Staged vs Concurrent Hardware Removal During Conversion Total Knee Arthroplasty.

BACKGROUND: Conversion total knee arthroplasty (TKA) in the presence of periarticular hardware can be associated with increased resource utilization, complications, and revisions. However, little guidance exists on the optimal approach to hardware removal. The purpose of this study is to compare outcomes of conversion TKA with hardware removal performed in either a staged or concurrent manner. METHODS: This is a retrospective study of 155 TKA operations performed with staged (45) or concurrent (110) removal of hardware at the time of TKA. Differences in patient data, case data, complications, reoperations, and revisions were evaluated. Subgroup comparisons of cases involving major hardware (plates, nails, rods), minor hardware (screws, buttons, wires), and tibial plates were performed. RESULTS: There were no differences in age, sex, body mass index, or comorbidities between patients who underwent staged or concurrent hardware removal. Rates of complications, reoperations, and revisions did not differ at multiple time points (90 days, 1 year, 2 years, 4 years). Patients who underwent staged hardware removal were more likely to have had prior surgery for fracture reconstruction (68% vs 33%, P < .001), to have had major hardware removed (84% vs 59%, P = .03), and were less likely to have had hardware removal performed through a single incision with TKA (50% vs 92%, P < .001). Subgroup analysis of major and minor hardware cases demonstrated comparable outcomes. CONCLUSION: There remains no established benefit to either a staged or concurrent approach to hardware removal at the time of TKA. This is true regardless of hardware burden. At this time, a case-by-case approach should be taken to conversion TKA in the presence of periarticular hardware.

Economic Recovery After the COVID-19 Pandemic: Resuming Elective Orthopedic Surgery and Total Joint Arthroplasty.

BACKGROUND: The economic effects of the COVID-19 crisis are not like anything the U.S. health care system has ever experienced. METHODS: As we begin to emerge from the peak of the COVID-19 pandemic, we need to plan the sustainable resumption of elective procedures. We must first ensure the safety of our patients and surgical staff. It must be a priority to monitor the availability of supplies for the continued care of patients suffering from COVID-19. As we resume elective orthopedic surgery and total joint arthroplasty, we must begin to reduce expenses by renegotiating vendor contracts, use ambulatory surgery centers and hospital outpatient departments in a safe and effective manner, adhere to strict evidence-based and COVID-19-adjusted practices, and incorporate telemedicine and other technology platforms when feasible for health care systems and orthopedic groups to survive economically. RESULTS: The return to normalcy will be slow and may be different than what we are accustomed to, but we must work together to plan a transition to a more sustainable health care reality which accommodates a COVID-19 world. CONCLUSION: Our goal should be using these lessons to achieve a healthy and successful 2021 fiscal year.

Characterization of Post-Operative Opioid Use Following Total Joint Arthroplasty.

BACKGROUND: The purpose of our study is to examine post-operative opioid use in total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients and describe factors associated with the need for refill prescriptions. METHODS: Using online prescription information, we calculated the number of filled prescriptions, total morphine equivalent dose (MED) and quantity of pills, and date of last opioid prescription (days) for 197 TKA and 186 THA patients. Patients were classified based on refill status. Opioid data were compared between TKA and THA patients. Relationships between comorbidities and refill status were examined. RESULTS: Number of prescriptions (P < .001), total quantity (P < .001) and MED (P < .001), and days on opioids (P < .001) were greater for TKA patients. TKA patients required more refills (P < .001) for a greater quantity of pills (P = .007). The presence of a comorbidity (P = .003) or anxiety/depression (P = .004) were correlated with refills for TKA patients only. A comorbidity increased the risk of refills by 3.1 times, while anxiety/depression had a 2.5 times greater risk of refills. CONCLUSION: Compared to THA patients, TKA patients were twice as likely to require refill opioid prescriptions and were prescribed a greater total MED for a longer period of time post-operatively. Patients undergoing TKA who present with a comorbidity or are currently being treated for anxiety or depression are more likely to require a refill.

Videoconference Interviews for an Adult Reconstruction Fellowship: Lessons Learned.

