Sequentially Irradiated and Annealed Highly Cross-Linked Polyethylene: Clinical and Radiographic Outcomes in Total Knee Arthroplasty at 10-Year Follow-up.

Highly cross-linked polyethylene (HXLPE) has become the preferred bearing surface in total hip arthroplasty. However, its acceptance in total knee arthroplasty (TKA) has not been as robust because of concerns pertaining to wear and its impact on implant failure. Therefore, this multicenter study was purposed to evaluate the 10-year (1) radiographic outcomes; (2) complications; and (3) implant survivorship in patients with TKA receiving a sequentially irradiated and annealed HXLPE. A retrospective, multi-center study was performed on 139 patients (171 TKAs) who underwent primary TKA with HXLPE and possessed a minimum of 10-year follow-up. Radiographs were analyzed for radiolucencies along the implant-fixation interface using the Modern Knee Society Radiographic Evaluation System. Kaplan-Meier analysis determined implant survivorship when the end points were revision for polyethylene wear and polyethylene revision for any reason. Sixteen TKAs (9.9%) demonstrated periprosthetic linear radio-lucencies. Seventeen TKAs (9.9%) required additional surgeries, 9 (5.3%) of which were revisions, with 1 (0.6%) TKA requiring revision because of polyethylene wear. Other causes of revision included instability (1.8%), infection (1.6%), and arthrofibrosis (1.6%). The mean time to revision was 5.9 years (range, 0.1-11.1 years). Survivorship pertaining to polyethylene revision for wear was 99.4%, whereas all-cause polyethylene revision was 94.7%. This study in patients undergoing primary TKA using a second-generation HXLPE demonstrated excellent results with respect to polyethylene wear characteristics and strength with a 99.4% survivorship at 10 years. [Orthopedics. 2023;46(2):e111-e117.].

Social Determinants of Health in Total Hip Arthroplasty: Are They Associated With Costs, Lengths of Stay, and Patient Reported Outcomes?

BACKGROUND: Social determinants of health (SDOH) may play a larger role in predicting patient outcomes as outpatient total hip arthroplasty (THA) expands. We specifically examined the association between SDOH and patient metrics (demographics and comorbidities) for: (1) 30-day post-discharge costs of care; (2) lengths of stay (LOS); and (3) patient-reported outcomes (Hip Disability and Osteoarthritis Outcomes Score for Joints Replacement (HOOS JR)). METHODS: Medicare patients who underwent primary THA between 2018 and 2019 were identified. Those who had complete social determinant data were included (n = 136). Data elements were drawn from institutional, regional, and government databases, as well as the Social Vulnerability Index (SVI). Multiple regression analyses were performed to determine SDOH and baseline comorbidities associations with costs, LOS, and HOOS JR scores. RESULTS: Various SDOH factors were associated with higher 30-day costs, including residing in a food desert ($53,695 ± 15,485; P < .001) and the following SVI themes: 'Minority Status and Language' ($24,075 ± 9845; P = .01) and 'Housing and Transportation' ($16,190 ± 8501; P = .06), although the latter did not meet statistical significance. Baseline depression was associated with longer LOS (P = .02), while none of the other SDOH or patient metrics affected LOS. No relationships were observed between SDOH and HOOS JR changes from baseline. CONCLUSION: Patients who live in food deserts and have minority status had higher costs of care after primary THA. Poor housing and transportation may also increase costs, albeit insignificantly. These results highlight the utility of assessing SDOH-related risk factors to optimize post-operative outcomes, with potential implications for bundled care.

National Trends for Reverse Shoulder Arthroplasty After the Affordable Care Act: An Analysis From 2011 to 2015.

Few studies have investigated nationwide patient trends and health care costs for reverse shoulder arthroplasty (RSA) after 2014. This study uses a large validated nationwide database to retrospectively assess changes in patient and hospital demographic features, hospital costs, and hospital charges for inpatient RSA procedures before and after implementation of the Affordable Care Act. The National Inpatient Sample database was used to identify all patients who underwent RSA between January 2011 and December 2015, yielding 163,171 patients (63.4% female; mean age, 72 years). Categorical data were assessed with chi-square/Fisher's exact test, and continuous data were assessed with analysis of variance. There was an increased proportion of RSA recipients identifying as Hispanic (4.1% to 4.8%) and Native American (0.1% to 0.4%; P<.0001). The proportion of patients who had Medicaid (1.4% to 2.4%) and private insurance (15.1% to 16.6%) increased as well (P<.0001). A decrease in mean hospital costs occurred between 2011 and 2015 (-$256; P=.002), whereas an increase occurred in hospital charges (+$6,314; P<.001). These findings provide insight on RSA use and patient demographic trends in the United States. Additionally, these results help to capture the effects of extended health coverage and new reimbursement models on hospital costs and charges. [Orthopedics. 2022;45(2):97-102.].

