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Background The purpose of this study is to determine the benefit of the analgesic liposomal bupivacaine compared to ropivacaine, by assessing pain and joint stiffness, and total oral opioid consumption by milligram morphine equivalent (MME) after total knee arthroplasty. Methods Patients were randomized to receive either the study drug (liposomal bupivacaine admixed with bupivacaine) or the control drug (ropivacaine) in an adductor canal block. Only the anesthesiologist performing the block was aware of which arm of the study the patient was randomized to. MME, pain, Knee injury and Osteoarthritis Outcome Score Joint Replacement, and overall benefit of analgesia scores were recorded 24, 48, and 72 hours post-surgery either face-to-face or via telephone depending on patient discharge status. Results One hundred patients were enrolled into the study and analyzed: 54 in the control group and 46 in the experimental group. Primary outcomes measured were pain as a numerical rating scale, MME, and length of stay in hours. Secondary outcomes were joint pain and stiffness recorded as Knee injury and Osteoarthritis Outcome Score Joint Replacement outcome and overall benefit of analgesia score. No statistically significant between-group differences were observed for any measured outcome. Conclusion We did not find any supporting evidence that liposomal bupivacaine yields increased pain relief following total knee arthroplasty compared to the control drug, ropivacaine.

Background Mechanically assisted crevice corrosion (MACC) is a described complication following metal-on-polyethylene (MoP) total hip arthroplasty (THA). The literature regarding outcomes following revision for MACC suggests that complication rates are high. The purpose of this investigation is to add to this literature with the largest reported series to date. Methods This is a retrospective cohort study of 552 consecutive patients who underwent 621 MoP primary THAs. We identified patients who subsequently underwent revision THA for a diagnosis of MACC. All patients were implanted with the same implant combination (Accolade I stem/cobalt-chromium low friction ion treatment femoral head). Patient demographic, surgical, and laboratory data were collected. Follow-up was calculated from the revision surgery and Hip Disability and Osteoarthritis Outcome Score Joint Replacement and hip subjective values (HSV) were examined at final follow-up. Descriptive statistics were performed. Results The revision rate for MACC was 11.6% and mean time to revision was 6.6 (±2.4) years. Revised patients (n = 69) had a mean preoperative serum cobalt-chromium ratio of 3.5 (±2.4). There were 8 cases of gross trunnion failure. At mean 3.2 (±1.9) years following revision, the overall major complication rate was 11.6% with a 5.8% reoperation rate. At final follow-up, mean Hip Disability and Osteoarthritis Outcome Score Joint Replacement scores were 83.2 (±15.6) and mean hip subjective value was 77.6 (±17.4). Revision resulted in significant increases in both parameters (P Conclusion The incidence of MACC in MoP THA is likely higher than previously reported, particularly for certain implant combinations. Revision surgery for MACC can achieve good outcomes but a high clinical suspicion with early detection and revision is likely key to success.

As a procedure with lower surgical morbidity, unicompartmental knee arthroplasty (UKA) may present a practical solution for elderly patients with unicompartmental arthritis. However, few studies have analyzed the results of UKA in the extreme elderly. This study compared the functional and perioperative outcomes between octogenarians and age-appropriate controls undergoing UKA.Prospectively collected data of 44 patients aged ≥80 years who underwent unilateral UKA were analyzed. Each octogenarian was matched 1:3 with 132 patients aged 65-74 years using propensity scores adjusting for gender, body mass index, Charlson comorbidity index, and preoperative scores. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement and Short Form-12 were collected preoperatively and 2 years postoperatively. Complications, reoperations, readmissions, and unplanned visits were recorded up to 1 year postoperatively.The mean age was 70.0 ± 2.7 years in the control group and 83.0 ± 3.0 years in the octogenarian group (P.001). The percentage of outpatient procedures was comparable (control 50.0%; octogenarian 45.5%; P = .601). With the exception of poorer Short Form-12 physical scores in octogenarians at 2 years (39.4 ± 14.1 vs 44.9 ± 9.2, P = .028), there was no difference in final postoperative scores or improvement in scores between the groups. The rate of complications, reoperations, readmissions, and emergency room visits was also similar. The five-year survivorship was 97% in the control group and 93% in the octogenarian group (P = .148).Octogenarians undergoing UKA can experience clinical outcomes that are similar to those of their younger counterparts. The clinical trajectory outlined may help clinicians provide valuable prognostic information to elderly patients and guide preoperative counseling.

