Evidence-based Perioperative Practice Utilization among Various Racial Populations-A Retrospective Cohort Trending Analysis of Lower Extremity Total Joint Arthroplasty Patients.

BACKGROUND: Various studies have demonstrated racial disparities in perioperative care and outcomes. The authors hypothesize that among lower extremity total joint arthroplasty patients, evidence-based perioperative practice utilization increased over time among all racial groups, and that standardized evidence-based perioperative practice care protocols resulted in reduction of racial disparities and improved outcomes. METHODS: The study analyzed 3,356,805 lower extremity total joint arthroplasty patients from the Premier Healthcare database (Premier Healthcare Solutions, Inc., USA). The exposure of interest was race (White, Black, Asian, other). Outcomes were evidence-based perioperative practice adherence (eight individual care components; more than 80% of these implemented was defined as "high evidence-based perioperative practice"), any major complication (including acute renal failure, delirium, myocardial infarction, pulmonary embolism, respiratory failure, stroke, or in-hospital mortality), in-hospital mortality, and prolonged length of stay. RESULTS: Evidence-based perioperative practice adherence rate has increased over time and was associated with reduced complications across all racial groups. However, utilization among Black patients was below that for White patients between 2006 and 2021 (odds ratio, 0.94 [95% CI, 0.93 to 0.95]; 45.50% vs. 47.90% on average). Independent of whether evidence-based perioperative practice components were applied, Black patients exhibited higher odds of major complications (1.61 [95% CI, 1.55 to 1.67] with high evidence-based perioperative practice; 1.43 [95% CI, 1.39 to 1.48] without high evidence-based perioperative practice), mortality (1.70 [95% CI, 1.29 to 2.25] with high evidence-based perioperative practice; 1.29 [95% CI, 1.10 to 1.51] without high evidence-based perioperative practice), and prolonged length of stay (1.45 [95% CI, 1.42 to 1.48] with high evidence-based perioperative practice; 1.38 [95% CI, 1.37 to 1.40] without high evidence-based perioperative practice) compared to White patients. CONCLUSIONS: Evidence-based perioperative practice utilization in lower extremity joint arthroplasty has been increasing during the last decade. However, racial disparities still exist with Black patients consistently having lower odds of evidence-based perioperative practice adherence. Black patients (compared to the White patients) exhibited higher odds of composite major complications, mortality, and prolonged length of stay, independent of evidence-based perioperative practice use, suggesting that evidence-based perioperative practice did not impact racial disparities regarding particularly the Black patients in this surgical cohort.

The stability of carbapenems before and after admixture to PMMA-cement used for replacement surgery caused by Gram-negative bacteria.

BACKGROUND: Prosthetic joint infection (PJI) is a serious complication of orthopedic implant surgery. Treatment often includes the use of an antibiotic-loaded Polymethyl methacrylate (PMMA) bone cement spacer. Several antibiotics are commonly used for the preparation of these spacers, but due to the increasing number of infections with resistant Gram-negative bacteria, there is a need for the use of carbapenem antibiotics such as meropenem and imipenem as drugs of last resort. Unfortunately, the reaction heat generated during the preparation of the bone cement can be a major problem for the stability of these antibiotics. In the present study, the stability of meropenem and imipenem was tested before and after the admixture to PMMA bone cements. METHODS: High-performance liquid chromatography with ion-pairing reversed-phase separation and spectrophotometric detection was used for analysis. Stability tests with meropenem and imipenem were performed with antibiotics in solution and solid form at different temperatures (37 °C, 45 °C, 60 °C, 90 °C) and times (30 min, 60 min, 120 min). To test the stability of both antibiotics in PMMA after exposure to the reaction heat during polymerization, three different bone cements were used to generate specimens that contained defined amounts of antibiotics. Reaction heat was measured. The form bodies were mechanically crushed and aliquots were dissolved in ethyl acetate. Samples were prepared for HPLC DAD analysis. RESULTS: Meropenem and imipenem showed the highest degradation levels after heat stressed in solution, with maximum levels of 75% and 95%, respectively. In solid form, degradation levels decreased dramatically for meropenem (5%) and imipenem (13%). Stability tests of both carbapenems in bone cement showed that they remained largely stable during PMMA polymerization, with retrieved amounts of about 70% in Palacos® R and Copal® G+V, and between 80 and 90% in Copal® spacem. CONCLUSIONS: In contrast to the results of meropenem and imipenem in solution, both antibiotics remain stable in solid form and mostly stable in the cement after PMMA polymerization. The low degradation levels of both antibiotics after exposure to temperatures > 100 °C allow the conclusion that they can potentially be used for an application in PMMA cements.

