Discordance in Published 30-Day Readmission Rates Following Primary Total Hip and Total Knee Arthroplasty: Centers for Medicare and Medicaid Services (CMS) Versus the National Surgical Quality Improvement Program (NSQIP).

Background: 30-day readmission is an important quality metric evaluated following primary total joint arthroplasty (TJA) that has implications for hospital performance and reimbursement. Differences in how 30-day readmissions are defined between Centers for Medicare and Medicaid Services (CMS) and other quality improvement programs (i.e., National Surgical Quality Improvement Program [NSQIP]) may create discordance in published 30-day readmission rates. The purpose of this study was to evaluate 30-day readmission rates following primary TJA using two different temporal definitions. Methods: Patients undergoing primary total hip and primary total knee arthroplasty at a single academic institution from 2015-2020 were identified via common procedural terminology (CPT) codes in the electronic medical record (EMR) and institutional NSQIP data. Readmissions that occurred within 30 days of surgery (consistent with definition of 30-day readmission in NSQIP) and readmissions that occurred within 30 days of hospital discharge (consistent with definition of 30-day readmission from CMS) were identified. Rates of 30-day readmission and the prevalence of readmission during immortal time were calculated. Results: In total, 4,202 primary TJA were included. The mean hospital length of stay (LOS) was 1.79 days. 91% of patients were discharged to home. 30-day readmission rate using the CMS definition was 3.1% (130/4,202). 30-day readmission rate using the NSQIP definition was 2.7% (113/4,202). Eight readmissions captured by the CMS definition (6.1%) occurred during immortal time. Conclusion: Differences in temporal definitions of 30-day readmission following primary TJA between CMS and NSQIP results in discordant rates of 30-day readmission. Level of Evidence: III.

Normal Values for Distal Tibiofibular Syndesmotic Space With and Without Subject-Driven External Rotation Stress.

BACKGROUND: The diagnosis and treatment of distal tibiofibular syndesmosis (DTFS) injury can be challenging, especially in cases of subtle instability that may be masked on 2-dimensional conventional radiographs. Weightbearing computed tomography (WBCT) has recently emerged as a useful diagnostic tool allowing direct assessment of distal tibiofibular area widening. The purpose of the current study was to examine and report normal threshold values for DTFS area measurements in a cohort of healthy volunteers, assessing the ankles in natural weightbearing position and under subject-driven external rotation stress. METHODS: In this prospective study, we enrolled 25 healthy volunteers without a history of DTFS injury or high ankle sprain, previous foot and ankle surgery, or current ankle pain. Subjects with any prior ankle injuries were excluded. Study participants underwent bilateral standing nonstress and external rotation stress WBCT scans. The DTFS area (mm2) was semiautomatically quantified on axial-plane WBCT images 1 cm proximal to the apex of the talar dome using validated software. Syndesmosis area values were compared between "unstressed" and "stressed" ankles, as well as left and right ankles. Statistical analysis was performed using independent t tests/Wilcoxon analysis with statistical significance defined as P <.05. RESULTS: The study cohort consisted of 50 ankles in 25 patients (12 males, 48%) with a mean age of 28.7 ± 9.3 years. In the unstressed ankle, the mean pooled DTFS area was determined to be 103.8 + 20.8 mm2. The mean syndesmosis area of unstressed left ankles (104.2 + 19.5 mm2) was similar to unstressed right ankles (109.2 + 17.2 mm2) in the cohort (P = .117). With external rotation stress, the DTFS area of left ankles (mean difference -0.304 mm2, CI -12.1 to 11.5; P = .082), right ankles (mean difference -5.5 mm2, CI 16.7-5.7; P = .132), and all ankles (mean difference -2.9 mm2, CI -10.8 to 5.1; P = .324) remained similar. CONCLUSION: This study presents normal values and range for DTFS area calculation. In uninjured ankles with expected intact ligaments, subject-driven external rotation stress did not result in significant widening of the DTFS space as imaged on with WBCT. LEVEL OF EVIDENCE: Level II, cross-sectional study.