Introduction There is debate regarding whether the use of computer-assisted technology, such as navigation and robotics, has any benefit on outcomes or patient-reported outcome measures (PROMs) following total knee arthroplasty (TKA). This study aims to report on the association between intraoperative use of technology and outcomes in patients who underwent primary TKA. Methods We retrospectively reviewed 7096 patients who underwent primary TKA from 2016-2020. Patients were stratified depending on the technology utilized: navigation, robotics, or no technology. Patient demographics, clinical data, Forgotten Joint Score-12 (FJS), and Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) were collected at various time points up to 1-year follow-up. Demographic differences were assessed with chi-square and ANOVA. Clinical data and PROMs were compared using univariate ANCOVA, controlling for demographic differences. Results A total of 287(4%) navigation, 367(5%) robotics, and 6442(91%) manual cases were included. Surgical-time significantly differed between the three groups (113.33 vs 117.44 vs 102.11; P Conclusion This study demonstrates shorter operative-time in cases with no utilization of technology and clinically similar PROMs associated with TKAs performed between all modalities. While the use of technology may aid surgeons, it has not currently translated to better short-term outcomes. Level III Evidence Retrospective Cohort.

Background Femoral stem subsidence is a known cause of early implant failure, increasing the risk for aseptic loosening and periprosthetic fracture. Overall survivorship and subsidence in a novel porous tantalum-coated femoral prosthesis have not been well-studied. Methods Consecutive patients undergoing primary total hip arthroplasty with a porous tantalum-coated femoral prosthesis between January 2008 and January 2015 with minimum 5-year follow-up were included. Clinical and radiographic data were obtained from hospital and office records. Multivariate logistic regression analyses were used to determine predictors of subsidence and clinical outcomes. Kaplan-Meier survivorship curves were performed to illustrate primary failure endpoints of (1) all-cause revision and (2) femoral prosthesis revision. Results A total of 398 patients with a mean (±standard deviation) age of 61.0 ± 11.5 years, body mass index (BMI) 32.8 ± 8.0 kg/m2, and follow-up of 6.9 (range 5.0-11.2 years) were included. Survivorship at 5 years was 94.9% for all-cause revision and 98.0% for femoral component revision. Average subsidence was 1.8 ± 1.3 mm (range 0-15.5), with 8.1% patients experiencing subsidence >5 mm. Statistically significant mean improvements were observed at latest follow-up in the Hip Disability and Osteoarthritis Outcome Score Joint Replacement (40.6 ± 11.5 vs 85.2 ± 10.1, P 3 mm. BMI was a statistically significant and independent predictor of subsidence >5 mm (OR 1.25, P 7 mm (OR 1.25, P Conclusion The trabecular metal taper femoral prosthesis conferred excellent clinical outcome improvement and survivorship. Increasing BMI was independently associated with an increased risk of subsidence in these patients and caution is recommended in utilizing this implant in obese, morbidly obese, and super morbidly obese populations.

Background There has been 25-year trend of decreasing value for orthopedic surgical work based on the Resource-Based Relative Value Scale (RBRVS) for Medicare reimbursement. This study was undertaken to estimate the time that Medicare payment rates for time spent in the office doing cognitive work will equal time dedicated in the operating room to performing procedural work based on long-term negative payment trends. Methods The RBRVS Update Committee database was accessed to extract the time elements for 2 procedures, total knee arthroplasty and total hip arthroplasty (27447 and 27130), on the day of surgery. The evaluation and management code mix for 2 mid-sized orthopedic practice was averaged to create an amalgamated rate for the reimbursement of office work on an hourly rate. A graph of the 25-year trend line in Medicare reimbursement for arthroplasty procedures was used to create a trend line. The trend line was then extrapolated to estimate the time in the future that the hourly rate for office work would equal the hourly rate for surgery. Results Time inputs and the Medicare conversion factor for 2021 were used in this analysis. Total procedural time for both 27447 and 27130 was 204 minutes (3.4 hours) on the day of surgery. An amalgamated hourly office rate of 7.9 relative value unit was calculated from the average of the 2 mid-sized private practices for an overall in office Medicare reimbursement of $318.89/h, with $1083.04 for the 3.4 hours allowed in the RBRVS Update Committee database for a joint replacement. When the trend line for reimbursement was extrapolated to the $1083.04 price point, the year corresponding to the point where hourly office reimbursement would equal hourly surgical work was 2024. Conclusion Policymakers in Washington and practicing orthopedic surgeons need to consider the looming economic parity of surgical and cognitive work for Medicare. Continued negative reimbursement rates are likely to decrease patient access to necessary surgical care and result in de facto rationing of arthroplasty services for Medicare patients. The deployment of the orthopedic workforce is likely to change to accommodate the decreases in the value of surgical work. This trend will have significant impact on the practice of musculoskeletal medicine and patient access to orthopedic services.

