Clinical Outcomes and Survivorship of Lateral Unicompartmental Knee Arthroplasty: A Large Single Surgeon Cohort.

BACKGROUND: Lateral unicompartmental knee arthroplasty (UKA) is an effective treatment for isolated lateral compartment osteoarthritis. However, due to the rarity of the procedure, long-term outcomes and survivorship are poorly understood. We report the clinical and radiographic outcomes after lateral UKA. METHODS: We retrospectively reviewed a consecutive series of patients who underwent lateral UKA by a single fellowship-trained arthroplasty surgeon from 2001 to 2021 with a minimum 2 year follow up. There were 161 knees in 153 patients (average age 69 years) that met inclusion criteria, with a mean follow up of 10.0 years (range 0.05 to 22.2). All patients underwent the procedure via a minimally invasive lateral parapatellar approach with a fixed-bearing implant. Patient demographics, complications, radiographic findings, patient-reported outcomes, and the need for revision surgery were evaluated. Survivorship was defined with the end point as revision of components. RESULTS: There were 8 patients (5.0%) who underwent conversion to total knee arthroplasty for lateral UKA implant failure or progression of arthritis. There were 3 patients (1.9%) who underwent ipsilateral medial UKA due to medial compartment arthritis progression with preserved mechanical alignment and patellofemoral joint. There were 8 additional procedures that did not require implant changes, including 5 irrigation and debridements for acute periprosthetic joint infection (3.1%), 2 wound closures for dehiscence (1.3%), and one loose body removal (0.6%). CONCLUSIONS: Lateral UKA showed a survivorship rate of 98.0% at 5 years, 96.0% at 10 years, and 94.5% at 15 years. When including patients who underwent additional surgery for the progression of arthritis, survivorship was 97.4% at 5 years, 95.4% at 10 years, and 91.3% at 15 years. Lateral UKA should be seen as a durable treatment option for isolated lateral compartment osteoarthritis.

Elective Joint Arthroplasty Should be Delayed by One Month After COVID-19 Infection to Prevent Postoperative Complications.

BACKGROUND: It remains unclear whether a history of recent COVID-19 infection affects the outcomes and risks of complications of total joint arthroplasty (TJA). The purpose of this study was to compare the outcomes of TJA in patients who have and have not had a recent COVID-19 infection. METHODS: A large national database was queried for patients undergoing total hip and total knee arthroplasty. Patients who had a diagnosis of COVID-19 within 90-days preoperatively were matched to patients who did not have a history of COVID-19 based on age, sex, Charlson Comorbidity Index, and procedure. A total of 31,453 patients undergoing TJA were identified, of which 616 (2.0%) had a preoperative diagnosis of COVID-19. Of these, 281 COVID-19 positive patients were matched with 281 patients who did not have COVID-19. The 90-day complications were compared between patients who did and did not have a diagnosis of COVID-19 at 1, 2, and 3 months preoperatively. Multivariate analyses were used to further control for potential confounders. RESULTS: Multivariate analysis of the matched cohorts showed that COVID-19 infection within 1 month prior to TJA was associated with an increased rate of postoperative deep vein thrombosis (odds ratio [OR]: 6.50, 95% confidence interval: 1.48-28.45, P = .010) and venous thromboembolic events (odds ratio: 8.32, confidence interval: 2.12-34.84, P = .002). COVID-19 infection within 2 and 3 months prior to TJA did not significantly affect outcomes. CONCLUSION: COVID-19 infection within 1 month prior to TJA significantly increases the risk of postoperative thromboembolic events; however, complication rates returned to baseline after that time point. Surgeons should consider delaying elective total hip arthroplasty and total knee arthroplasty until 1 month after a COVID-19 infection.

Low Risk of Acute Iatrogenic Periprosthetic Joint Infection After Prosthetic Joint Aspiration.