Partnership Across Transitions to Improve Outcomes in the Lower Extremity Total Joint Population.

BACKGROUND: With the urgency related to improving quality and creating efficiency in healthcare, partnership is emerging as a critical concept related to transitions of care. PURPOSE: This quality improvement project included facilitation of hospital partnership with skilled nursing facilities to improve outcomes associated with the lower extremity total joint arthroplasty population. METHODS: The clinical nurse specialist (CNS) utilized a standardized framework to implement partnership strategies with multidisciplinary teams. Outcomes were monitored for the 2 quarters of partnership activities. RESULTS: All recommendations for developing a partnership model were facilitated within the project timeline. Patient experience and quality measures remained at, or improved, from baseline and met all strategic targets. Efficiency through episode payment demonstrated improvement at each interval during the study period. Analysis revealed a significant (p < .05) reduction in the mean hospital length of stay. CONCLUSION: The CNS practice outcomes suggest that the use of structured partnership strategies between agencies improves efficiency of care and accelerates rapid spread of innovation.

Challenges to Implementing Total Joint Replacement Programs in Developing Countries.

In this review article, the authors present the many challenges that orthopedic surgeons in developing countries face when implementing arthroplasty programs. The issues of cost, sterility, and patient demographics are specifically addressed. Despite the many challenges, developing countries are beginning to offer hip and knee reconstructive surgery to respond to the increasing demand for such elective operations as the prevalence of osteoarthritis continues to increase. The authors shed light on these nascent arthroplasty programs.

International Collaboration in Total Joint Arthroplasty: A Framework for Establishing Meaningful International Alliances.

Despite the increase in utilization of total joint arthroplasty (TJA) throughout high-income countries, there is a lack of access to basic surgical care, including TJA, in low- and middle-income countries (LMICs). Multiple strategies, including short-term surgical trips, establishment of local TJA centers, and education-based international academic collaborations, have been used to bridge the gap in access to quality TJA. The authors review the obstacles to providing TJA in LMICs, the outcomes of the 3 strategies in use to bridge gaps, and a framework for the establishment and maintenance of meaningful international collaborations.

Development of a Knee Joint CT-FEM Model in Load Response of the Stance Phase During Walking Using Muscle Exertion, Motion Analysis, and Ground Reaction Force Data.

Background and objectives: There are no reports on articular stress distribution during walking based on any computed tomography (CT)-finite element model (CT-FEM). This study aimed to develop a calculation model of the load response (LR) phase, the most burdensome phase on the knee, during walking using the finite element method of quantitative CT images. Materials and Methods: The right knee of a 43-year-old man who had no history of osteoarthritis or surgeries of the knee was examined. An image of the knee was obtained using CT and the extension position image was converted to the flexion angle image in the LR phase. The bone was composed of heterogeneous materials. The ligaments were made of truss elements; therefore, they do not generate strain during expansion or contraction and do not affect the reaction force or pressure. The construction of the knee joint included material properties of the ligament, cartilage, and meniscus. The extensor and flexor muscles were calculated and set as the muscle exercise tension around the knee joint. Ground reaction force was vertically applied to suppress the rotation of the knee, and the thigh was restrained. Results: An FEM was constructed using a motion analyzer, floor reaction force meter, and muscle tractive force calculation. In a normal knee, the equivalent stress and joint contact reaction force in the LR phase were distributed over a wide area on the inner upper surface of the femur and tibia. Conclusions: We developed a calculation model in the LR phase of the knee joint during walking using a CT-FEM. Methods to evaluate the heteromorphic risk, mechanisms of transformation, prevention of knee osteoarthritis, and treatment may be developed using this model.

