Streamlining Hospital Treatment of Prosthetic Joint Infection.

BACKGROUND: Prosthetic joint infection (PJI) is associated with significant morbidity, mortality, and costs. We developed a fast-track PJI care system using an infectious disease physician to work directly with the TJA service and coordinate in the treatment of PJI patients. We hypothesized that streamlined care of patients with hip and knee PJI decreases the length of the acute hospital stay without increasing the risk of complication or incorrect antibiotic selection. METHODS: A single-center retrospective chart review was performed for all patients treated operatively for PJI. A cohort of 78 fast-track patients was compared to 68 control patients treated before the implementation of the program. Hospital length of stay (LOS) and cases of antibiotic mismatch were primary outcomes. Secondary outcomes, including 90-day readmissions, reoperations, mortality, rate of reimplantation, and 12-month reimplant survival, were compared. Cox regressions were analyzed to assess the effects on LOS of patient demographics and the type of surgery performed. RESULTS: Average hospital LOS from infection surgery to discharge was significantly lower in the fast-track cohort (3.8 vs 5.7 days; P = .012). There were no episodes of antibiotic mismatch in the fast-track group vs 1 recorded episode in the control group. No significant differences were noted comparing 90-day complications, reimplantation rate, or 12-month reimplant survival rates. CONCLUSION: Through the utilization of an orthopedic-specific infectious disease physician, a fast-track PJI protocol can significantly shorten hospital LOS while remaining safe. Streamlining care pathways may help decrease the overall healthcare costs associated with treating PJI.

The Atypical Patient With Slipped Capital Femoral Epiphyses May Be at Increased Risk for a Missed Contralateral Slip.

Slipped capital femoral epiphysis (SCFE) is a commonly encountered hip disorder. The goal of this study was to describe the incidence of missed contra-lateral SCFE as well as to identify risk factors. The authors hypothesized that contralateral slips are more often missed in patients with severe involvement of the treated side. After institutional review board approval was obtained, a retrospective chart review was performed of all pediatric patients who were treated for sequential and bilateral SCFE at a single institution during an 18-year period. Medical records were reviewed for demographic features and attending surgeon. Radiographs were reviewed for skeletal maturity, Klein's line, and severity of the treated slip. All radiographs were reviewed by 3 pediatric orthopedists. Contralateral SCFE was deemed present when consensus was achieved. Comparisons were made with Fisher's exact test, and P<.05 was considered significant. Of the records that were reviewed, 56 patients met the study criteria. Of these, 19 patients had bilateral involvement and 5 missed slips were identified (8.9%). The patients with missed disease tended to be younger (mean age, 10.8 vs 11.4 years), with a lower body mass index. Fellowship-trained pediatric surgeons were more likely to identify bilateral disease compared with orthopedists without pediatric training (P=.0065). A contralateral slip was more likely to be present in patients who had a positive finding for Klein's line (P<.0001). Severity of the treated slip did not increase the likelihood of missing a contralateral slip. Although Klein's line is a useful tool in the diagnosis of SCFE, a false-negative rate of 40% was observed. The authors recommend increased vigilance when an "atypical" patient with SCFE presents with unilateral disease. [Orthopedics. 2020;43(2):e114-e118.].

Cost Analysis and Bundled Care of Hip and Knee Replacement.

Financial success in a bundled payment system requires knowledge of the costs of care throughout the period of risk. Understanding the significant cost-drivers of total joint arthroplasty (TJA) is crucial in this effort. This article inspects the basics of reimbursement under Medicare's bundled care programs as well as some common investigative tools used in the literature to measure cost. Additionally, the effects of standardized enhanced recovery clinical pathways on costs are reviewed. Finally, drivers of implant costs and several proven measures for implant cost-reduction are evaluated. This review provides surgeons and hospitals successful measures to reduce the cost of TJA via enhanced recovery pathways and reduced implant pricing. (Journal of Surgical Orthopaedic Advances 28(4):241-249, 2019).

After-Hours Calls in a Joint Replacement Practice.

