Mini-Navigation Utilization in THA Results in Shorter Length of Stay, Increased Home Discharge, and Higher Physical Therapy Mobilization Scores Compared to THA Without Navigation.

BACKGROUND: As volume of total hip arthroplasty (THA) continues to increase, the utilization and availability of in-traoperative advanced technologies to arthroplasty surgeons continues to rise as well. Our primary goal was to determine whether the use of a mini navigation technology extended operative times and secondarily if it affected postoperative outcomes following elective THA. METHODS: A single-institution total joint arthroplasty da-tabase was utilized to identify adult patients who underwent elective THA from 2017 to 2019. Baseline demographic data along with surgical operative time, length of stay (LOS) and discharge disposition were collected. The Activity Measure for Post-Acute Care (AM-PAC) was used to determine physi-cal therapy progress. RESULTS: A total of 1,162 THAs were performed of which 69.1% (803) used navigation while 30.9% (359) did not. Baseline demographics including age, sex, body mass index (BMI), insurance, and smoking status were not statistically different between groups. The operative time was shorter in the navigation group compared to THA without navigation (115.1 vs. 118.9 min, p < 0.0001). Mean LOS was signifi-cantly shorter in the navigation THA group as compared to THA without navigation (2.1 vs. 2.6 days, p < 0.0001). Postoperative AM-PAC scores were higher in the navigation group on postoperative day 1 as compared to patients with-out navigation (18.87 vs. 17.52, p < 0.0001). Additionally, a greater percentage of patients were discharged directly home after THA with navigation as compared to THA without navigation (89.54% vs. 83.57%, p < 0.0001). CONCLUSION: Our study demonstrates that hip navigation technology in the setting of THA is associated with reduced operative times and higher AM-PAC mobilization scores. Hip mini navigation technology shortens operative times while improving early patient outcome scores in association with shorter LOS and greater home-based discharge.

Cement Burn of the Skin Following Total Knee Arthroplasty Case Report and Review of the Literature.

INTRODUCTION: Cement burns following arthroplasty pro-cedures are a rare but serious complication. To the authors' knowledge, this report is the first of its kind in total knee arthroplasty. CASE: A 61-year-old female underwent an otherwise rou-tine left total knee arthroplasty. On postoperative day one, a 3 cm by 3 cm cement burn was noted on the distal aspect of the popliteal fossa of the operative leg. The burn was noted to be a full-thickness (third degree) burn that required plastic surgery burn service management and limited the patient's postoperative recovery and function. CONCLUSIONS: Cement burns of the skin following total joint arthroplasty are rare, though when they do occur, they can cause significant pain and distress. Recognizing the depth of the skin involvement is important to determine the burn classification, treatment, and ultimately the prognosis to optimize outcomes.

The State of Meniscal Allograft Transplantation in New York Over the Last Decade.

BACKGROUND: The purpose of this study was to evaluate for changes in the incidence of arthroscopic meniscal procedures, especially meniscal allograft transplantation (MAT) in New York State (NYS) between 2005 to 2014. METHODS: The New York Statewide Planning and Research Cooperative Systems (SPARCS) database was queried from 2005 through 2014 to identify patients undergoing meniscetomies, meniscal repairs, and MAT. Patients were followed longitudinally to determine the incidence of subsequent ipsilateral knee procedures. The impact of patient demographics and surgeon volume on reoperation was explored. RESULTS: From 2005 through 2014, there were 524,737 arthroscopic meniscal procedures. Of these, there were 510,406 meniscectomies, 14,214 meniscal repairs, and 117 MATs. The number of MATs increased 15.5% per year, with the largest increase being between 2013 to 2014 (an increase of 86.5%). Average MAT patient age was 29.8 ± 11.1 years; 65.0% of patients were male; 66% were Caucasian; 84% were privately-insured; and 23% of surgeons met the criteria for high-volume (five or more MATs in a year). A total of 25.6% (30/117) patients underwent subsequent surgery; 26 patients underwent knee procedures at mean of 18.9 ± 18.3 months after initial MAT, the most common of which were ipsilateral meniscectomies (19/26). Four patients underwent total knee arthroplasty (TKA) at a mean of 21.0 ± 9.2 months after initial MAT. Patients undergoing TKA after MAT were significantly older (42.0 ± 15.0 years vs, 29.3 ± 10.7 years; p = 0.0242) than patients who did not. Neither demographics nor surgeon volume were statistically significant factors for undergoing subsequent surgery (p > 0.05). CONCLUSION: Meniscal allograft transplantation, though relatively uncommon, is being performed with greater frequency in NYS. Surgeons should counsel patients regarding the likelihood of requiring subsequent knee surgery after MAT, with repeat arthroscopic partial meniscectomy being the most commonly performed procedure.

