To Bundle or Not to Bundle? The Financial Impact of Pathologic Hip Disease on Hip Arthroplasty Episodes of Care.

BACKGROUND: The Comprehensive Care for Joint Replacement model aims to support more efficient care for patients. We examined the impact of patient and surgical characteristics, post-acute care, and clinical outcomes on episode of care (EOC) costs in patients undergoing hip arthroplasty for all diagnoses. METHODS: We retrospectively collected data from a large database of patients undergoing hip arthroplasty for oncologic and nononcologic diagnoses between 2014 and 2017. We compared EOC costs and outcomes between the 2 groups using Student's t-tests. We estimated the association between an oncologic-associated procedure and EOC costs from a multiple regression analysis. RESULTS: There were 2122 total patients included: 1993 in the nononcologic group and 129 in the oncologic group. The length of stay was significantly greater in the oncologic group (7.2 vs 4.2 days, P = .00). In the post-acute period, a greater proportion of oncologic patients was readmitted (29% vs 14%, P = .05) and discharged to skilled nursing (93% vs 51%, P = .00). Index hospitalization costs (mean difference [MD] $1561, P = .05), skilled nursing costs (MD $5932, P = .001), and total EOC costs (MD $20,012, P = .00) were all greater in the oncologic group. Along with increasing age and fracture diagnosis, an oncologic diagnosis is independently associated with greater EOC costs from a multivariate analysis (ß = 16,163 ± 2258, P = .00, r2 = 29%). CONCLUSION: Comprehensive Care for Joint Replacement should incorporate risk adjustment for oncologic disease because hip arthroplasty for an oncologic diagnosis is associated with worse outcomes and greater costs than in the general population.

Hip Range of Motion: Which Plane of Motion Is More Predictive of Lower Extremity Injury in Elite Soccer Players? A Prospective Study.

The objective of this study was to determine which plane of hip motion (rotational or sagittal) is more predictive of lower extremity (LE) injury in elite soccer players. A total of 69 athletes (43 professional and 26 collegiate) were examined (mean age, 22.6 years). Bilateral hip internal rotation (IR), external rotation, extension, and flexion measurements were taken along with the modified Thomas test during preseason physicals. There were 42 LE injuries (injury rate 3.74/1000 athlete exposures). Mean IR was 25.2. and 29.9° for injured versus noninjured extremities, respectively (p = .009). There was a significant association between decreased IR (categorized as IR < 28°) and incidence of ipsilateral LE injury (p = .042). Extremities with IR < 28° were 2.81 times more likely to sustain a LE injury (95% CI, 1.15.6.84; p = .023). With a utilitarian focus, the current study has identified a measurement of decreased hip IR with potential for substantial clinical value in collegiate and professional soccer players. (Journal of Surgical Orthopaedic Advances 28(3):201-208, 2019).

Can the Workplace Limitations Questionnaire Capture Short-term Productivity Losses in Acute Distal Radius Fractures Treated With Operative Fixation Versus Cast Immobilization in the Working Population?

Background: Distal radius fractures (DRFs) contribute substantially to overall morbidity in the elderly population. We believe that accurately capturing total productivity losses is vital to understanding the true economic impact of these injuries in working patients. Methods: We conducted a prospective nonrandomized cohort study and enrolled working patients with DRF treated with either casting or operative fixation. We administered the Workplace Limitations Questionnaire (WLQ, Tufts Medical Center) at the first visit following injury and at 2 weeks, 6 weeks, and 3 months after definitive treatment. The WLQ measures the degree to which employed individuals are experiencing limitations on-the-job due to their health problems and estimates health-related productivity loss. We also calculated the monetary value of work time lost at market value in US dollars. The treatment groups were analyzed for statistical similarity using Student t tests. Results: A total of 30 patients met our study's inclusion criteria. The WLQ index score trended downward in both groups across all time points and was lower in the operative cohort compared with the nonoperative cohort at 6 weeks (1.4% vs 12.9% productivity loss, P = .17). The monetary value of work time lost trended downward across all time points and was lower in the operative cohort compared with the nonoperative cohort ($200.21 vs $2846.90, P = .12). Conclusions: In this pilot study, we successfully applied the WLQ to working patients treated for DRF. The WLQ is effective in capturing short-term productivity losses following DRF and may suggest a decreased at-work burden among patients treated with operative fixation compared with casting.

