Cost Difference in Performing Total Knee Arthroplasty at Ambulatory Surgical Centers Compared With Hospital-Based Outpatient Departments: Observational Study.

BACKGROUND: As total knee arthroplasty (TKA) further transitions toward an outpatient procedure, it becomes important to identify the resource utilization after TKAs at different outpatient facilities. The objective of this study was to determine the 90-day cost of patients who underwent TKAs at an ambulatory surgical center (ASC) or a hospital outpatient department (HOPD). METHODS: An observational cohort study was conducted using the Marketscan database with patients who had a TKA at an ASC or HOPD between January 1st, 2019, and October 2nd, 2021. The primary outcome was cost in a 90-day period (including the day of surgery), with inpatient admissions and ED visits as secondary outcomes. Multivariable regression analyses were conducted, adjusting for patient characteristics. RESULTS: The study population consisted of 47,261 patients with 7,874 ASC patients and 39,387 HOPD patients. 90-day costs for ASC patients were lower compared with HOPD patients ($35,634 ± 19,030 vs. $38,096 ± 24,389, P < 0.001). 90-day inpatient admission rates were lower for ASC than HOPD patients (2.5% vs. 4.8%, P < 0.001). 90-day ED visits for ASC patients were lesser compared with HOPD patients (8.9% vs. 12.7%, P < 0.001). CONCLUSION: Patients with TKAs at an ASC had an overall lower cost, inpatient admissions, and ED visits over a 90-day period compared with HOPD patients. Future consideration for which outpatient facilities patients have their TKA at is necessary as TKAs shift toward bundle payments and outpatient procedures.

Revision Total Knee Arthroplasty in an Outpatient Setting: A Growing Alternative.

BACKGROUND: Recent studies have focused on the safety and efficacy of performing primary total knee arthroplasty (TKA) in an outpatient setting. Despite being associated with greater costs, much less is known about the accompanying impact on revision TKA (rTKA). The purpose of this study was to describe the trends in costs and outcomes of patients undergoing inpatient and outpatient rTKA. METHODS: An observational cohort study was conducted using commercial claims databases. Patients who underwent 1-component and 2-component rTKA in an inpatient setting, hospital outpatient department (HOPD), or ambulatory surgery center (ASC) from 2018 to 2020 were included. The primary outcome was the 30-day episode-of-care costs following rTKA. Secondary outcomes included surgical cost, 90-day readmission rate, and emergency department visit rate. Covariates for analyses included patient demographics, surgery type, and indication for revision. RESULTS: There were 6,515 patients who were identified, with 17.0% of rTKAs taking place in an outpatient setting. On adjusted analysis, patients in the highest quartile of 30-day postoperative costs were more likely to be those whose rTKA was performed in an inpatient setting. One-component revisions were more common in an outpatient setting (HOPD, 50.7%; ASC, 62.0%) compared to an inpatient setting (39.6%). The 90-day readmission rates were higher (P = .003) for rTKAs performed in inpatient (+9.2%) and HOPD (+8.6%) settings compared to those in an ASC. CONCLUSIONS: The ASC may be a suitable setting for simpler revisions performed for less severe indications and is associated with lower costs and 90-day readmission and emergency department visit rates.

Failure Following Revision Total Hip Arthroplasty After Cobalt-Chrome Femoral Heads are Placed on a Retained Femoral Stem.

BACKGROUND: Failure due to trunnionosis with adverse local tissue reaction (ALTR) has been reported with cobalt-chrome (CoCr) heads in total hip arthroplasty (THA); however, there are limited data on the use of these heads in the revision setting. The purpose of this study was to analyze the outcomes of patients who underwent revision THA with a retained femoral component and received a CoCr femoral head on a used trunnion. METHODS: In this retrospective review, we identified all patients who underwent revision THA with a retained femoral component and received a CoCr femoral head between February 2006 and March 2014. Demographic factors, implant details, and postoperative complications, including the need for repeat revisions, were recorded. In total, 107 patients were included (mean age 67 years, 74.0% women). Of the 107 patients, 24 (22.4%) required repeat revisions. RESULTS: Patients who required repeat revision were younger than those who did not (mean age: 62.9 versus 69, P = .03). The most common indications for repeat revision were instability (8 of 24, 33.3%), ALTR (5 of 24, 20.8%), and infection (4 of 18, 16.7%). Evidence of ALTR or metallosis was identified at the time of reoperation in 10 of the 24 patients who underwent re-revision (41.7%). CONCLUSIONS: The placement of a new CoCr femoral head on a used trunnion during revision THA with a retained femoral component carries a significant risk of complication (22.4%) and should be avoided when possible.