BACKGROUND: Synovial fluid analysis is an essential tool in diagnosing periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). However, concern exists that aspiration may introduce infection into a noninfected joint. Therefore, the purpose of this study was to evaluate the incidence of iatrogenic PJI following diagnostic knee aspiration done within 6 months of the primary TKA. METHODS: Between 2017 and 2021, the senior surgeon performed over 4,000 primary TKAs and aspirated 155 knees in 137 patients for whom there was a suspicion for PJI within 6 months of their primary TKA. There were 22 knees diagnosed as infected from the initial aspiration and therefore were excluded from the study. The remaining 133 aspirates in 115 patients who were negative for infection were followed for 6 months for signs and symptoms of PJI to elucidate whether aspiration introduced infection into an initially noninfected joint. RESULTS: There were 70 of 133 knees (52.6%) aspirated between 0 and 6 weeks after index TKA, 40 of 133 (30.1%) between 6 weeks and 3 months, and 23 of 133 (17.3%) between 3 and 6 months. At final follow-up, none of the 133 initially noninfected knees exhibited evidence of subsequent iatrogenic PJI or had subsequent surgery for infection. CONCLUSION: While joint aspiration is a procedure with inherent risks, this study shows that the rate of iatrogenic PJI is extremely low (0%). Therefore, if infection is suspected, the surgeon should consider joint aspiration, even in the initial postoperative period, as the risk for introducing infection is far outweighed by the risk of missing an infection.

Vitamin D3 Supplementation Prior to Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: The purpose of this randomized controlled trial was to determine if a one-time dose of vitamin D3 prior to total knee arthroplasty improves function and patient-reported outcomes, while decreasing complications. METHODS: One hundred seven patients undergoing primary total knee arthroplasty were randomized to receive 50,000 international units vitamin D3 (57 patients) or placebo (50 patients) on the morning of surgery. Power analysis determined 45 patients were required in each cohort to detect a minimal clinically important difference of 6 points in the functional component of the 2011 version of the Knee Society Score (KSS), assuming an alpha of 0.05 and power of 80%. KSS and a Timed Up and Go Test (TUGT) were measured preoperatively and at 3 and 6 weeks postoperatively. RESULTS: There was no difference in improvement of KSS at 3 weeks (+4.8 points vitamin D3 versus +3.0 points placebo; P = .6) or 6 weeks (+14.5 points vitamin D3 versus +12.4 points placebo; P = .5) from baseline. There was no difference in change in TUGT at 3 weeks (+1.2 seconds vitamin D3 versus +0.6 seconds placebo; P = .6) or 6 weeks (-0.3 seconds vitamin D3 versus -0.9 seconds placebo; P = .6) from baseline. There were 4 complications in the placebo cohort within the first 90 days postoperatively and 5 complications in the vitamin D3 cohort (P = 1.0). CONCLUSION: Supplementation with 50,000 international units vitamin D3 on the day of surgery failed to demonstrate statistical significant differences in functional KSS, TUGT times, or complications in the early postoperative period compared to placebo. LEVEL OF EVIDENCE: Level I, therapeutic study.

General Versus Neuraxial Anesthesia in Revision Surgery for Periprosthetic Joint Infection.

BACKGROUND: The purpose of this study was to compare neuraxial and general anesthesia in revision surgery for periprosthetic joint infection (PJI). METHODS: Patients undergoing revision arthroplasty for PJI were identified in the 2005-2019 American College of Surgeons National Surgical Quality Improvement Program databases. Thirty-day outcomes were compared between general and neuraxial anesthesia. Propensity-score matching and multivariate analysis were used to control patient and procedural variables. RESULTS: Neuraxial anesthesia was used in 1511 (16.8%) cases and general anesthesia in 7468 (83.2%) cases. Neuraxial anesthesia had a lower risk of any adverse event (odds ratio [OR] 0.70, P < .001), serious adverse events (OR 0.77, P < .001), and minor adverse events (OR 0.66, P < .001). Among 875 reoperations and 1351 readmissions, two had a diagnosis of intraspinal abscess, both occurring after general anesthesia. CONCLUSIONS: Neuraxial anesthesia was associated with a lower risk of adverse events when compared to general anesthesia in revision surgery for PJI.