Impact of Admission Source on Shoulder Arthroplasty.

BACKGROUND: The purpose of this study was to determine the relationship between admission source and postoperative length of stay (LOS), index admission hospital charges, and discharge disposition, in patients undergoing shoulder arthroplasty. METHODS: The New York Statewide Planning and Research Cooperative System (SPARCS) was used to identify all patients that underwent elective shoulder arthroplasty from 1994 through 2015. Patients were grouped into institutionalized (INS) versus non-institutionalized (n-INS) groups based on admission source. The two groups were compared regarding demographics, Charleston comorbidity index (CCI), postoperative blood transfusion requirement, LOS, and total charges. RESULTS: A total of 33,248 patients were identified (32,875 n-INS, 373 INS). Patientsin the INS cohort were significantly older (71.9 versus 68.1 years) and had a higher CCI (1.3 vs. 0.7). The mean LOS in the INS group was nearly 1 week longer(9.5 days vs. 2.8 days) and had a significantly higher postoperative blood transfusion rate (37.5% vs. 9.2%, odds ratio: 5.9). The mean total hospital charges in the INS group were also significantly higher ($63,988 vs. $36,826). DISCUSSION: Institutionalized patients undergoing shoulder arthroplasty have a protracted postoperative hospital course and this ultimately resulted in poorer outcomes and increased resource utilization.

Primary Quadriceps Tendon Suture Anchor Repair: Case Presentation and Surgical Technique.

SUMMARY: This case presentation described a technique for repairing an acute quadriceps tendon rupture with suture anchors. The patient was a 51-year-old man who sustained an acute quadriceps tendon rupture after a fall. We used a midline incision over the quadriceps tendon and muscle. The tendon was found to be completely avulsed from the superior border of the patella. Three suture anchors were used to re-approximate the quadriceps tendon to the patella and additional sutures were used to repair the medial and lateral patellar retinacula. The patient had excellent range of motion at his 6-week follow-up appointment after the procedure.

The Effects of Patient Point of Entry and Medicaid Status on Postoperative Opioid Consumption and Pain After Primary Total Hip Arthroplasty.

INTRODUCTION: Medicaid expansion has allowed more patients to undergo total hip arthroplasty (THA). Given the continued focus on the opioid epidemic, we sought to determine whether patients with Medicaid insurance differed in their postoperative pain and narcotic requirements compared with privately or Medicare-insured patients. METHODS: A single-institution database was used to identify adult patients who underwent elective THA between 2016 and 2019. Patients in the Medicaid group received Medicaid insurance, while the non-Medicaid group was insured commercially or through Medicare. Subgroup analysis was done, separating the private pay from Medicare patients. RESULTS: A total of 5,845 cases were identified: 326 Medicaid (5.6%) and 5,519 non-Medicaid (94.4%). Two thousand six hundred thirty-five of the non-Medicaid group were insured by private payors. Medicaid patients were younger (56.1 versus 63.28 versus 57.4 years; P < 0.001, P < 0.05), less likely to be White (39.1% versus 78.2% versus 76.2%; P < 0.001), and more likely to be active smokers (21.6% versus 8.8% versus 10.5%; P < 0.001). Surgical time (113 versus 96 versus 98 mins; P < 0.001) and length of stay (2.7 versus 1.7 versus 1.4 days; P < 0.001) were longer for Medicaid patients, with lower home discharge (86.5% versus 91.8% versus 97.2%; P < 0.001). Total opioid consumption (178 morphine milligram equivalents [MMEs] versus 89 MME versus 82 MME; P < 0.001) and average MME/day in the first 24 hours and 24 to 48 hours (52.3 versus 44.7 versus 44.45; P < 0.001 and 73.8 versus 28.4 versus 29.8; P < 0.001) were higher for Medicaid patients. This paralleled higher pain scores (2.71 versus 2.31 versus 2.38; P < 0.001) and lower Activity Measure for Post-Acute Care scores (18.77 versus 20.98 versus 21.61; P < 0.001). CONCLUSIONS: Medicaid patients presenting for THA demonstrated worse postoperative pain and required more opioids than their non-Medicaid counterparts. This highlights the need for preoperative counseling and optimization in this at-risk population. These patients may benefit from multidisciplinary intervention to ensure that pain is controlled while mitigating the risk of continuation to long-term opioid use.