Increased arthroplasty surgeon energy consumption when performing primary total hip arthroplasty compared to total knee arthroplasty.

Introduction: Previously published studies have hypothesized that total hip arthroplasty (THA) requires the surgeon to expend more energy that total knee arthroplasty (TKA). However, techniques for performing these procedures have evolved. Therefore, we sought to compare if primary THA had increased energy expenditure compared to primary TKA. Methods: We prospectively recorded the heart rate, respiratory rate, minute ventilation, cadence, and energy expenditure of a single fellowship-trained arthroplasty surgeon while performing primary THA and TKA on 372 patients. Patient demographics and operative records were reviewed to evaluate differences in the physical demands of each surgical case. Age (64.3 versus 65.9 years, p = 0.1) and gender (54.8% versus 51.0% female, p = 0.5) were similar between THA and TKA, but TKAs had a higher body mass index (31.1 versus 28.7 kg/m2, p < 0.001). Chi-square and independent-samples t-tests were used to compare cohorts. Significance was set at p < 0.05. Results: THA tended to have 1.1 times longer operative time than TKA (102.2 versus 88.9 min, p < 0.001). THA had a statistically higher heart rate compared to TKA, although this is unlikely to be clinically significant (82.5 versus 80.7 beats/minute, p < 0.001). Respiratory Rate was 1.1 times higher (15.9 versus 14.9 respirations/minute, p < 0.001) and minute ventilation was 1.2 times higher (19.6 versus 16.9 L/min, p < 0.001) when performing THA. Cadence was 1.5 times higher when performing TKA (4.2 versus 2.8 steps/minute, p < 0.001). THA had a 1.2 times higher energy expenditure/patient (378.8 versus 312.0 Calories/patient, p < 0.001) and a 1.1 times higher energy expenditure/minute (3.7 versus 3.5 Calories/minute, p = 0.01) compared to TKA. Discussion: THA is associated with longer operative time and increased energy expenditure per compared to TKA. Despite THA and TKA procedures becoming more efficient, arthroplasty surgery continues to have heavy physical burden on the surgeon. Further research is needed to understand ways to decrease surgeon energy expenditure and promote career longevity.

Correlation of Patient-Reported Preoperative Narcotic Use and Postoperative Requirements in Total Joint Arthroplasty.

Preoperative narcotic use is associated with diminished outcomes and increased complications in patients undergoing primary total joint arthroplasty (TJA). The goal of this study was to compare self-reported and state database identified preoperative narcotic use and correlate it with perioperative narcotic requirements in patients undergoing primary arthroplasty. A total of 788 patients undergoing unilateral TJA from a single institution were examined using self-reported preoperative narcotic use questionnaires and were verified using the Massachusetts Prescriber Awareness Tool (MassPAT). Demographic data, perioperative morphine milligram equivalents, and postdischarge refills were recorded and analyzed. Of the total population, 16.4% of patients undergoing TJA had verified MassPAT narcotics prescriptions preoperatively. Of these patients, 55% accurately reported use to their surgeon. Patients with verified MassPAT narcotic prescriptions required more morphine milligram equivalents than patients without MassPAT prescriptions, regardless of their preoperative self-report at all time points in the study. Patients who accurately reported use required more narcotics than those who did not. Patients with MassPAT prescriptions required more postdischarge refills than patients without MassPAT prescriptions. These data suggest that state-run narcotics databases may be more useful than self-reports for identifying which patients may require more opioids both immediately postoperatively and after hospital discharge. [Orthopedics. 2024;47(1):34-39.].

Arthroscopic Procedures Are Performed in 5% of Patients With Knee Osteoarthritis 1 Year Preceding Total Knee Arthroplasty and Are Associated With Increased Stiffness and Increased Costs.