The Efficacy and Safety of Periarticular Injection in Total Joint Arthroplasty: A Direct Meta-Analysis.

BACKGROUND: Periarticular injection (PAI) is administered intraoperatively to help reduce postoperative pain and opioid consumption after primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of PAI in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine. METHODS: The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to March 2020 on PAI in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of PAI. RESULTS: Three thousand six hundred and ninety nine publications were critically appraised to provide 60 studies regarded as the best available evidence for an analysis. The meta-analysis showed that intraoperative PAI reduces postoperative pain and opioid consumption. Adding ketorolac or a corticosteroid to a long-acting local anesthetic (eg, ropivacaine or bupivacaine) provides an additional benefit. There is no difference between liposomal bupivacaine and other nonliposomal long-acting local anesthetics. Morphine does not provide any additive benefit in postoperative pain and opioid consumption and may increase postoperative nausea and vomiting. There is insufficient evidence to draw conclusions on the use of epinephrine and clonidine. CONCLUSION: Strong evidence supports the use of a PAI with a long-acting local anesthetic to reduce postoperative pain and opioid consumption. Adding a corticosteroid and/or ketorolac to a long-acting local anesthetic further reduces postoperative pain and may reduce opioid consumption. Morphine has no additive effect and there is insufficient evidence on epinephrine and clonidine.

The Impact of Race and Socioeconomic Status on Total Joint Arthroplasty Care.

BACKGROUND: Racial minorities and patients from lower socioeconomic backgrounds are less likely to undergo total joint arthroplasty (TJA) for degenerative joint disease (DJD). However, when these patients do present for care, little is known about the overall severity of DJD and surgical wait times. METHODS: A retrospective cohort of 407 patients (131 black and 276 white) who presented to an arthroplasty clinic and went on to receive TJA was established. Severity of osteoarthritis was assessed radiographically via Kellgren-Lawrence (KL) grade. Preoperative Knee Society Score (KSS) and Harris Hip Score (HHS) were used to measure joint pain and function. Multivariate regression modeling and analysis of covariance were used to examine racial and socioeconomic differences in KL grade, KSS, HHS, and time to surgery. RESULTS: Black patients presented with significantly greater KL scores than white patients (P = .046, odds ratio = 1.65, 95% confidence interval [1.01, 2.70]). In contrast, there were no statistically significant racial differences in the mean preoperative KSS (P = .61) or HHS (P = .69). Black patients were also found to wait, on average, 35% longer for TJA (P = .03, hazard ratio = 1.35, 95% confidence interval [1.04, 1.75]). Low income was associated with higher KL grade (P = .002), lower KSS (P = .07), and lower HHS (P = .001). CONCLUSION: Despite presenting with more advanced osteoarthritis, black patients reported similar levels of joint dysfunction and had longer surgical wait times when compared with white patients. Lower socioeconomic status was similarly associated with more severe DJD.

The Past, Present, and Future of Orthopedic Education: Lessons Learned From the COVID-19 Pandemic.

The COVID-19 global pandemic has upended nearly every medical discipline, dramatically impacted patient care and has had far-reaching effects on surgeon education. In many areas of the country, elective orthopedic surgery has completely stopped to ensure that resources are available for the critically ill and to minimize the spread of disease. COVID-19 is forcing many around the world to re-evaluate existing processes and organizations and adapt to carry out business, of which medicine and education are not immune. Most national and international orthopedic conferences, training programs, and workshops have been postponed or canceled, and we are now critically evaluating the delivery of education to our colleagues as well as residents and fellows. This article describes the evolution of orthopedic education and significant paradigm shifts necessary to continue to teach ourselves and the future leaders of our noble profession.

Rapid Discharge and Outpatient Total Joint Arthroplasty Introduce a Burden of Care to the Surgeon.

