Re-irradiation for prophylaxis of heterotopic ossification after hip surgery.

Heterotopic ossification (HO) may occur after total hip arthroplasty, but fortunately most patients are asymptomatic. Rick factors for HO include previous HO, hypertrophic osteoarthritis, diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, Paget's disease and post-traumatic arthritis. Both pre-operative and post-operative radiotherapy are effective in the prevention of HO in 85-95% of high-risk patients treated. In the few patients who needed re-operation for a variety of reasons, we found that re-irradiation is possible and safe. These case reports present our experience with single dose re-irradiation of the hip in an attempt to prevent post-operative HO.

Athletic activity after joint replacement.

The first decade of the 21st century has been declared the "Bone and Joint Decade" by 35 nations and 44 states in the United States as of March 2001. It is not surprising that Americans are interested in musculoskeletal disease and the treatment of bone and joint disorders because our population is aging, the prevalence of arthritic joints is increasing, and senior Americans are demonstrating a strong desire to stay active in activities of daily living and athletics. One of the most successful treatments for painful arthritic joints, which limit activity, is total joint replacement, which predictably relieves pain and improves function. Much has been written about the technical aspects of total joint arthroplasty. Less has been written about safe and appropriate activities for patients who have had joint replacement operations. This article evaluates athletic activity after joint replacement by reviewing the orthopaedic literature and surveying members of The Hip Society, The Knee Society, and The American Shoulder and Elbow Surgeons Society. The authors have developed consensus recommendations for appropriate athletic activity for patients who have had joint replacement operations. This article is intended to serve as a guide for orthopaedic surgeons and primary care physicians who give patients recommendations for athletic activity after joint replacement. This article is also intended to stimulate further research in the area of athletic activity after total joint arthroplasty.

Displaced femoral neck fractures in the elderly: outcomes and cost effectiveness.

The optimal treatment for displaced femoral neck fractures in elderly patients is a matter of controversy. Four surgical options are well supported in the orthopaedic literature: reduction with internal fixation, unipolar hemiarthroplasty, bipolar hemiarthroplasty, and total hip arthroplasty. Based on a review of the outcomes literature regarding treatment of femoral neck fractures and a cost-effectiveness analysis, an algorithm for surgical treatment of displaced femoral neck fractures in elderly patients is presented. Cost-effectiveness analysis of these four surgical treatment options shows that arthroplasty is the most cost-effective treatment when complication rate, mortality, reoperation rate, and function are evaluated during a 2-year postoperative period. These data were strongly supported by a two-way sensitivity analysis that varied the effectiveness of the interventions and the costs. Literature derived outcome studies show that elderly patients with displaced femoral neck fractures achieve the best functional results with a well healed femoral neck without osteonecrosis after reduction and internal fixation. Achieving this result may be difficult, and it is not as cost effective as arthroplasty.

Athletic activity after total knee arthroplasty.

Americans are aging, elderly Americans are more active, and the prevalence of total knee arthroplasty is increasing. Indications for knee replacement include pain, deformity, and a desire to improve function. When patients have knee replacement operations, frequently they increase their activities. It is important for patients with knee replacements to understand the impact of athletic activity on the outcome of knee replacements. Orthopaedic surgeons should educate patients regarding athletic activity after total knee arthroplasty. Considerations and risk factors for athletic activity after knee replacements include athletic activity before surgery, preoperative rehabilitation, surgical reconstruction, implant failure or fracture, implant fixation or loosening, and joint bearing surface wear. Anatomic reconstruction and compulsive postoperative rehabilitation with restoration of muscular control are important for optimum function after total knee arthroplasty. In general, patients with knee replacements are encouraged to participate in low-impact, low-demand sports, and to avoid high-impact, high-demand sports.

The role of bladder catheterization in total knee arthroplasty.