Purpose: To describe the different types of arthroscopic procedures that patients undergo in the year prior to total knee arthroplasty (TKA), reveal the cost associated with these procedures, and understand the relationship between preoperative arthroscopy and clinical outcomes after TKA. Methods: An observational cohort study was conducted using the IBM Watson Health MarketScan databases. Patients with knee osteoarthritis who underwent unilateral isolated primary TKA between January 1, 2018, and September 30, 2019, were included. Knee arthroscopic procedures performed in the 1-year period before a primary TKA was identified. The primary outcomes of interest were cost of these procedures and the risk of 90-day postoperative complications. Results: In total, 2,904 patients, representing 5.2% of the analyzed cohort, underwent arthroscopic procedures in the year prior to TKA. The most common procedure and diagnosis were meniscectomy and meniscal tear, respectively, with procedures performed an average of 7.2 ± 3.0 months before TKA. Average per patient costs were $9,716 ± $5,500 in the highest payment quartile vs $1,789 ± 636 in the lowest payment quartile. Patients with a history of arthroscopy were more likely to develop postoperative stiffness (P = .001), while no difference was found in the risk of 90-day periprosthetic joint infection (PJI). Conclusions: Of the patients, 5.2% underwent knee arthroscopy in the year prior to TKA. While no association was seen with PJI risk, the costs associated with these procedures are high and may increase the overall cost of management of knee osteoarthritis. Level of Evidence: Level III, retrospective comparative study.

Energy expenditure of femoral broaching in direct anterior total hip replacements-Comparison between manual and automated techniques.

INTRODUCTION: Little information is known regarding the energy expenditure of the surgeon during total hip arthroplasty (THA). We sought to compare the energy expenditure associated with femoral broaching using two techniques: manual and automated. METHODS: We recorded energy expenditure, minute ventilation, heart rate, and total broaching time of a single surgeon while broaching the femoral canal during direct anterior THA using two different techniques: Manual broaching (n = 26) and automated broaching (n = 20). RESULTS: Manual broaching required a longer time than automated broaching (6.1 ± 1.1 vs. 3.7 ± 0.9 min; p < 0.001) with an increase in energy expenditure (32.6 ± 7.0 vs. 16.0 ± 7.1 Calories; p < 0.001). Heart rate was higher with manual broaching (99.4 ± 9.8 vs. 90.1 ± 9.8 beats per min; p = 0.003), along with minute ventilation (36.5 ± 7.0 vs. 30.3 ± 5.8 L/min; p = 0.003). There were no intraoperative complications. CONCLUSIONS: Automated femoral broaching during THA can decrease the energy expenditure of broaching by 50% and time of broaching by 40%, when compared to manual technique. CLINICAL TRIAL REGISTRATION: This research was not a clinical trial.

No Increased Risk of Aseptic Loosening with Tourniquetless Cemented Total Knee Arthroplasty.

Our study examined whether risk of revision for aseptic loosening following cemented total knee arthroplasty (TKA) is (1) increased with tourniquetless surgery and (2) affected by patient characteristics or surgical factors. Primary cemented TKAs from 2005-2012 with 2-year follow up were analyzed (n = 5,508 with tourniquet; n=101 without). Revision for aseptic loosening was compared between TKA performed with and without a tourniquet. Patient characteristics were recorded. At mean 4.8-year follow up, risk of aseptic loosening was similar between TKA performed with or without a tourniquet (p = 0.3151). Aseptic loosening was more likely in men (p = 0.0018) and patients younger than 50 (p < 0.0001). No difference was observed between cruciate-retaining and posterior-stabilized implants (p = 0.1250). With the numbers available for study, we did not observe an increased risk of aseptic loosening with tourniquetless cemented primary TKA. Patients younger than 50, particularly men, should be counselled on the increased risk of TKA revision for aseptic loosening. (Journal of Surgical Orthopaedic Advances 32(2):111-113, 2023).

The Cost of Stiffness After Total Knee Arthroplasty.

