Revision Total Knee Arthroplasty in an Outpatient Setting: A Growing Alternative.

BACKGROUND: Recent studies have focused on the safety and efficacy of performing primary total knee arthroplasty (TKA) in an outpatient setting. Despite being associated with greater costs, much less is known about the accompanying impact on revision TKA (rTKA). The purpose of this study was to describe the trends in costs and outcomes of patients undergoing inpatient and outpatient rTKA. METHODS: An observational cohort study was conducted using commercial claims databases. Patients who underwent 1-component and 2-component rTKA in an inpatient setting, hospital outpatient department (HOPD), or ambulatory surgery center (ASC) from 2018 to 2020 were included. The primary outcome was the 30-day episode-of-care costs following rTKA. Secondary outcomes included surgical cost, 90-day readmission rate, and emergency department visit rate. Covariates for analyses included patient demographics, surgery type, and indication for revision. RESULTS: There were 6,515 patients who were identified, with 17.0% of rTKAs taking place in an outpatient setting. On adjusted analysis, patients in the highest quartile of 30-day postoperative costs were more likely to be those whose rTKA was performed in an inpatient setting. One-component revisions were more common in an outpatient setting (HOPD, 50.7%; ASC, 62.0%) compared to an inpatient setting (39.6%). The 90-day readmission rates were higher (P = .003) for rTKAs performed in inpatient (+9.2%) and HOPD (+8.6%) settings compared to those in an ASC. CONCLUSIONS: The ASC may be a suitable setting for simpler revisions performed for less severe indications and is associated with lower costs and 90-day readmission and emergency department visit rates.

Failure Following Revision Total Hip Arthroplasty After Cobalt-Chrome Femoral Heads are Placed on a Retained Femoral Stem.

BACKGROUND: Failure due to trunnionosis with adverse local tissue reaction (ALTR) has been reported with cobalt-chrome (CoCr) heads in total hip arthroplasty (THA); however, there are limited data on the use of these heads in the revision setting. The purpose of this study was to analyze the outcomes of patients who underwent revision THA with a retained femoral component and received a CoCr femoral head on a used trunnion. METHODS: In this retrospective review, we identified all patients who underwent revision THA with a retained femoral component and received a CoCr femoral head between February 2006 and March 2014. Demographic factors, implant details, and postoperative complications, including the need for repeat revisions, were recorded. In total, 107 patients were included (mean age 67 years, 74.0% women). Of the 107 patients, 24 (22.4%) required repeat revisions. RESULTS: Patients who required repeat revision were younger than those who did not (mean age: 62.9 versus 69, P = .03). The most common indications for repeat revision were instability (8 of 24, 33.3%), ALTR (5 of 24, 20.8%), and infection (4 of 18, 16.7%). Evidence of ALTR or metallosis was identified at the time of reoperation in 10 of the 24 patients who underwent re-revision (41.7%). CONCLUSIONS: The placement of a new CoCr femoral head on a used trunnion during revision THA with a retained femoral component carries a significant risk of complication (22.4%) and should be avoided when possible.

The Cost of Stiffness After Total Knee Arthroplasty.

BACKGROUND: Stiffness after primary total knee arthroplasty (TKA) is debilitating and poorly understood. A heterogenous approach to the treatment is often utilized, including both nonoperative and operative treatment modalities. The purpose of this study was to examine the prevalence of treatments used between stiff and non-stiff TKA groups and their financial impact. METHODS: An observational cohort study was conducted using a large database. A total of 12,942 patients who underwent unilateral primary TKA from January 1, 2017, to December 31, 2017, were included. Stiffness after TKA was defined as manipulation under anesthesia and a diagnosis code of stiffness or ankylosis, and subsequent diagnosis and procedure codes were used to identify the prevalence and financial impact of multiple common treatment options. RESULTS: The prevalence of stiffness after TKA was 6.1%. Stiff patients were more likely to undergo physical therapy, medication, bracing, alternative treatment, clinic visits, and reoperation. Revision surgery was the most common reoperation in the stiff TKA group (7.6%). The incidence of both arthroscopy and revision surgery were higher in the stiff TKA population. Dual component revisions were costlier for patients who had stiff TKAs ($65,771 versus $48,287; P < .05). On average, patients who had stiffness after TKA endured costs from 1.5 to 7.5 times higher than the cost of their non-stiff counterparts during the 2 years following index TKA. CONCLUSION: Patients who have stiffness after primary TKA face significantly higher treatment costs for both operative and nonoperative treatments than patients who do not have stiffness.