The Incidence and Outcomes Following Treatment of Capsulolabral Adhesions in Hip Arthroscopy: A Systematic Review.

Background: To perform a systematic review to evaluate the incidence of capsulolabral adhesions following hip arthroscopy (HA) for femoroacetabular impingement (FAI); including risk factors and post-treatment outcomes. Methods: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we queried PubMed, EMBASE, and Cochrane Central Register of Controlled Trials for English-language studies with minimum 6-month follow-up after primary or revision HA for FAI, which reported the incidence of capsulolabral adhesions. Potential adhesion risk factors, such as anchor type used and protocol for capsule closure, were assessed. Pre-operative and post-operative modified Harris Hip Score (mHHS) values were compared in studies that reported them. Results: Thirty-seven articles were included (24 primary HA; 13 revision HA). There were 6747 patients who underwent primary HA (6874 hips; 3005 female, 44%). The incidence of capsulolabral adhesions, confirmed surgically during revision HA, was low. Patients undergoing surgical treatment reported postoperative improvement per modified Harris Hip Scores. Data for 746 patients undergoing second revision HA (761 hips; 449 female, 60%), showed an incidence of adhesions greater than that of primary HA patients. Conclusion: While the incidence of symptomatic capsulolabral adhesions after primary hip arthroscopy is low; revision hip arthroscopy is strongly associated with adhesion development. Lysis of adhesions in primary hip arthroscopy patients reliably improved patient-reported outcomes. Level of Evidence: IV.

Did Rapid Expansion of Same Day Discharge Hip and Knee Arthroplasty During the COVID-19 Pandemic Increase Early Complications?

Background: The COVID-19 pandemic has had a lasting impact on patients seeking total hip and knee arthroplasty (THA, TKA) including more patients undergoing same day discharge (SDD) following total joint arthroplasty (TJA). The purpose of this study was to assess whether expansion of SDD TJA during the COVID-19 pandemic resulted in more early complications following TJA. We anticipated that as many institutions quickly launched SDD TJA programs there may be an increase in 30-day complications. Methods: We retrospectively queried the ACS-NSQIP database for all patients undergoing primary elective TJA from January 1, 2018, to December 31, 2020. Participants who underwent THA or TKA between January 1, 2018 and March 1, 2020 were grouped into pre-COVID and between March 1, 2020 and December 31, 2020 were grouped into post-COVID categories. Patients with length of stay greater than 0 were excluded. Primary outcome was any complication at 30 days. Secondary outcomes included readmission and re-operation 30 days. Results: A total of 14,438 patients underwent TKA, with 9,580 occurring pre-COVID and 4,858 post-COVID. There was no difference in rates of total complication between the pre-COVID (3.55%) and post-COVID (3.99%) groups (p=0.197). Rates of readmissions for were similar for the pre-COVID (1.75%) and post-COVID (1.98%) groups (p=0.381). There was no statistically significant difference in respiratory complications between the pre-COVID (0.41%) and post-COVID group (0.23%, p=0.03). A total of 12,265 patients underwent THA, with 7,680 occurring pre-COVID and 4,585 post-COVID. There was no difference in rates of total complication between the pre-COVID (3.25%) and post-COVID (3.49%) groups (p=0.52). Rates of readmissions for were similar for the pre-COVID (1.77%) and post-COVID (1.68%) groups (p=0.381). There was no statistically significant difference in respiratory complications between the pre-COVID (0.16%) and post-COVID group (0.07%, p=0.26). Combined data to include THA and TKA patients did not find a statistical difference in the rate of complications or readmission but did note a decrease in the rate of combined respiratory complications in the post-COVID group (0.15% vs. 0.30%, p=0.028). Conclusion: Rapid expansion of SDD TJA during the COVID-19 pandemic did not increase overall complication, readmission, or re-operation rates. Level of Evidence: IV.

The Agility Total Ankle Arthroplasty: A Concise Follow-up at a Minimum of 20 Years.