A Novel Approach to Improving Patient Experience in Orthopedics.

The patient experience domain comprises a significant portion of the Hospital Value-Based Purchasing program. This study investigated whether an intervention focusing on attending physician awareness, resident and physician assistant education, and multidisciplinary patient-centric care had an effect on patient perceived physician communication and overall hospital ratings. Responses to the Hospital Consumer Assessment of Healthcare Providers and Systems survey were reviewed in 2014 and 2015. Patients' perceptions that the physician explained their condition in ways they understood and the overall hospital rating improved significantly after implantation of the model ( P < .05). Patient-physician communication is important for high-quality health care and is becoming increasingly more important in hospital economics. These methods may serve as a protocol for other institutions to improve the patient experience.

Role of Ethnicity in Alignment Compensation: Propensity Matched Analysis of Differential Compensatory Mechanism Recruitment Patterns for Sagittal Malalignment in 288 ASD Patients From Japan, Korea, and United States.

STUDY DESIGN: Retrospective review of adult spinal deformity patients in a multiethnic database. OBJECTIVE: To investigate the role of ethnicity on recruitment of compensatory mechanisms for sagittal spinal deformity. SUMMARY OF BACKGROUND DATA: While the impacts of age, sex, and pelvic morphology on the ability to compensate for sagittal malalignment have been investigated, the role of ethnicity in compensatory mechanism recruitment is poorly understood. METHODS: Patients from USA (85% Caucasian) >25 y/o were propensity matched by age, sex, and pelvic incidence with patients from Korea and Japan. Only primary patients or those with existing fusion below T12 were retained for analysis. Groups were subclassified by deformity severity (aligned: sagittal vertical axis (SVA) <50 mm; moderate malalignment: SVA 50-100 mm; severe malalignment: SVA >100 mm). Radiographic measurements including pelvic retroversion, thoracic kyphosis, loss of lumbar lordosis (PI minus LL), cervical lordosis, and cervical SVA were compared between the groups. RESULTS: There were 288 patients (96 each in USA, KOR, JPN), with similar age (64-67 yr) and PI (49-53°). USA had smaller pelvic incidence minus lumbar lordosis in every alignment group (P <0.05). In moderate malalignment, JPN had more pelvic retroversion than USA (30° vs. 20°), and KOR had more thoracic hypokyphosis than USA (15 vs. 31°). In severe malalignment, JPN had more pelvic retroversion than USA (39° vs. 27°), and KOR had more thoracic hypokyphosis than USA (15° vs. 31°). KOR had smaller cSVA than USA in both aligned (11 vs. 27 mm) and moderate (19 vs. 31 mm) malalignment. In severe malalignment, KOR had less cervical lordosis (13° KOR vs. 15° USA vs. 27° JPN). All differences with P <0.05. CONCLUSION: Compensation for sagittal is ethnicity dependent. Korean patients favor thoracic compensation via hypokyphosis, and Japanese patients favor pelvic compensation via retroversion. Patient ethnicity should be considered when evaluating the sagittal plane and surgical correction strategies. LEVEL OF EVIDENCE: 3.

Geographic and Ethnic Variations in Radiographic Disability Thresholds: Analysis of North American and Japanese Operative Adult Spinal Deformity Populations.