A Safe Number of Perioperative Opioids to Reduce the Risk of New Persistent Usage Among Opioid-Naïve Patients Following Total Joint Arthroplasty.

BACKGROUND: Higher initial opioid dosing increases the risk of prolonged opioid use following total joint arthroplasty (TJA), and the safe amounts to prescribe are unknown. We examined the relationship between perioperative opioid exposure and new persistent usage among opioid-naïve patients after total knee and hip arthroplasty. METHODS: In this retrospective cohort study, 22,310 opioid-naïve patients undergoing primary TJA between 2018 and 2019 were identified within a commercial claims database. Perioperative opioid exposure was defined as total dose of opioid prescription in morphine milligram equivalents (MME) between 1 month prior to and 2 weeks after TJA. New persistent usage was defined as at least one opioid prescription between 90 and 180 days postoperatively. Multivariate regression analyses were performed to examine the relationship between the perioperative dosage group and the development of new persistent usage. RESULTS: For the total patient cohort, 8.1% developed new persistent usage. Compared to patients who received <300 MME, patients who received 600-900 MME perioperatively had a 77% increased risk of developing new persistent usage (odds ratio 1.77, 95% CI, 1.44-2.17), and patients who received ≥1,200 MME perioperatively had a 285% increased risk (odds ratio 3.85, 95% CI, 3.13-4.74). CONCLUSION: We found a dose-dependent association between perioperative MME and the risk of developing new persistent usage among opioid-naïve patients following TJA. We recommend prescribing <600 MME (equivalent to 80 pills of 5 mg oxycodone) during the perioperative period to reduce the risk of new persistent usage. LEVEL OF EVIDENCE: Level III.

No Increased Risk of Aseptic Loosening with Tourniquetless Cemented Total Knee Arthroplasty.

Our study examined whether risk of revision for aseptic loosening following cemented total knee arthroplasty (TKA) is (1) increased with tourniquetless surgery and (2) affected by patient characteristics or surgical factors. Primary cemented TKAs from 2005-2012 with 2-year follow up were analyzed (n = 5,508 with tourniquet; n=101 without). Revision for aseptic loosening was compared between TKA performed with and without a tourniquet. Patient characteristics were recorded. At mean 4.8-year follow up, risk of aseptic loosening was similar between TKA performed with or without a tourniquet (p = 0.3151). Aseptic loosening was more likely in men (p = 0.0018) and patients younger than 50 (p < 0.0001). No difference was observed between cruciate-retaining and posterior-stabilized implants (p = 0.1250). With the numbers available for study, we did not observe an increased risk of aseptic loosening with tourniquetless cemented primary TKA. Patients younger than 50, particularly men, should be counselled on the increased risk of TKA revision for aseptic loosening. (Journal of Surgical Orthopaedic Advances 32(2):111-113, 2023).

Accelerated neutral atom beam (ANAB) modified polyethylene for decreased wear and reduced bacteria colonization: An in vitro study.

Ultra-high molecular weight polyethylene (UHMWPE) model implants were modified using accelerated neutral atom beam (ANAB) technology and tested for in vitro wear properties and bacteria colonization. Material characterization studies using atomic force microscopy (AFM), surface energy, and in vitro protein adsorption events were also conducted to better understand the mechanism behind such wear properties and bacteria colonization. ANAB modified UHMWPE showed significantly reduced wear properties compared to controls due to nanostructured features, greater surface energy, and improved adsorption of lubricin, a synovial fluid lubricating protein. There was significantly greater adsorption of proteins known to reduce bacteria colonization (specifically, mucin, casein, and lubricin) after 4 h on UHMWPE after ANAB treatment. Such changes in initial protein events led to significantly decreased bacteria (including methicillin resistant Staph. aureus (or MRSA), Staph. aureus, E. coli, multi-drug resistant E. coli, Pseudomonas aeruginosa and Staph. epidermidis) colonization after 24 h without resorting to antibiotic use.