BACKGROUND: In 2017, approximately 90% of U.S. orthopaedic residents chose to participate in orthopaedic fellowships. The process of applying and interviewing for an orthopaedic fellowship is expensive and time-consuming for both orthopaedic residents and orthopaedic residency programs. Considerable physician man-hours are allocated to fellowship interviews and the match ranking process, and there are unintended consequences of time away from work for the resident and his or her training program. To reduce time and cost allocated to fellowship interviews, we implemented videoconference interviews for our adult reconstruction fellowship. The purpose of this article was to communicate the lessons that we learned about this innovation. METHODS: Candidates and faculty who participated in videoconference interviews for our adult reconstruction fellowship during 2015 through 2017 were surveyed to learn more about the utility and acceptance of videoconference interviewing. RESULTS: Eighty-five percent of the 47 videoconference interview candidates who responded to our survey believed that the videoconference interviews gave them a satisfactory understanding of our adult reconstruction fellowship; 85% of candidates stated that the fellowship manual and the videoconference interviews gave them a satisfactory understanding of our fellowship; 89% of candidates stated that the videoconference interview met their expectations; 85% of candidates believed that the videoconference interviews allowed them to present themselves to the program to their satisfaction; and 81% of candidates were comfortable ranking our program after the videoconference interviews. Furthermore, there was universal gratitude in the subjective comments for the convenience and low cost of the videoconference interviews. However, we are concerned that 15% of the candidates did not believe that they had the opportunity to present themselves to their satisfaction with videoconference interviews; 19% of applicants were not comfortable ranking our program after a videoconference interviews; 34% of videoconference interview candidates stated that the videoconference interviews had an unfavorable impact on their ranking of our program; and 30% of candidates believed that the videoconference interview was not a good format for fellowship interviews. CONCLUSIONS: This review presents what we learned about using videoconference interviews for evaluating and selecting adult reconstruction fellows. The role of videoconference interviews for selecting adult reconstruction fellows remains to be determined.

Incidence of Distal Femoral Periprosthetic Fractures after Total Knee Arthroplasty.

BACKGROUND: The incidence of distal femoral periprosthetic fractures associated with total knee arthroplasty (TKA) has been reported as 0.3% to 2.5%. This study examined the incidence of distal femoral periprosthetic fractures at one hospital over a 16-year period. We hypothesized that the incidence of these fractures would be lowered after the introduction of lugged femoral implants and insertion of a distal femoral intramedullary bone graft during TKA. METHODS: From 1994 to 2010, 4,943 primary TKAs were performed. Following these TKA operations, 21 distal femoral fractures occurred. The surgical technique and implant design changed during this interval. Lugged femoral implants were introduced in 2000. Intramedullary bone grafting of the distal femoral intramedullary guide hole was introduced in 2002. RESULTS: The incidence of distal femoral periprosthetic fracture in this series of 4,943 TKA operations was 0.42% (21/4943). Six fractures occurred in 1,236 knees with femoral implants without femoral fixation lugs (0.49%). Fifteen fractures occurred in 3,707 knees with femoral implants with femoral fixation lugs (0.40%). Eight fractures occurred in 1,653 knees that did not have intramedullary bone grafts (0.48%). Thirteen fractures occurred in 3,290 knees that had intramedullary bone grafts (0.40%). Two fractures occurred in 417 knees with lugged femoral implants and no bone graft (0.48%). CONCLUSIONS: In this series, there was no significant difference in the incidence of distal femoral periprosthetic fractures associated with adding fixation lugs to the femoral implant and filling the femoral intramedullary hole with bone graft.

Preventing Hospital Readmissions and Limiting the Complications Associated With Total Joint Arthroplasty.

Total joint arthroplasty is a highly successful surgical procedure for patients who have painful arthritic joints. The increasing prevalence of total joint arthroplasty is generating substantial expenditures in the American healthcare system. Healthcare payers, specifically the Centers for Medicare and Medicaid Services, currently target total joint arthroplasty as an area for healthcare cost-savings initiatives, which has resulted in increased scrutiny surrounding orthopaedic care, health resource utilization, and hospital readmissions. Identifying the complications associated with total hip and total knee arthroplasty that result in readmissions will be critically important for predictive modeling and to decrease the number of readmissions after total joint arthroplasty. In addition, improving perioperative optimization, providing seamless episodic care, and intensifying posthospital coordination of care may decrease the number of unnecessary hospital readmissions. Identified modifiable risk factors that substantially contribute to poor clinical outcomes after total joint arthroplasty include morbid obesity; poorly controlled diabetes and nutritional deficiencies; Staphylococcus aureus colonization; tobacco use; venous thromboembolic disease; cardiovascular disease; neurocognitive, psychological, and behavioral problems; and physical deconditioning and fall risk. Both clinical practice and research will be enhanced if defined total joint arthroplasty complications are standardized and stratification schemes are used to identify high-risk patients. Subsequently, clinical intervention will be warranted to address modifiable risk factors before proceeding with total joint arthroplasty.

