Onlay Patellofemoral Arthroplasty in Patients With Isolated Patellofemoral Arthritis: A Systematic Review.

BACKGROUND: Patellofemoral arthroplasty (PFA) for isolated patellofemoral osteoarthritis (OA) remains controversial due to variable postoperative outcomes and high failure rates. Second-generation (2G) onlay prostheses have been associated with improved postoperative outcomes. This systematic review was performed to assess the current overall survivorship and functional outcomes of 2G PFA. METHODS: A search was performed using PubMed, Cochrane Library, EMBASE, and Google Scholar. Thirty-three studies published in the last 15 years (2005-2020) were included; of these 22 studies reported patient-reported outcome measures. Operative and nonoperative complications were analyzed. Pooled statistical analysis was performed for survivorship and functional scores using Excel 2016 and Stata 13. RESULTS: The mean age of the patients was 59.7. When analyzing all studies, weighted survival at mean follow-up of 5.52 was 87.72%. Subanalysis of studies with minimum 5 years of follow up showed a survival of 94.24%. Fifteen studies reported Oxford Knee Score with a weighted mean postoperative Oxford Knee Score of 33.59. Mean American Knee Society Score pain was 79.7 while mean American Knee Society Score function was 79.3. The most common operative complication was OA progression for all implants. The percentage of revisions and conversions reported after analyzing all studies was 1.37% and 7.82% respectively. CONCLUSION: Safe and acceptable results of functional outcomes and PFA survivorship can result from 2G PFAs at both short and mid-term follow-up for patients with isolated patellofemoral OA. However, long-term follow-up outcomes are still pending for the newer implants. More extensive studies using standardized functional outcomes and long-term cost benefits should be evaluated.

Access to Elective Orthopaedic Surgery After the Affordable Care Act Medicaid Expansion: The New York State Experience.

BACKGROUND: As part of the Patient Protection and Affordable Care Act, states were given the option of expanding Medicaid coverage to include adults younger than age 65 years with income at or below 138% of the federal poverty level. Although this expansion was intended to provide health care coverage to an estimated 20 million Americans, several studies have shown increased coverage does not equate to increased access to care by specialty providers. METHODS: We queried the New York Statewide Planning and Research Cooperative System database and identified all patients who underwent the 10 most common elective orthopaedic surgeries from January 1, 2012, through March 31, 2016. Medicaid monthly enrollment for the 4-year study period was obtained from NY Department of Health Medicaid Managed Care Enrollment Reports. RESULTS: Our query identified 700,159 patients who underwent the investigated orthopaedic surgeries. Of these, 60,786 were Medicaid recipients. During the 4-year study period, Medicaid enrollment and the number of procedures reimbursed by Medicaid increased significantly (P < 0.001 for both). CONCLUSIONS: Affordable Care Act-supported Medicaid expansion was associated with an increase in Medicaid enrollment and a concomitant increase in the utilization of orthopaedic surgery by Medicaid beneficiaries in New York State.

Preoperative Bariatric Surgery Utilization Is Associated With Increased 90-day Postoperative Complication Rates After Total Joint Arthroplasty.

BACKGROUND: This study evaluates the incidence of bariatric surgery (BS) before total joint arthroplasty (TJA) in New York State and compares patient comorbidities and 90-day postoperative complications of patients with and without BS before TJA. METHODS: The NY Statewide Planning and Research Cooperative System database between 2005 and 2014 was reviewed and 343,710 patients with TJA were identified. Patients were stratified into the following three cohorts: group 1 (patients who underwent BS < 2 years before TJA [N = 1,478]); group 2 (obese patients without preoperative BS [N = 60,259]); and group 3 (nonobese patients without preoperative BS [N = 281,973]). Principal outcomes measured were patient comorbidities, 90-day complication rates, length of inpatient stay, discharge disposition, mortality rate, and total hospital costs. RESULTS: BS before TJA incidence increased from 0.11 of 100,000 to 2.4 of 100,000 from 2006 to 2014. Preoperative BS did not notably change the number of patient comorbidities at the time of TJA. Group 1 had more patients with 90-day complications (40.7% versus 36.0%, P < 0.001) than group 2. No difference was found between group 1 and the other groups in home discharge, pulmonary embolism, deep vein thrombosis, and mortality rates. Total hospital costs were higher for group 1 ($18,869 ± 9,022 versus $17,843 ± 8,095, P < 0.001) compared with those for group 2. CONCLUSION: BS before TJA has increased annually over a 10-year period in New York State and is associated with greater 90-day postoperative complication rates and higher immediate hospital costs when compared with obese patients without BS.