BACKGROUND: Rapid-pathway outpatient (OTJA) and one-night inpatient (ITJA) arthroplasty require close follow-up by the surgeon. We quantify and characterize the total perioperative touches required in the first 7 days, and compare OTJA and ITJA patients. METHODS: We reviewed 103 consecutive primary total joint arthroplasty (TJA) patients from April 2014 without exclusion; all patients were discharged either within 5 hours or the morning after surgery. All telephone and office visits during the first 7 days following surgery were studied. Specialized outpatient TJA education was included. We measured the frequency, duration, and subject matter of phone calls. Simple Poisson regression analysis and t-tests were used to determine significance. RESULTS: None of the 103 rapid pathway patients were lost to follow-up. Average age was 61.2 years (range 26.9-83.0), with 49 females (47.6%), 78 total knee arthroplasties, average Charlson Comorbidity Index score of 2.1, and average body mass index of 29.5 kg/m2. There were 253 touches required, averaging 2.5/patient. One hundred sixty were outgoing phone calls by the surgical team and 93 were incoming calls from patients. The average duration of each call was 4.74 minutes (SD 3.7). The entire group required 19 hours and 35 minutes of telephone contact. After including specialized education time, this cohort required 83.1 hours of clinical time, or 48.4 minutes per patient. CONCLUSION: Postoperative care after rapid pathway TJA requires a significant burden of resources, shifted from the hospital to the surgeon. We found that both rapid pathway groups require similar work by the surgeon's team. This additional work should be considered by policymakers.

Primary Total Hip Arthroplasty in Patients Less Than 50 Years of Age at a Mean of 16 Years: Highly Crosslinked Polyethylene Significantly Reduces the Risk of Revision.

BACKGROUND: The purpose of this study is to evaluate clinical and radiographic outcomes of patients less than 50 years of age undergoing primary total hip arthroplasty (THA) at a minimum of 10 years. METHODS: Three hundred nine consecutive THAs performed on 273 patients were reviewed. At a minimum of 10 years, 13 were deceased and 23 were lost to follow-up leaving 273 THAs in 237 patients who were followed for a mean of 16 years (range 10-19.9). The cohort consisted of 116 females (49%) and 121 males (51%), with a mean age of 42.3 years at the time of surgery (range 19-49). The majority of preoperative diagnoses included osteoarthritis in 149 (63%) and avascular necrosis in 55 (23%). Two hundred sixteen had highly crosslinked polyethylene (HXLPE) and 57 had non-HXLPE acetabular liners. The femoral stems were cementless in 98% (266/273) and the acetabular components were cementless in all cases. Femoral head composition was cobalt-chromium in all cases and the majority of sizes in the non-HXLPE cohort were 28 mm (52/57; 91%), while the HXLPE group primarily consisted of 28 mm (141/216; 65%) and 32 mm (74/216; 34%) heads. Analysis involved Kaplan-Meier survivorship with a log-rank test for equivalence, Fisher's exact test for pairwise comparisons, and a paired t-test for Harris Hip Score, with alpha = 0.05 being statistically significant. RESULTS: There were 6 revisions for wear in the non-HXLPE group (10.5%) compared to none in the HXLPE group (P < .001). Similarly, survivorship with revision for any reason as the endpoint at 16 years was significantly higher at 93.0% in the XLPE group (95% confidence interval 88.7-95.7) compared to 85.7% (95% confidence interval 73.5-92.6) in the non-HXLPE group (P = .023). Additional revisions in the HXLPE group included 6 for instability (2.8%), 5 secondary to infection (2.4%), and 3 stem failures (1.4%). Non-wear-related revisions in the non-HXLPE group included 5 due to instability (8.8%) and 3 due to stem failures (5.3%). The mean Harris Hip Scores for the entire cohort improved from a mean of 46.2 points preoperatively to 89.8 points at most recent follow-up (P < .001). CONCLUSION: The use of HXLPE has led to a significant reduction in the risk of failure in patients <50 years old, with over 93% survivorship at 16 years. Instability and infection, however, remain substantial causes of failure. LEVEL OF EVIDENCE: Therapeutic Level III.