The use of a urinary bladder catheter in the perioperative period for patients undergoing total knee arthroplasty is controversial. In the current study, two bladder management protocols were studied. One group of patients had an indwelling catheter inserted into the bladder before total knee arthroplasty. The other group of patients was observed and treated for urinary retention as necessary. From 1993 to 1998, 652 patients undergoing primary, unilateral total knee arthroplasty were randomized by surgeon into two groups: one group underwent preoperative insertion of an indwelling bladder catheter (306 patients), and one group (346 patients) had a catheter inserted postoperatively as necessary. Sixty-six percent (229 of 346) of these patients required catheterization (203 had indwelling catheters and 26 had intermittent straight catheters). A urinary tract infection developed in five patients (1.6%) in whom a catheter was inserted preoperatively. A urinary tract infection developed in six patients (1.7%) in whom a catheter was inserted if necessary. Five of these urinary tract infections developed in patients with delayed indwelling bladder catheters. A urinary tract infection did not develop in any patient in whom a straight catheter was inserted. There was no significant difference in the length of stay in the hospital between the two groups. The group in whom a catheter always was inserted generated $491 greater cost for total knee arthroplasty than patients in whom a catheter was inserted if necessary.

Single Price/Case Price Purchasing in orthopaedic surgery: experience at the Lahey Clinic.

BACKGROUND: Hospital revenues for orthopaedic operations are not keeping pace with inflation or with rising hospital expenses. In an attempt to reduce the hospital cost of orthopaedic operations by reducing the cost of operating-room supplies, we developed a Single Price/Case Price Purchasing Program for implants used in total hip arthroplasty, total knee arthroplasty, and total shoulder arthroplasty as well as for arthroscopic shavers and burrs, interference screws, and bone-suture anchors. METHODS: The Lahey Clinic asked orthopaedic vendors to supply all instruments, implants, and disposable items related to these selected products for one single price per unit or case. For example, a single price for total hip arthroplasty implants included instruments, acetabular cups, acetabular liners, acetabular screws, femoral stems, femoral heads, and stem centralizers, if required. The hospital implemented the Single Price/ Case Price Purchasing Program with a competitive-bid request for proposal. Surgeons evaluated the responses to the bidding process, and they made final decisions on product selection. RESULTS: The Single Price/Case Price Purchasing Program at the Lahey Clinic was successful in reducing the cost of orthopaedic implants and supplies. In the present article, we could not disclose the specific prices that we agreed to pay our vendors. The specific cost reductions were 32 percent for hip implants with a change of vendor, 23 percent for knee implants without a change of vendor, 25 percent for shoulder implants with a change of vendor, 45 percent for arthroscopic shavers and burrs without a change of vendor, 45 percent for interference screws without a change of vendor, and 23 percent for bone-suture anchors without a change of vendor. CONCLUSIONS: The Single Price/Case Price Purchasing Program at the Lahey Clinic allowed the hospital to reduce its cost of orthopaedic operations by lowering the cost of operating-room supplies. This cost reduction is important in a health-care economy in which hospital revenues per unit of service or care are decreasing.

The association of excessive warfarin anticoagulation and postoperative ileus after total joint replacement surgery.

Patients undergoing joint replacement who show signs of ileus in the postoperative period that require insertion of a nasogastric tube (NGT) must be monitored closely to avoid bleeding complications. The diagnosis of postoperative ileus was documented in 40 of 2,526 (1.6%) consecutive joint replacement operations between January 1, 1990, and March 1, 1998, at 1 hospital. Of the 40 patients with postoperative ileus, 34 received warfarin postoperatively. Of these 34 patients, 19 required a NGT for >48 hours, and 15 patients required a NGT for <48 hours or did not require a NGT. Of the 19 patients who required a NGT for >48 hours and who received warfarin anticoagulation, 17 had a prothrombin time of >20 seconds or an international normalized ratio (INR) of >2.0. None of the 15 patients who required a NGT for <48 hours and who received warfarin anticoagulation had a prothrombin time of >20 seconds or an INR of >2.0. This difference was highly statistically significant (P < .001).

Comparison of the hospital cost of primary and revision total hip arthroplasty after cost containment.