Payments, Policy, Patients, and Practice Evolution and Impact of Reimbursements in Total Joint Arthroplasty.

Current trajectories are set to create a large gap between total joint arthroplasty (TJA) supply and demand. Economics dictates that when the demand of consumers (TJA patients) exceeds supply (surgeons performing TJA), a new equilibrium should ideally be established at a higher price point. However, in TJA, the price is set by the government and, therefore, not subject to traditional economic models. Thus, reimbursements for TJA have decreased steadily over time. Fee for service is no longer the dominant reimbursement model for most orthopedic care. Surgeons play a critical role in the evolution and success of Value-Based Care (VBC) models, but this work is not reflected in recent payment changes for TJA. The regulatory environment is notoriously complex and affects our patients, surgeons, and institutions. It is imperative for orthopedic surgeons to continue to advocate for themselves by engaging with leadership, responding to surveys, and balancing outside influences to preserve patient access to TJA. Future payment models for musculoskeletal care must risk-stratify patients, appropriately reimburse for the work of revision TJA, and consider non-modifiable socioeconomic factors. Perioperative orthopedic surgical home (POSH) tools can ensure early appropriate care and proper care coordination for discharge. All of these factors, despite being framed within payment policy, ultimately affect access to orthopedic care for our patients.

Learning curve for active robotic total knee arthroplasty.

PURPOSE: Total Knee Arthroplasty (TKA) procedures incorporate technology in an attempt to improve outcomes. The Active Robot (ARo) performs a TKA with automated resections of the tibia and femur in efforts to optimize bone cuts. Evaluating the Learning Curve (LC) is essential with a novel tool. The purpose of this study was to assess the associated LC of ARo for TKA. METHODS: A multi-center prospective FDA cohort study was conducted from 2017 to 2018 including 115 patients that underwent ARo. Surgical time of the ARo was defined as Operative time (OT), segmented as surgeon-dependent time (patient preparation and registration) and surgeon-independent time (autonomous bone resection by the ARo). An average LC for all surgeons was computed. Complication rates and patient-reported outcome (PRO) scores were recorded and examined to evaluate for any LC trends in these patient related factors. RESULTS: The OT for the cases 10-12 were significantly quicker than the OT time of cases 1-3 (p < 0.028), at 36.5 ± 7.4 down from 49.1 ± 17 min. CUSUM and confidence interval analysis of the surgeon-dependent time showed different LCs for each surgeon, ranging from 12 to 19 cases. There was no difference in device related complications or PRO scores over the study timeframe. CONCLUSION: Active Robotic total knee arthroplasty is associated with a short learning curve of 10-20 cases. The learning curve was associated with the surgical time dedicated to the robotic specific portion of the case. There was no learning curve-associated device-related complications, three-dimensional component position, or patient-reported outcome scores. LEVEL OF EVIDENCE: Level II.

History, indications, and advantages of orthopaedic operating room tables: a review.

