI, -0.09 to 0.02; P = .27). Conclusions and Relevance: In this cohort study of Medicare beneficiaries with arthritis, the CJR model was not associated with a decline in joint replacement utilization among beneficiaries with ADRD compared with beneficiaries without ADRD in the first 2 years of the program, thereby alleviating patient selection concerns.

Same-Day Outpatient Lower-Extremity Joint Replacement: A Critical Analysis Review.

➢ The economics of transitioning total joint arthroplasty (TJA) to standalone ambulatory surgery centers (ASCs) should not be capitalized on at the expense of patient safety in the absence of established superior patient outcomes. ➢ Proper patient selection is essential to maximizing safety and avoiding complications resulting in readmission. ➢ Ambulatory TJA programs should focus on reducing complications frequently associated with delays in discharge. ➢ The transition from hospital-based TJA to ASC-based TJA has substantial financial implications for the hospital, payer, patient, and surgeon.

Skeletal infections: microbial pathogenesis, immunity and clinical management.

Osteomyelitis remains one of the greatest risks in orthopaedic surgery. Although many organisms are linked to skeletal infections, Staphylococcus aureus remains the most prevalent and devastating causative pathogen. Important discoveries have uncovered novel mechanisms of S. aureus pathogenesis and persistence within bone tissue, including implant-associated biofilms, abscesses and invasion of the osteocyte lacuno-canalicular network. However, little clinical progress has been made in the prevention and eradication of skeletal infection as treatment algorithms and outcomes have only incrementally changed over the past half century. In this Review, we discuss the mechanisms of persistence and immune evasion in S. aureus infection of the skeletal system as well as features of other osteomyelitis-causing pathogens in implant-associated and native bone infections. We also describe how the host fails to eradicate bacterial bone infections, and how this new information may lead to the development of novel interventions. Finally, we discuss the clinical management of skeletal infection, including osteomyelitis classification and strategies to treat skeletal infections with emerging technologies that could translate to the clinic in the future.

Patient Reported Outcomes After Conversion vs. Primary Total Hip Arthroplasty: A Propensity Matched Analysis.

Background: Conversion total hip arthroplasty (cTHA) is increasingly utilized as a salvage procedure for complications associated with fracture fixation around the hip and acetabulum and for failed hip preservation surgery. While primary THA (pTHA) has a high success rate, little is known about outcomes following conversion THA. The purpose of this study is to evaluate patient reported outcomes (PROs) and complication rates following conversion THA compared to primary THA. Methods: Patients that underwent cTHA or pTHA from 2015-2020 at a large tertiary referral academic center were retrospectively identified. THA patients were propensity matched in a 1:1 fashion by age, body mass index (BMI), and sex. Pain scores and PROMIS physical function (PF), pain interference (PI), and depression (DA) scores were compared at preoperative and final postoperative follow up timepoints using independent t-tests. Differences in complication and reoperation rates between cohorts were assessed using chi square analysis. Results: A total of 118 THAs (59 cTHA, 59 pTHA) were included in this analysis with an average follow up of 21.3 months. cTHAs were most commonly performed following hip fracture fixation (50.8%). The conversion cohort had significantly longer lengths of stay (3.6 days vs 1.9 days, p<0.01) and greater use of revision-type implants (39.0% vs 0.0%, p<0.01) compared to pTHA. There was no significant difference in complication rates (cTHA = 15.3%, pTHA = 8.5%; p=0.26), with intraoperative fracture being the most common for both. Primary and conversion THA groups also experienced similar reoperation rates (cTHA = 5.1%, pTHA = 6.8%; p=0.70). No significant differences in PROs at final follow up were identified between groups. Conclusion: Patients undergoing cTHA required increased utilization of revision hip implants and had longer lengths of stay, but had comparable complication and reoperation rates, and ultimately demonstrated similar improvements in PROMIS scores compared to a matched cohort of pTHA patients. Level of Evidence: III.

Does Hypothetical Centralization of Revision THA and TKA Exacerbate Existing Geographic or Demographic Disparities in Access to Care by Increased Patient Travel Distances or Times? A Large-database Study.