Inpatient dislocation after primary total hip arthroplasty: incidence and associated patient and hospital factors.

INTRODUCTION: Inpatient dislocation following total hip arthroplasty (THA) may incur substantial financial penalties for hospitals in the United States. However, limited studies report on current incidence and variability of dislocations. We utilised a large national database to evaluate inpatient hip dislocation trends regarding: (1) yearly incidences; (2) lengths of stay (LOS); (3) demographic factors; and (4) hospital metrics. METHODS: The National Inpatient Sample was queried from 2012 to2016 for primary THA patients (n = 1,610,155), identifying 2490 inpatient dislocations. Various patient demographics and hospital characteristics were assessed. Multivariate regression analyses were conducted to identify dislocation risk factors. RESULTS: Dislocation rates increased from 0.11% in 2012 to 0.18% in 2016 (p < 0.001). Dislocated patients experienced significantly longer LOS (p < 0.001). Patient demographic factors associated with dislocation were sex, race, Medicaid insurance, alcohol use disorder, psychosis, hemiparesis/hemiplegia, chronic renal failure, and obesity. Spinal fusion was not associated with inpatient dislocation. Dislocations were likeliest in the South and least likely in teaching hospitals. CONCLUSION: Inpatient dislocation has increased in recent years. Optimised management and recognition of the patient and hospital factors outlined in this study may help decrease inpatient dislocation risks following THA, thus avoiding hospital reimbursement penalties for this preventable complication.

Same Day versus Staged Total Knee Arthroplasty: Do Cost Savings Justify the Risk?

Same-day bilateral total knee arthroplasties (BTKAs) are associated with increased complications compared with staged procedures; however, as complication rates and lengths of stay (LOS) for same-day procedures decrease, they may become attractive alternatives to staged procedures. The void of recent nationwide studies comparing the 30-day total cost and risks of these procedures inspired this propensity matched review. Therefore, we compared 30-day outcomes in staged and same-day BTKAs occurring in 2016 and 2017 using the National Readmission Database (NRD), a nationwide database. The NRD was queried for all same-day and staged BTKA patients from January 1 to November 30 for both 2016 and 2017. Since the NRD links readmissions within one calendar year, TKAs occurring in this month were excluded to allow 30-day follow-up. Propensity matching was performed based on demographics, producing 19,334 patients in both cohorts. Thirty-day readmission, revision, and mortality rates, hospital costs, LOS, discharge dispositions, and complications were analyzed. Chi-square and Student's t-tests assessed categorical and continuous variables, respectively. A p-value of <0.05 was set as the threshold for statistical significance. The analysis demonstrated that less same-day patients were readmitted, with statistical but not clinical difference in revisions, and mortality (all p < 0.050). Higher 30-day cost ($33,522 vs. $29,053, p < 0.001), decreased total LOS (4.52 vs. 4.94 days, p < 0.001), and lower rates of PEs (0.3 vs. 1.1%, p < 0.001) and transfusions (2.1 vs. 8.5%, p < 0.001) but similar total complications (p >0.050) were associated staged compared with same-day BTKAs. The results suggest inpatient cost savings associated with same-day surgeries should be weighed against the slight increase in LOS and PEs. Ultimately, as LOS and PE rates continue to decrease from innovations and quality improvements, same-day BTKA may become an attractive alternative to staged BTKAs, especially if payer's incentive surgeons by increasing physician reimbursements.

The pericapsular nerve group block: a step towards outpatient total hip arthroplasty?