BACKGROUND: Early discharge after joint arthroplasty requires additional resources to manage patients safely after surgery. Patient concerns must be addressed during nonbusiness hours to keep patients out of the emergency department and avoid readmissions. The goal of our study was to determine how type of system is utilized in a busy early discharge joint replacement practice. METHODS: In our total joint program, we have utilized a Google phone number to give patients access to a member of the surgical team after business hours and on weekends. The duration, chief complaint, and resolution of from the phone calls were collected prospectively for 3 months (July 3, 2017-October 3, 2017). RESULTS: Sixty-eight calls were received from 55 patients during the 3-month study period. Three hundred twenty-five cases were performed. The average duration of a call was 3.9 minutes. The average length of time from surgery to call was 17.5 days (range 0-442 days). Suboptimal health literacy was associated with increased calls within the first week after surgery (odds ratio = 4.1, 95% confidence interval = 1.2-14.5, P = .022). A chief complaint of pain was associated with primary versus revision surgery. (odds ratio = 3.23, 95% confidence interval = 1.08-9.86). DISCUSSION: An "after-hours" telephone contact service with a member of the surgical team may help avoid unnecessary emergency department visits. About one phone call was received per day, with an average duration of 3.9 minutes per call. These additional resources are necessary to maintain patient safety and satisfaction in early discharge joint replacement.

The effect of radial head prosthesis diameter on posterolateral rotatory instability of the elbow.

BACKGROUND: The purpose of this study is to investigate how different diameters of radial head replacement affect posterolateral translation with a valgus and supination force. We hypothesized that there would be less posterolateral rotatory translation with larger implant diameter. METHODS: Eleven cadaveric arms were stressed at 30 and 60° of flexion with a consistent supination and valgus stress force under five conditions: native radial head, radial head excision, and with 3 sizes of radial head prosthesis. Displacement of the radial head posteriorly in relation to the capitellum on radiographs was measured. Displacement was expressed as a percentage relative to the average of the maximum and minimum native radial head diameters. FINDINGS: The native radial heads had average minimum and maximum diameters of 23.3 mm and 25.2 mm, respectively. The angle of testing did not significantly change translation of the radial head. There was increased posterior translation relative to native head as the radial head sizes decreased from 24 mm to 20 mm and with excision of the radial head. Compared to the native head, the differences in displacement were statistically significant for the 20 mm radial head, but not for the 22 mm or 24 mm replacements. Radial head translation significantly increased after radial head excision. INTERPRETATIONS: This cadaveric study illustrates that patients treated with radial head excision and radial head prosthesis with undersized diameters have increased posterior translation with a valgus and supination stress. The larger the radial head prosthesis (closer to native radial head), the more closely it approximated the amount of translation of the native radial head.

Standardization of Acrylic Bone Cement Mixing Protocols for Total Knee Arthroplasty Results in Cost Savings.

Cost reduction is important in total joint replacement surgery. Bone cement is used to fixate implants in most knee replacement procedures. The authors instituted a 4-pronged approach to reduce the cost of cement. Their approach included reducing the cost of the cement powder, changing the type of mixing method, using less antibiotic cement, and decreasing the amount of cement required for smaller implants. The authors evaluated the implementation of this program and measured the overall costs of cementation during knee replacement. A retrospective review of total knee replacement cementation technique and cost was performed before and after the cost-reduction program was implemented. The type of cement and cement mixing equipment used, the amount of cement used, and the cost of cement and cement mixing equipment were examined. The authors also reported the short-term complication rate including 90-day readmission rate and 30-day revision rate. The program resulted in an overall decrease in cement-related costs from approximately $310 to $105 per case. Reductions in the amount of cement used and the use of antibiotic cement were shown. Among the 3 surgeons, adoption of the program varied. Bone cement is an expense of modern total knee replacement. Implementing a cost-reduction program can reduce cement costs without changing quality of cementation. [Orthopedics. 2018; 41(5):e671-e675.].

Is Rapid Recovery Hip and Knee Replacement Possible and Safe in the Octogenarian Patient?