This study compared the hospital cost of primary and revision total hip arthroplasty (THA) after the introduction of cost-containment programs (clinical pathway, hip implant standardization, and competitive bid purchasing of hip implants). Hospital financial records for 290 primary and 85 revision THAs performed from October 1993 through September 1995 were analyzed. A cost-accounting system provided actual hospital cost data for each procedure. Accurate calculation of hospital income or loss was determined. Average hospital length of stay was 4.9 days for primary THA and 5.9 days for revision THA. Average hospital cost was $11,104 for primary THA and $14,935 for revision THA. Average net income (hospital revenue hospital expense) for primary THA was $2486. Average loss from revision THA was $401. The payer mix included commercial insurance, Blue Cross/Blue Shield, managed care, Medicare, Medicaid, and workmen's compensation. For primary THA, all payers were profitable except Medicaid and selected managed care contracts. For revision THA, profit was achieved with payment from commercial insurance only. Despite the introduction of cost-containment programs, revision THA did not achieve profitability at our institution.

Comparison of the hospital cost of primary and revision total knee arthroplasty after cost containment.

Revision total knee arthroplasty (TKA) consumes more time, more work, and more supplies than primary TKA. This study compared the hospital cost of primary and revision TKA after the introduction of cost-containment programs (implant standardization, clinical pathway, and competitive bid implant purchasing) at our hospital. Hospital financial records of 207 primary unilateral TKA operations and 32 revision TKA operations performed from October 1993 through September 1995 were analyzed. A cost-accounting system provided actual hospital cost data for each procedure. Accurate calculation of hospital income or loss was determined for all 239 procedures. The average hospital length of stay was 4.7 days for primary unilateral TKA and 5.1 days for revision TKA. There were 26 three-component revision operations and 6 one- or two-component revision operations. The average hospital cost was $10,421 for primary TKA and $11,906 for revision TKA. The average net hospital income (hospital revenue - hospital expense) was $3211 for primary TKA and $1853 for revision TKA. The payer mix included indemnity insurance, Medicare, Medicaid, managed care, and workmen's compensation. All payers were profitable except for Medicaid and selected managed care contracts for both primary and revision TKA. As a result of cost-containment programs, revision TKA can be profitable at our institution.

Opportunities for control of hospital costs for total joint arthroplasty after initial cost containment.

Financial analysis of 391 joint replacement operations performed during 1996 determined that almost 80% of the hospital cost for joint replacement procedures was generated in the operating room, nursing units, recovery room, and pharmacy during the first 48 hours of hospitalization. Attempts to control or reduce the hospital cost of joint replacement operations should focus on these specific areas of opportunity.

Knee implant standardization: an implant selection and cost reduction program.

The largest single unit cost in the hospital cost for total knee arthroplasty (TKA) is the cost of knee implants. We developed a knee implant standardization program to provide guidelines for knee implant selection and to reduce the cost of knee implants for hospitals. Patients are assigned to demand categories based on five criteria: age, weight, expected activity, general health, and bone stock. Implants are assigned to demand categories based on an implant's projected capacity to handle the patient's projected demand. The program was applied retrospectively to 127 knee replacement operations performed on 93 patients during 1992. If this program had been in place, 8.4% of what was actually spent on knee implants for these 127 patients would have been saved. If the most expensive implants allowed in each demand category had actually been used, the program would have saved our hospital 12.8% of the cost of knee implants for these patients. Potential savings were noted in higher demand categories I and II by reducing the use of expensive cementless, porous-coated implants. The greatest potential savings were noted in lower demand categories III and IV: 11% savings could have been realized in demand category III, and 27% savings could have been achieved in the cost of knee implants in demand category IV. Potential savings would have been realized in these lower demand categories because of the recommended use of an all-polyethylene tibial component in 38 of 92 patients. This knee implant standardization program has the potential to assist surgeons in selecting knee implants and reduce the cost of knee implants without compromising outcome following TKA.

Impact of a clinical pathway and implant standardization on total hip arthroplasty: a clinical and economic study of short-term patient outcome.

This study evaluates the impact of a clinical pathway (CP) and a hip implant standardization program (HISP) on the quality and cost of total hip arthroplasty (THA). Two hundred six unilateral THA operations for osteoarthritis were evaluated: 89 operations were performed in 1991 without a CP or HISP (4-year follow-up period); 117 operations were performed in 1993 with a CP and HISP (2-year follow-up period). All patients had good clinical results and excellent outcomes with short-term follow-up evaluation. No differences were seen between groups in terms of patient ratings of outcome and satisfaction or in terms of complication rates in the hospital. Implementation of a CP and HISP did not adversely affect the short-term outcome of THA but did reduce hospital length of stay and hospital cost for THA.