INTRODUCTION: A new regional anaesthetic technique, coined the pericapsular nerve group (PENG) block, targets the anterior hip capsule by blocking the articular branches of the femoral nerve and accessory obturator nerve. In this study, we evaluated: (1) patient outcomes; (2) postoperative pain scores; and (3) postoperative opioid consumption in total hip arthroplasty (THA) patients who received a PENG block in comparison to a control group. METHODS: A retrospective chart review was performed for patients who underwent primary THA and met criteria at a single institution (n = 48), with an additional cohort of patients collected as controls (n = 48). Postoperative pain scores were measured by obtaining the cumulative visual analogue scores (VAS) at 12-hour intervals until the 48-hour benchmark. All administered opioids were collected from postoperative day (POD) 0 to POD2 and converted to morphine milligram equivalents (MME). RESULTS: In the PENG group, length of stay was significantly shorter (p < 0.001) and the initial postoperative distance walked was significantly farther (p = 0.001). The PENG group consistently demonstrated significantly lower mean cumulative pain scores until the 48-hour mark (p < 0.001 for all). Patients receiving the PENG block also experienced a significantly longer therapeutic window before requiring their first opioid (p < 0.002). The PENG group required significantly less opioid MMEs on POD1, POD2, and cumulatively over the entire stay (p < 0.022 for all). CONCLUSIONS: Our findings suggest that the PENG block has the potential of impacting THA recovery pathways and contributing to cost savings. Thus, its use further supports the transition to the outpatient setting and drives us towards achieving value-driven healthcare.

Access to Total Knee Arthroplasty Among Patients With Low Incomes Has Not Increased Under Global Budget Revenue.

In 2014, Maryland implemented an experimental reimbursement model, Global Budget Revenue (GBR). This model provided hospitals with a capitated annual budget each fiscal year to use toward all services, regardless of payer. Goals of GBR include reductions in cost, improvements in care quality, and increased access for patients to high-volume procedures, such as total knee arthroplasty (TKA). We assessed demographics and outcomes among patients with low incomes and patients of racial minority groups in Maryland who underwent TKA before and after GBR implementation. Patients undergoing TKAs from 2011 to 2016 were queried from the Maryland State Inpatient Database, resulting in 71,066 patients. There were 13,722 patients with low incomes and 19,846 patients of racial minority groups. The chi-square test was used for sex, income, insurance, Charlson Comorbidity Index, and morbid obesity, with the Student's t test being reserved for age before and after GBR. The proportion of patients with low incomes decreased the year before GBR but increased with GBR and maintained (P<.001). The proportion of patients of racial minority groups increased the year before GBR implementation, decreased slightly, and then maintained (P<.001). Mean cost decreased for both cohorts of patients (both P<.001). Discharges to home increased for both cohorts (P<.001), while length of stay decreased (both P<.001). Global Budget Revenue decreased cost while improving outcomes for TKA patients post-GBR. Patients with low incomes have not increased their use of TKA, contrary to patients of racial minority groups. This suggests that barriers remain. Further follow-up of GBR performance in subsequent years will increase understanding of the sustainability of this trend and the degree to which any increase in access is dependent on the implementation of the Affordable Care Act. [Orthopedics. 2022;45(1):e11-e16.].

The Rise of Obesity among Total Knee Arthroplasty Patients.

In the United States, one-third of adults are considered obese, and demand for total knee arthroplasty (TKA) is expected to rise in these patients. Surgeons are reluctant to operate on obese patients, but it is important to understand how obesity has affected TKA utilization. This study utilizes a national database to evaluate incidence, demographics, outcomes, charges, and cost in nonobese, overweight, nonmorbidly obese, and morbidly obese TKA patients. We queried the National Inpatient Sample from 2009 to 2016 for primary TKA patients identifying 4,053,037 nonobese patients, 40,077 overweight patients, 809,649 nonmorbidly obese patients, and 428,647 morbidly obese patients. Chi-square was used to analyze categorical variables, and one-way analysis of variance was used to analyze continuous variables. Nonmorbidly obese and morbidly obese patients represented 23.2% of all TKAs. TKA utilization increased 4.1% for nonobese patients, 121.6% for overweight patients, 73.6% for nonmorbidly obese patients, and 83.9% for morbidly obese patients. Morbidly obese patients were younger (p < 0.001), female (p < 0.001), Black (p < 0.001), poor (p < 0.001), and utilized private insurance (p < 0.001). They also had the longest length of stay (p < 0.001) and the highest mortality rate (p < 0.001). More morbidly obese patients were discharged to other facilities (p < 0.001), and they had the highest rate of complications (p < 0.001). Patients with morbid obesity had the highest charges (p < 0.001), but overweight patients had the highest costs (p < 0.001). The results of this study demonstrate the rise in obese and morbidly obese patients seeking TKAs, which may be reflection of the obesity epidemic in America. Although TKA utilization has increased for morbidly obese patients, this body mass index (BMI) category also has the highest rates of charges and complications, suggesting morbid obesity to be a modifiable risk factor leading to worse surgical and economic outcomes. Obese patients undergoing TKA may benefit from preoperative optimization of their weight, in an effort to reduce the risk of adverse outcomes.