Peripheral Nerve Blocks and Immediate Postoperative Recovery: A Single-Institution Survey of Perianesthesia Nurses' Preferences and Opinions.

PURPOSE: To ascertain the preferences of perianesthesia nurses regarding peripheral nerve blocks (PNBs) and their impact on patient recovery after total joint replacement (TJR). DESIGN: Survey of perianesthesia nurses at a single medical center. METHODS: Fifty-nine perianesthesia nurses completed a 23-question survey on PNBs for TJR. FINDINGS: Most agreed PNBs improved patients' pain after knee, hip, and shoulder TJR (35 [92.1%], 35 [92.1%], and 34 [91.9%], respectively). Most felt lower extremity PNBs increased risk of falling (26 [70.3%]), whereas 7 of 35 (20.0%) felt patients fell more after spinal anesthesia than after general anesthesia. Respondents preferred a block to opioid-based analgesia if they were to have lower extremity TJR or total shoulder replacement (100% [30/30 and 33/33]). CONCLUSIONS: The perianesthesia nurses surveyed felt PNBs improved pain control and patient recovery despite a perceived risk of falling for lower extremity TJR, and they preferred PNB when considering TJR surgery for themselves.

Shared Medical Appointments in Preoperative Joint Replacement: Assessing Patient and Healthcare Member Satisfaction.

BACKGROUND: Shared medical appointments (SMAs) have proven to be effective in improving patient access and education while augmenting productivity. In shifting from a traditional visit model, patient and interdisciplinary healthcare team (IHCT) member satisfaction is imperative. Predominantly seen in primary care, SMA use in orthopedics is limited. After identification of access and productivity concerns, the SMA was implemented as a quality improvement project in a rural clinic. The lower extremity joint replacement (LEJR) population was chosen because of multiple preoperative appointments and costs on the healthcare system. PURPOSE: To assess patients' and IHCT members' satisfaction levels in using an SMA for the preparation of LEJR. RELEVANCE TO HEALTHCARE QUALITY: The SMA is an effective model offering an efficient, cost-effective methodology aligning with the Institute for Healthcare Improvement's Triple Aim. RESULTS: Twenty SMAs were conducted. Sixty-three patients and 14 ICHT members participated. Mean (M) satisfaction rating for SMA patients (M = 4.90, SD 0.26) was significantly higher than mean for traditional patients (M = 4.03, SD 0.39). Interdisciplinary healthcare team members' attitudes toward SMAs revealed a mean score of 4.58. Incidentally, cycle times improved as did lengths of stay. CONCLUSIONS: Lower extremity joint replacement patients and IHCT members reported high satisfaction with SMAs.

Femoral side-only revision options for the Birmingham resurfacing arthroplasty.

BACKGROUND: The Birmingham Hip Resurfacing (BHR) system (Smith and Nephew) was developed as an alternative to conventional total joint replacement for younger, more active patients. Among other complications exists the risk for femoral component failure. The only marketed revision option for such a complication involves exchange of all components for a total replacement arthroplasty. This presents as a considerable and potentially unnecessary operative burden where revision of only the femoral prosthesis would suffice. We have analysed revision options for BHR in the context of periprosthetic femoral fractures with a stable acetabular component. METHODS: Technical details of dual mobility hip systems available in Australia were collated and analysed to assess for potential 'off label' use with an existing BHR acetabular component. These data were then compared with the custom-made Smith and Nephew dual mobility implant with respect to clearance and sizing. RESULTS: Two dual mobility articulation modalities from two companies were identified as appropriate for potential usage with four products analysed in detail. These two demonstrated acceptable sizing and clearance measurements. CONCLUSION: Comparison between readily available dual mobility prostheses with custom-made implants showed off label dual mobility prosthetic use to be a viable alternative for femoral-only revisions with in situ BHR. Single component revision has several advantages which include: a less complex surgical procedure, shorter operative time, decreased blood loss and the expectation of resultant lower morbidity. Furthermore, this less complex revision surgery should give comparable results to that of primary total hip arthroplasty.