Although surgical procedures have been occurring as early at 6500 BC, the modern sense of the operating room (OR) did not exist until more recently. As aseptic techniques and surgical procedures began to evolve, so too did the OR table. The OR table began to transition from a static, wooden table to a dynamic table with the ability to position patients for a variety of procedures. With the advent of intraoperative imaging for orthopaedic procedures, OR tables have adapted and allow for imaging of bony anatomy by using radiolucent materials. These changes have led to the development of numerous OR tables, each with their own sets of advantages and disadvantages. There is currently no summary of the development, indications, benefits, and disadvantages of the various OR tables available to orthopaedic surgeons in the literature. The purpose of this review is to provide a comprehensive review of orthopaedic operating tables for both the junior orthopaedic resident and experienced attending surgeon.

Total knee arthroplasty is associated with greater immediate post-surgical pain and opioid use than total hip arthroplasty.

BACKGROUND: As greater emphasis is being placed on opioid reduction strategies and implementation of multimodal analgesia, we sought to determine whether immediate post-surgical opioid consumption was different between THA and TKA. METHODS: A single-institution total joint arthroplasty database was used to identify patients who underwent elective THA and TKA from 2016 to July 2019. Baseline demographic data, operative time (defined by incision time), and American Society of Anesthesiologist (ASA) class were collected. Morphine milligram equivalents (MME) were calculated and derived from prospectively documented nursing opioid administration events, while visual analog scale (VAS) scores represented pain levels, both of which were collected as part of our institution's standard protocols. Activity Measure for Post-Acute Care (AMPAC) was used to determine physical therapy progress. RESULTS: A total of 11,693 cases were identified: 5,909 THA (50.53%) and 5784 (49.47%) TKA. THA patients tended to be slightly younger (63.38 years, SD 11.61 years, vs 65.72 years, SD 9.56 years; p < 0.01) and have lower BMIs (28.92 kg/m2 vs 32.52 kg/m2; p < 0.01). THA patients had lower ASA scores in comparison to TKA patients (p < 0.01). Aggregate opioid consumption (93.76 MME vs 147.55 MME; p < 0.01) along with first 24-h and 48-h usage was significantly less for THA as compared to TKA. Similarly, mean pain scores (4.15 vs 5.08; p < 0.01) were lower for THA, while AMPAC mobilization scores were higher (20.88 vs 19.29; p < 0.01) when compared to TKA. CONCLUSION: THA patients reported lower pain scores and were found to require less opioid medication in the immediate post-surgical period than TKA patients.

Discontinuation of the liposomal delivery of bupivacaine has no effect on pain management after primary total knee arthroplasty : no effect on pain scores, opioid consumption, or functional status.

AIMS: Liposomal bupivacaine (LB) as part of a periarticular injection protocol continues to be a highly debated topic in total knee arthroplasty (TKA). We evaluated the effect of discontinuing the use of LB in a periarticular protocol on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. METHODS: On 1 July 2019, we discontinued the use of intraoperative LB as part of a periarticular injection protocol. A consecutive group of patients who received LB as part of the protocol (Protocol 1) and a subsequent group who did not (Protocol 2) were compared. All patients received the same opioid-sparing protocol. Verbal rating scale (VRS) pain scores were collected from our electronic data warehouse and averaged per patient per 12-hour interval. Events relating to the opiate administration were derived as morphine milligram equivalences (MMEs) per patient per 24-hour interval. The Activity Measure for Post-Acute Care (AM-PAC) tool was used to assess the immediate postoperative function. RESULTS: A total of 888 patients received Protocol 1 and while 789 received Protocol 2. The mean age of the patients was significantly higher in those who did not receive LB (66.80 vs 65.57 years, p = 0.006). The sex, BMI, American Society of Anesthesiologists physical status score, race, smoking status, marital status, operating time, length of stay, and discharge disposition were similar in the two groups. Compared with the LB group, discontinuing LB showed no significant difference in postoperative VRS pain scores up to 72 hours (p > 0.05), opioid administration up to 96 hours (p > 0.05), or AM-PAC scores within the first 24 hours (p > 0.05). CONCLUSION: The control of pain after TKA with a multimodal management protocol is not improved by the addition of LB compared with traditional bupivacaine. Cite this article: Bone Joint J 2021;103-B(6 Supple A):102-107.