BACKGROUND: Between 1984 and 1994, a single surgeon performed 132 primary cementless total ankle replacements using the Agility total arthroplasty system. The purpose of this study was to report on the 20-year follow-up, which we believe is the first study with this length of follow-up. METHODS: Living patients were contacted and interviewed to determine the status of their implant (revised or unrevised) and to answer a simple questionnaire concerning overall satisfaction, pain, and functional improvement, as in a previous study. Thirty-three (26.2%) patients with 33 (25%) ankles of the original series were alive at a minimum of 20 years postoperatively, with a median follow-up of 22 years. They were asked to return to the office for standing anteroposterior and lateral ankle and foot radiographs or to send these radiographs if performed elsewhere. Radiographs were evaluated for radiolucencies around the components and subsidence (talar component) or migration (tibial component) of components. RESULTS: Seventeen (13.5%) ankles of the 126 available for follow-up, including 5 (15.2%) ankles in living patients, had undergone revision (n = 10) or arthrodesis (n = 7) for loosening. One additional ankle was revised for infection and 1 for talar component malposition; thus, 19 (15.1%) ankles were revised. CONCLUSION: These results should provide a 20-year benchmark for newer total ankle arthroplasty designs when a similar length of follow-up becomes available. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Mammary-type Myofibroblastoma of the Pre-sacral Space: A Rare Neoplasm.

INTRODUCTION: Mammary-type myofibroblastoma is a very rare, benign, mesenchymal neoplasm that is histologically identical to a myofibroblastoma of the breast but located in an extra-mammary location. To our knowledge, there have been about 160 cases of extra-mammary myofibroblastoma reported to date. Our report describes a mammary-type myofibroblastoma located retro-rectally in the pre-sacral space. CASE REPORT: Our patient is a 55-year-old male that presented via referral for evaluation of a pelvic mass. He noted having a few loose stools since the mass had become apparent but did not report any other associated symptoms. An MRI of the pelvis revealed a 9 cm, fat containing, solid, retro-rectal mass within the pre-sacral space, which did not appear to be contiguous with the rectum, ureters, or pelvic sidewall. He elected to have the mass surgical removed. The mass was removed as a single specimen that measured 9.5 x 7.5 x 7.0 cm. By immunohistochemistry, the neoplastic cells show co-expression of desmin, CD34, estrogen receptor, and loss of RB1 expression, which is consistent with the diagnosis of mammary-type myofibroblastoma. DISCUSSION: Mammary-type myofibroblastoma is a very rare, benign, soft tissue neoplasm. These neoplasms most often present as a painless slow growing mass in a middle-aged male. Although exceedingly rare, mammary-type myofibroblastoma should be on the differential diagnosis of patients presenting with a mass that was found incidentally or one that is producing mass-effect symptoms. When found, these tumors should be investigated to rule out other more serious pathologies and removed due to their high curability with surgical resection.

Incidental Schwannoma Identified During Laparoscopic Appendectomy for Acute Appendicitis: a Case Report.

INTRODUCTION: Schwannomas are benign neurogenic tumors that make up less than 1 percent of all gastrointestinal tumors. Schwannoma can occur along peripheral nerves anywhere throughout the body. Gastrointestinal schwannoma is relatively rare and most commonly occurs in the stomach, small intestine, and colon, respectively. There have only been a handful of case reports describing appendiceal schwannomas. Approximately 30-50 percent of appendicular tumors show clinical symptoms and signs similar to those of appendicitis. CASE REPORT: A 36-year-old male presented initially for right lower quadrant pain of one day duration. He denied any other associated symptoms. CT imaging of abdomen and pelvis showed a fluid-filled and dilated appendix with fat stranding consistent with appendicitis. He underwent laparoscopic appendectomy without complication. The pathology report showed a well-defined proliferation of bland uniform cells that contained small smooth nuclei and abundant foamy cytoplasm at the tip of the appendix. Scattered eosinophils were noted. These neoplastic cells were positive for S100 and negative for CD68, CD34, and CD117, most consistent with a schwannoma. DISCUSSION: Diagnosing appendiceal schwannoma pre-operatively is a challenging task due to the rare nature of the tumors and the lack of clinical features to separate it from other appendiceal pathology. Appendiceal schwannomas are benign but it is unclear if malignant transformation is possible if left untreated. While there are currently no agreed upon treatment guidelines for appendiceal schwannoma, it is currently thought that complete surgical resection is the best treatment while chemotherapy and radiotherapy are not effective.