Clinical Impact of Routine Complete Blood Counts Following Total Knee Arthroplasty.

BACKGROUND: Routine laboratory studies are generally obtained following total knee arthroplasty (TKA), and often continued daily until discharge. This study aims to investigate the utility and cost-effectiveness of complete blood count (CBC) tests following TKA. METHODS: Retrospective review identified 484 patients who underwent primary TKA under a tourniquet at a single institution. Preoperative and postoperative CBC values were collected along with demographic data, use of tranexamic acid (TXA), and transfusion rates. Logistic regression models were calculated for all variables. RESULTS: Twenty-five patients required transfusion following TKA (5.2%). Patients requiring transfusion had significantly lower preoperative hemoglobin compared to patients who did not require transfusion (11.47 vs 13.58 g/dL, P = .005). Risk of transfusion was 5.2 times higher in patients with preoperative anemia (95% confidence interval 2.90-9.35, P < .001). Without TXA, patients were 2.75 times more likely to receive transfusion (95% confidence interval 1.43-5.30, P < .001). An average of 2.9 CBC tests were collected per patient who did not receive medical intervention, costing a total of $144,773.80 in associated hospital charges ($316.10 per patient). CONCLUSION: Ensuring quality, cost-effective patient care following total joint arthroplasty is essential in the era of bundled payments. Routine postoperative CBCs do not add value for patients with normal preoperative hemoglobin who receive TXA during TKA performed under tourniquet. Patients who are anemic preoperatively or do not receive TXA should obtain a postoperative CBC test. Daily CBCs are unnecessary if the first postoperative CBC does not prompt intervention.

Total Knee Arthroplasty in Patients Less Than 50 Years of Age: Results at a Mean of 13 Years.

BACKGROUND: Patients between 45 and 54 years old will be the fastest-growing cohort seeking total knee arthroplasty (TKA) over the next 15 years. The purpose of this investigation is to determine the clinical outcomes of TKA in patients less than 50 years old at a minimum of 10 years. We hypothesized that this patient population would have a high rate of survivorship that is similar to that of older patients. METHODS: We reviewed 298 consecutive TKAs on 242 patients at a minimum of 10 years postoperatively. Twenty patients died and 30 TKAs were lost to follow-up leaving 248 TKAs in 202 patients (91 male, 111 female) with a mean age of 45.7 years (range, 26-49) at the time of surgery. Patient-reported outcomes, survivorship, causes of reoperation, and initial postoperative radiographic parameters were collected. RESULTS: At a mean of 13.0 years, there were 9 revisions for tibial loosening (3.6%), 8 for deep infection (3.2%), 7 for polyethylene wear (2.8%), and 3 for failed ingrowth of a cementless femoral component (1.2%). Kaplan-Meier analysis demonstrated 92.0% survivorship with failures defined as aseptic component revision and 83.9% survivorship for all-cause reoperation at 13 years. Patients with tibial alignment of 4° or more of varus or 10° or more of posterior slope were found to have increased rate of failure. CONCLUSION: While overall durability was good in this young patient population, tibial fixation and deep infection were relatively common causes of failure. In addition, increased tibial varus and slope were found to increase the rate of failure. Furthermore, the nearly 3% risk of revision for wear suggests that the use of more wear-resistant bearing surfaces may reduce the risk of failure in this patient population.

Preoperative Patient Profile in Total Hip and Knee Arthroplasty: Predictive of Increased Medicare Payments in a Bundled Payment Model.