BACKGROUND: Higher hospital volume is associated with lower rates of adverse outcomes after revision total joint arthroplasty (TJA). Centralizing revision TJA care to higher-volume hospitals might reduce early complication and readmission rates after revision TJA; however, the effect of centralizing revision TJA care on patient populations who are more likely to experience challenges with access to care is unknown. QUESTIONS/PURPOSES: (1) Does a hypothetical policy of transferring patients undergoing revision TJA from lower-to higher-volume hospitals increase patient travel distance and time? (2) Does a hypothetical policy of transferring patients undergoing revision TJA from lower- to higher-volume hospitals disproportionately affect travel distance or time in low income, rural, or racial/ethnic minority populations? METHODS: Using the Medicare Severity Diagnosis Related Groups 466-468, we identified 37,147 patients with inpatient stays undergoing revision TJA from 2008 to 2016 in the Statewide Planning and Research Cooperative System administrative database for New York State. Revisions with missing or out-of-state patient identifiers (3474 of 37,147) or those associated with closed or merged facilities (180 of 37,147) were excluded. We chose this database for our study because of relative advantages to other available databases: comprehensive catchment of all surgical procedures in New York State, regardless of payer; each patient can be followed across episodes of care and hospitals in New York State; and New York State has an excellent cross-section of hospital types for TJA, including rural and urban hospitals, critical access hospitals, and some of the highest-volume centers for TJA in the United States. We divided hospitals into quartiles based on the mean revision TJA volume. Overall, 80% (118 of 147) of hospitals were not for profit, 18% (26 of 147) were government owned, 78% (115 of 147) were located in urban areas, and 48% (70 of 147) had fewer than 200 beds. The mean patient age was 66 years old, 59% (19,888 of 33,493) of patients were females, 79% (26,376 of 33,493) were white, 82% (27,410 of 33,493) were elective admissions, and 56% (18,656 of 33,493) of admissions were from government insurance. Three policy scenarios were evaluated: transferring patients from the lowest 25% by volume hospitals, transferring patients in the lowest 50% by volume hospitals, and transferring patients in the lowest 75% by volume hospitals to the nearest higher-volume institution by distance. Patients who changed hospitals and travelled more than 60 miles or longer than 60 minutes with consideration for average traffic patterns after the policy was enacted were considered adversely affected. The secondary outcome of interest was the impact of the three centralization policies, as defined above, on lower-income, nonwhite, rural versus urban counties, and Hispanic ethnicity. RESULTS: Transferring patients from the lowest 25% by volume hospitals resulted in only one patient stay that was affected by an increase in travel distance and travel time. Transferring patients from the lowest 50% by volume hospitals resulted in 9% (3050 of 33,493) of patients being transferred, with only 1% (312 of 33,493) of patients affected by either an increased travel distance or travel time. Transferring patients from the lowest 75% by volume hospitals resulted in 28% (9323 of 33,493) of patients being transferred, with 2% (814 of 33,493) of patients affected by either an increased travel distance or travel time. Nonwhite patients were less likely to encounter an increased travel distance or time after being transferred from the lowest 50% by volume hospitals (odds ratio 0.31 [95% CI 0.15 to 0.65]; p = 0.002) or being transferred from the lowest 75% by volume hospitals (OR 0.10 [95% CI 0.07 to 0.15]; p < 0.001) than white patients were. Hispanic patients were more likely to experience increased travel distance or time after being transferred from the lowest 50% by volume hospitals (OR 12.3 [95% CI 5.04 to 30.2]; p < 0.001) and being transferred from the lowest 75% by volume hospitals (OR 3.24 [95% CI 2.24 to 4.68]; p < 0.001) than non-Hispanic patients were. Patients from a county with a lower median income were more likely to experience increased travel distances or time after being transferred from the lowest 50% by volume hospitals (OR 69.5 [95% CI 17.0 to 283]; p < 0.001) and being transferred from the lowest 75% by volume hospitals (OR 3.86 [95% CI 3.21 to 4.64]; p < 0.001) than patients from counties with a higher median income. Patients from rural counties were more likely to be affected after being transferred from the lowest 50% by volume hospitals (OR 98 [95% CI 49.6 to 192.2]; p < 0.001) and being transferred from the lowest 75% by volume hospitals (OR 11.7 [95% CI 9.89 to 14.0]; p < 0.001) than patients from urban counties. CONCLUSION: Although centralizing revision TJA care to higher-volume institutions in New York State did not appear to increase the travel burden for most patients, policies that centralize revision TJA care will need to be carefully designed to minimize the disproportionate impact on patient populations that already face challenges with access to healthcare. Further studies should examine the feasibility of establishing centers of excellence designations for revision TJA, the effect of best practices adoption by lower volume institutions to improve revision TJA care, and the potential role of care-extending technology such as telemedicine to improve access to care to reduce the effects of travel distances on affected patient populations. LEVEL OF EVIDENCE: Level III, prognostic study.

