A Simple, Personalized Opioid Stratification Pathway Dramatically Reduces Opioid Utilization.

Orthopaedic surgeons account for the largest proportion of opioid prescriptions in the United States among surgical specialties. In total joint arthroplasty, increased opioid use has been associated with poorer clinical and functional outcomes. Despite an abundance of literature on opioid mitigation strategies, most fail to provide personalized prescriptions. Typically, most protocols prescribe the same opioid regimen regardless of patient factors or the extent of the planned procedure. We present a simple opioid stratification pathway that can be used by physicians and office staff as they prepare patients for arthroplasty. We have found this to be easy to implement, effective, and sustainable at a tertiary academic institution and allows for iterative improvements over time.

Revision Arthroplasty Does Not Require More Opioids Than Primaries: A Review of Prescribing Practices After Implementation of a Structured Perioperative Pain Management Strategy.

BACKGROUND: There is a growing body of literature on opioid mitigation strategies following total joint arthroplasty. However, these have almost exclusively been studied in populations undergoing primary procedures, with revision arthroplasty historically thought to be more resistant due to procedural variability and complexity. We report on opioid utilization for revision arthroplasty following implementation of a structured, standardized opioid reduction strategy. METHODS: Beginning January 2015, a comprehensive multidisciplinary pain protocol was developed and applied universally to all patients undergoing hip and knee arthroplasty, including revisions, without exclusion. We performed a retrospective review of opioid prescription trends for the revision arthroplasty subgroup between January 2014 and July 2018, with the first year serving as a baseline for comparison. Inpatient and outpatient opioid prescription data, inpatient satisfaction scores, and quality metrics were also reviewed. RESULTS: We identified 1273 revision arthroplasty cases in the study period. There was a significant reduction in average oral morphine equivalents utilized per procedure when comparing preintervention and postimplementation values. Overall, inpatient prescriptions decreased 24.1% and outpatient utilization decreased 62.4% over the study period. Significant reductions were seen in both the total hip (60.6%) and total knee (64.0%) subgroups. Although revision arthroplasty patients were prescribed 32.5% more oral morphine equivalents at baseline, at year 5 there was no significant difference in outpatient prescriptions between primary and revision subgroups. CONCLUSION: At our institution, a standardized opioid reduction strategy has resulted in marked reduction in opioid prescriptions for revision arthroplasty patients in line with generally successful reductions for primary arthroplasty. More importantly, with this approach, revision arthroplasty patients required no more outpatient opioids than their primary counterparts. LEVEL OF EVIDENCE: Level III, Retrospective cohort study.

Outpatient total knee arthroplasty: is it economically feasible in the hospital setting?

BACKGROUND: With the removal of total knee arthroplasty (TKA) from the Medicare inpatient-only list, outpatient TKA can now be offered, irrespective of payer, in multiple sites. We compared time- and cost-effectiveness of outpatient TKA performed in a hospital outpatient department (HOPD) to that at an inpatient academic medical center (AMC). METHODS: We reviewed all outpatient TKAs performed at our AMC and our HOPD from August 2018 to July 2019. Time efficiency by phase of care was determined, and cost data were obtained from the hospital financial department. Patient selection for outpatient surgery was identical for each site of care. RESULTS: We identified 21 knees that had surgery at the HOPD and 65 knees that had surgery at the AMC. Demographics were similar in both groups. The AMC group had significantly longer in-facility to operating room (Δ (difference) = 33.5 minute, P = .0003), postanesthesia care unit to discharge (Δ = 158.8 minute, P < .0001) and in-facility to discharge (Δ = 199.3 minute, P < .0001) time periods compared to the HOPD group. The HOPD was significantly more cost-effective for the preoperative period (Δ = $75.7, P < .0001), postoperative period (Δ = $315.1, P < .0001), and total cost (Δ = $241, P < .0001). CONCLUSIONS: Outpatient TKAs performed in an HOPD spend significantly less time within the facility than the ones performed in an AMC and cost significantly less. It is expected that approval of Medicare TKAs at ambulatory surgery centers will further improve cost and efficiency.

Does having prior rotator cuff repair affect outcomes in reverse shoulder arthroplasty? A matched cohort study.

BACKGROUND: This study compares outcomes of reverse total shoulder arthroplasty (RTSA) in patients with prior rotator cuff repair to matched control patients without prior surgery. PATIENTS AND METHODS: All primary RTSAs with prior surgery were retrospectively identified from a prospective research database between 2000 and 2014. RTSA patients with prior open or arthroscopic rotator cuff repair and minimum 2-year follow-up, with age- and sex-matched controls, were identified. Active range of motion (ROM) and functional outcomes were evaluated. Preoperative, postoperative, and improvement in outcomes were compared between groups. RESULTS: One hundred fifty RTSA patients were included, with 75 patients in each group (42 female, 33 male). Mean age of the RTSA group with prior rotator cuff repair was 69.6years (average follow-up: 3.8years) compared to the RTSA group without prior surgery (control) aged 70.0years (average follow-up: 3.3years). Preoperatively and postoperatively, RTSA patients with prior cuff repair had slightly worse overhead ROM and outcome scores compared to controls but none were statistically different. The RTSA and control groups had similar and significant improvements in all postoperative ROM and outcome scores. Complications were similar between groups. DISCUSSION: RTSA patients with prior rotator cuff repair had similar ROM, functional outcome scores, and complications compared to a matched control group without prior surgery. LEVEL OF EVIDENCE: III, treatment study.

Clinical Evaluation of Alpha Defensin Test Following Staged Treatment of Prosthetic Joint Infections.