Drivers of Unequal Healthcare Costs in the Nonoperative Treatment of Late-Stage Knee Osteoarthritis Prior to Primary Total Knee Arthroplasty.

BACKGROUND: In the United States, patients with late-stage knee osteoarthritis (OA) often undergo several nonoperative treatments and related procedures prior to total knee arthroplasty. The costs of these treatments and procedures are substantial, and the variation in healthcare costs among different groups of patients may exist. The purpose of this study is to examine these costs and determine the drivers of costs in patients with the highest healthcare expenditure. METHODS: An observational cohort study was conducted using the IBM Watson Health MarketScan databases from January 1, 2017 to December 31, 2019. The primary outcome was the cost of payments for nonoperative procedures which included (i) physical therapy (PT), (ii) bracing, (iii) intra-articular injections: professional fee, hyaluronic acid (IA-HA), and corticosteroids (IA-CS), (iv) medication: nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and acetaminophen, and (v) knee-specific imaging. RESULTS: Among the 24,492 patients included in the study, the total payments per patient for nonoperative care were $3,735 ± 3,049 in the highest payment quartile (Q4) and $137 ± 70 in the lowest payment quartile (Q1). Per-patient-per-month costs generally increased across quartiles for procedures. Comparing Q4 to Q1, the largest changes in prevalence were found in IA-HA (348×), bracing (10×), and PT (7×). Patients who were prescribed IA-HA and PT had a 28.3-times and 4.8-times greater likelihood, respectively, to be a higher-paying patient. CONCLUSION: Unequal healthcare costs in the nonoperative treatment of late-stage knee OA are driven by differences in prevalent management strategies. Overall healthcare expenditure may be reduced if only guideline-concordant treatments are used.

Reducing Narcotic Usage With 0.5% Bupivacaine Periarticular Injections in Total Knee Arthroplasty.

BACKGROUND: Periarticular injections (PAIs) and adductor canal blocks (ACBs) are widely accepted pain management strategies for total knee arthroplasty (TKA); however, the optimal anesthetic concentration to provide adequate pain relief while avoiding toxicity remains controversial. The purpose of this study is to evaluate the efficacy of different anesthetic concentrations for PAI alone and in combination with ACB. METHODS: This retrospective cohort study of patients undergoing primary TKAs between January 2019 and November 2020 included 3 groups: 0.25% PAI (50 cc of 0.25% bupivacaine PAI diluted with 50 cc of saline and ketorolac), 0.5% PAI (50 cc of 0.5% bupivacaine with 50 cc of saline and ketorolac), and PAI + ACB (ultrasound-guided preoperative anesthesiologist-administered ACB and 0.25% PAI). RESULTS: In total, 368 TKAs were analyzed (123 0.25%, 132 0.5%, and 113 PAI + ACB). Total overall hospital narcotic usage in oral morphine equivalents (OME) was significantly lower for the 0.5% group (120.09 vs 165.26 and 175.75) compared to the 0.25% and PAI + ACB groups, respectively (P < .0001). Cumulative OME for the first 3 shifts was also lower for 0.5% (68.7 vs 83.7 and 76.4) compared to the 0.25% and PAI + ACB groups, respectively (P = .030). Total postoperative narcotics in OME were significantly lower for 0.5% (617.9 vs 825.2 and 1047.6) than 0.25% and PAI + ACB, respectively (P = .0003). Number of prescriptions within 6 weeks postoperatively were also significantly lower for 0.5% (1.7) than 0.25% (2.1) and PAI + ACB (2.4) (P = .0003). CONCLUSION: Patients receiving 0.5% PAI had lower narcotic usage compared to 0.25% PAI or PAI + ACB. ACB may be eliminated without compromising pain control if the dose of local anesthetic in the PAI is sufficiently high.