We characterize variation in total hip arthroplasty (THA) episode payments in the United States. Medicare population immediately preceding implementation of the comprehensive care for joint replacement (CJR) bundled care model and propose a model for ongoing evaluation of hospital performance.We identified THA episodes in Medicare part A 2014-2016 (n = 366,380) and compared 90-day episode payments across years and geographic regions. We fit hierarchical models that regressed episode payments on patient-level fixed and region-level and hospital-level random effects. Random effects estimates were used to characterize risk-adjusted hospital cost performance. We ranked hospitals (n = 3218) in each region by their cost performance estimate and constructed 95% confidence intervals to visualize high-performing and low-performing hospitals.Mean part A episode payments declined from 2014 to 2016 throughout the United States ($19,925-$17,775; P.001), primarily attributable to decreased postacute care payments. Ninety-day readmission rates fell by a percentage point (from 7.9% to 6.8%; P.001). We found significant variation in risk-adjusted episode payments, postacute care utilization, and readmission rates across regions, and ever greater variation at the hospital level.Medicare part A payments decreased for THA episodes between 2014 and 2016. The time frame for this decrease is notable for preceding full implementation of CJR, thus suggesting a more universal embrace of value-based care principles before the start date of CJR. These decreases were primarily because of decreased postacute care utilization and possibly related to falling readmission rates. Yet, significant variation in hospital cost performance remains, even after risk adjustment.

Background Extensor mechanism (EM) disruption after total knee arthroplasty is a catastrophic complication. Reconstruction using monofilament polypropylene mesh (Marlex Mesh; CR Bard, Franklin Lakes, NJ) has emerged as the preferred treatment, but reports are limited to the designing institution. This study describes a nondesigner experience and compares 2 postoperative immobilization strategies: long leg cast vs knee immobilizer. Methods A retrospective review of consecutive EM reconstructions between 2012 and 2019 was performed. Primary repairs and allograft reconstructions were excluded, leaving 33 knees (30 patients) who underwent Marlex reconstruction. Mean time from disruption to reconstruction was 14 months, and 14 of 33 (42%) had previous repair or reconstruction attempts. The mean age was 69 years, and mean body mass index was 35 kg/m2. Postoperatively, extension was maintained using a knee immobilizer in 19 of 33 (58%) patients, whereas 14 of 33 (42%) patients were long leg casted. Kaplan-Meier analysis determined all-cause survivorship free of mesh failure. Results At mean 25-month follow-up, 19 of 33 (58%) EM reconstructions were functioning. Excluding explanted infections (5 recurrent and 2 new), 19 of 26 (73%) EM reconstructions were in situ. Six-year survivorship was 69% and not influenced by immobilization type (cast: 67%, immobilizer: 71%; P = .74). Extensor lag was not associated with immobilization type, improving from a mean preoperative lag of 43° to a mean postoperative lag of 9°. Among successes, University of California at Los Angeles activity and Knee Injury and Osteoarthritis Outcome Score - Joint Replacement score improvements exceeded minimal clinically important difference (2.2-3.3 and 52.5-64.0, respectively). Conclusion Marlex mesh EM reconstruction is a durable and reliable treatment with acceptable clinical results achievable outside the designer institution. Provided sufficient duration and compliance with postoperative immobilization, similar outcomes can be obtained with either a cast immobilizer or a knee immobilizer.

Background Web-based physical therapy (WBPT) is a potential means to reduce costs following total knee arthroplasty (TKA). Although outcomes data support the use of self-directed therapy after TKA, there is a paucity of literature evaluating its cost-effectiveness. This study aimed to determine utilization trends of either outpatient physical therapy (OPPT) or WBPT after TKA, assess the outcomes of patients based on their use of WBPT, OPPT, or both, and evaluate OPPT costs based on the amount of WBPT used. Methods A retrospective review of 701 patients (731 TKAs) was performed. Patients were given a prescription for OPPT and access to a self-directed WBPT program. Functional scores were obtained preoperatively and 6 months postoperatively, and the rate of manipulation under anesthesia (MUA), range of motion, and PT costs were recorded. Results About 49.8% of patients utilized WBPT, 34.7% of patients utilized WBPT and OPPT, and 23% of patients utilized neither source of therapy. Patients that utilized both WBPT and OPPT demonstrated the lowest rates of MUA. There were no differences in postoperative outcomes based on the number of WBPT logins. Overall, PT cost was 3.4× higher for those that underwent MUA. Subgroup analysis of patients that utilized WBPT revealed that the cost and number of PT visits decreased as the number of logins increased. Patients younger than 65 utilized more WBPT and OPPT while demonstrating worse outcomes (lower Knee Injury and Osteoarthritis Outcome Score for Joint Replacement postoperative scores and more MUAs). Conclusion WBPT can be an effective option to offset costs associated with OPPT, without compromising outcomes.