Sequentially Irradiated and Annealed Highly Cross-Linked Polyethylene: Linear Vector and Volumetric Wear in Total Hip Arthroplasty at 10 Years.

BACKGROUND: There is a paucity of data on the long-term performance of highly cross-linked polyethylene (HXLPE). Therefore, this study evaluated 10-year 1) functional, 2) radiographic, and 3) surgical outcomes in patients who underwent total hip arthroplasty with sequentially irradiated and annealed HXLPE. METHODS: A retrospective, multicenter study was conducted on patients who underwent primary total hip arthroplasty and received HXLPE polymer (n = 151). Two-dimensional radiographic linear and volumetric wear analyses were quantified using the Martell Hip Analysis software, while functional outcomes were assessed by analyzing postoperative Short-Form-12 (SF-12) Physical and Mental Health Surveys and Harris Hip Scores. Radiographic outcomes included yearly linear (mm/y) and volumetric (mm3/y) wear rates. Surgical outcomes included additional operations and survivorship. RESULTS: SF-12 scores were within 1 standard deviation (SD) of the normal population (SF-12 Physical: 47.0; SF-12 Mental: 52.0), while the Harris Hip Scores of 89.5 was borderline between "good" and "excellent." Total and annual linear wear rates were 0.164 mm (SD: 0.199 mm) and 0.015 mm/y (SD: 0.018 mm/y), respectively. The mean total volumetric wear rate was 141.4 mm3 (SD: 165.0) and 12.6 mm3/y (SD: 14.9 mm3/y) when broken down into a yearly rate. Eleven patients required revisions, resulting in an all-cause polyethylene survivorship of 92.7%, with a polyethylene wear survivorship of 100.0%. CONCLUSIONS: Our results demonstrate clinically undetectable linear and volumetric wear rates after 10 years in those who received the unique sequentially irradiated and annealed HXLPE. Furthermore, high rates of survivorship coupled with low all-cause revision rates illustrate the polymers' capability to potentially increase implant longevity.

Complications Associated With Same-Day Bilateral Total Knee Arthroplasties.

Same-day bilateral total knee arthroplasties (SBTKAs) are associated with shorter rehabilitation and lower cost. However, controversy surrounding the safety of SBTKAs exists. Recent studies are lacking to determine whether patient selection has brought SBTKA in line with unilateral total knee arthroplasty (UTKA). Therefore, the authors evaluated and compared patient characteristics, hospital characteristics, and inpatient course between UTKA and SBTKA from 2009 to 2016. The National Inpatient Sample was queried from 2009 to 2016 for UTKA and SBTKA patients. Of the 5,329,466 patients identified, 5,084,328 (95.4%) patients received UTKAs and 245,138 (4.6%) patients underwent SBTKAs. Incidence, rate, patient and hospital characteristics, health status, length of stay (LOS), discharge disposition, hospital charges, hospital costs, and complications were analyzed and statistically compared. The incidence (-1.4%) and rate (15.8%) of SBTKAs decreased (both P<.001). The SBTKA cohort had more patients who were younger, male, White, obese, healthier, and using private insurance (P<.001 for all). The SBTKA cohort had longer LOS, a higher proportion of discharges to skilled nursing facilities, higher cost and charges, and more complications, including deep venous thromboses/pulmonary emboli (DVT/PE) and transfusions (P<.001 for all). Conversely, SBTKA was associated with fewer myocardial infarctions (P<.001). Although improved from previous literature, SBTKA is still associated with longer LOS, higher cost and charges, and more complications, including DVT/PE and transfusions, although with a lower rate of myocardial infarction. However, studies are needed to determine whether the risk of 1 SBTKA outweighs the cumulative risk of staged UTKAs. [Orthopedics. 2021;44(3):e407-e413.].