BACKGROUND: The shift toward value-based bundled payment models in total joint arthroplasty highlights the need for identification of modifiable risk factors for increased spending as well as opportunities to mitigate perioperative treatment of chronic disease. The purpose of this study was to identify preoperative comorbidities that result in an increased financial burden using institutional data at a single institution. METHODS: We conducted a retrospective review of total joint arthroplasty patients and collected payment data from the Center for Medicare and Medicaid Services for each patient up to 90 days after surgery in accordance with the regulations of the Comprehensive Care for Joint Replacement initiative. Statistical analysis and comparison of preoperative profile and Medicare payments as a surrogate for cost were completed. RESULTS: Six hundred ninety-four patients were identified over a 4-year time period who underwent surgery before adoption of the Comprehensive Care for Joint Replacement but that met criteria for inclusion. The median total payment per patient episode of care was $20,048. Preoperative diagnosis of alcoholism, anemia, diabetes, and obesity was found to have a statistically significant effect on total payments. The model predicted a geometric mean increase from $1425 to $9308 for patients bearing these comorbidities. CONCLUSION: With Medicare payments as a surrogate for cost, we demonstrate that specific patient comorbidities and a cumulative increase in comorbidities predict increased costs. This study was based on institutional data rather than administrative data to gain actionable information on an institutional level and highlight potential flaws in research based on administrative data.

When Should Complete Blood Count Tests Be Performed in Primary Total Hip Arthroplasty Patients?

BACKGROUND: Routine laboratory studies are often obtained following total hip arthroplasty (THA). Moreover, laboratory studies are often continued daily until the patient is discharged regardless of medical management. The purpose of this study was to investigate the use of routine complete blood count (CBC) tests following THA. Secondarily, the purpose was to identify patient factors associated with abnormal postoperative lab values. METHODS: This retrospective review identified 352 patients who underwent primary THA at a single institution from 2012 to 2014. Preoperative and postoperative CBC values were collected along with demographic data, use of tranexamic acid (TXA), and transfusion rates. Logistic regression models were used to identify factors associated with an abnormal postoperative lab and risk of transfusion. RESULTS: Of the 352 patients, 54 patients were transfused (15.3%). Patients who underwent transfusion had a significantly lower preoperative hemoglobin (Hb; 12.0 g/dL) compared to patients who did not undergo transfusion (13.5 g/dL; P < .001). Patients who did not receive TXA were 3.7 times more likely to receive a transfusion. No patients received medical intervention based on the outcome of postoperative platelet or white blood counts. A Hb value below 11.94 g/dL for patients who are anemic preoperative or did not receive TXA predicted transfusion after postoperative day 1. CONCLUSION: Under value-based care models, cost containment while maintaining high-quality patient care is critical. Routine postoperative CBC tests in patients with a normal preoperative Hb who receive TXA do not contribute to actionable information. Patients who are anemic before THA or do not receive TXA should at minimum obtain a CBC on postoperative day 1.

The Utility of Basic Metabolic Panel Tests After Total Joint Arthroplasty.

INTRODUCTION: Routine laboratory studies are often obtained daily after total joint arthroplasty (TJA) regardless of medical management. The purpose of this study was to investigate the utility of routine basic metabolic panel (BMP) tests after TJA. Furthermore, the goal was to identify factors that may predispose patients to abnormal laboratory values that require medical intervention. METHODS: A retrospective review was performed on 767 patients who underwent primary TJA at a single institution. Preoperative and postoperative potassium, sodium, creatinine, and glucose values were collected along with demographic data, comorbidities, and procedural characteristics. Multivariable logistic regression models were used to determine independent risk factors for abnormal postoperative laboratory values. RESULTS: Diabetes was associated with abnormal glucose (odds ratio [OR] 23.4, 95% confidence interval [CI] 10.7-51.0, P < .001), while chronic kidney disease was associated with abnormal creatinine (OR 3.1, 95% CI 1.7-5.8, P < .001) and potassium (OR 1.8, 95% CI 1.1-2.8, P = .014) requiring medical intervention. An abnormal preoperative laboratory value was also associated with medical treatment for each of sodium, potassium, and creatinine (all P < .001). Average number of BMP tests collected for patients who did not receive medical intervention was 2.8. This equated to $472,372.56 in total hospital charges. CONCLUSION: Cost containment while maintaining high-quality patient care is critical. Routine postoperative BMP tests in patients with normal preoperative values without major medical comorbidities do not contribute to actionable information. Patients with diabetes, chronic kidney disease, or with abnormal preoperative values should obtain a BMP after TJA.