Differences in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Scores for a Single Surgeon Comparing Two Institutions: An Unfair Reimbursement Metric.

BACKGROUND: Emphasis on value-based purchasing links physician financial remuneration to patient-derived outcome scores. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys aim to provide a uniform comparison tool. Of the 22 different survey questions, only 3 (13.6%) focus on experience related to doctors. We sought to determine how HCAHPS scores differ for a single surgeon performing more than 500 total joint arthroplasties annually, divided almost equally between two centers. METHODS: HCAHPS data from 2015 to 2018 for a single, fellowship-trained arthroplasty surgeon were collected from two different hospitals. More than 200 cases were performed at each center with the same staff. One center is a large metropolitan academic-teaching hospital, and the other is a suburban private hospital. The purpose of the study was to determine if differences existed regarding HCHAPS scores between the two institutions. RESULTS: A significant difference was found between institutions regarding questions pertaining to "hospital environment," "admission process," and "hospital staff concern for pain," with more patients responding favorably in Institution Two than Institution One. CONCLUSION: Patient perceptions and ratings of overall experience differ significantly between hospitals even when surgery is performed by a single surgeon. These results lend credence to the fact that surgeons should not be unduly penalized for the hospital in which they operate, and financial remuneration involving HCAHPS scores must be approached with caution. This unfair system could potentially drive surgeons to perform the majority of their cases in the hospital system with higher scores in the nonphysician related domains as this would affect overall patient satisfaction, and thus, financial compensation.

Revision total hip arthroplasty is associated with significantly higher opioid consumption as compared to primary total hip arthroplasty in the acute postoperative period.

BACKGROUND: There are currently a lack of investigations that characterised narcotic utilisation following revision total hip arthroplasty (THA). We sought to determine if immediate post-surgical opioid use was different between revision THA and primary THA. METHODS: A single institution total joint arthroplasty database was used to identify adult patients who underwent revision THA or primary THA from 2016 to 2019. Morphine milligram equivalents (MME) were calculated for different time periods. RESULTS: 6977 patients were identified, 89.72% primary THA and 10.28% revision THA. Aggregate opioid consumption was higher for revision THA patients (317.40 MME vs. 93.01 MME), as was opioid consumption in the first 24 hour and second 24-hour periods. Visual analogue pain (VAS) scores were significantly higher in the 0-12 hour postoperative and the 12-24 hours postoperative periods in the revision THA group. CONCLUSIONS: Patients undergoing revision THA had significantly higher narcotic utilisation than those undergoing primary THA, particularly in the first 24 hours postoperatively.

What Are the Effects of Patient Point of Entry and Medicaid Status on Postoperative Opioid Consumption and Pain Following Primary Total Knee Arthroplasty?

BACKGROUND: Total knee arthroplasty (TKA) provides excellent results across a variety of pathologies. As greater focus is placed on the opioid epidemic, we sought to determine if patients presenting for TKA via the Medicaid clinic (Medicaid) differed in terms of their opioid requirements compared to patients presenting via private office clinics (non-Medicaid). METHODS: A single-institution total joint arthroplasty database was utilized to identify patients who underwent elective TKA between January 2016 and May 2019. Medicaid clinic patients were insured by some form of Medicaid, whereas private office patients had commercial or Medicare insurance. Morphine milligram equivalents (MMEs) and Activity Measure for Post-Acute Care scores were calculated. RESULTS: A total of 6509 patients were identified: 413 (6.35%) Medicaid and 6096 (93.65%) non-Medicaid. Medicaid patients were younger (63.32 vs 66.21 years, P < .0001), less likely to be of Caucasian race (21.31% vs 56.82%, P < .0001), and more likely to be active smokers (11.14% vs 7.73%, P < .0001). Although surgical time and home discharge rates were similar, Medicaid patients had longer length of stay (2.80 vs 2.46 days, P < .0001). Opioid requirements were higher for Medicaid patients (200.1 vs 132.2 MMEs, P < .0001), paralleling higher pain scores (3.03 vs 2.55, P < .0001). No differences were found in Activity Measure for Post-Acute Care scores (18.47 vs 18.77, P = .1824). CONCLUSION: Medicaid patients tended to be younger, of minority race, and active smokers compared to non-Medicaid patients. Medicaid patients demonstrated worse postoperative pain scores and required 51% greater MMEs immediately following TKA, highlighting the need for preoperative counseling in traditionally at-risk socioeconomic groups. LEVEL OF EVIDENCE: III, Retrospective Observational Analysis.