Student Initiative Improves HIV Screening Rate in Student-Run Free Clinic.

Background The Center for Disease Control provides recommendations for preventative services and screenings including recommendations for a one-time HIV screening of all adult patients between the ages of 13-64. But not all clinics are fully compliant with these recommendations. We identified a need for increased screening at two clinics in a rural setting. As a healthcare quality improvement initiative, we developed educational informatics to increase screening compliance. Methods This project assessed HIV screening rates before and after educational interventions at two clinics, the Coyote Clinic and the Avera Downtown Clinic. Three changes were implemented to increase the HIV screening rate and ultimately provide more effective high-quality health care. The three initiatives focused on patients, physicians, and student volunteers in order to provide a strong foundation of knowledge to all parties involved in a patient's care. Results Prior to any interventions, the baseline screening rate (screenings/100 persons) at the Avera Downtown Clinic was 0.84 while the screening rate at the Coyote Clinic was 0.00. After the proposed interventions, the screening rate of the Downtown Clinic improved to 3.97 and the screening rate at the Coyote Clinic improved to 29.4. Using a Fisher's Exact test, we found a statistically significant post-intervention increase in HIV screening at the Coyote Clinic after the intervention (p = 0.0002) but not at the Downtown Clinic (p = 0.0940.) Conclusion HIV screening rates improved after the implementation of interventional education initiatives tailored for patients, medical students, and physicians. Implementation of low-cost quality improvement measures such as the ones detailed herein may significantly improve long-term patient management, particularly in the context of screening tests.

Cortical Bone Thickness of the Distal Part of the Tibia Predicts Bone Mineral Density.

BACKGROUND: Poor bone density may affect surgical planning, treatment outcome, and postoperative protocols. Many patients with foot and ankle problems have not undergone a dual x-ray absorptiometry (DXA) scan, which is currently the gold standard for determining bone density. The purpose of this study was to determine if the cortical bone thickness (CBT) of the distal part of the tibia measured on radiographs correlated with bone mineral density. METHODS: After exclusion criteria were applied, 167 consecutive adult patients (mean age and standard deviation [SD], 62 ± 11.62 years) who had had standardized ankle radiographs and a DXA scan within 6 months of each other were included in this retrospective study. The CBT was measured with both the gauge and the average method on standardized anteroposterior, lateral, and hindfoot alignment radiographs. The relationship between CBT in the distal part of the tibia and DXA findings in the hip, proximal part of the femur, and lumbar spine was assessed with Pearson correlations. The interrater and intrarater reliability of CBT measurements was assessed with intraclass correlation coefficients. Subgroup analysis was performed to determine the ability of CBT thresholds to predict osteoporosis. RESULTS: Average CBT measurements on the anteroposterior, lateral, and hindfoot alignment views strongly correlated with DXA findings in the proximal part of the femur (r = 0.70, 0.64, and 0.55, respectively; p < 0.0001), the hip (r = 0.74, 0.67, and 0.53; p < 0.0001), and the lumbar spine (r = 0.61, 0.60, and 0.47; p < 0.0001). The interrater and intrarater reliability of the CBT measurements was excellent. Use of a 3.5-mm average CBT of the distal part of the tibia on the anteroposterior view as the threshold value for predicting osteoporosis (T score less than -2.5) had a sensitivity of 100%, a specificity of 25%, an accuracy of 33%, a positive predictive value of 19%, and a negative predictive value of 100%. CONCLUSIONS: Measurement of the average CBT of the distal part of the tibia is a quick and reliable method for obtaining information on bone quality. CBT measured on standard ankle radiographs correlated strongly with DXA results and may prove to be a useful screening tool for osteoporosis. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.