BACKGROUND: Stiffness after primary total knee arthroplasty (TKA) is debilitating and poorly understood. A heterogenous approach to the treatment is often utilized, including both nonoperative and operative treatment modalities. The purpose of this study was to examine the prevalence of treatments used between stiff and non-stiff TKA groups and their financial impact. METHODS: An observational cohort study was conducted using a large database. A total of 12,942 patients who underwent unilateral primary TKA from January 1, 2017, to December 31, 2017, were included. Stiffness after TKA was defined as manipulation under anesthesia and a diagnosis code of stiffness or ankylosis, and subsequent diagnosis and procedure codes were used to identify the prevalence and financial impact of multiple common treatment options. RESULTS: The prevalence of stiffness after TKA was 6.1%. Stiff patients were more likely to undergo physical therapy, medication, bracing, alternative treatment, clinic visits, and reoperation. Revision surgery was the most common reoperation in the stiff TKA group (7.6%). The incidence of both arthroscopy and revision surgery were higher in the stiff TKA population. Dual component revisions were costlier for patients who had stiff TKAs ($65,771 versus $48,287; P < .05). On average, patients who had stiffness after TKA endured costs from 1.5 to 7.5 times higher than the cost of their non-stiff counterparts during the 2 years following index TKA. CONCLUSION: Patients who have stiffness after primary TKA face significantly higher treatment costs for both operative and nonoperative treatments than patients who do not have stiffness.

The trend and future projection of technology-assisted total knee arthroplasty in the United States.

BACKGROUND: As technology-assisted surgery has boosted in the last decades, we aimed to investigate the factors affecting adoption and to predict the future utilization of technology among patients who underwent total knee arthroplasty (TKA). METHODS: Patients underwent TKA in 2017-2019 in the MarketScan Database were included. Percentage of technology-assisted surgery was calculated. Multivariable logistic regression models were performed to analyse the factors and make the prediction. RESULTS: Of 112,161 TKA procedures, 7.2% were technology-assisted. The proportion of technology-assisted TKA is expected to reach 50% by 2032. The West showed the highest proportion of technology-assisted TKA (12.3%), while the South had the lowest (5.7%). Over time, the Midwest showed the greatest increase in technology adoption (OR = 1.26 compared to the Northeast, 95% CI [1.15, 1.38]). CONCLUSIONS: Technology adoption rate of TKA will continue to increase for the next 20 years in the United States with a slight geographical variation.

A Safe Number of Perioperative Opioids to Reduce the Risk of New Persistent Usage Among Opioid-Naïve Patients Following Total Joint Arthroplasty.

BACKGROUND: Higher initial opioid dosing increases the risk of prolonged opioid use following total joint arthroplasty (TJA), and the safe amounts to prescribe are unknown. We examined the relationship between perioperative opioid exposure and new persistent usage among opioid-naïve patients after total knee and hip arthroplasty. METHODS: In this retrospective cohort study, 22,310 opioid-naïve patients undergoing primary TJA between 2018 and 2019 were identified within a commercial claims database. Perioperative opioid exposure was defined as total dose of opioid prescription in morphine milligram equivalents (MME) between 1 month prior to and 2 weeks after TJA. New persistent usage was defined as at least one opioid prescription between 90 and 180 days postoperatively. Multivariate regression analyses were performed to examine the relationship between the perioperative dosage group and the development of new persistent usage. RESULTS: For the total patient cohort, 8.1% developed new persistent usage. Compared to patients who received <300 MME, patients who received 600-900 MME perioperatively had a 77% increased risk of developing new persistent usage (odds ratio 1.77, 95% CI, 1.44-2.17), and patients who received ≥1,200 MME perioperatively had a 285% increased risk (odds ratio 3.85, 95% CI, 3.13-4.74). CONCLUSION: We found a dose-dependent association between perioperative MME and the risk of developing new persistent usage among opioid-naïve patients following TJA. We recommend prescribing <600 MME (equivalent to 80 pills of 5 mg oxycodone) during the perioperative period to reduce the risk of new persistent usage. LEVEL OF EVIDENCE: Level III.

Costs of Nonoperative Procedures for Knee Osteoarthritis in the Year Prior to Primary Total Knee Arthroplasty.