Complications of Total Hip Arthroplasty: Standardized List, Definitions, and Stratification Developed by The Hip Society.

BACKGROUND: Reporting of complications after total hip arthroplasty (THA) is not standardized, and it is done inconsistently across various studies on the topic. Advantages of standardizing complications include improved patient safety and outcomes and better reporting in comparative studies. QUESTIONS/PURPOSES: The purpose of this project was to develop a standardized list of complications and adverse events associated with THA, develop standardized definitions for each complication, and stratify the complications. A further purpose was to validate these standardized THA complications. METHODS: The Hip Society THA Complications Workgroup proposed a list of THA complications, definitions for each complication, and a stratification scheme for the complications. The stratification system was developed from a previously validated grading system for complications of hip preservation surgery. The proposed complications, definitions, and stratification were validated with an expert opinion survey of members of The Hip Society, a case study evaluation, and analysis of a large administrative hospital system database with a focus on readmissions. RESULTS: One hundred five clinical members (100%) of The Hip Society responded to the THA complications survey. Initially, 21 THA complications were proposed. The validation process reduced the 21 proposed complications to 19 THA complications with definitions and stratification that were endorsed by The Hip Society (bleeding, wound complication, thromboembolic disease, neural deficit, vascular injury, dislocation/instability, periprosthetic fracture, abductor muscle disruption, deep periprosthetic joint infection, heterotopic ossification, bearing surface wear, osteolysis, implant loosening, cup-liner dissociation, implant fracture, reoperation, revision, readmission, death). CONCLUSIONS: Acceptance and use of these standardized, stratified, and validated THA complications and adverse events could advance reporting of outcomes of THA and improve assessment of THA by clinical investigators. LEVEL OF EVIDENCE: Level V, therapeutic study.

Preventing Hospital Readmissions and Limiting the Complications Associated With Total Joint Arthroplasty.

Total joint arthroplasty is a highly successful surgical procedure for patients with painful arthritic joints. The increasing prevalence of the procedure is generating significant expenditures in the American healthcare system. Healthcare payers, specifically the Center for Medicare and Medicaid Services, currently target total joint arthroplasty as an area for healthcare cost-savings initiatives, resulting in increased scrutiny surrounding orthopaedic care, health resource utilization, and hospital readmissions. Identifying the complications associated with total hip and total knee arthroplasty that result in readmissions will be critically important for predictive modeling and for decreasing the number of readmissions following total joint arthroplasty. Additionally, improving perioperative optimization, providing seamless episodic care, and intensifying posthospital coordination of care may result in a decreasing number of unnecessary hospital readmissions. Identified modifiable risk factors that significantly contribute to poor clinical outcome following total joint arthroplasty include morbid obesity; poorly controlled diabetes and nutritional deficiencies; Staphylococcus aureus colonization; tobacco use; venous thromboembolic disease; cardiovascular disease; neurocognitive, psychological, and behavioral problems; and physical deconditioning and fall risk. Both clinical practice and research will be enhanced if there is standardization of defined total joint arthroplasty complications and utilization of stratification schemes to identify high-risk patients. Subsequently, clinical intervention would be warranted to address modifiable risk factors before proceeding with total joint arthroplasty.

Can Administrative Data Be Used to Analyze Complications Following Total Joint Arthroplasty?

We hypothesized that the Centers for Medicare and Medicaid Services Limited Dataset (CMS-LDS) could be used to validate the complications associated with total hip and knee arthroplasty (THA and TKA) endorsed by the Hip and Knee Societies. Using ICD-9 procedure and diagnosis codes, cases were extracted from the first three quarters of the 2009 CMS-LDS to allow all complications within 90-days be captured in the same calendar year. We were unable to validate the Hip and Knee Societies' complications as we could not connect readmissions or outpatient visits to index admissions. In addition, well-known complications were not detected, raising concerns about coding accuracy and stratification. Furthermore, the assignment of outpatient and inpatient codes allows for duplication of complications which may falsely elevate the true incidence.