Total Joint Arthroplasty Is Associated With a Decreased Risk of Traumatic Falls: An Analysis of 499,094 Cases.

INTRODUCTION: The rate of traumatic falls in the aging cohort is estimated to increase across the United States. We sought to determine whether patients with lower extremity osteoarthritis (OA) who underwent total joint arthroplasty (TJA) had a reduced risk of falling compared with those with OA who did not undergo TJA. METHODS: The New York Statewide Planning and Research Cooperative System database was queried from 2000 to 2015 to identify 499,094 cases with primary diagnosis of hip or knee OA. Patients were stratified into 4 cohorts: group 1 (hip OA with total hip arthroplasty [THA] [N = 168,234]), group 2 (hip OA without THA [N = 22,482]), group 3 (knee OA with total knee arthroplasty [TKA] [N = 275,651]), and group 4 (knee OA without TKA [N = 32,826]). Patients were followed up longitudinally to evaluate the long-term risks of subsequent traumatic falls. Cox proportional hazards models were conducted to examine the relationship between patients' demographics and clinical characteristics and the risk of subsequent traumatic falls and reported as hazard ratios (HRs) with 95% confidence intervals (95% CIs). RESULTS: Nineteen thousand seven hundred seventeen patients with hip OA underwent 168,234 primary THAs (88.2%), and 308,477 patients with knee OA underwent 275,651 primary TKAs (89.4%) during the period 2000 to 2015. Compared with patients without TJA, those who underwent TJA were at a decreased risk of falls (THA HR 0.56 [95% CI, 0.48 to 0.66]) and TKA HR 0.66 [95% CI, 0.57 to 0.76]). Compared with age 40 to 49 years, risk increases for ages 70 to 79 years (HR = 4.3, 95% CI: 2.8 to 6.6) and 80 years or older (HR = 5.5, 95% CI: 3.8 to 8.1). CONCLUSION: TJA is associated with a decreased risk of long-term traumatic falls in elderly patients with the primary diagnosis of hip or knee osteoarthritis. LEVEL OF EVIDENCE: Level III Retrospective Case-control study.

What are the prevalence and risk factors for repeat ipsilateral knee arthroscopy?

