A dedicated revision total knee service: a surgeon's perspective.

AIMS: Revision total knee arthroplasty (rTKA) accounts for approximately 5% to 10% of all TKAs. Although the complexity of these procedures is well recognized, few investigators have evaluated the cost and value-added with the implementation of a dedicated revision arthroplasty service. The aim of the present study is to compare and contrast surgeon productivity in several differing models of activity. MATERIALS AND METHODS: All patients that underwent primary or revision TKA from January 2016 to June 2018 were included as the primary source of data. All rTKA patients were categorized by the number of components revised (e.g. liner exchange, two or more components). Three models were used to assess the potential surgical productivity of a dedicated rTKA service : 1) work relative value unit (RVU) versus mean surgical time; 2) primary TKA with a single operating theatre (OT) versus rTKA with a single OT; and 3) primary TKA with two OTs versus rTKA with a single OT. RESULTS: In total, 4570 procedures were performed: 4128 primary TKAs, 51 TKA liner exchanges, and 391 full rTKAs. Surgical time was significantly different between the primary TKA, liner exchange, and rTKA cohorts (100.6, 97.1, and 141.7 minutes, respectively; p < 0.001). Primary TKA yielded a mean of 7.1% more RVU/min per procedure than rTKA. Our one-OT model demonstrated that primary TKA (n = 4) had a 1.9% RVU/day advantage over rTKA (n = 3). If two OTs are used for primary TKA (n = 6), the outcome strongly favours primary TKA by an added 34.6% RVUs/day. CONCLUSION: Our results suggest that a dedicated rTKA service would lead to lower surgeon remuneration based on the current RVU paradigm. Revision arthroplasty specialists may need additional or alternative incentives to promote the development of a dedicated revision service. Through such an approach, healthcare organizations could enhance the quality of care provided, but surgeon productivity measures would need to be adjusted to reflect the burden of these cases. Cite this article: Bone Joint J 2019;101-B:675-681.

Ninety-day and one-year healthcare utilization and costs after knee arthroplasty.

OBJECTIVES: This study examined ninety-day and one-year postoperative healthcare utilization and costs following total knee arthroplasty (TKA) from the health sector and patient perspectives. DESIGN: This study relied on: 1) patient-reported medical resource utilization data from diaries in the Knee Arthroplasty Pain Coping Skills Training (KASTPain) trial; and 2) Medicare fee schedules. Medicare payments, patient cost-sharing, and patient time costs were estimated. Generalized linear mixed models were used to identify baseline predictors of costs. RESULTS: In the first ninety days following TKA, patients had an average of 29.7 outpatient visits and 6% were hospitalized. Mean total costs during this period summed to $3,720, the majority attributed to outpatient visit costs (84%). Over the year following TKA, patients had an average of 48.9 outpatient visits, including 33.2 for physical therapy. About a quarter (24%) of patients were hospitalized. Medical costs were incurred at a decreasing rate, from $2,428 in the first six weeks to $648 in the last six weeks. Mean total medical costs across all patients over the year were $8,930, including $5,328 in outpatient costs. Total costs were positively associated with baseline Charlson comorbidity score (P < 0.01). Outpatient costs were positively associated with baseline Charlson comorbidity score (P = 0.03) and a bodily pain burden summary score (P < 0.01). Mean patient cost-sharing summed to $1,342 and time costs summed to $1,346. CONCLUSIONS: Costs in the ninety days and year after TKA can be substantial for both healthcare payers and patients. These costs should be considered as payers continue to explore alternative payment models.

Model-based pain and function outcome trajectory types for patients undergoing knee arthroplasty: a secondary analysis from a randomized clinical trial.

OBJECTIVE: Knee arthroplasty (KA) is an effective surgical procedure. However, clinical studies suggest that a considerable number of patients continue to experience substantial pain and functional loss following surgical recovery. We aimed to estimate pain and function outcome trajectory types for persons undergoing KA, and to determine the relationship between pain and function trajectory types, and pre-surgery predictors of trajectory types. DESIGN: Participants were 384 patients who took part in the KA Skills Training randomized clinical trial. Pain and function were assessed at 2-week pre- and 2-, 6-, and 12-months post-surgery. Piecewise latent class growth models were used to estimate pain and function trajectories. Pre-surgery variables were used to predict trajectory types. RESULTS: There was strong evidence for two trajectory types, labeled as good and poor, for both Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain and Function scores. Model estimated rates of the poor trajectory type were 18% for pain and function. Dumenci's latent kappa between pain and function trajectory types was 0.71 (95% CI: 0.61-0.80). Pain catastrophizing and number of painful body regions were significant predictors of poor pain and function outcomes. Outcome-specific predictors included low income for poor pain and baseline pain and younger age for poor function. CONCLUSIONS: Among adults undergoing KA, approximately one-fifth continue to have persistent pain, poor function, or both. Although the poor pain and function trajectory types tend to go together within persons, a significant number experience either poor pain or function but not both, suggesting heterogeneity among persons who do not fully benefit from KA.