BACKGROUND: The convergence of national priorities to reduce health-care costs and deliver high-value care warrants the need to examine health-care utilization. The objective of this study was to describe the costs associated with nonoperative procedures in the 1-year period leading up to primary total knee arthroplasty (TKA). METHODS: An observational cohort study was conducted using the IBM Watson Health MarketScan databases. Patients with late-stage knee osteoarthritis (OA) who underwent unilateral, isolated primary TKA from January 1, 2018, to December 31, 2019, were included. The main outcome was the cost of knee OA-related payments for identified nonoperative procedures in the 1-year period before surgery. Nonoperative procedures examined were (1) physical therapy (PT); (2) bracing; (3) intra-articular injections: professional fee, hyaluronic acid (IA-HA), and corticosteroids (IA-CS); (4) medication: nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and acetaminophen; and (5) knee-specific imaging. RESULTS: The study population included 24,492 TKA patients with a mean age of 60.4 ± 8.0 years. The average total cost of nonoperative procedures per patient was $1,355 ± $2,087. The most common nonoperative treatment prescribed was IA-CS (54.3%). The nonoperative procedure with the highest cost per patient was IA-HA ($1,019 ± $913 per patient). The total cost of nonoperative procedures was higher among female compared with male patients ($1,440 ± $2,159 versus $1,254 ± $1,992 per patient; p < 0.01). The highest costs were found for patients in the Northeast ($1,740 ± $2,437 per patient). A total of 14,346 (58.6%) and 7,831 (32.0%) of the patients had >1 and ≥3 nonoperative treatments, respectively. CONCLUSIONS: There is substantial variation in the type and the cost of nonoperative treatment for patients with late-stage OA. Future studies should investigate the effectiveness of nonoperative treatments at different stages of the disease. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Continuous Femoral Nerve Block Reduces the Need for Manipulation Following Total Knee Arthroplasty.

Peripheral nerve blocks improve both pain control and functional outcomes following total knee arthroplasty (TKA). However, few studies have examined the effects of different peripheral nerve block protocols on postoperative range of motion. The present study assessed the impact of a single-shot femoral nerve block (SFNB) versus continuous femoral nerve block (CFNB) on postoperative range of motion and the need for subsequent manipulation following TKA. Methods: We retrospective reviewed patient charts to identify patients who had undergone primary elective unilateral TKA by 2 surgeons at a high-volume orthopaedic specialty hospital over a 3-year period. A total of 1,091 patients received either SFNB or CFNB and were included in the data analysis. Identical surgical techniques, postoperative oral analgesic regimens, and rehabilitation protocols were used for all patients. Patients with <90° of flexion at 6 weeks postoperatively underwent closed manipulation under anesthesia (MUA). Results: Overall, 608 patients (55.7%) received CFNB and 483 patients (44.3%) received SFNB. Overall, 94 patients (8.6%) required postoperative manipulation for stiffness, including 36 (5.9%) in the CFNB group and 58 (12%) in the SFNB group. The 50% reduction in the need for manipulation in the CFNB group was independent of primary surgeon (p > 0.05). No significant differences were observed between the groups in terms of postoperative range of motion, either at the time of discharge or at 6 weeks postoperatively. A history of knee surgery, decreased preoperative range of motion, and decreased range of motion at the time of discharge were significantly associated with the need for further MUA (p = 0.0002, p < 0.0001, and p < 0.0001, respectively). Conclusions: Despite similar final postoperative range of motion between patients in both groups, our results suggest that CFNB may be superior to SFNB for reducing the need for postoperative manipulation after primary TKA. Furthermore, a history of ipsilateral knee surgery, decreased preoperative range of motion, and decreased range of motion at the time of discharge were identified as independent risk factors for postoperative stiffness requiring MUA after primary TKA. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Drivers of Unequal Healthcare Costs in the Nonoperative Treatment of Late-Stage Knee Osteoarthritis Prior to Primary Total Knee Arthroplasty.