PURPOSE: The number of arthroscopic knee surgeries performed annually has increased over the last decade. It remains unclear what proportion of individuals undergoing knee arthroscopy is at risk for subsequent ipsilateral procedures. Better knowledge of risk factors and the incidence of reoperative ipsilateral arthroscopy are important in setting expectations and counselling patients on treatment options. The aim of this study is to determine the incidence of repeat ipsilateral knee arthroscopy, and the risk factors associated with subsequent surgery over long-term follow-up. METHODS: The New York Statewide Planning and Research Cooperative Systems outpatient database was reviewed from 2003 to 2016 to identify patients who underwent elective, primary knee arthroscopy for one of the following diagnosis-related categories of procedures: Group 1: cartilage repair and transfer; Group 2: osteochondritis dissecans (OCD) lesions; Group 3: meniscal repair, debridement, chondroplasty, and synovectomy; Group 4: multiple different procedures. Subjects were followed for 10 years to determine the odds of subsequent ipsilateral knee arthroscopy. Risk factors including the group of arthroscopic surgery, age group, gender, race, insurance type, surgeon volume, and comorbidities were analysed to identify factors predicting subsequent surgery. RESULTS: A total of 765,144 patients who underwent knee arthroscopy between 2003 and 2016, were identified. The majority (751,873) underwent meniscus-related arthroscopy. The proportion of patients undergoing subsequent ipsilateral knee arthroscopy was 2.1% at 1-year, 5.5% at 5 years, and 6.7% at 10 years of follow-up. Among patients who underwent subsequent arthroscopic surgery at 1-, 5-, and 10-year follow-up, there was a greater proportion of patients with worker's compensation insurance (p < 0.001), index operations performed by very high volume surgeons (p < 0.001), and cartilage restoration index procedures (p < 0.001), compared with those who never underwent repeat ipsilateral surgery. CONCLUSION: Understanding the incidence of subsequent knee arthroscopy after index procedure in different age groups and the patterns over 10 years of follow-up is important in counselling patients and setting future expectations. The majority of subsequent surgeries occur within the first 5 years after index surgery, and subjects tend to have higher odds of ipsilateral reoperation for up to 10 years if they have worker's compensation insurance, or if their index surgery was performed by a very high volume surgeon, or was a cartilage restoration procedure. LEVEL OF EVIDENCE: III.

Treatment for Symptomatic SLAP Tears in Middle-Aged Patients Comparing Repair, Biceps Tenodesis, and Nonoperative Approaches: A Cost-Effectiveness Analysis.

PURPOSE: To evaluate the cost-effectiveness of nonoperative management, primary SLAP repair, and primary biceps tenodesis for the treatment of symptomatic isolated type II SLAP tear. METHODS: A microsimulation Markov model was constructed to compare 3 strategies for middle-aged patients with symptomatic type II SLAP tears: SLAP repair, biceps tenodesis, or nonoperative management. A failed 6-month trial of nonoperative treatment was assumed. The principal outcome measure was the incremental cost-effectiveness ratio in 2017 U.S. dollars using a societal perspective over a 10-year time horizon. Treatment effectiveness was expressed in quality-adjusted life-years (QALY). Model results were compared with estimates from the published literature and were subjected to sensitivity analyses to evaluate robustness. RESULTS: Primary biceps tenodesis compared with SLAP repair conferred an increased effectiveness of 0.06 QALY with cost savings of $1,766. Compared with nonoperative treatment, both biceps tenodesis and SLAP repair were cost-effective (incremental cost-effectiveness ratio values of $3,344/QALY gained and $4,289/QALY gained, respectively). Sensitivity analysis showed that biceps tenodesis was the preferred strategy in most simulations (52%); however, for SLAP repair to become cost-effective over biceps tenodesis, its probability of failure would have to be lower than 2.7% or the cost of biceps tenodesis would have to be higher than $14,644. CONCLUSIONS: When compared with primary SLAP repair and nonoperative treatment, primary biceps tenodesis is the most cost-effective treatment strategy for type II SLAP tears in middle-aged patients. Primary biceps tenodesis offers increased effectiveness when compared with both primary SLAP repair and nonoperative treatment and lower costs than primary SLAP repair. LEVEL OF EVIDENCE: Level III, economic decision analysis.

Trends and Risk Factors for 1-Year Revision of the Latarjet Procedure: The New York State Experience During the Past Decade.