BACKGROUND: Diagnosing persistent infection following staged treatment of prosthetic joint infection (PJI) is challenging. The alpha defensin (AD) test has been shown to be an accurate diagnostic test for the primary diagnosis PJI but has limited evaluation for use following a staged treatment of PJI. The goal of this study was to evaluate the diagnostic accuracy of AD testing following staged treatment of PJI before reimplantation surgery and to determine if negative AD test predicted success following reimplantation using Delphi Criteria at time of last follow-up. METHODS: Patients who underwent AD testing prior to reimplantation after staged treatment of PJI (n = 52) were reviewed. Preoperative data (AD result, synovial fluid [SF], C-reactive protein level [mg/L], SF culture, SF white blood cell count, % of polymorphonuclear lymphocytes, serum C-reactive protein/erythrocyte sedimentation rate) and intraoperative data (purulence and tissue culture) were reviewed and used to classify patients using 2018 Musculoskeletal Infectious Disease Society criteria for infection, which was then used as a gold standard test to calculate diagnostic accuracy. Chart review was used to determine if patients who underwent reimplantation surgery would go on to treatment failure as defined by Delphi Criteria. RESULTS: The sensitivity and specificity of AD test result as compared with Musculoskeletal Infectious Disease Society criteria in diagnosing PJI was calculated to be 71% and 97.78%. Positive predictive value was calculated to be 83.3%, and negative predictive value was calculated to be 95.65%. Patients who underwent reimplantation (46/52 patients) all had negative AD test results, and 9/46 or 19.5% would have treatment failure as defined by the Delphi Criteria with an average follow-up of 588 days. CONCLUSION: AD demonstrates high specificity and negative predictive value, with low sensitivity when utilized after staged treatment of PJI. Further investigation of this and other diagnostic tests following staged treatment of PJI is needed. Additionally, validated criteria used to identify persistent infection following staged treatment of PJI are required.

Shoulder arthroplasty after prior anterior stabilization procedures: do reverses have better outcomes?

BACKGROUND: Few studies have focused on shoulder arthroplasty after anterior stabilization procedures. This study compares the outcomes of total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA) after anterior stabilization surgical procedures. METHODS: All primary shoulder arthroplasties from 2000 to 2014 with prior surgery were retrospectively reviewed from a prospective research database. The inclusion criteria were primary TSA or RTSA, a history of anterior stabilization surgery, and minimum 2-year follow-up. Soft-tissue and bony anterior stabilization procedures were included. We compared the following between TSA and RTSA patients: active range of motion (ROM) and Shoulder Pain and Disability Index 130; Simple Shoulder Test; American Shoulder and Elbow Surgeons (ASES); Short Form 12; University of California, Los Angeles; and Constant scores. The RTSA group was also compared with an RTSA control group. RESULTS: The study included 15 TSA and 10 RTSA patients with average follow-up periods of 3.3 and 4.0 years, respectively. RTSA patients experienced greater improvements in all ROMs except internal rotation; these were not statistically significant despite the mean values for RTSA being above the minimal clinically important difference compared with TSA for forward flexion and abduction. RTSA patients had better improvements in all functional outcomes; only the ASES score was statistically significant. TSA patients had a 33% complication rate and a 20% reoperation rate. RTSA patients had no complications or reoperations. The group that underwent RTSA with prior anterior stabilization surgery had similar improvements in ROM and outcome measures to the RTSA control group. CONCLUSION: RTSA patients had better postoperative improvement in most ROMs and all functional scores; only the ASES score was statistically significant. This study suggests better outcomes with a lower complication rate with RTSA after prior anterior stabilization procedures compared with TSA.

Clinical Evaluation of Synovial Alpha Defensin and Synovial C-Reactive Protein in the Diagnosis of Periprosthetic Joint Infection.

BACKGROUND: Diagnosing periprosthetic joint infection after total joint arthroplasty is often challenging. The alpha defensin test has been recently reported as a promising diagnostic test for periprosthetic joint infection. The goal of this study was to determine the diagnostic accuracy of alpha defensin testing. METHODS: One hundred and eighty-three synovial alpha defensin and synovial fluid C-reactive protein (CRP) tests performed in 183 patients undergoing evaluation for periprosthetic joint infection were reviewed. Results were compared with the Musculoskeletal Infection Society (MSIS) criteria for periprosthetic joint infection. RESULTS: Alpha defensin tests were performed prior to surgical treatment for infection, and 37 of these patients who had these tests were diagnosed by MSIS criteria as having infections. Among this group, the alpha defensin test had a sensitivity of 81.1% (95% confidence interval [CI], 64.8% to 92.0%) and a specificity of 95.9% (95% CI, 91.3% to 98.5%). There were 6 false-positive results, 4 of which were associated with metallosis. There were 7 false negatives, all of which were associated with either draining sinuses (n = 3) or low-virulence organisms (n = 4). A combined analysis of alpha defensin and synovial fluid CRP tests was performed in which a positive result was represented by a positive alpha defensin test and a positive synovial fluid CRP test (n = 28). Among this group, the sensitivity was calculated to be 73.0% (95% CI, 55.9% to 86.2%) and the specificity was calculated to be 99.3% (95% CI, 96.2% to 99.9%). An additional combined analysis was performed where a positive result was represented by a positive alpha defensin test or positive synovial fluid CRP test (n = 64). Among this group, the sensitivity was calculated to be 91.9% (95% CI, 78.1% to 98.3%) and the specificity was calculated to be 79.5% (95% CI, 72.0% to 85.7%). CONCLUSIONS: Alpha defensin in combination with synovial fluid CRP demonstrates very high sensitivity for diagnosing periprosthetic joint infection, but may yield false-positive results in the presence of metallosis or false-negative results in the presence of low-virulence organisms. When both alpha defensin and synovial fluid CRP tests are positive, there is a very high specificity for diagnosing periprosthetic joint infection. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.