Early Postoperative Pneumonia After Elective Primary Total Hip Arthroplasty in "COVID-19 Survivor": A Case Report.

CASE: A 57-year-old woman with a history of COVID-19 pneumonia, myelodysplastic syndrome, type II diabetes mellitus, and nonalcoholic steatohepatitis underwent elective total hip arthroplasty 3 months after her COVID-19 infection had clinically resolved. Her postoperative course was complicated by COVID-19-negative pneumonia within 24 hours postoperatively requiring ICU admission. CONCLUSION: Patients who have previously recovered from COVID-19 infection may have long-lasting cardiopulmonary effects that may be asymptomatic. Further assessment of postoperative risk and guidance on preoperative evaluation of COVID-19 "survivors" is needed.

Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement.

Importance: The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. Objective: To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. Design, Setting, and Participants: This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. Exposures: Implementation of the CJR model in 2016. Main Outcomes and Measures: Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. Results: The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. Conclusions and Relevance: Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.

Early complications and reoperation rates are similar amongst open reduction internal fixation, intramedullary nail, and distal femoral replacement for periprosthetic distal femur fractures: a systematic review and meta-analysis.

BACKGROUND: Our purpose was to perform a systematic review and meta-analysis to evaluate complication and revision rates for periprosthetic distal femur fractures (PPDFF) treated with: (1) ORIF using periarticular locking plates (ORIF), (2) retrograde intramedullary nail (IMN), and (3) distal femoral replacement (DFR). METHODS: Systematic review of the literature was performed to identify eligible studies (N = 52). Identified treatment groups were: ORIF (N = 1205 cases), IMN (N = 272 cases), and DFR (N = 353 cases). Median follow-up was 30 months (range 6-96 months). Primary outcomes were: (1) major complication rates and (2) reoperation rates over the follow-up period. Secondary outcomes were incidence of deep infection, periprosthetic fracture, mortality over the follow-up period, 1-year mortality, non-union, malunion, delayed union, and hardware failure. Data for primary and secondary outcomes were pooled and unadjusted analysis was performed. Meta-analysis was performed on subset of individual studies comparing at least two of three treatment groups (N = 14 studies). Odds-ratios and their respective standard errors were determined for each treatment group combination. Maximum likelihood random effects meta-analysis was conducted for primary outcomes. RESULTS: From the systematic review, major complication rates (p = 0.55) and reoperation rates (p = 0.20) were not significantly different between the three treatment groups. DFR group had a higher incidence of deep infection relative to IMN and ORIF groups (p = 0.03). Malunion rates were higher in IMN versus ORIF (p = 0.02). For the meta-analysis, odds of major complications were not significantly different between IMN versus DFR (OR 1.39 [0.23-8.52]), IMN versus ORIF (OR 0.86 [0.48-1.53]), or the ORIF versus DFR (OR 0.91 [0.52-1.59]). Additionally, odds of a reoperation were not significantly different between IMN versus DFR (OR 0.59 [0.08-4.11]), IMN versus ORIF (OR 1.26 [0.66-2.40]), or ORIF versus DFR (OR 0.91 [0.51-1.55]). CONCLUSIONS: There was no difference in major complications or reoperations between the three treatment groups. Deep infection rates were higher in DFR relative to internal fixation, malunion rates were higher in IMN versus ORIF, and periprosthetic fracture rates were higher in DFR and IMN versus ORIF.