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).

Readability of Patient Educational Materials for Total Hip and Knee Arthroplasty.

This study aimed to evaluate patient education materials that are focused on total hip arthroplasty (THA) and total knee arthroplasty (TKA) using health literacy best practices and plain language principles as frameworks. Readability assessments were conducted on a sample of nine patient education documents that are commonly given to THA and TKA surgery patients. Mean readability scores were compared across the sample. The mean readability grade level for the nine arthroplasty educational documents analyzed in this study was 11th grade (10.5). The mean readability ranged from 9th to 12th grade. The documents in this study were written at levels that exceed recommendations by health literacy experts. Health literacy best practices and plain language principles were suggested to reduce the demands on patients so that the documents are easier to understand. Incorporating health literacy best practices into patient education materials for THA and TKA can contribute to improved communication with patients that is necessary for patient understanding and satisfaction. (Journal of Surgical Orthopaedic Advances 27(1):72-76, 2018).

Predictors of Acute Ischemic Stroke After Total Knee Arthroplasty.

Although acute ischemic stroke (AIS) is a feared medical complication after total knee arthroplasty (TKA), little is known about its incidence and risk factors. The purpose of this retrospective populationbased study using the Nationwide Inpatient Sample (2008-2011) was to determine the incidence and predictors of AIS following TKA. The rate of perioperative AIS was 0.08%. Patients undergoing bilateral TKA were almost three times more likely to develop AIS compared with unilateral TKA patients. The age group with the highest odds of AIS was ≥85 years. Sex and race and ethnicity were not independently associated with AIS. The comorbidity with the highest risk for AIS was history of stroke, followed by cardiac valvular disease, peripheral vascular disease, atrial fibrillation, complicated diabetes, coagulopathy, and ischemic heart disease. The data in this article might prove useful for preoperative counseling and decision making, resource allocation, and implementation of strategies to minimize the occurrence of AIS after TKA. (Journal of Surgical Orthopaedic Advances.

Preoperative Education for Hip and Knee Replacement: Never Stop Learning.

PURPOSE OF REVIEW: Participation in alternative payment models has focused efforts to improve outcomes and patient satisfaction while also lowering cost for elective hip and knee replacement. The purpose of this review is to determine if preoperative education classes for elective hip and knee replacement achieve these goals. RECENT FINDINGS: Recent literature demonstrates that patients who attend education classes prior to surgery have decreased anxiety, better post-operative pain control, more realistic expectations of surgery, and a better understanding of their surgery. As a result, comprehensive clinical pathways incorporating a preoperative education program for elective hip and knee replacement lead to lower hospital length of stay, higher home discharge, lower readmission, and improved cost. In summary, we report convincing evidence that preoperative education classes are an essential element to successful participation in alternative payment models such as the Bundle Payment Care Initiative.

Dental Antibiotic Prophylaxis: What to do with Current Recommendations..

Periprosthetic joint infection (PJI) leads to increased patient morbidity and mortality. Current literature reveals a strong link between bacteremia and oral procedures, and therefore elevated risk of PJI. However, evidence that dental procedures do not increase risk of PJI and that antibiotic prophylaxis does not decrease PJI risk exists. In Arkansas, we continue to see patients with bacteremic-induced PJI, therefore we recommend routine prophylaxis for all dental pro- cedures for patients who can tolerate the antibiotics during the first year after joint replacement. Antibiotics are associated with known risks, therefore, a discussion between the physician, dentist, and patient is recommended.

Are Range of Motion Measurements Needed When Calculating the Harris Hip Score?

BACKGROUND: Often the patient-reported outcome (PRO) component of the Harris Hip Score (HHS) is completed, but the physician-assessed range of motion (ROM) component is not. The PRO component only is called a modified Harris Hip Score (mHHS). The purpose of this study was to determine if a statistically significant or clinically meaningful difference existed when calculating the HHS with and without the physician-reported ROM portion. METHODS: Included patients had complete HHS data (both physician and PRO components). Surgical procedure (primary or revision) was recorded for each subject. American Society of Anesthesiologists score was divided into low and high groups. Body mass index was divided into 4 categories. The study used a repeated measures design. RESULTS: Data on 483 patients were collected between 12 and 60 months postoperatively (mean follow-up: 32.5 months, mean age: 55.9 ± 13.5 years). A mean difference of 4 points existed between the 2 groups: HHS group average score was 84.56 ± 13.18, and mHHS group average score was 88.74 ± 13.77. American Society of Anesthesiologists score, body mass index, and surgical type demonstrated a significant interaction with the HHS calculation method (P < .001). Primary total joint patients demonstrated a greater difference between the 2 scoring methods compared with revision patients. CONCLUSION: No clinically meaningful difference in outcomes was found between the mHHS and the HHS. The calculation of the HHS is dependent on the inclusion of the ROM measurement. However, the small point difference between the HHS and mHHS indicates that the mHHS is still useful as an accurate determinant of patient clinical outcome, and ROM assessment is not essential.

Volume and length of stay in a total joint replacement program.

To determine the impact of the new Joint Academy on volume and length of stay (LOS), the authors undertook a retrospective record review for January-March of 2006 and 2007. A total of 413 primary and revision total joint replacements performed by two surgeons were reviewed, with 10.7% more procedures in 2007 than in 2006. The weighted average LOS in 2006 was 3.44 days; in 2007 it was 3.36 days. Significantly, the authors also compared volumes and LOS by weekday of admission and found no statistical variance in average length of stay (ALOS) by weekday of admission. Revisions negatively affected ALOS but added volume. It was concluded that the Joint Academy had a positive impact on volume and LOS, with most patients successfully discharged on postoperative day 3 due to the program's standardized order sets and appropriate resource allocation.

Posterior-stabilized versus posterior cruciate ligament-retaining total knee arthroplasty.

Posterior-stabilized and posterior cruciate retaining total knee arthroplasty prostheses have had high success rates, but it is unclear whether one design has superior outcomes. The purpose of the present study was to directly compare the outcomes of these two designs. Forty-five patients who received a posterior-stabilized prosthesis were compared to 46 consecutive patients who received a cruciate-retaining implant. At a mean follow-up time of 60 months (range, 49 to 69 months), the mean Knee Society knee scores improved from 42 points (range, 20 to 73 points) to 93 points (range, 39 to 100 points) for the cruciate-retaining group and from 38 points (range, 20 to 70 points) to 94 points (range, 60 to 100 points) for the posterior-stabilized group. The mean Knee Society functional scores improved from 36 points (range, 10 to 60 points) to 71 points (range, 15 to 100 points) for the cruciate-retaining group and from 32 points (range, 10 to 70 points) to 73 points (range, 32 to 100 points) for the posterior-stabilized group. The ranges of motion were 125 degrees (range, 100 to 140 degrees ) and 118 degrees (range, 87 to 135 degrees ) in the cruciate-retaining and posterior-stabilized groups, respectively, at final follow-up. Radiographic analysis revealed no radiolucencies that were progressive or were greater than 1 millimeter in length. There were no re-operations in either group. This study did not conclusively demonstrate the superiority of one knee design over the other, suggesting that the choice of implant should be based on surgeon preference and existing pathology of the posterior cruciate ligament.