BACKGROUND: Rapid recovery programs are now aimed to reduce costs of hip and knee arthroplasties by discharging patients directly home, shortening hospital length of stay (LOS), and reducing readmission rates. Although patients aged 80 years and older are included in the Medicare bundle, little work has been performed to determine if older patients can safely participate in rapid recovery programs. METHODS: We retrospectively reviewed 2482 patients undergoing primary and revision total hip and knee arthroplasties (THA and TKA) who all participated in a multifaceted rapid recovery program. The goals of this program were next day discharge to home without the use of home services or post-acute care admission. We examined the hospital LOS and the percentage of patients discharged home as well as 90-day readmission rates to determine efficacy and safety of this program in the patients aged 80 years and older. RESULTS: Octogenarians receiving primary THA and TKA were discharged home >90% of the time with LOSs <2 days and low readmission rates. Revision THA and TKA patients aged 80 years and older were discharged home about 70% of the time with significantly longer LOSs than patients aged more than 80 years. The revision THA patients aged more than 80 years had the highest readmission rates. CONCLUSION: Patients aged more than 80 years can successfully and safely participate in rapid recovery programs.

Modifiable Risk Factors Are Common in Early Revision Hip and Knee Arthroplasty.

BACKGROUND: Obesity, smoking, uncontrolled diabetes, and poor dental health are modifiable risk factors for revision total joint arthroplasty. To protect patients from revision surgery while also reducing cost, some joint arthroplasty practices use these conditions as contraindications until they are improved. However, this practice is variable among joint arthroplasty surgeons. We hypothesize that a relatively high rate of revision arthroplasty patients had modifiable risk factors at the time of primary surgery. METHODS: A retrospective review of all revision total hip and knee arthroplasties performed at an academic, tertiary referral center within 2 years of primary surgery was conducted. The presence of body mass index >40, hemoglobin A1c >8, poor dentition, and smoking status were obtained from the electronic medical record. Risk factors were described and compared between infected revisions and noninfected revisions. RESULTS: A total of 128 revision arthroplasties were performed at our institution in one year. And 23 of 57 (40.4%) total hip revision and 31 of 71 (43.7%) total knee revision patients had at least 1 modifiable risk factor. Infected hip revision patients were more likely to have increased body mass index compared to noninfected patients. Infected knee revision patients were more likely to smoke, have poor dentition, and have >1 contraindication compared to noninfected patients. CONCLUSION: A high percentage of patients undergoing early revision arthroplasty had at least 1 modifiable risk factor for a primary joint arthroplasty. Joint arthroplasty surgeons may help reduce revision surgery through counseling and appropriate referral for modification of risk factors.

External validation of the clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures.

INTRODUCTION: On evaluation of the clinical indications of computed tomography (CT) scan of head in the patients with low-energy geriatric hip fractures, Maniar et al. identified physical evidence of head injury, new onset confusion, and Glasgow Coma Scale (GCS)<15 as predictive risk factors for acute findings on CT scan. The goal of the present study was to validate these three criteria as predictive risk factors for a larger population in a wider geographical distribution. PATIENTS AND METHODS: Patients ≥65 years of age with low-energy hip fractures from 6 trauma centers in a wide geographical distribution in the United States were included in this study. In addition to the relevant patient demographic findings, the above mentioned three criteria and acute findings on head CT scan were gathered as categorical variables. RESULTS: In total 799 patients from 6 centers were included in the study. There were 67 patients (8.3%) with positive acute findings on head CT scan. All of these patients (100%) had at least one criteria positive. There were 732 patients who had negative acute findings on head CT scan with 376 patients (51%) having at least one criteria positive and 356 patients (49%) having no criteria positive. Sensitivity of 100% and negative predictive value of 100% was observed to predict negative acute findings on head CT scan when all the three criteria were negative. CONCLUSION: With the observed 100% sensitivity and 100% negative predictive value, physical evidence of acute head injury, acute retrograde amnesia, and GCS<15 can be recommended as a clinical decision guide for the selective use of head CT scans in geriatric patients with low energy hip fractures. All the patients with positive acute head CT findings can be predicted in the presence of at least one positive criterion. In addition, if these criteria are used as a pre-requisite to order the head CT, around 50% of the unnecessary head CT scans can be avoided.