The Impact of Arthroplasty Fellowship Training on Total Joint Arthroplasty: Comparison of Peri-Operative Metrics between Fellowship-Trained Surgeons and Non-Fellowship-Trained Surgeons.

BACKGROUND: We sought to identify differences between total joint arthroplasties (TJAs) performed by adult reconstruction fellowship-trained surgeons (FT) than non-fellowship-trained surgeons (NFT). METHODS: A single-institution database was utilized to identify patients who underwent elective TJA between 2016 and 2019. RESULTS: In total, 16,882 TJAs were identified: 9111 total hip arthroplasties (THAs) and 7771 total knee arthroplasties (TKAs). Patients undergoing THA by FT surgeons were older (63.11 vs 61.84 years, P < .001), more likely to be white, insured by Medicare, and less likely to be active smokers (P < .0001). Both surgical time (90.03 vs 113.1 minutes, P < .0001) and mean length of stay (LOS) (1.85 vs 2.72 days, P < .0001) were significantly shorter for THAs performed by FT surgeons than NFT surgeons. A significantly greater percentage of patients were discharged home after THA by FT surgeons than NFT surgeons (88.7% vs 85.2%, P = .002). FT patients were quicker to mobilize with therapy and required 25% less opioids. TKAs performed by FT surgeons were associated with shorter surgical times (87.4 vs 94.92 minutes, P < .0001), LOS (2.62 vs 2.84 days, P < .0001), and nearly 19% less opioid requirement in the peri-operative period. In addition to higher Activity Measure for Post-Acute Care scores associated with FT surgeons after TKA, a significantly greater percentage of patients were discharged home after TKA by FT surgeons than NFT surgeons (83.97% vs 80.16%, P < .001). CONCLUSION: For both THA and TKA, patients had significantly shorter surgical times, LOS, and required less opioids when their procedure was performed by FT surgeons compared to NTF surgeons. Patients who had their TJA performed by a FT surgeon achieved higher Activity Measure for Post-Acute Care scores and were discharged home more often than NFT surgeons. In an era of value-based care, more attention should be paid to the patient outcomes and financial implications associated with arthroplasty fellowship training. LEVEL III EVIDENCE: Retrospective Cohort Study.

Differences in Pain, Opioid Use, and Function Following Unicompartmental Knee Arthroplasty compared to Total Knee Arthroplasty.

BACKGROUND: We sought to determine if immediate postsurgical pain, opioid use, and clinical function differed between unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). METHODS: A single-institution database was utilized to identify patients who underwent elective total joint arthroplasty between 2016 and 2019. RESULTS: In total, 6616 patients were identified: 98.20% TKA (6497) and 1.80% (119) UKA. UKA patients were younger, had lower body mass index, and more often male than the TKA cohort. Aggregate opioid consumption (75.94 morphine milligram equivalents vs 136.5 morphine milligram equivalents; P < .001) along with the first 24-hour and 48-hour usage was significantly less for UKA as compared to TKA. Similarly, pain scores (1.98 vs 2.58; P < .001) were lower for UKA while Activity Measure for Post-Acute Care mobilization scores were higher (21.02 vs 18.76; P < .001). UKA patients were able to be discharged home on the day of surgery 37% of the time as compared to 2.45% of TKA patients (P < .0001). Notably, when comparing UKA and TKA patients who were discharged home on the day of surgery, no differences regarding pain scores, opioid utilization, or mobilization were observed. CONCLUSION: UKA patients are younger, have lower body mass index and American Society of Anesthesiologists scores, and more often male than TKA patients. UKA patients had significantly shorter length of stay than TKA patients and were discharged home more often than TKA patients, on both the day of surgery and following hospital admission. Most notably, UKA patients reported lower pain scores and were found to require 45% lower opioid medication in the immediate postsurgical period than TKA patients. Surprisingly, UKA and TKA patients discharged on the day of surgery did not differ in terms of pain scores, opioid utilization, or mobilization, suggesting that our rapid rehabilitation UKA protocols can be successfully translated to outpatient TKAs with similar outcomes. LEVEL III EVIDENCE: Retrospective Cohort Study.