BACKGROUND: In the United States, patients with late-stage knee osteoarthritis (OA) often undergo several nonoperative treatments and related procedures prior to total knee arthroplasty. The costs of these treatments and procedures are substantial, and the variation in healthcare costs among different groups of patients may exist. The purpose of this study is to examine these costs and determine the drivers of costs in patients with the highest healthcare expenditure. METHODS: An observational cohort study was conducted using the IBM Watson Health MarketScan databases from January 1, 2017 to December 31, 2019. The primary outcome was the cost of payments for nonoperative procedures which included (i) physical therapy (PT), (ii) bracing, (iii) intra-articular injections: professional fee, hyaluronic acid (IA-HA), and corticosteroids (IA-CS), (iv) medication: nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and acetaminophen, and (v) knee-specific imaging. RESULTS: Among the 24,492 patients included in the study, the total payments per patient for nonoperative care were $3,735 ± 3,049 in the highest payment quartile (Q4) and $137 ± 70 in the lowest payment quartile (Q1). Per-patient-per-month costs generally increased across quartiles for procedures. Comparing Q4 to Q1, the largest changes in prevalence were found in IA-HA (348×), bracing (10×), and PT (7×). Patients who were prescribed IA-HA and PT had a 28.3-times and 4.8-times greater likelihood, respectively, to be a higher-paying patient. CONCLUSION: Unequal healthcare costs in the nonoperative treatment of late-stage knee OA are driven by differences in prevalent management strategies. Overall healthcare expenditure may be reduced if only guideline-concordant treatments are used.

Effect of the COVID-19 Pandemic on Rates of Ninety-Day Peri-Prosthetic Joint and Surgical Site Infections after Primary Total Joint Arthroplasty: A Multicenter, Retrospective Study.

Background: The impact of the coronavirus 2019 (COVID-19) pandemic on the rate of primary total joint arthroplasty (TJA) peri-prosthetic joint infection (PJI) and superficial surgical site infections (SSI) is currently unknown. The purpose of this multicenter study was to evaluate any changes in the rates of 90-day PJI or 30-day SSI, including trends in microbiology of the infections, during the COVID-19 pandemic compared to the three years prior. Patients and Methods: An Institutional Review Board-approved, multicenter, retrospective study was conducted with five participating academic institutions across two healthcare systems in the northeastern United States. Primary TJA patients from the years 2017-2019 were grouped as a pre-COVID-19 pandemic cohort and patients from the year 2020 were grouped as a COVID-19 pandemic cohort. Differences in patient demographics, PJI, SSI, and microbiology between the two cohorts were assessed. Results: A total of 14,844 TJAs in the pre-COVID-19 pandemic cohort and 5,453 TJAs in the COVID-19 pandemic cohort were evaluated. There were no substantial differences of the combined 90-day PJI and 30-day superficial SSI rates between the pre-COVID-19 pandemic cohort (0.35%) compared with the COVID-19 pandemic cohort (0.26%; p = 0.303). Conclusions: This study did not find any change in the rates of 90-day PJI or 30-day superficial SSI in patients undergoing primary TJA between a pre-COVID-19 pandemic and COVID-19 pandemic cohort. Larger national database studies may identify small but substantial differences in 90-day PJI and 30-day superficial SSI rates between these two time periods. Our data may support continued efforts to maintain high compliance with hand hygiene, use of personal protective equipment, and limited hospital visitation whenever possible.

Accelerated neutral atom beam (ANAB) modified polyethylene for decreased wear and reduced bacteria colonization: An in vitro study.

Ultra-high molecular weight polyethylene (UHMWPE) model implants were modified using accelerated neutral atom beam (ANAB) technology and tested for in vitro wear properties and bacteria colonization. Material characterization studies using atomic force microscopy (AFM), surface energy, and in vitro protein adsorption events were also conducted to better understand the mechanism behind such wear properties and bacteria colonization. ANAB modified UHMWPE showed significantly reduced wear properties compared to controls due to nanostructured features, greater surface energy, and improved adsorption of lubricin, a synovial fluid lubricating protein. There was significantly greater adsorption of proteins known to reduce bacteria colonization (specifically, mucin, casein, and lubricin) after 4 h on UHMWPE after ANAB treatment. Such changes in initial protein events led to significantly decreased bacteria (including methicillin resistant Staph. aureus (or MRSA), Staph. aureus, E. coli, multi-drug resistant E. coli, Pseudomonas aeruginosa and Staph. epidermidis) colonization after 24 h without resorting to antibiotic use.