Effect of Risk Acceptance for Bundled Care Payments on Clinical Outcomes in a High-Volume Total Joint Arthroplasty Practice After Implementation of a Standardized Clinical Pathway.

BACKGROUND: The Bundled Payments for Care Improvement (BPCI) initiative and the Arkansas Payment Improvement (API) initiative seek to incentivize reduced costs and improved outcomes compared with the previous fee-for-service model. Before participation, our practice initiated a standardized clinical pathway (CP) to reduce length of stay (LOS), readmissions, and discharge to postacute care facilities. METHODS: This practice implemented a standardized CP focused on patient education, managing patient expectations, and maximizing cost outcomes. We retrospectively reviewed all primary total joint arthroplasty patients during the initial 2-year "at risk" period for both BPCI and API and determined discharge disposition, LOS, and readmission rate. RESULTS: During the "at risk" period, the average LOS decreased in our total joint arthroplasty patients and our patients discharged home >94%. Patients within the BPCI group had a decreased discharge to home and decreased readmission rates after total hip arthroplasty, but also tended to be older than both API and nonbundled payment patients. CONCLUSION: While participating in the BPCI and API, continued use of a standardized CP in a high-performing, high-volume total joint practice resulted in maintenance of a low-average LOS. In addition, BPCI patients had similar outcomes after total knee arthroplasty, but had decreased rates of discharge to home and readmission after total hip arthroplasty.

Are the anatomy textbooks wrong? A clinical patho-anatomic study of foveal vessels in the round ligament of the hip.

BACKGROUND: The foveal vessels of the ligamentum teres are an anterior branch of the posterior division of the obturator artery, providing blood to the capitis of the femoral head. However, the basic anatomic description of foveal vasculature in the ligamentum teres of the hip is widely variable, with some studies reporting that the vessels are not patent in roughly one third of all adults. Therefore, the purpose of this study was to evaluate the status of foveal vessels in primary total hip arthroplasty (THA) patients. Specifically, we evaluated: (I) if the foveal vessels were intact; and we (II) correlated foveal vessel status with (i) patient demographics, including gender and age; as well as (ii) perioperative data, such as operative time and blood loss. METHODS: The macroscopic status of the foveal vessels in the ligamentum teres femoris was documented in 266 patients at the time of primary unilateral THA performed between August 2015 and April 2017. The vessels were considered to be intact if active bleeding was directly visible from the acetabular stump of the severed ligamentum teres femoris. Demographics including age, gender, and preoperative diagnosis were collected. The perioperative outcome variables included estimated blood loss (EBL) and operative time. Foveal vessel status defined as intact or not intact, was also correlated with patient demographics and perioperative data. A student's t-test was used to compare the continuous variables and a chi square test was used for categorical variables. RESULTS: The foveal vessels were intact in 161 patients (61%) and not intact in 105 patients (39%). The mean age for patients with intact foveal vessels was found to be 64 years (range, 18 to 94 years) vs. 65 years (range, 29 to 94 years) (P>0.05) for not intact. No correlation was found between preoperative diagnosis, gender, operative time, and EBL and foveal vessel status. CONCLUSIONS: The results of this clinical patho-anatomic study of the foveal vessels in the ligamentum teres femoris of the hip refutes the polarized claims of prior anatomy texts that document the vessels as either "absent in adults" or "always intact." Rather, the results of this study reveal an alternate option: that foveal vessels can be present and either be intact (61%) or not intact (39%). No correlation was found between age, gender, operative time, and EBL and foveal vessel status.

Recognizing and Reducing the Risk of Opioid Misuse in Orthopaedic Practice.

Orthopaedic surgeons often treat patients with chronic musculoskeletal pain. This musculoskeletal pain is increasingly being treated with opioid medications, contributing to the growing opioid epidemic in the United States. Opioid use and abuse before orthopaedic surgery are associated with worse clinical outcomes. This article reviews the risk factors for opioid use, misuse, and other behaviors in chronic pain patients, discusses the screening tools for opioid misuse in chronic pain patients, and provides recommendations for the orthopaedic surgeon's role in managing these complicated patients.