Stratification of standardized TKA complications and adverse events: a brief communication.

BACKGROUND: The Total Knee Arthroplasty (TKA) Complications Workgroup of the Knee Society developed a standardized list and definitions of complications associated with TKA. Twenty-two complications and adverse events believed important for reporting outcomes of TKA were identified. The Editorial Board of Clinical Orthopaedics and Related Research (®), the Executive Board of the Knee Society, and the members of the Knee Society TKA Complications Workgroup came to the conclusion that reporting of a list of TKA adverse events and complications would be more valuable if they were stratified using a validated classification system. QUESTIONS/PURPOSES: The purpose of this article was to stratify the previously published standardized list of TKA adverse events and complications. METHODS: A modified version of the Sink adaptation of the Clavien-Dindo Surgical Complication Classification was applied to the list of standardized TKA complications and adverse events. RESULTS: The proposed stratified classifications of TKA complications were reviewed and endorsed by the Knee Society. CONCLUSIONS: Stratification of TKA complications will allow more in-depth and detailed outcome reporting for surgeons, hospitals, third-party payers, government agencies, joint replacement registries, and orthopaedic researchers. This improvement in reporting of TKA complications will also improve the quality of orthopaedic literature.

Bundled payments for care improvement initiative: the next evolution of payment formulations: AAHKS Bundled Payment Task Force.

The Patient Protection and Affordable Care Act contains a number of provision for improving the delivery of healthcare in the United States, among the most impactful of which may be the call for modifications in the packaging of and payment for care that is bundled into episodes. The move away from fee for service payment models to payment for coordinated care delivered as comprehensive episodes is heralded as having great potential to enhance quality and reduce cost, thereby increasing the value of the care delivered. This effort builds on the prior experience around delivering care for arthroplasty under the Acute Care Episode Project and offers extensions and opportunities to modify the experience moving forward. Total hip and knee arthroplasties are viewed as ideal treatments to test the effectiveness of this payment model. Providers must learn the nuances of these modified care delivery concepts and evaluate whether their environment is conducive to success in this arena. This fundamental shift in payment for care offers both considerable risk and tremendous opportunity for physicians. Acquiring an understanding of the recent experience and the determinants of future success will best position orthopaedic surgeons to thrive in this new environment. Although this will remain a dynamic exercise for some time, early experience may enhance the chances for long term success, and physicians can rightfully lead the care delivery redesign process.

Complications of total knee arthroplasty: standardized list and definitions of the Knee Society.

BACKGROUND: Despite the importance of complications in evaluating patient outcomes after TKA, definitions of TKA complications are not standardized. Different investigators report different complications with different definitions when reporting outcomes of TKA. QUESTIONS/PURPOSES: We developed a standardized list and definitions of complications and adverse events associated with TKA. METHODS: In 2009, The Knee Society appointed a TKA Complications Workgroup that surveyed the orthopaedic literature and proposed a list of TKA complications and adverse events with definitions. An expert opinion survey of members of The Knee Society was used to test the applicability and reasonableness of the proposed TKA complications. For each complication, members of The Knee Society were asked "Do you agree with the inclusion of this complication as among the minimum necessary for reporting outcomes of knee arthroplasty?" and "Do you agree with this definition?" RESULTS: One hundred two clinical members (100%) of The Knee Society responded to the survey. All proposed complications and definitions were endorsed by the members, and 678 suggestions were incorporated into the final work product. The 22 TKA complications and adverse events include bleeding, wound complication, thromboembolic disease, neural deficit, vascular injury, medial collateral ligament injury, instability, malalignment, stiffness, deep joint infection, fracture, extensor mechanism disruption, patellofemoral dislocation, tibiofemoral dislocation, bearing surface wear, osteolysis, implant loosening, implant fracture/tibial insert dissociation, reoperation, revision, readmission, and death. CONCLUSIONS: We identified 22 complications and adverse events that we believe are important for reporting outcomes of TKA. Acceptance and utilization of these standardized TKA complications may improve evaluation and reporting of TKA outcomes.

All-polyethylene and metal-backed tibial components are equivalent with BMI of less than 37.5.