Inpatient Consults and Complications During Primary Total Joint Arthroplasty in a Bundled Care Model.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) are implementing changes in hospital reimbursement models for total joint arthroplasty (TJA), moving to value-based bundled payments from the fee-for-service model. The purpose of this study is to identify consults and complications during the perioperative period that increase financial burden. METHODS: We combined CMS payment data for inpatient, professional, and postoperative with retrospective review of patients undergoing primary TJA and developed profiles of patients included in the Comprehensive Care for Joint Replacement bundle undergoing TJA. Statistical comparison of episode inpatient events and payments was conducted. Multiple regression analysis was adjusted for length of stay, disposition, and Charlson-Deyo comorbidity profile. RESULTS: Median total payment was $21,577.36, which exceeded the median bundle target payment of $20,625.00. Adjusted analyses showed that psychiatry consults (increase of $73,123.32; P < .001), internal medicine consults ($5789.38; P ≤ .001), pulmonary embolism ($35,273.68; P < .001), intensive care unit admission ($14,078.37; P < .001), and deep vein thrombosis ($9471.26; P = .019) resulted in increased payments using multivariate analysis adjusted for length of stay, Charlson-Deyo comorbidities, and discharge disposition. CONCLUSION: Patients with inpatient complications such as pulmonary embolism and/or deep vein thrombosis, intensive care unit admission, and medical/psychiatric consultation exceeded the CMS target. Although study results showed typical complication rates, acute inpatient consultation significantly increased utilization beyond the CMS target even when adjusted for length of stay, patient comorbidities, and discharge. Needed medical care should continue to be a priority for inpatients, and allowance for individual outliers should be considered in policy discussions.

Assessment of glenoid chondral healing: comparison of microfracture to autologous matrix-induced chondrogenesis in a novel rabbit shoulder model.

BACKGROUND: Management of glenohumeral arthrosis in young patients is a considerable challenge, with a growing need for non-arthroplasty alternatives. The objectives of this study were to develop an animal model to study glenoid cartilage repair and to compare surgical repair strategies to promote glenoid chondral healing. METHODS: Forty-five rabbits underwent unilateral removal of the entire glenoid articular surface and were divided into 3 groups--untreated defect (UD), microfracture (MFx), and MFx plus type I/III collagen scaffold (autologous matrix-induced chondrogenesis [AMIC])--for the evaluation of healing at 8 weeks (12 rabbits) and 32 weeks (33 rabbits) after injury. Contralateral shoulders served as unoperated controls. Tissue assessments included 11.7-T magnetic resonance imaging (long-term healing group only), equilibrium partitioning of an ionic contrast agent via micro-computed tomography (EPIC-µCT), and histologic investigation (grades on International Cartilage Repair Society II scoring system). RESULTS: At 8 weeks, x-ray attenuation, thickness, and volume did not differ by treatment group. At 32 weeks, the T2 index (ratio of T2 values of healing to intact glenoids) was significantly lower for the MFx group relative to the AMIC group (P = .01) whereas the T1ρ index was significantly lower for AMIC relative to MFx (P = .01). The micro-computed tomography-derived repair tissue volume was significantly higher for MFx than for UD. Histologic investigation generally suggested inferior healing in the AMIC and UD groups relative to the MFx group, which exhibited improvements in both integration of repair tissue with subchondral bone and tidemark formation over time. DISCUSSION: Improvements conferred by AMIC were limited to magnetic resonance imaging outcomes, whereas MFx appeared to promote increased fibrous tissue deposition via micro-computed tomography and more hyaline-like repair histologically. The findings from this novel model suggest that MFx promotes biologic resurfacing of full-thickness glenoid articular injury.

Clinical outcome of revision meniscal allograft transplantation: minimum 2-year follow-up.