Utilization of a Novel Opioid-Sparing Protocol in Primary Total Hip Arthroplasty Results in Reduced Opiate Consumption and Improved Functional Status.

BACKGROUND: Total hip arthroplasty (THA) candidates have historically received high doses of opioids within the perioperative period; however, the amounts are being continually reduced as awareness of opioid abuse spreads. Here we seek to evaluate the effectiveness of a novel opiate-sparing protocol (OSP) for primary THAs in reducing opiate administrations, while maintaining similar levels of pain control and postoperative function. METHODS: All patients undergoing primary THA between January 1, 2019 and June 30, 2019 were placed under a novel OSP. Data were prospectively collected as part of standard of care. To assess the primary outcome of opiate consumption, nursing documented opiate administration events were converted into morphine milligram equivalences (MMEs) per patient encounter per 24-hour interval. Postoperative pain and functional status were assessed as secondary outcomes using the Verbal Rating Scale for pain and the Activity Measure for Post-Acute Care scores, respectively. RESULTS: One thousand fifty primary THAs had received our institution's OSP, and 953 patients were utilized as our historical control. OSP patients demonstrated significantly lower 0-24, 24-48, and 48-72 hours with less opiate administration variance (total MME: Control 75.55 ± 121.07 MME vs OSP 57.10 ± 87.48 MME; 24.42% decrease, P < .001). Although pain scores reached statistical significance between 0 and 12 (Control 2.09 vs OSP 2.36, P < .001), their differences were not clinically significant. Finally, OSP patients demonstrated a trend toward higher Activity Measure for Post-Acute Care scores across all 6 domains (total scores: Control 20.53 ± 3.67 vs OSP 20.76 ± 3.64, P = .18). CONCLUSION: Implementation of an OSP can significantly decrease the utilization of opioids in the immediate postoperative period. Inpatient opioid administration can be significantly reduced while maintaining a comparable and non-inferior level of pain and function.

Preoperative Bariatric Surgery Utilization Is Associated With Increased 90-day Postoperative Complication Rates After Total Joint Arthroplasty.

BACKGROUND: This study evaluates the incidence of bariatric surgery (BS) before total joint arthroplasty (TJA) in New York State and compares patient comorbidities and 90-day postoperative complications of patients with and without BS before TJA. METHODS: The NY Statewide Planning and Research Cooperative System database between 2005 and 2014 was reviewed and 343,710 patients with TJA were identified. Patients were stratified into the following three cohorts: group 1 (patients who underwent BS < 2 years before TJA [N = 1,478]); group 2 (obese patients without preoperative BS [N = 60,259]); and group 3 (nonobese patients without preoperative BS [N = 281,973]). Principal outcomes measured were patient comorbidities, 90-day complication rates, length of inpatient stay, discharge disposition, mortality rate, and total hospital costs. RESULTS: BS before TJA incidence increased from 0.11 of 100,000 to 2.4 of 100,000 from 2006 to 2014. Preoperative BS did not notably change the number of patient comorbidities at the time of TJA. Group 1 had more patients with 90-day complications (40.7% versus 36.0%, P < 0.001) than group 2. No difference was found between group 1 and the other groups in home discharge, pulmonary embolism, deep vein thrombosis, and mortality rates. Total hospital costs were higher for group 1 ($18,869 ± 9,022 versus $17,843 ± 8,095, P < 0.001) compared with those for group 2. CONCLUSION: BS before TJA has increased annually over a 10-year period in New York State and is associated with greater 90-day postoperative complication rates and higher immediate hospital costs when compared with obese patients without BS.