Combined treatment of intraoperative cell-salvage and tranexamic acid for primary unilateral total hip arthroplasty: Are there added benefits?

BACKGROUND: Blood management strategies in total hip arthroplasty (THA) are essential in reducing intraoperative blood loss, blood transfusion and associated complications. This study investigates whether using intraoperative cell-salvage (ICS) with tranexamic acid (TXA) has additional effects on blood loss and allogeneic transfusion in primary THA. Additionally, we evaluated the financial impact of using ICS on our institution. METHODS: Using an institutional database, 1171 cases of primary unilateral THA performed between May 2015 and January 2016 were identified. Subjects were separated into those who received only TXA (n = 323) and those who received TXA and ICS (n = 848). Calculated blood loss and post-operative blood transfusions were assessed using logistic regression. Drop in hematocrit was assessed using linear regression. Multivariable models adjusted for intraoperative blood transfusions, pre-operative autologous blood donation, anticoagulation medications, sex, and body mass index. Pricing data was used to calculate the costs associated with these interventions. RESULTS: The likelihood of post-operative allogeneic blood transfusion was similar for the combined group relative to the TXA group (OR = 0.63; 95% CI: 0.26, 1.54), as was the likelihood of any post-operative blood transfusion (OR = 1.13; 95% CI: 0.63, 2.01). There was no correlative relationship between use of ICS and hematocrit drop when accounting for baseline hematocrit (R2 = 0.118). Factoring in rental, service fees, and disposable equipment, the utilization of ICS added $146 to each case, resulting in a gross expenditure of over $123,000 during the study period. CONCLUSIONS: The combination of ICS with TXA for primary unilateral THA did not improve blood loss or transfusion outcomes compared to TXA alone. As there was no observed clinical benefit to combined treatment, additional costs associated with routine usage of ICS may not be justifiable. Our institution would have reduced expenditures for blood loss management products by 85% during the study period if all patients had only received TXA.

Anatomic and Patient Risk Factors for Postoperative Periprosthetic Hip Fractures: A Case-Control Study.

BACKGROUND: Periprosthetic fracture remains a major source of reoperation following total hip arthroplasty (THA). Within 90 days of surgery, fractures may occur spontaneously or with minor injury and are therefore more likely related to patient factors including anatomic variation. METHODS: From 2008 to 2018, 16,254 primary THAs were performed at our institution; of those, 48 were revised for periprosthetic fracture within 90 days of surgery. A control group of 193 patients undergoing THA for hip osteoarthritis (OA) was randomly selected from the source population. We excluded patients with genetic bone disease and THA performed for hip fracture. We used logistic regression to analyze associations between patient factors (demographics, anatomical factors, comorbidities, surgical technique, and implants) and odds of 90-day periprosthetic fracture. RESULTS: Increased age was significantly associated with fracture (P = .002), as was female gender (P = .046). After adjusting for age and gender, absence of contralateral OA was associated with increased odds of fracture relative to patients with contralateral OA (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.60-9.29), as was having a contralateral THA in place (OR 3.70, 95% CI 1.59-8.60). The neck-shaft angle, femoral offset, and the Dorr classification were not associated with increased odds of fracture. Additionally, the distance from the tip of the trochanter to the top of the femoral head was associated with increased odds of fracture per half centimeter (OR 1.48, 95% CI 1.14-1.93). CONCLUSION: Risk of early postoperative periprosthetic fracture following THA is increased with age, female gender, and increasing distance from the greater trochanter to the top of the femoral head; and decreased in the setting of contralateral hip OA. The trochanter-head distance correlation with periprosthetic hip fracture indicates that the preoperative anatomy may influence PPF, particularly regarding how that anatomy is reconstructed.

2018 John Charnley Award: Analysis of US Hip Replacement Bundled Payments: Physician-initiated Episodes Outperform Hospital-initiated Episodes.