Reducing Narcotic Usage With 0.5% Bupivacaine Periarticular Injections in Total Knee Arthroplasty.

BACKGROUND: Periarticular injections (PAIs) and adductor canal blocks (ACBs) are widely accepted pain management strategies for total knee arthroplasty (TKA); however, the optimal anesthetic concentration to provide adequate pain relief while avoiding toxicity remains controversial. The purpose of this study is to evaluate the efficacy of different anesthetic concentrations for PAI alone and in combination with ACB. METHODS: This retrospective cohort study of patients undergoing primary TKAs between January 2019 and November 2020 included 3 groups: 0.25% PAI (50 cc of 0.25% bupivacaine PAI diluted with 50 cc of saline and ketorolac), 0.5% PAI (50 cc of 0.5% bupivacaine with 50 cc of saline and ketorolac), and PAI + ACB (ultrasound-guided preoperative anesthesiologist-administered ACB and 0.25% PAI). RESULTS: In total, 368 TKAs were analyzed (123 0.25%, 132 0.5%, and 113 PAI + ACB). Total overall hospital narcotic usage in oral morphine equivalents (OME) was significantly lower for the 0.5% group (120.09 vs 165.26 and 175.75) compared to the 0.25% and PAI + ACB groups, respectively (P < .0001). Cumulative OME for the first 3 shifts was also lower for 0.5% (68.7 vs 83.7 and 76.4) compared to the 0.25% and PAI + ACB groups, respectively (P = .030). Total postoperative narcotics in OME were significantly lower for 0.5% (617.9 vs 825.2 and 1047.6) than 0.25% and PAI + ACB, respectively (P = .0003). Number of prescriptions within 6 weeks postoperatively were also significantly lower for 0.5% (1.7) than 0.25% (2.1) and PAI + ACB (2.4) (P = .0003). CONCLUSION: Patients receiving 0.5% PAI had lower narcotic usage compared to 0.25% PAI or PAI + ACB. ACB may be eliminated without compromising pain control if the dose of local anesthetic in the PAI is sufficiently high.

Combined treatment of intraoperative cell-salvage and tranexamic acid for primary unilateral total hip arthroplasty: Are there added benefits?

BACKGROUND: Blood management strategies in total hip arthroplasty (THA) are essential in reducing intraoperative blood loss, blood transfusion and associated complications. This study investigates whether using intraoperative cell-salvage (ICS) with tranexamic acid (TXA) has additional effects on blood loss and allogeneic transfusion in primary THA. Additionally, we evaluated the financial impact of using ICS on our institution. METHODS: Using an institutional database, 1171 cases of primary unilateral THA performed between May 2015 and January 2016 were identified. Subjects were separated into those who received only TXA (n = 323) and those who received TXA and ICS (n = 848). Calculated blood loss and post-operative blood transfusions were assessed using logistic regression. Drop in hematocrit was assessed using linear regression. Multivariable models adjusted for intraoperative blood transfusions, pre-operative autologous blood donation, anticoagulation medications, sex, and body mass index. Pricing data was used to calculate the costs associated with these interventions. RESULTS: The likelihood of post-operative allogeneic blood transfusion was similar for the combined group relative to the TXA group (OR = 0.63; 95% CI: 0.26, 1.54), as was the likelihood of any post-operative blood transfusion (OR = 1.13; 95% CI: 0.63, 2.01). There was no correlative relationship between use of ICS and hematocrit drop when accounting for baseline hematocrit (R2 = 0.118). Factoring in rental, service fees, and disposable equipment, the utilization of ICS added $146 to each case, resulting in a gross expenditure of over $123,000 during the study period. CONCLUSIONS: The combination of ICS with TXA for primary unilateral THA did not improve blood loss or transfusion outcomes compared to TXA alone. As there was no observed clinical benefit to combined treatment, additional costs associated with routine usage of ICS may not be justifiable. Our institution would have reduced expenditures for blood loss management products by 85% during the study period if all patients had only received TXA.