Social determinants of health in total knee arthroplasty : are social factors associated with increased 30-day post-discharge cost of care and length of stay?

AIMS: Social determinants of health (SDOHs) may contribute to the total cost of care (TCOC) for patients undergoing total knee arthroplasty (TKA). The aim of this study was to investigate the association between demographic data, health status, and SDOHs on 30-day length of stay (LOS) and TCOC after this procedure. METHODS: Patients who underwent TKA between 1 January 2018 and 31 December 2019 were identified. A total of 234 patients with complete SDOH data were included. Data were drawn from the Chesapeake Regional Information System, the Centers for Disease Control social vulnerability index (SVI), the US Department of Agriculture, and institutional electronic medical records. The SVI identifies areas vulnerable to catastrophic events with four themed scores: socioeconomic status; household composition and disability; minority status and language; and housing and transportation. Food deserts were defined as neighbourhoods located one or ten miles from a grocery store in urban and rural areas, respectively. Multiple regression analyses were performed to determine associations with LOS and costs after controlling for various demographic parameters. RESULTS: Divorced status was significantly associated with an increased LOS (p = 0.043). Comorbidities significantly associated with an increased LOS included chronic obstructive pulmonary disease/asthma and congestive heart failure (p = 0.043 and p = 0.001, respectively). Communities with a higher density of tobacco stores were significantly associated with an increased LOS (p = 0.017). Comorbidities significantly associated with an increased TCOC included chronic obstructive pulmonary disease (p = 0.004), dementia (p = 0.048), and heart failure (p = 0.007). Increased TCOCs were significantly associated with patients who lived in food deserts (p = 0.001) and in areas with an increased density of tobacco stores (p = 0.023). CONCLUSION: Divorced marital status was significantly associated with an increased LOS following TKA. Living in food deserts and in communities with more tobacco stores were significant risk factors for increased LOS and TCOC. Food access and ease of acquiring tobacco may both prove to be prognostic of outcome after TKA and an opportunity for intervention. Cite this article: Bone Joint J 2021;103-B(6 Supple A):113-118.

Trends of Obese and Morbidly Obese Patients in Same-Day Bilateral Total Knee Arthroplasty from 2009 to 2016.

As obesity in the United States increases, the proportion of obese and morbidly obese patients undergoing same-day bilateral total knee arthroplasty (sd-BTKA) remains unknown. Therefore, this study analyzed: (1) incidence, (2) patient demographics, (3) patient course, and (4) patient outcomes in obese and morbidly obese patients undergoing sd-BTKA in the United States from 2009 to 2016. The National Inpatient Sample was queried for all sd-BTKA patients from 2009 to 2016, yielding 39,901 obese and 20,394 morbidly obese patients. Analyzed variables included overall incidence, age, length of stay (LOS), sex, race, payer, Charlson comorbidity index (CCI) status, disposition, complications, location/teaching status, region of hospital, costs, and charges. Categorical variables were evaluated with chi-square analysis, while continuous variables were analyzed by Student's t-tests. Overall, the number of sd-BTKAs decreased over the study period, although the proportion of both obese and morbidly obese patients increased (p < 0.001 for all). The most common CCI status, 3 + , decreased in proportion for both groups (p < 0.001 for all). Hospital costs decreased and charges increased for both groups (p < 0.001 for all). Mean LOS decreased and patients were most commonly discharged to skilled nursing facilities, although these proportions decreased (p < 0.001 for all). Respiratory failures (p < 0.001 for all) increased for both groups, while proportion of deep vein thromboses and hematomas/seromas (p < 0.001 for all) increased for obese patients and proportion of pulmonary emboli (p < 0.001) increased for morbidly obese patients. The results of this study appear to portray improving optimization and patient selection of higher body mass index (BMI) individuals undergoing this procedure. More information is needed comparing the safety of the sd-BTKA across patients of all BMI groups.

Two-Stage Exchange Using a Short Intramedullary Nail for Treatment of Periprosthetic Knee Infections: A Technique Worth Questioning.

Periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA) are serious orthopaedic complications that pose marked burdens to both patients and health care systems. At our institution, two-stage exchange with a temporary short antibiotic cement-coated intramedullary nail was utilized for the treatment of repeat PJIs in a series of compromised patients with considerable bone loss. This study reports on (1) success rates, (2) functional and pain outcomes, (3) and complications for patients receiving a temporary short intramedullary nail for the treatment of PJI. Our institutional database was queried for all repeat knee PJI patients between March 1st, 2009 and February 28th, 2015. Patients with type II/III Anderson Orthopaedic Research Institute (AORI) bone defects who underwent two-stage exchange arthroplasty with a short antibiotic-coated intramedullary nail were included for analysis (n = 31). Treatment success was determined using the Delphi-based consensus definition of a successfully treated PJI: infection eradication (healed wound with no recurrence of infection by the same organism), no further surgical intervention for infection after reimplantation, and no PJI-related mortality. A paired t-test was performed to assess for continuous variables. A total of 26 patients went on to reimplantation, while 5 patients retained the intramedullary nail. Overall treatment success was 74.2%. Range of motion significantly decreased postoperatively (102.1 vs. 87.3 degrees; p < 0.001), while Knee Society Scores (function) significantly increased (55.6 vs. 77.7, p < 0.001). A majority of patients were full weight-bearing immediately following surgery (38.7%). Treating poor health status patients with PJI of the knee can be difficult after multiple revisions. With a success rate similar to conventional methods, our results demonstrate that two-stage exchange with a temporary short intramedullary nail may be a desirable treatment option for patients with bony defects wishing to avoid amputation or permanent arthrodesis. However, this method does not outperform other treatment modalities, and may not be suitable for all patients. Patient expectations and health status should be carefully assessed to determine if this procedure is appropriate in this complex patient population.

Maryland's Global Budget Revenue Model: How Do Costs and Readmission Rates Fare for Patients Undergoing Total Knee Arthroplasty?

In 2014, Maryland implemented the Global Budget Revenue (GBR) model for cost reduction and quality improvement. This study evaluated GBR's effect on demographics and outcomes for patients who underwent primary total knee arthroplasty (TKA) by comparing Maryland to the United States (U.S.). We identified primary TKA patients in Maryland's State Inpatient Database (n = 71,022) and the National Inpatient Sample (n = 4,045,245) between 2011 and 2016 utilizing International Classification of Disease (ICD)-9 and ICD-10 diagnosis codes. Multiple regression was used for difference-in-difference (DID) analyses to compare the intervention cohort (Maryland) to the nonintervention cohort (U.S.) between the pre-GBR (2011-2013) and post-GBR (2014-2016) periods. After GBR implementation, there were proportionally less white, obese, morbidly obese, Medicare, and Medicaid patients with proportionally more routine discharge patients in Maryland and the U.S. (all p < 0.001). There were proportionally less home health care (HHC) patients in Maryland, but more in the U.S. (both p < 0.001). The mean lengths of stay (LOS), costs, and complications decreased for both cohorts, while charges increased for the U.S. (all p < 0.001). The DID analysis suggested Maryland saw more Asian and Medicaid patients and less obese and morbidly obese patients under GBR. The DID assessments also found decreased LOS, costs, and charges (p < 0.001 for all) for patients under GBR. As other states such as Pennsylvania and Vermont explore hospital budgets, Maryland may provide a more viable model for future health care policies that incorporate global budgets.

Comparing Outcomes for Female Total Knee Arthroplasty Patients Under Global Budget Revenue.