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) launched the Bundled Payment for Care Improvement (BPCI) initiative in 2013 to create incentives to improve outcomes and reduce costs in various clinical settings, including total hip arthroplasty (THA). This study seeks to quantify BPCI initiative outcomes for THA and to determine the optimal party (for example, hospital versus physician group practice [PGP]) to manage the program. QUESTIONS/PURPOSES: (1) Is BPCI associated with lower 90-day payments, readmissions, or mortality for elective THA? (2) Is there a difference in 90-day payments, readmissions, or mortality between episodes initiated by PGPs and episodes initiated by hospitals for elective THA? (3) Is BPCI associated with reduced total Elixhauser comorbidity index or age for elective THA? METHODS: We performed a retrospective analysis on the CMS Limited Data Set on all Medicare primary elective THAs without a major comorbidity performed in the United States (except Maryland) between January 2013 and March 2016, totaling more than USD 7.1 billion in expenditures. Episodes were grouped into hospital-run BPCI (n = 42,922), PGP-run BPCI (n = 44,662), and THA performed outside of BPCI (n = 284,002). All Medicare Part A payments were calculated over a 90-day period after surgery and adjusted for inflation and regional variation. For each episode, age, sex, race, geographic location, background trend, and Elixhauser comorbidities were determined to control for major confounding variables. Total payments, readmissions, and mortality were compared among the groups with logistic regression. RESULTS: When controlling for demographics, background trend, geographic variation, and total Elixhauser comorbidities in elective Diagnosis-Related Group 470 THA episodes, BPCI was associated with a 4.44% (95% confidence interval [CI], -4.58% to -4.30%; p < 0.001) payment decrease for all participants (USD 1244 decrease from a baseline of USD 18,802); additionally, odds ratios (ORs) for 90-day mortality and readmissions were unchanged. PGP groups showed a 4.81% decrease in payments (95% CI, -5.01% to -4.61%; p < 0.001) after enrolling in BPCI (USD 1335 decrease from a baseline of USD 17,841). Hospital groups showed a 4.04% decrease in payments (95% CI, -4.24% to 3.84%; p < 0.01) after enrolling in BPCI (USD 1138 decrease from a baseline of USD 19,799). The decrease in payments of PGP-run episodes was greater compared with hospital-run episodes. ORs for 90-day mortality and readmission remained unchanged after BPCI for PGP- and hospital-run BPCI programs. Patient age and mean Elixhauser comorbidity index did not change after BPCI for PGP-run, hospital-run, or overall BPCI episodes. CONCLUSIONS: Even when controlling for decreasing costs in traditional fee-for-service care, BPCI is associated with payment reduction with no change in adverse events, and this is not because of the selection of younger patients or those with fewer comorbidities. Furthermore, physician group practices were associated with greater payment reduction than hospital programs with no difference in readmission or mortality from baseline for either. Physicians may be a more logical group than hospitals to manage payment reduction in future healthcare reform. LEVEL OF EVIDENCE: Level II, economic and decision analysis.

Knee osteoarthritis patients with more subchondral cysts have altered tibial subchondral bone mineral density.

BACKGROUND: Subchondral bone cysts are a widely observed, but poorly understood, feature in patients with knee osteoarthritis (OA). Clinical quantitative computed tomography (QCT) has the potential to characterize cysts in vivo but it is unclear which specific cyst parameters (e.g., number, size) are associated with clinical signs of OA, such as disease severity or pain. The objective of this study was to use QCT-based image-processing techniques to characterize subchondral tibial cysts in patients with knee OA and to explore relationships between proximal tibial subchondral cyst parameters and subchondral bone density as well as clinical characteristics of OA (alignment, joint space narrowing (JSN), OA severity, pain) in patients with knee OA. METHODS: The preoperative knee of 42 knee arthroplasty patients was scanned using QCT. Patient characteristics were obtained, including OA severity, knee pain, JSN, and alignment. We used 3D image processing techniques to obtain cyst parameters including: cyst number, cyst number per proximal tibial volume, cyst volume per proximal tibial volume, as well as maximum and average cyst volume across the proximal tibia, as well as regional bone mineral density (BMD) excluding cysts. We used Spearman's correlation coefficients to explore associations between patient characteristics and cyst parameters. RESULTS: At both the medial and lateral compartments of the proximal tibia, greater cyst number and volume were associated with higher BMD. At the lateral region, cyst number and volume were also associated with lateral OA severity, lateral JSN, alignment and sex. Pain was not associated with any cyst parameters at any region. CONCLUSION: Cyst number and volume were associated with BMD at both the medial and lateral compartments. Lateral cyst number and volume were also associated with joint alignment, OA severity, JSN and sex. This is the first study to use clinical QCT to explore subchondral tibial cysts in patients with knee OA and provides further evidence of the relationships between subchondral cysts and clinical OA characteristics.