Statistical Methods Dictate the Estimated Impact of Body Mass Index on Major and Minor Complications After Total Joint Arthroplasty.

BACKGROUND: Elevated body mass index (BMI) is considered a risk factor for complications after THA and TKA. Stakeholders have proposed BMI cutoffs for those seeking arthroplasty. The research that might substantiate BMI cutoffs is sensitive to the statistical methods used, but the impact of the statistical methods used to model BMI has not been defined. QUESTIONS/PURPOSES: (1) How does the estimated postarthroplasty risk of minor and major complications vary as a function of the statistical method used to model BMI? (2) What is the prognostic value of BMI for predicting complications with each statistical method? METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2012, we investigated the impact of BMI on major and minor complication risk for THA and TKA. Analyses were weighted with covariate-balancing propensity scores to account for the differential rate of comorbidities across the range of BMI. We specified BMI in two ways: (1) categorically by World Health Organization (WHO) BMI classes; and (2) as a smooth, continuous variable using splines. Models of risk for major complications (deep surgical site infection [SSI], pulmonary embolism, stroke, cardiac arrest, myocardial infarction, wound disruption, implant failure, unplanned intubation, > 48 hours on a ventilator, acute renal insufficiency, coma, sepsis, reoperation, or mortality) and minor complications (superficial SSI, pneumonia, urinary tract infection, deep vein thrombosis, or peripheral nerve injury) were constructed and were adjusted for confounding variables known to correlate with complications (eg, American Society of Anesthesiologists classification). Results were compared for different specifications of BMI. Receiver operating characteristic (ROC) curves were compared to determine the additive prognostic value of BMI. RESULTS: The type of BMI parameterization leads to different assessments of risk of postarthroplasty complications for BMIs > 30 kg/m and < 20 kg/m with the spline specification showing better fit in all adjusted models (Akaike Information Criteria favors spline). Modeling BMI categorically using WHO classes indicates that BMI cut points of 40 kg/m for TKA or 35 kg/m for THA are associated with higher risks of major complications. Modeling BMI continuously as a spline suggests that risk of major complications is elevated at a cut point of 44 kg/m for TKA and 35 kg/m for THA. Additionally, in these models, risk does not uniformly increase with increasing BMI. Regardless of the method of modeling, BMI is a poor prognosticator for complications with area under the ROC curves between 0.51 and 0.56, false-positive rates of 96% to 97%, and false-negative rates of 2% to 3%. CONCLUSIONS: The statistical assumptions made when modeling the effect of BMI on postarthroplasty complications dictate the results. Simple categorical handling of BMI creates arbitrary cutoff points that should not be used to inform larger policy decisions. Spline modeling of BMI avoids arbitrary cut points and provides a better model fit at extremes of BMI. Regardless of statistical management, BMI is an inadequate independent prognosticator of risk for individual patients considering total joint arthroplasty. Stakeholders should instead perform comprehensive risk assessment and avoid use of BMI as an isolated indicator of risk. LEVEL OF EVIDENCE: Level III, diagnostic study.

Improving Total Joint Replacement with Continuous Quality Improvement Methods and Tools.

Faced with increasing pressure to reduce costs, hospitals must find new ways to eliminate waste while simultaneously maintaining the highest quality of care. For any institution, these can types of changes can be complex and burdensome. This article outlines several methods that have been successful in reducing costs while maintaining high quality and highlights feasible methodologies that can help health care providers implement new quality improvement protocols.

In-vivo study of osseointegration in Prestige LP cervical disc prosthesis.