Maryland implemented the all-payer, rater-setting Global Budget Revenue (GBR) payment model in 2014 to reduce cost and improve quality. This study assessed the effect of GBR on total knee arthroplasty (TKA) outcomes by sex. Specifically, the authors assessed (1) demographics and (2) outcomes of males and females undergoing TKA before and after GBR implementation. The Maryland State Inpatient Database was queried from 2011 to 2016. There were 71,066 TKAs (male, n=25,413; female, n=45,634). For continuous and categorical variables, t testing and chi-square analyses were used, respectively. Difference-in-difference analyses using multiple regression compared changes in sex from the pre-GBR period (2011-2013) with the post-GBR period (2014-2016). The female proportion decreased (-1.9%; P=.040). Proportionally more TKA patients were Hispanic and Asian, from high-income areas, using Medicare and Medicaid, and morbidly obese (all P<.001). The mean length of stay (LOS), charges, and costs were decreased after GBR implementation (all P<.001). More patients were discharged routine and had fewer readmissions (both P<.001). There were fewer complications, including deep venous thromboses/pulmonary emboli, urinary tract infections, and blood transfusions (all P<.001). The difference-in-difference analyses suggested more females were discharged with home health care and had longer LOS than did males (both P<.001). The GBR appears to meet its main objective of cost reduction and improvements in quality of care. However, the proportion of females receiving TKA decreased, and their LOS did not improve as much as that of males. As other states consider global budgets, more research is needed to ensure this all-payer, rate-setting, capitated system does not cause decreased access to care. [Orthopedics. 2021;44(2):e266-e273.].

Short-term Outcomes of 3D-Printed Titanium Metaphyseal Cones in Revision Total Knee Arthroplasty.

Recently, 3-dimensional (3D) printing technology has been used in the development of titanium metaphyseal cones to manage severe bone loss in revision total knee arthroplasty (rTKA). This study assessed (1) radiographs; (2) functional outcomes; (3) complications; and (4) 2-year implant survivorship in patients receiving 3D-printed titanium metaphyseal cones for moderate-to-severe tibial and femoral bone loss in rTKA. A single institution, retrospective chart review was performed for patients with large bone defects treated with a 3D-printed femoral or tibial titanium metaphyseal cone between 2015 and 2017 during rTKA (N=54). Paired sample t tests analyzed Knee Society Scores (KSS). Kaplan-Meier analyses determined implant survivorship when the endpoint was cone revision for aseptic loosening, cone revision for any reason, and reoperation for any reason. The authors found that 51 (98.1%) of 52 available radiographs demonstrated well-fixed components without any evidence of loosening or migration. Mean postoperative KSS scores were significantly higher when compared with preoperative scores (80.4 vs 52.0; P>.001). One patient experienced aseptic loosening of their cone. Seven additional cones were explanted as a consequence of reinfection, 1 of which was removed prior to arthrodesis. Cone survivorship was 98.5% when the endpoint was cone revision due to aseptic loosening, 88.2% when cone revision was due to any reason, and 77.9% for any reoperation. Metaphyseal cones appear to be well-suited for large bone defects during rTKA and the authors' findings suggest that cones may be a viable option for metaphyseal fixation during rTKA. Future studies should focus on their durability during a longer time period. [Orthopedics. 2021;44(1):43-47.].

Closing the Socioeconomic Gap in Massachusetts: Trends in Total Hip Arthroplasty From 2013 to 2015.

To extend insurance coverage to all residents, Massachusetts legislation expanded Medicaid eligibility and added new private insurance categories. To date, no one has analyzed the effect of these changes and compared recent trends in total hip arthroplasty (THA) utilization. Therefore, this study sought to update the current trends of THA utilization in Massachusetts from 2013 to 2015. The Massachusetts State Inpatient Database was queried for all patients who underwent primary THA between 2013 and 2015, and 30,308 patients were identified. Analyzed variables included age, sex, race, Charlson Comorbidity Index, median household income, primary payer, discharge disposition, length of stay, hospital charges, hospital costs, and complications. Categorical and continuous variables were assessed using chi-square analyses and analyses of variance, respectively. Between 2013 and 2015, annual THAs increased from 9361 to 10,562. Race did not vary significantly (P=.447), although an increase in patients using Medicaid and a decrease in patients using other insurance was observed (P<.001). Patients with an income quartile of 1 increased, whereas the number of THA patients in quartile 3 decreased (P<.001). There was a decrease in both hospital charges (P<.001) and costs (P<.001). Mean length of stay decreased (P<.001), and the number of patients with complications decreased (P<.001). Massachusetts has been successful in increasing access to THA procedures for low-income patients and increasing the number of patients who use Medicaid for THAs. The current delivery of health care in Massachusetts has shown improvement for its residents, serving as an example that other states can learn from. [Orthopedics. 2021;44(2):e167-e172.].

Modified Allograft Reconstruction of a Disrupted Patella Tendon: A Technical Case Report.