Prospective Randomized Trial Comparing Femoral Nerve Block With Intraoperative Local Anesthetic Injection of Liposomal Bupivacaine in Total Knee Arthroplasty.

BACKGROUND: Postoperative pain after total knee arthroplasty (TKA) may impact long-term results and incidence of complications. Femoral nerve block (FNB) provides excellent pain relief after TKA, although associated risks include weakness, delayed participation in therapy, and nerve injury. Liposomal bupivacaine (LB) is a potentially longer acting local anesthetic that may reduce postoperative pain. METHODS: We performed a prospective, randomized, double-blind study of 373 TKA patients randomized to receive either an FNB (control group), or an intraoperative periarticular injection (PAI) with LB and a placebo saline FNB (experimental group). Patients were evaluated with visual analog scores for pain, range of motion, performance of straight leg raise (SLR), walking distance, and Short Form-12 up to 1 year postoperatively. RESULTS: Twelve and 24 hours postoperatively, the control group had significantly lower pain scores (mean 3.24 vs 3.87; P = .02) and higher range of motion (84.54° vs 78°; P < .001). The patients receiving LB PAI were significantly more likely to perform a straight leg raise 12 hours postoperatively (73% vs 50%; P = .0003). Patients in the LB (experimental) group scored better in the physical function component of the Short Form-12 (-23 vs -27, P = .01) 3 months postoperatively. CONCLUSION: While pain scores were slightly lower in the control group in the first 24 hours after TKA compared with LB PAI, the magnitude of the difference was small, and excellent pain relief was provided by both interventions. Use of LB PAI in TKA is a reasonable alternative to FNB, which avoids the additional weakness and other risk associated with FNB procedures.

High Rate of Early Revision After Custom-Made Unicondylar Knee Arthroplasty.

BACKGROUND: There has been a recent interest in custom-made partial knee arthroplasties to provide patient-specific instrumentation and better fit of the prosthesis. While unicondylar knee arthroplasties (UKAs) have demonstrated good outcomes and durable results in many studies, there is little evidence on outcomes of these custom-made implants. METHODS: We performed a retrospective review of all custom-made UKAs performed at our institution by one surgeon from 2008 to 2015. We analyzed preoperative demographics, clinical follow-up evaluations, and radiographs and performed an analysis of risk factors including age, gender, height, weight, body mass index, and tibial insert thickness. The incidence of revision surgery, radiographic failures indicating component loosening, and symptomatic clinically failed implants was calculated at an average of 54.0 months of follow-up. RESULTS: We analyzed 115 consecutive custom-made medial UKAs from a single surgeon at our institution and found 29 (25.2%) UKAs had failed at an average of 33.1 months after surgery. Reasons for failure included aseptic femoral loosening (10), aseptic tibial loosening (8), loosening of both components (4), infection (3), progression of osteoarthritis (2), pain (1), and dislodged polyethylene insert (1). We found a significant relationship between implant failure and body mass index; no other study variables were statistically significant. CONCLUSION: We found a relatively high rate of aseptic loosening and particularly femoral component loosening in the short- to intermediate-term follow-up period. While further study of larger numbers of custom-made UKA from multiple institutions may help verify these findings, we recommend careful consideration of the use of this implant.

Effects of Coronal Limb Alignment and Ligament Balance on Pain and Satisfaction Following Total Knee Arthroplasty at Short-Term Follow Up.