PURPOSE: The purpose of this study was to assess the clinical and radiographic outcomes after revision meniscal allograft transplantation (RMAT). METHODS: Eleven patients underwent RMAT performed by the senior author (B.J.C.). These patients were studied prospectively and completed standardized outcome surveys (including International Knee Documentation Committee [IKDC], Cincinnati Knee-Rating System, Tegner score, Lysholm score, Short Form-12, Knee Injury and Osteoarthritis Outcome Score [KOOS], and overall satisfaction) preoperatively and annually thereafter for a minimum of 2 years. Radiographic analysis before surgery and at the most recent follow-up included anteroposterior, Rosenberg, lateral, and sunrise views graded by the Kellgren and Lawrence (K & L) scale. The status of the articular cartilage was graded intraoperatively using the Outerbridge classification. Two patients were lost to follow-up and one declined further participation. RESULTS: The average time to RMAT from the index procedure was 3.45 ± 2.52 years, with a mean follow-up after RMAT of 3.83 ± 1.3 years. One patient progressed to arthroplasty during follow-up and was not included in subjective outcome score follow-up. Clinical outcome scores that demonstrated significant improvements included IKDC (43 ± 12 to 61 ± 16; P = .03) and KOOS pain score (66 ± 12 to 79 ± 11; P = .047). Along with this, the subjective symptom rate significantly improved from 5.0 ± 0.9 preoperatively to 6.7 ± 1.8 postoperatively (P = .011). Radiographic (P = .7) and Outerbridge (P = .809) grading did not show progression. Seven of 8 patients would have surgery again, and satisfaction at final follow-up was 7.6 ± 2.6. CONCLUSIONS: In this small series with short-term follow-up, RMAT resulted in high patient satisfaction and significant symptom reduction on validated outcome scores (IKDC and KOOS pain score), proving the original hypothesis that outcomes after RMAT would be improved compared with preoperative conditions. Identifiable causes of MAT failure may help predict response to RMAT. Because arthroplasty is still not favored in young active patients, a thorough discussion with the patient is necessary to best align their goals with those of the surgery when considering revision meniscus transplantation. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

An epidemiologic analysis of clinical practice guidelines for non-arthroplasty treatment of osteoarthritis of the knee.

PURPOSE: To analyze the current practice patterns of non-arthroplasty treatment of knee osteoarthritis (OA) and to assess the impact of the American Academy of Orthopaedic Surgeons clinical practice guidelines on the management of OA of the knee, particularly as they relate to the use of arthroscopic treatment. METHODS: The United Healthcare Database (2004-2009, 11 million patients, 216 million records) was used for the study and was searched using Boolean language for International Classification of Diseases, Ninth Edition, Clinical Modification and Current Procedural Terminology, fourth revision codes. A reference group was defined as patients treated with knee arthroplasty in 2009 and diagnosed with knee OA in the same record. Clinical practice patterns in the 5 years preceding arthroplasty were analyzed in this group. RESULTS: The reference group consisted of 12,806 patients undergoing total knee arthroplasty in 2009 with a documented diagnosis of OA at the time of surgery, with prior nonoperative treatment strategies analyzed during the preceding 5 years (2004-2009); 10.0% of patients were prescribed physical therapy specific to OA, 2.6% received an unloader brace, 0.52% underwent acupuncture, 43.5% were administered intra-articular corticosteroids, and 15.4% received viscosupplementation injections. During the 5 years before arthroplasty, 2,505 patients (19.6%) underwent arthroscopy and debridement/lavage, 35% of whom did not have a diagnosis code for mechanical pathology. Within 1 year of knee arthroplasty, 2,028 of the 2,505 knee arthroscopies (80.9%) were performed. CONCLUSIONS: The findings show that significant gaps do exist between the evidence-based American Academy of Orthopaedic Surgeons recommendations and actual practice patterns in the United States between 2004 and 2009. LEVEL OF EVIDENCE: Level IV, diagnostic study.