Shared Decision-Making Is Associated with Better Outcomes in Patients with Knee But Not Hip Osteoarthritis: The DECIDE-OA Randomized Study.

BACKGROUND: Current guidelines recommend shared surgical decision-making, yet it is unclear whether shared decision-making improves health outcomes in patients who are considering knee and hip replacement. The purpose of the present study was to examine whether patients who made high-quality, informed, patient-centered (IPC) decisions had better health outcomes, higher satisfaction, and less decision regret compared with those who made lower-quality decisions. METHODS: A multisite, randomized study of 2 decision aids for patients with hip and knee osteoarthritis was utilized to collect data on decision-making and health outcomes at 2 time points: shortly after the initial surgical evaluation and about 6 months after treatment. We calculated the percentage of patients who made an IPC decision and examined the a priori hypotheses that IPC decisions would be associated with better health outcomes, satisfaction, and less regret at 6 months. Linear and logistic regression models were utilized to examine the relationships. RESULTS: The analytic sample included 854 patients with a mean age of 65 years (standard deviation, 9 years), of whom 58% were female, 93% were White non-Hispanic, 67% had knee (compared with hip) osteoarthritis, and 62% underwent operative treatment within 6 months of the initial evaluation. The majority of patients (68%) made IPC decisions. The IPC group had significantly larger gains in quality of life (mean difference in EuroQol-5 Dimension, 0.04; 95% confidence interval [CI], 0.02 to 0.07; p < 0.001) compared with the non-IPC group. For knee patients, the IPC group also had significantly better Knee injury and Osteoarthritis Outcome Scores (mean difference, 4.9; 95% CI, 1.5 to 8.3; p = 0.004), higher satisfaction (adjusted odds ratio [aOR], 1.7; 95% CI, 1.2 to 2.3; p = 0.003), much better pain relief (aOR, 2.1; 95% CI, 1.3 to 3.5; p = 0.002), and were more likely to have no decision regret (aOR, 2.3; 95% CI, 1.3 to 4.1; p = 0.003). For hip patients, IPC decisions were not associated with better Harris hip scores or satisfaction and were associated with more regret. CONCLUSIONS: Higher-quality decisions predicted small improvements in health outcomes, as well as greater satisfaction and less regret for patients with knee osteoarthritis, but not for patients with hip osteoarthritis. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Total Knee Arthroplasty Hospital Costs by Time-Driven Activity-Based Costing: Robotic vs Conventional.

BACKGROUND: Total knee arthroplasty (TKA) represents a major national health expenditure. The last decade has seen a surge in robotic-assisted TKA (roTKA); however, literature on the costs of roTKA as compared to conventional TKA (cTKA) is limited. The purpose of this study was to assess the costs associated with roTKA as compared to cTKA. METHODS: This was a retrospective cohort cost-analysis study of patients undergoing primary, elective roTKA or cTKA from July 2020 to March 2021. Time-driven activity-based costing (TDABC) was used to determine granular costs. Patient demographics, medical/surgical details, and costs were compared. RESULTS: A total of 2058 TKAs were analyzed (1795 cTKAs and 263 roTKAs). roTKA patients were more often male (50.2% vs 42.3%; P = .016), and discharged home (98.5% vs 93.7%; P = .017), and had longer operating room (OR) time (144.6 vs 130.9 minutes; P < .0001), and lower length of stay (LOS) (1.8 vs 2.1 days; P < .0001). roTKA costs were 2.17× greater for supplies excluding implant (P < .0001), 1.18× for total supplies (P < .0001), 1.12× for OR personnel (P < .0001), and 1.05× for total personnel (P = .0001). Implant costs were similar (P = .076), but 0.98× cheaper for post-anesthesia care unit personnel (P = .018) and 0.84× for inpatient personnel (P < .0001). Overall hospital costs for roTKA were 1.10× more than cTKA (P < .0001). CONCLUSION: roTKA had higher total hospital costs than cTKA. Despite a lower LOS, the longer OR time with higher supply and personnel costs resulted in a costlier procedure. Understanding the costs of roTKA is essential when considering the value (ie, outcomes per dollars spent) of this modern technology.