INTRODUCTION: Few studies have evaluated the concomitant effect of both total knee arthroplasty (TKA) limb alignment and ligament laxity. Therefore, the primary aim of this study is to evaluate the impact of lower extremity alignment on the short-term outcome (one year) following TKA, including pain relief, function, and patient satisfaction. The secondary aim of the study is to evaluate the impact of ligament laxity and balance on early outcomes following TKA. MATERIALS AND METHODS: A prospective evaluation of mechanical alignment and ligament tension was performed for 110 consecutive TKAs using an identical surgical technique. Patients were evaluated with knee society score, visual analog pain score, and satisfaction one year following TKA. Linear regression analysis was then performed to determine the effect of lower extremity alignment and ligament laxity. RESULTS: There was no significant relationship between lower extremity alignment and outcome measures. A significant relationship was identified between medial collateral laxity in full extension and knee society scores for function, but not for pain. There was also a significant relationship identified between lateral knee laxity at 90 degrees of flexion and knee society score and pain at one-year follow up. CONCLUSION: Our results demonstrated no correlation between mechanical alignment restoration and pain or function. However, more interestingly, this study found patients with medial laxity in extension and lateral laxity in knee flexion, similar to normal physiologic knee laxity, to have less pain and greater function and satisfaction at one-year short-term follow up.

Influence of Soft Tissue Preservation in Total Hip Arthroplasty: A 16-Year Experience.

BACKGROUND: Surgical technique in total hip arthroplasty (THA) has been a topic of debate over the last 50 years. Evidence-based studies are needed to compare one technique to another. This study investigated the outcome of the direct superior approach in primary THA as measured by patient perception of pain and recovery over a 16-year period. MATERIALS AND METHODS: We retrospectively reviewed a series of 3,357 consecutive patients who underwent primary THA by a single surgeon using the direct superior approach between 2001 and 2017. The surgical technique was modified twice during this 16-year period. The first modification (2007) consisted of piriformis tendon preservation. The second modification (2012) consisted of iliotibial band (ITB) preservation. These two modifications of the surgical technique created three different patient groups. A telephone interview regarding patient pain and recovery after each THA was conducted with 147 patients who had staged bilateral THA procedures wherein the surgical technique was modified between the first and second (contralateral) THA. RESULTS: Results show the addition of ITB preservation to capsular repair, with or without piriformis preservation, greatly improves the patient's perception of pain and recovery, causing the majority of patients to prefer their ITB-preserving surgery over their ITB-sacrificing surgery. In addition, the dislocation rate over this 16-year period is 0.17%. CONCLUSION: The direct superior approach to the hip results in excellent stability with a dislocation rate of 0.17%. The patient's perception of pain and recovery is dramatically improved with preservation of the iliotibial band.

Cost Savings in a Surgeon-Directed BPCI Program for Total Joint Arthroplasty.

BACKGROUND: There are few studies available on the savings generated and strategies employed for cost reduction in total joint arthroplasty. In this study, our organization-a group of private practices partnering with a consultant-aimed to analyze the impact of a preoperative protocol on overall cost savings. MATERIALS AND METHODS: Using administrative data from the Medicare Bundled Payments for Care Improvement (BPCI) initiative, 771 consecutive total joint arthroplasty patients from 2009-2014 were compared with 408 consecutive BPCI patients from 2014-2017. The 30-day episode and Medicare part B total cost of care was analyzed. This included inpatient and post-discharge expenditure, laboratory and imaging costs, physician and ER visits, and readmission. RESULTS: Average total episode cost declined by $3,174 or 13% from $23,925 to $20,752 (p<0.001) in the BPCI period. Readmission rate was unchanged (p=0.20), and there was a 48% reduction in the percent of patients presenting to the emergency room (p=.03). There was a decline of $2,647 (78%) in skilled nursing cost per case, which represented the majority of savings. Post-discharge imaging, laboratory test claims, postoperative emergency room visits, primary care physician (PCP) visits, and cost per episode all decreased. The decrease in PCP utilization did not result in increased medical complications or readmissions. CONCLUSION: Our preoperative patient-education protocol has decreased non-home discharge, unnecessary postoperative physician visits, and diagnostic testing resulting in an episode cost savings of 13%. With Advanced BPCI on the horizon, orthopedic surgeon control as the awardee of the bundle, combined with an increasing focus on patient education, will continue to lower costs and improve patient care.