CASE: A 19-year-old woman with a history of Hoffa fat pad syndrome underwent infrapatellar fat pad synovectomy and subsequently developed extensor mechanism disruption secondary to iatrogenic patellar tendon injury. She received a modified extensor mechanism patella-patellar tendon-tibial tubercle allograft to restore extensor function with satisfactory results at 2-year follow-up. We also review alternative techniques that were considered for her extensor mechanism repair. CONCLUSION: The patient demonstrated satisfactory outcomes, similar to other established techniques. This modified extensor mechanism allograft reconstruction may be an effective alternative for patients experiencing acute extensor mechanism disruptions.

Same-Day Bilateral Total Knee Arthroplasty: Incidence and Perioperative Outcome Trends from 2009 to 2016.

BACKGROUND: Same-day bilateral total knee arthroplasty (BiTKA) is a controversial topic in orthopedics, prompting a consensus statement to be released by national experts. To date, no studies have evaluated the trends of this method since these recommendations. This study utilized a national database to evaluate: 1) incidence; 2) patient characteristics; 3) hospital characteristics; and 4) inpatient course for same-day BiTKAs in the United States from 2009 to 2016. METHOD: The National Inpatient Sample database was queried for individuals undergoing same-day BiTKAs, yielding 245,138 patients. Patient demographics included age, sex, race, obesity status and Charlson Comorbidity Index (CCI) score. Hospital characteristics consisted of location/teaching status, geographic region, charges, and costs. Inpatient course included length of stay, discharge disposition, and complications. RESULTS: Same-day BiTKA incidence decreased from 5.6% to 4.0% over the study (p < 0.001). Decreases in patient age and female proportion (p < 0.001 for both) were seen, while African American and Hispanic patients increased (p < 0.001), as did obese patient proportions (p < 0.001). Patients with CCI scores of 2 increased, while those with ≥3 decreased (p < 0.001). Hospital charges increased, while costs decreased (p < 0.001 for both). Length of stay following same-day BiTKA decreased (p < 0.001) and routine home discharges increased (p < 0.001). Most inpatient complications decreased, although the percentage of mechanical complications and respiratory failures increased (p < 0.01 for all). CONCLUSIONS: During the study period, younger patients with fewer comorbidities underwent BiTKAs, which likely resulted from improved patient assessment and management. Future investigations should include an evaluation of long-term complications and outcomes in certain patient populations for this procedure.

Obesity and its effect on outcomes in same-day bilateral total knee arthroplasty.

BACKGROUND: The niche surgery of same-day bilateral total knee arthroplasty (sd-BTKA) continues to create debate amongst specialists in arthroplasty. To date, there is a significant lack of literature on obese patients undergoing sd-BTKA, and no study has evaluated outcomes of this procedure when compared to non-obese patients. Therefore, this study will perform a retrospective analysis to compare (I) incidence, (II) demographics, and (III) complications of sd-BTKA in non-obese, obese, and morbidly obese patients in the United States from 2009 to 2016. METHODS: The National Inpatient Sample (NIS) database was queried for all individuals that underwent sd-BTKA from 2009 to 2016. This returned 184,844 non-obese patients, 39,901 obese patients, and 20,394 morbidly obese patients. Analyzed variables included mean age, mean length of stay (LOS), race, payer, age-adjusted Charlson Comorbidity Index score, discharge disposition, hospital charges, hospital costs, and complications. Chi-square analyses and analyses of variance were utilized to assess categorical and continuous variables, respectively. RESULTS: Non-obese patients most commonly underwent sd-BTKA over the course of the study. As weight status increased, mean age decreased and the proportion of females, LOS, hospital charges and costs, and proportion of discharges to skilled nursing facilities increased. Regression analysis demonstrated obese and morbidly obese cohorts were at an overall increased odds for experiencing complications. Specifically, obese patients were at increased risk for pulmonary emboli, periprosthetic joint infections, and respiratory failures, while morbidly obese patients are at increased risk for pulmonary emboli, respiratory failures, and urinary tract infections. CONCLUSIONS: Surgeons should thoroughly evaluate the risks and benefits of performing sd-BTKA on obese and morbidly obese patients, as both confer higher overall complication rates and increased length of stay. More research is necessary to characterize the cost analysis of this procedure, as health care models continue to transition to more cost-effective procedures.