BACKGROUND: A study was designed to quantify the extent of porous osseointegration at the prosthesis-bone interface in the Prestige LP prosthesis containing a plasma-sprayed titanium coating. METHODS: Using an anterior surgical approach, cervical disc arthroplasty was performed in 8 mature male goats at the C3-C4 segment, followed by implantation of the Prestige LP prosthesis. The vertebral specimens were examined using microcomputed tomograph for histomorphometric quantification, and proceeded by routine paraffin processing for histological observation. Hence, the porous osseointegration at the prosthesis-bone interface was evaluated based on histologic and histomorphometric analyses. RESULTS: At 6 months after surgery, there was no evidence of prosthesis migration, loosening, subsidence, or neurologic or vascular complications. Based on gross histologic analysis, there was excellent porous ingrowth at the prosthesis-bone interface, without significant histopathologic changes. Histomorphometric analysis at the prosthesis-bone interface indicated the mean porous ingrowth of 48.5% ± 10.4% and the total ingrowth range of 36.6 to 59.8%. CONCLUSIONS: As the first comprehensive in vivo investigation into the Prestige LP prosthesis, this project established a successful animal model in the evaluation of cervical disc arthroplasty. Moreover, histomorphometric analysis of porous ingrowth at the prosthesis-bone interface was more favorable for cervical disc arthroplasty with the Prestige LP prosthesis compared to historical reports of appendicular total joint arthroplasty.

Adding Value to Total Joint Arthroplasty Care in an Academic Environment: The Utah Experience.

BACKGROUND: Adding value in a university-based academic health care system provides unique challenges when compared to other health care delivery models. Herein, we describe our experience in adding value to joint arthroplasty care at the University of Utah, where the concept of value-based health care reform has become an embraced and driving force. METHODS: To improve the value, new resources were needed for care redesign, physician leadership, and engagement in alternative payment models. The changes that occurred at our institution are described. RESULTS: Real-time data and knowledgeable personnel working behind the scenes, while physicians provide clinical care, help move clinical pathway redesigns. Engaged physicians are essential to the successful implementation of value creation and care pathway redesign that can lead to improvements in value. An investment of money and resources toward added infrastructure and personnel is often needed to realize large-scale improvements. Alignment of providers, payers, and hospital administration, including by means of gainsharing programs, can lead to improvements. CONCLUSION: Although significant care pathway redesign efforts may realize substantial initial cost savings, savings may be asymptotic in nature, which calls into question the likely sustainability of programs that incentivize or penalize payments based on historical targets.

Postoperative Joint Replacement Complications in Swedish Patients With a Family History of Venous Thromboembolism.

Importance: The associations of a family history of venous thromboembolism (FH-VTE) with postoperative venous thromboembolism (VTE) and major bleeding after joint replacement surgical procedures are unknown. Objective: To determine the risk of VTE and major bleeding in patients after primary hip or knee replacement surgical procedures. Design, Setting, and Participants: Cohort study using nationwide population-based databases of Swedish patients without a history of VTE who underwent joint replacement surgical procedures. Patients who had primary hip or knee replacement surgical procedures between July 1, 2005, and August 31, 2012, were identified. Patients born after 1931 without previous VTE were identified in the Swedish Multi-Generation Register. Only individuals with at least 1 parent and 1 full sibling alive between 1964 and the date for the surgical procedure were included. The data analysis was performed from September 1, 2017, to June 15, 2018. Exposures: Family history of VTE in a parent and/or a full sibling before the date of the surgical procedure. Main Outcomes and Measures: Venous thromboembolism and major bleeding within 90 days of the surgical procedure. Results: Of 69 505 study participants, 37 989 (54.7%) were women, and the median (interquartile range) age at the date of discharge was 65 (59-70) years. A total of 803 of 69 505 (1.2%) patients experienced postoperative VTE and 1285 (1.8%) experienced major bleeding. The cumulative VTE risk for those with FH-VTE was 231 of 15 858 (1.5%) and for those without an FH-VTE was 572 of 53 647 (1.1%) (P < .001). The cumulative bleeding risk for those with FH-VTE was 261 of 15 858 (1.6%) and for those without an FH-VTE was 1024 of 53 647 (1.9%) (P = .03). There was an association of patients with an FH-VTE who had increased VTE risk (adjusted hazard ratio [HR], 1.36; 95% CI, 1.17-1.59) and reduced bleeding risk (adjusted HR, 0.84; 95% CI, 0.74-0.97). There was an interaction between time after discharge and FH-VTE regarding VTE and major bleeding. An FH-VTE was not associated with VTE after discharge during the first week (HR, 1.13; 95% CI, 0.86-1.49). After 7 days from discharge, FH-VTE was associated with VTE (HR, 1.49; 95% CI, 1.24-1.79). An FH-VTE reduced major bleeding risk during the first 7 days after discharge (HR, 0.78; 95% CI, 0.66-0.91) but not thereafter (HR, 1.10; 95% CI, 0.84-1.44). Postoperative VTE heritability (SE) was 20% (6%). Conclusions and Relevance: Familial and most likely genetic factors appear to affect VTE and major bleeding risk following hip and knee replacement surgical procedures. Prolonged VTE prophylaxis might be beneficial in predisposed individuals. There may be a possible evolutionary advantage of prothrombotic genes protecting against traumatic bleeding.