Oral Tranexamic Acid Reduces Transfusions in Total Knee Arthroplasty.

BACKGROUND: Tranexamic acid (TXA) reduces intraoperative blood loss and transfusions in patients undergoing total knee arthroplasty. Although numerous studies demonstrate the efficacy of intravenous and topical TXA in these patients, few demonstrate the effectiveness and appropriate dosing recommendations of oral formulations. METHODS: A retrospective cohort study was performed to evaluate differences in transfusion requirements in patients undergoing primary unilateral total knee arthroplasty with either no TXA (n = 866), a single-dose of oral TXA (n = 157), or both preoperative and postoperative oral TXA (n = 1049). Secondary outcomes included postoperative hemoglobin drop, total units transfused, length of stay, drain output, and cell salvage volume. RESULTS: Transfusion rates decreased from 15.4% in the no-oral tranexamic acid (OTA) group to 9.6% in the single-dose OTA group (P < .001) and 7% in the 2-dose group (P < .001), with no difference in transfusion rates between the single- and 2-dose groups (P = .390). In addition, postoperative hemoglobin drop was reduced from 4.2 g/dL in the no-OTA group to 3.5 g/dL in the single-dose group (P < .01) and to 3.4 g/dL in the 2-dose group (P < .01), without a difference between the single- and 2-dose groups (P = .233). CONCLUSION: OTA reduces transfusions, with greater ease of administration and improved cost-effectiveness relative to other forms of delivery.

Total Hip Intraoperative Femur Fracture: Do the Design Enhancements of a Second-Generation Tapered-Wedge Stem Reduce the Incidence?

BACKGROUND: Intraoperative femur fracture (IFF) is a well-known complication in primary uncemented total hip arthroplasty (THA). Variations in implant instrumentation design and operative technique may influence the risk of IFF. This study investigates IFF between a standard uncemented tapered-wedge femoral stem and its second-generation successor with the following design changes: size-specific medial curvature, proportional incremental stem growth, modest reduction in stem length, and distal lateral relief. METHODS: A single experienced surgeon's patient database was retrospectively queried for IFF occurring during primary uncemented THA using a standard tapered-wedge femoral stem system or a second-generation stem. All procedures were performed using soft tissue preserving anatomic capsule repair and posterior approach. The primary outcome measure was IFF. A z-test of proportions was performed to determine significant difference between the 2 stems with respect to IFF. Patient demographics, Dorr classification, and implant characteristics were also examined. RESULTS: Forty-one of 1510 patients (2.72%) who received a standard tapered-wedge femoral stem sustained an IFF, whereas 5 of 800 patients (0.63%) using the second-generation stem incurred an IFF. No other significant associations were found. CONCLUSION: A standard tapered-wedge femoral stem instrumentation system resulted in greater than 4 times higher incidence of IFF than its second-generation successor used for primary uncemented THA. Identifying risk factors for IFF is necessary to facilitate implant system improvements and thus maximize patient outcomes.

Total Hip Arthroplasty Dislocation after Cardioversion: A Case Report.

New onset postoperative atrial fibrillation (AF) is the most common perioperative arrhythmia in the elderly. The incidence after total joint arthroplasty is much lower than other non-cardiac surgeries. Since postoperative atrial fibrillation can cause increased length of hospital stay, mortality, and healthcare costs, it is critical to focus on prevention and prompt management. New onset atrial fibrillation is treated with rhythm control for patients who demonstrate hemodynamic instability or refractory to rate control measures. Electrical cardioversion is an effective option for unstable patients with known complications. However, there is limited data on orthopedic problems after cardioversion. A unique case is reported presenting postoperative total hip arthroplasty (THA) dislocation after electrical cardioversion for new onset atrial fibrillation in the postanesthesia care unit (PACU).