Young age, female gender, Caucasian race, and workers' compensation claim are risk factors for reoperation following arthroscopic ACL reconstruction.

PURPOSE: Given the increasing incidence of arthroscopic anterior cruciate ligament reconstruction (ACLR), mid- to long-term rates of reoperations were investigated on the ipsilateral knee following ACLR. METHODS: New York Statewide Planning and Research Cooperative Systems (SPARCS) database was queried from 2003 to 2012 to identify patients with a primary ICD-9 diagnosis for ACL tear and concomitant CPT code for ACLR. Patients were longitudinally followed for at least 2 years to determine incidence and nature of subsequent ipsilateral knee procedures. RESULTS: The inclusion criteria were met by 45,231 patients who had undergone ACLR between 2003 and 2012. Mean age was found to be 29.7 years (SD 11.6). Subsequent ipsilateral outpatient knee surgery after a mean of 25.7 ± 24.5 months was performed in 10.7% of patients. Revision ACLR was performed for nearly one-third of reoperations. Meniscal pathology was addressed in 58% of subsequent procedures. Age 19 or younger, female gender, worker's compensation (WC) insurance, and Caucasian race were identified as independent risk factors for any ipsilateral reoperation. An initial isolated ACLR and initial ACLR performed by a high-volume surgeon were found to be independently associated with lower reoperation rates. Tobacco use was not significant. Survival rates of 93.4%, 89.8% and 86.7% at 2-, 5- and 10 years, respectively, were found for any ipsilateral reoperation. CONCLUSION: A 10.7% ipsilateral reoperation rate at an average of 25.9 (SD 24.5) months after ACLR and an overall ACLR revision rate of 3.1% were demonstrated by the analysis. Meniscal pathology was addressed in the majority of subsequent interventions. Age 19 or younger, female gender, Caucasian race, and WC claim were associated with reoperation. Initial isolated ACLR and procedure performed by high-volume surgeon were associated with reduced reoperation. LEVEL OF EVIDENCE: Level III.

Total Joint Arthroplasty Is Associated With a Decreased Risk of Traumatic Falls: An Analysis of 499,094 Cases.

INTRODUCTION: The rate of traumatic falls in the aging cohort is estimated to increase across the United States. We sought to determine whether patients with lower extremity osteoarthritis (OA) who underwent total joint arthroplasty (TJA) had a reduced risk of falling compared with those with OA who did not undergo TJA. METHODS: The New York Statewide Planning and Research Cooperative System database was queried from 2000 to 2015 to identify 499,094 cases with primary diagnosis of hip or knee OA. Patients were stratified into 4 cohorts: group 1 (hip OA with total hip arthroplasty [THA] [N = 168,234]), group 2 (hip OA without THA [N = 22,482]), group 3 (knee OA with total knee arthroplasty [TKA] [N = 275,651]), and group 4 (knee OA without TKA [N = 32,826]). Patients were followed up longitudinally to evaluate the long-term risks of subsequent traumatic falls. Cox proportional hazards models were conducted to examine the relationship between patients' demographics and clinical characteristics and the risk of subsequent traumatic falls and reported as hazard ratios (HRs) with 95% confidence intervals (95% CIs). RESULTS: Nineteen thousand seven hundred seventeen patients with hip OA underwent 168,234 primary THAs (88.2%), and 308,477 patients with knee OA underwent 275,651 primary TKAs (89.4%) during the period 2000 to 2015. Compared with patients without TJA, those who underwent TJA were at a decreased risk of falls (THA HR 0.56 [95% CI, 0.48 to 0.66]) and TKA HR 0.66 [95% CI, 0.57 to 0.76]). Compared with age 40 to 49 years, risk increases for ages 70 to 79 years (HR = 4.3, 95% CI: 2.8 to 6.6) and 80 years or older (HR = 5.5, 95% CI: 3.8 to 8.1). CONCLUSION: TJA is associated with a decreased risk of long-term traumatic falls in elderly patients with the primary diagnosis of hip or knee osteoarthritis. LEVEL OF EVIDENCE: Level III Retrospective Case-control study.