Clinical outcome and survivorship analysis of core decompression for early osteonecrosis of the femoral head.

Thirty-three hips in 23 patients (followed for 5.3 years) were treated with core decompression for early osteonecrosis of the femoral head (Ficat and Arlet I, IIA, IIB). When the clinical endpoint of severe pain was used for survivorship, 76% of hips survived 1 year, 52% survived 2 years, and 44% survived 5 years. When the radiographic endpoint of progression to stage III disease was used, no progression was found in 72% of hips at 1 year, 61% at 2 years, and 37% at 5 years. When total hip arthroplasty was used as an endpoint, 90% of hips survived 1 year, 70% survived 2 years, and 61% survived 5 years. Lower radiographic stage was associated with a better result. Patients who weighed less than 79.4 kg (175 lb.) (P = .03) or whose bone stock was good (femoral index < 0.56, P < .001) had significantly improved survival. Outcome evaluation documented a 70% overall patient satisfaction rate in patients not undergoing total hip arthroplasty.

Medial reconstruction during total knee arthroplasty for severe valgus deformity.

A painful arthritic knee with severe valgus deformity may be treated successfully with total knee arthroplasty using several techniques: constrained implant with lateral release, nonconstrained implant with lateral release and a thick tibial insert, or nonconstrained implant with lateral release and medial reconstruction. Eight patients with Type II valgus deformity were treated with nonconstrained total knee arthroplasty implants, lateral ITB release at the level of the tibial osteotomy, and proximal medial collateral ligament advancement with bone plug recession. The reconstruction led to predictably successful outcomes in all patients at 4- to 9-years followup. All patients were satisfied with the operation. All knees were stable with a functional range of motion at the time of last followup.

Opportunities for control of hospital cost for total knee arthroplasty.

The hospital financial records of 120 consecutive patients who underwent unilateral knee replacement surgery at one hospital during 1995 were reviewed to determine opportunities for control of hospital cost for total knee arthroplasty. The average hospital length of stay for these patients was 4.27 days (range, 3-10 days). The average hospital cost was $10,231. All 120 patients were classified under Diagnosis Related Group 209, principle procedure 81.54 primary total knee arthroplasty. Medicare paid for 70% of the patients. All payers were profitable except Medicaid and one managed care organization. When hospital cost for total knee arthroplasty was allocated to hospital service centers, 78% of the cost was attributed to the operating room, nursing units, recovery room, and pharmacy. When hospital cost for total knee arthroplasty was allocated to hospital days, 80% of the hospital cost occurred during the first 48 hours of hospitalization. Hospital reimbursement for total knee arthroplasty is primarily a prospective case price payment system. After initial cost containment efforts reduce the hospital length of stay for total knee arthroplasty to 4 to 6 days, additional control of hospital cost should focus on these areas of opportunity.

Implant standardization for total hip arthroplasty. An implant selection and a cost reduction program.

Total hip arthroplasty (THA) has been targeted by the United States federal government for cost control because of its high cost and rising incidence in the aging population. The hospital cost for THA during the 1980s was controlled by utilization review and a reduction in the volume of services delivered for each THA. The single largest increase in the cost of THA during the 1980s was the cost of hip implants. The Lahey Clinic Hip Implant Standardization Program was developed to provide objective guidelines for hip implant selection. These guidelines are based on the demands a patients is expected to place on his or her hip prosthesis. Because not every patient requires an expensive high-demand hip prosthesis, the standardization program also has the potential to reduce the hospital cost for hip implants without compromising patient care. Patients are assigned to four demand categories based on five objective criteria: age, weight, expected activity, general health, and bone stock. Selection of the prosthesis in each of the four demand categories is intended to match the implant's capacity with expected patient demand. The standardization program was retrospectively applied to 103 THAs performed during 1991. Analysis of variance demonstrated that patient variables and demand categories were statistically significant groupings. The cost of hip implants would have been reduced by 25.7% with the Lahey Clinic Hip Implant Standardization Program. A prospective outcome study is required to determine the long-term validity of this standardization program.