BACKGROUND: Thresholds for spinal pelvic parameters in adult spinal deformity (ASD) were previously defined in North American patients and are commonly used to guide surgical planning. However, it is unclear whether these same threshold parameters can be more widely applied in other geographic regions and in other ethnicities. OBJECTIVE: To evaluate the variation in the radiographic disability thresholds between North American and Japanese ASD populations and to adjust sagittal modifier thresholds accordingly. METHODS: Retrospective case series of 717 patients with ASD who had baseline radiographs and Oswestry Disability Index (ODI) from North America (n = 518) and Japan (n = 199) were studied. Patients were compared at baseline for ODI, ODI offset from age- and ethnic-specific values (ODIni), and radiographic parameters. RESULTS: Significant differences in classification were observed: A greater proportion of Japanese patients had marked pelvic tilt deformity, whereas a greater proportion of US patients had marked SVA deformity; no difference in the pelvic incidence-lumbar lordosis mismatch sagittal modifier was observed. Health-related quality-of-life scores also differed, with a greater ODI raw value observed in the US patients but similar ODIni scores between cohorts. Stratifying ODIni scores by sagittal modifier grades revealed similar disability scores corresponding to the 0 to + thresholds for pelvic tilt, pelvic incidence-lumbar lordosis mismatch, and sagittal vertical axis across ethnicities. Finally, linear regression analysis demonstrated that compared with US patients, Japanese patients had a lower estimated ODI corresponding to established thresholds of radiographic deformity. CONCLUSION: Our findings demonstrate significant variability in health-related quality-of-life measures and radiographic parameters between North American and Japanese patients, supporting the need for population-adjusted sagittal modifiers to more accurately classify deformity. ABBREVIATIONS: ASD, adult spinal deformityHRQOL, health-related quality of lifeLL, lumbar lordosisODI, Oswestry Disability IndexODIni, Oswestry Disability Index need for improvementPCS, physical component summaryPI, pelvic incidencePI-LL, pelvic incidence-lumbar lordosis mismatchPT, pelvic tiltSRS, Scoliosis Research SocietySVA, sagittal vertical axisTK, thoracic kyphosis.

Systematic Review of Thigh Symptoms after Lateral Transpsoas Interbody Fusion for Adult Patients with Degenerative Lumbar Spine Disease.

BACKGROUND: Lateral transpsoas interbody fusion (LTIF) is a minimally invasive technique for achieving lumbar spinal fusion. While it has many advantages over open techniques it carries with it a distinct set of risks, most commonly post-operative ipsilateral thigh pain, weakness and sensory disturbances. It is vital for both the surgeon and patient to understand the risks for and outcomes of injury associated with this procedure. We conducted a systematic review of the literature to evaluate the incidence, risks, and long-term clinical outcomes of post-operative thigh symptoms in patients treated with LTIF. METHODS: We conducted a search of MEDLINE, EMBASE, CINAHL, Scopus, Web of Science and the Cochrane Collaboration Library, using keywords and MeSH terms, for English-language literature published through September 2014, as well as reference lists from key articles. Studies were then manually filtered to retrieve articles that met inclusion criteria. We were interested in studies that reported postoperative lower extremity symptoms after LTIF, such as pain, weakness and changes in sensation. The strength of evidence was determined based on precepts outlined by the Grades of Recommendation Assessment, Development and Evaluation Working Group (GRADE). RESULTS: A total of 392 articles were initially retrieved, with 24 ultimately meeting criteria for inclusion. The incidence of any post-operative thigh symptom varied, ranging as high as 60.7%, with 9.3% of patients experiencing a motor deficit related to direct nerve injury. Several studies reported cases of persistent symptoms at 6 months follow up. Additionally, inclusion of the L4-5 disc space and a longer duration of surgery were both identified as risks for developing postoperative thigh symptoms. CONCLUSION: The risk of postoperative thigh symptoms after LTIF is high. Thigh pain, paresthesias and weakness were the most commonly reported symptoms. While most patients' symptoms resolved by 6 months follow up, several studies reported patients with symptoms persistent as far as 12 months removed from surgery. Surgery at the L4-5 disc space and longer surgical duration place the patient at greater risk for developing postoperative and long-term thigh symptoms.