What is the impact of a clinically related readmission measure on the assessment of hospital performance?

BACKGROUND: The Hospital Readmission Reduction Program (HRRP) penalizes hospitals for high all-cause unplanned readmission rates. Many have expressed concern that hospitals serving patient populations with more comorbidities, lower incomes, and worse self-reported health status may be disproportionately penalized by readmissions that are not clinically related to the index admission. The impact of including clinically unrelated readmissions on hospital performance is largely unknown. We sought to determine if a clinically related readmission measure would significantly alter the assessment of hospital performance. METHODS: We analyzed Medicare claims for beneficiaries in Michigan admitted for pneumonia and joint replacement from 2011 to 2013. We compared each hospital's 30-day readmission rate using specifications from the HRRP's all-cause unplanned readmission measure to values calculated using a clinically related readmission measure. RESULTS: We found that the mean 30-day readmission rates were lower when calculated using the clinically related readmission measure (joint replacement: all-cause 5.8%, clinically related 4.9%, p < 0.001; pneumonia: all cause 12.5%, clinically related 11.3%, p < 0.001)). The correlation of hospital ranks using both methods was strong (joint replacement: 0.95 (p < 0.001), pneumonia: 0.90 (p < 0.001)). CONCLUSIONS: Our findings suggest that, while greater specificity may be achieved with a clinically related measure, clinically unrelated readmissions may not impact hospital performance in the HRRP.

Wait time management strategies for total joint replacement surgery: sustainability and unintended consequences.

BACKGROUND: In Canada, long waiting times for core specialized services have consistently been identified as a key barrier to access. Governments and organizations have responded with strategies for better access management, notably for total joint replacement (TJR) of the hip and knee. While wait time management strategies (WTMS) are promising, the factors which influence their sustainable implementation at the organizational level are understudied. Consequently, this study examined organizational and systemic factors that made it possible to sustain waiting times for TJR within federally established limits and for at least 18 months or more. METHODS: The research design is a multiple case study of WTMS implementation. Five cases were selected across five Canadian provinces. Three success levels were pre-defined: 1) the WTMS maintained compliance with requirements for more than 18 months; 2) the WTMS met requirements for 18 months but could not sustain the level thereafter; 3) the WTMS never met requirements. For each case, we collected documents and interviewed key informants. We analyzed systemic and organizational factors, with particular attention to governance and leadership, culture, resources, methods, and tools. RESULTS: We found that successful organizations had specific characteristics: 1) management of the whole care continuum, 2) strong clinical leadership; 3) dedicated committees to coordinate and sustain strategy; 4) a culture based on trust and innovation. All strategies led to relatively similar unintended consequences. The main negative consequence was an initial increase in waiting times for TJR and the main positive consequence was operational enhancement of other areas of specialization based on the TJR model. CONCLUSIONS: This study highlights important differences in factors which help to achieve and sustain waiting times. To be sustainable, a WTMS needs to generate greater synergies between contextual-level strategy (provincial or regional) and organizational objectives and constraints. Managers at the organizational level should be vigilant with regard to unintended consequences that a WTMS in one area can have for other areas of care. A more systemic approach to sustainability can help avoid or mitigate undesirable unintended consequences.