BACKGROUND: Modular, metal-backed tibial (MBT) components are associated with locking mechanism dysfunction, breakage, backside wear, and osteolysis, which compromise survivorship. All-polyethylene tibial (APT) components eliminate problems associated with MBTs, but, historically, APT utilization has generally been limited to older, less active patients. However, it is unclear whether APT utilization can be expanded to a nonselected patient population. QUESTIONS/PURPOSES: We therefore determined the survivorship of APT components compared with MBT components in a non-age- or activity-selected population who underwent TKA. METHODS: Using a longitudinal database, we identified 775 patients with primary TKAs utilizing a single implant design between 1999 and 2007. Of these, 558 (72%) patients had APT components (APT2), while 217 (28%) patients with tibial bone loss or defects, contralateral MBT components, or a BMI of greater than 37.5 received MBT components. We determined the survivorship in the two groups. The minimum followup was 2 years for both groups (mean ± SD: MBT, 80 ± 29 months; APT, 63 ± 27 months). The APT group was older (average age: APT2, 70 years; MBT, 64.7 years) and had a lower BMI than the MBT group (APT2, 30.8; MBT, 33.8). RESULTS: Survivorship, as defined by revision for any reason, was 99% for the APT group and 97% for the MBT group. There were four (2%) tibial failures in the MBT group in patients with a BMI of greater than 40. There were no revisions for loosening or osteolysis in the APT group. CONCLUSION: APT implants perform as well as MBT implants in a non-age- or activity-selected TKA population with a BMI of less than 37.5.

Diabetes mellitus, hemoglobin A1C, and the incidence of total joint arthroplasty infection.

Patients with diabetes have a higher incidence of infection after total joint arthroplasty (TJA) than patients without diabetes. Hemoglobin A1c (HbA1c) levels are a marker for blood glucose control in diabetic patients. A total of 3468 patients underwent 4241 primary or revision total hip arthroplasty or total knee arthroplasty at one institution. Hemoglobin A1c levels were examined to evaluate if there was a correlation between the control of HbA1c and infection after TJA. There were a total of 46 infections (28 deep and 18 superficial [9 cellulitis and 9 operative abscesses]). Twelve (3.43%) occurred in diabetic patients (n = 350; 8.3%) and 34 (0.87%) in nondiabetic patients (n = 3891; 91.7%) (P < .001). There were 9 deep (2.6%) infections in diabetic patients and 19 (0.49%) in nondiabetic patients. In noninfected, diabetic patients, HbA1c level ranged from 4.7% to 15.1% (mean, 6.92%). In infected diabetic patients, HbA1c level ranged from 5.1% to 11.7% (mean, 7.2%) (P < .445). The average HbA1c level in patients with diabetes was 6.93%. Diabetic patients have a significantly higher risk for infection after TJA. Hemoglobin A1c levels are not reliable for predicting the risk of infection after TJA.

Hospital economics of primary total knee arthroplasty at a teaching hospital.

BACKGROUND: The hospital cost of total knee arthroplasty (TKA) in the United States is a major growing expense for the Centers for Medicare & Medicaid Services (CMS). Many hospitals are unable to deliver TKA with profitable or breakeven economics under the current Diagnosis-Related Group (DRG) hospital reimbursement system. QUESTIONS/PURPOSES: The purposes of the current study were to (1) determine revenue, expenses, and profitability (loss) for TKA for all patients and for different payors; (2) define changes in utilization and unit costs associated with this operation; and (3) describe TKA cost control strategies to provide insight for hospitals to improve their economic results for TKA. RESULTS: From 1991 to 2009, Lahey Clinic converted a $2172 loss per case on primary TKA in 1991 to a $2986 profit per case in 2008. The improved economics was associated with decreasing revenue in inflation-adjusted dollars and implementation of hospital cost control programs that reduced hospital expenses for TKA. Reduction of hospital length of stay and reduction of knee implant costs were the major drivers of hospital expense reduction. CONCLUSIONS: During the last 25 years, our economic experience with TKA is concerning. Hospital revenues have lagged behind inflation, hospital expenses have been reduced, and our institution is earning a profit. However, the margin for TKA is decreasing and Managed Medicare patients do not generate a profit. The erosion of hospital revenue for TKA will become a critical issue if it leads to economic losses for hospitals or reduced access to TKA. LEVEL OF EVIDENCE: Level III, Economic and Decision Analyses. See Guidelines for Authors for a complete description of levels of evidence.