The cost-effectiveness of dual mobility in a spinal deformity population with high risk of dislocation: a computer-based model.

AIMS: The routine use of dual-mobility (DM) acetabular components in total hip arthroplasty (THA) may not be cost-effective, but an increasing number of patients undergoing THA have a coexisting spinal disorder, which increases the risk of postoperative instability, and these patients may benefit from DM articulations. This study seeks to examine the cost-effectiveness of DM components as an alternative to standard articulations in these patients. PATIENTS AND METHODS: A decision analysis model was used to evaluate the cost-effectiveness of using DM components in patients who would be at high risk for dislocation within one year of THA. Direct and indirect costs of dislocation, incremental costs of using DM components, quality-adjusted life-year (QALY) values, and the probabilities of dislocation were derived from published data. The incremental cost-effectiveness ratio (ICER) was established with a willingness-to-pay threshold of $100 000/QALY. Sensitivity analysis was used to examine the impact of variation. RESULTS: In the base case, patients with a spinal deformity were modelled to have an 8% probability of dislocation following primary THA based on published clinical ranges. Sensitivity analysis revealed that, at its current average price ($1000), DM is cost-effective if it reduces the probability of dislocation to 0.9%. The threshold cost at which DM ceased being cost-effective was $1180, while the ICER associated with a DM THA was $71 000 per QALY. CONCLUSION: These results indicate that under specific clinical and economic thresholds, DM components are a cost-effective form of treatment for patients with spinal deformity who are at high risk of dislocation after THA. Cite this article: Bone Joint J 2018;100-B:1297-1302.

Specificity in the interactions of extracellular matrix proteins with subpopulations of the glycosaminoglycan heparin.

Many extracellular matrix glycoproteins--including laminin, fibronectin, thrombospondin, type I collagen, and other collagens--bind the glycosaminoglycan heparin, yet little is known about the functional significance of these interactions. It is also not known if heparin-binding extracellular matrix proteins recognize distinct structural elements in heparin, nor whether all extracellular matrix proteins recognize the same or different aspects of heparin structure. If extracellular matrix proteins each recognize distinct features of heparin, such specificity could be of importance in vivo, where structurally distinct heparan sulfate species occur. To investigate specificity in the binding between extracellular matrix proteins and heparin, the method of affinity coelectrophoresis (ACE) was used [Lee, M. K., & Lander, A. D. (1991) Proc. Natl. Acad. Sci. U.S.A. 88, 2768-2772]. Low M(r) (approximately 6 kDa) 125I-heparin was fractionated by electrophoresis through agarose gel lanes containing extracellular matrix proteins at various concentrations; from heparin migration patterns, binding affinities were calculated. The results indicate that fibronectin, type I collagen, and laminin--but not thrombospondin--each fractionate heparin into subpopulations that differ substantially in binding affinity. From ACE gels containing either fibronectin, type I collagen, or laminin, fractions of heparin were isolated that represent the 25% of molecules most strongly bound and the 25% least strongly bound by each of these proteins. Subsequent ACE analysis of these six fractions showed that (1) for each of fibronectin, type I collagen, and laminin, strongly- and weakly-binding heparin subfractions differ approximately 5-30-fold in Kd; (2) heparin that binds strongly to any one of fibronectin, type I collagen, or laminin also binds strongly to the other two; (3) heparin that binds weakly to any one of fibronectin, type I collagen, or laminin, also binds weakly to the other two; (4) heparin subfractions that differ greatly in affinity for fibronectin, type I collagen, and laminin show little difference in Kd for thrombospondin or for the heparin-binding growth factor basic fibroblast growth factor (bFGF); (5) neither heterogeneity in molecular charge [as measured by diethylaminoethyl (DEAE) chromatography] nor size nor the presence or absence of antithrombin III recognition sequences can account for the selective binding of heparin subpopulations to fibronectin, type I collagen, and laminin. These results suggest that structural elements within heparin can confer preferential binding to extracellular matrix proteins. Sensitivity of some, but not all, extracellular matrix proteins to these structural features suggests that similar features, if present in heparan sulfates or other glycosaminoglycans, may be physiologically relevant in vivo.