Little research has been conducted evaluating surgical trends during the past 10 years and subsequent procedure risk factors for patients undergoing bone-blocking procedures for the treatment of anterior shoulder instability. The Statewide Planning and Research Cooperative System database was queried between 2003 and 2014 to identify patients undergoing soft tissue or bone-blocking procedures for anterior shoulder instability in New York. Patient demographics and 1-year subsequent procedures were analyzed. Multivariate logistic regression analyses were conducted to identify 1-year subsequent procedure risk factors. From 2003 through 2014, a total of 540 patients had Latarjet procedures performed. During this period, the volume of Latarjet procedures increased by 950%, from 12 procedures in 2003 to 126 procedures in 2014. The volume of open Bankart repairs declined by 77%; arthroscopic Bankart repairs fluctuated, being up (328%) between 2003 and 2012 and then down (6%) between 2012 and 2014. Of the 540 patients, 2.4% (13 of 540) required intervention for recurrent shoulder instability events. Age older than 20 years and workers' compensation were identified as independent risk factors for reoperation. The number of bone-blocking procedures, such as the Latarjet, has increased by nearly 1000% during the past decade in New York. Only 2.4% (13 of 540) of the patients had subsequent shoulder instability interventions. [Orthopedics. 2018; 41(3):e389-e394.].

Preoperative Bariatric Surgery and the Risk of Readmission Following Total Joint Replacement.

The purpose of this study was to compare nonelective and all-cause readmission rates and to identify risk factors for readmission of total joint arthroplasty (TJA) patients who had preoperative bariatric surgery (BS) compared with TJA patients without preoperative BS. The New York Statewide Planning and Research Cooperative System database was queried to identify 343,710 TJA patients between 2005 and 2014. Three patient groups were evaluated: group 1 (patients with preoperative BS within 2 years of TJA [N=1478]); group 2 (obese patients without preoperative BS [N=60,259]); and group 3 (nonobese patients without preoperative BS [N=281,973]). Nonelective and all-cause readmission rates (30 days, 90 days, and 1 year) were compared, and multivariate analyses of readmission risk factors were performed. Group 1 had no significant difference in nonelective readmission rates compared with groups 2 and 3. However, when elective TJA readmissions were included, group 1 had significantly higher all-cause readmission rates at 30 days, 90 days, and 1 year compared with groups 2 and 3. Bariatric surgery was not a risk factor for nonelective readmissions at any time point. When elective TJA admissions were included, BS was an independent risk factor for all-cause readmission at all time points. Patients who have BS prior to TJA do not have higher nonelective readmission rates than obese TJA patients without BS. Bariatric surgery is not a risk factor for nonelective readmissions. However, BS is a significant predictor of elective TJA admissions up to 1 year following the index TJA. [Orthopedics. 2018; 41(2):107-114.].

Joint Replacement Volume Positively Correlates With Improved Hospital Performance on Centers for Medicare and Medicaid Services Quality Metrics.

BACKGROUND: The Center for Medicare and Medicaid Services (CMS) is transitioning Medicare from a fee-for-service program into a value-based pay-for-performance program. In order to accomplish this goal, CMS initiated 3 programs that attempt to define quality and seek to reward high-performing hospitals and penalize poor-performing hospitals. These programs include (1) penalties for hospital-acquired conditions (HACs), (2) penalties for excess readmissions for certain conditions, and (3) performance on value-based purchasing (VBP). The objective of this study was to determine whether high-volume total joint hospitals perform better in these programs than their lower-volume counterparts. METHODS: We analyzed data from the New York Statewide Planning and Research Cooperative System database on total New York State hospital discharges from 2013 to 2015 for total knee and total hip arthroplasty. This was compared to data from Hospital Compare on HAC's, excess readmissions, and VBP. From these databases, we identified 123 hospitals in New York, which participated in all 3 Medicare pay-for-performance programs and performed total joint replacements. RESULTS: Over the 3-year period spanning 2013-2015, hospitals in New York State performed an average of 1136.59 total joint replacement surgeries and achieved a mean readmission penalty of 0.005909. The correlation coefficient between surgery volume and combined performance score was 0.277. Of these correlations, surgery volume and VBP performance, and surgery volume and combined performance showed statistical significance (P < .01). CONCLUSION: Our study demonstrates that there is a positive association between joint replacement volumes and overall hospital quality, as well as joint replacement volumes and VBP performance, specifically. These findings are consistent with previously reported associations between patient outcomes and procedure volumes. However, a relationship between joint replacement volume and HAC scores or readmission penalties could not be demonstrated.