Background Skeletal dysplasias are a heterogeneous group of >400 genetic disorders characterized by abnormal bone growth. Many individuals experience joint pain and limitation, coming to require joint replacement much earlier than the average-statured population. In addition, prosthesis survival rate is less in the dysplastic population. The purpose of this study is to identify risk factors for surgery and provide recommendations to improve surgical outcomes. Methods This a retrospective review of 29 individuals with a skeletal dysplasia who had 64 joint replacements between April 1985 and January 2019 at a single institution. We collected demographics, physical examination, medical history, imaging studies, surgical indication, and complications. Results Spondyloepiphyseal dysplasia was the most common skeletal dysplasia (7), followed by pseudoachondroplasia (4) and multiple epiphyseal dysplasia (4). Average age of the cohort was 40.6 years (range 14-64). Hip arthroplasty (34) was the most commonly performed surgery. The majority of arthroplasties (75%) required custom components. Complication rate was 37.3%, most commonly pulmonary embolism (3) and pneumonia (3). Most complications (81.8%) occurred in individuals with either a pre-existing cardiopulmonary comorbidity or lumbar/sacral deformity. Body mass index did not correlate with complication severity (R = −0.042, P = .752) or rate (R = 0.006, P = .963). Conclusion Surgical complications are highest in patients with pre-existing cardiopulmonary conditions. Body mass index does not predict complications in this cohort. Preoperative evaluations for individuals with skeletal dysplasias should include comprehensive work-up of spine issues and extraskeletal systems that present an operative risk. Intraoperative protocol should include special consideration for placement on the table, airway maintenance, and spinal cord monitoring in select cases.

Background The Comprehensive Care for Joint Replacement model aims to support more efficient care for patients. We examined the impact of patient and surgical characteristics, post-acute care, and clinical outcomes on episode of care (EOC) costs in patients undergoing hip arthroplasty for all diagnoses. Methods We retrospectively collected data from a large database of patients undergoing hip arthroplasty for oncologic and nononcologic diagnoses between 2014 and 2017. We compared EOC costs and outcomes between the 2 groups using Student’s t-tests. We estimated the association between an oncologic-associated procedure and EOC costs from a multiple regression analysis. Results There were 2122 total patients included: 1993 in the nononcologic group and 129 in the oncologic group. The length of stay was significantly greater in the oncologic group (7.2 vs 4.2 days, P = .00). In the post-acute period, a greater proportion of oncologic patients was readmitted (29% vs 14%, P = .05) and discharged to skilled nursing (93% vs 51%, P = .00). Index hospitalization costs (mean difference [MD] $1561, P = .05), skilled nursing costs (MD $5932, P = .001), and total EOC costs (MD $20,012, P = .00) were all greater in the oncologic group. Along with increasing age and fracture diagnosis, an oncologic diagnosis is independently associated with greater EOC costs from a multivariate analysis (β = 16,163 ± 2258, P = .00, r2 = 29%). Conclusion Comprehensive Care for Joint Replacement should incorporate risk adjustment for oncologic disease because hip arthroplasty for an oncologic diagnosis is associated with worse outcomes and greater costs than in the general population.

Background In January 2018, the Center for Medicare and Medicaid Services (CMS) removed total knee arthroplasty (TKA) from the inpatient-only list. This impacted hospital reimbursement, Comprehensive Joint Replacement (CJR) bundle volumes, and bundle performance. We describe these impacts at an academic teaching hospital. Methods We reviewed CJR bundle data provided by CMS and internal databases to identify the shift in CJR TKA episode volume since January 2018, the impact on postacute care (PAC) utilization rates and readmissions, financial impact to the bundle, and impact on hospital reimbursement. We used data provided to CJR participants, internal hospital sources, and the Medicare Limited Data Set. Results Between 2017 and 2018, CJR TKA episodes decreased from 91 to 51 (44% reduction). Inpatient PAC utilization was significantly higher in 2018 (20% vs 8%). The 90-day readmission rates increased from 5.5% to 12.7%. Average variance to target dropped from 15% to 5%. Average CMS reimbursement for TKA at our institution in 2019 was $14,823 for inpatients and $9299 for outpatients. We experienced $930,463 in decreased reimbursement from January 2018 to September 2019 as a result of the shift from inpatient to outpatient. In addition, we expect $625,143 in decreased incentive payments as higher functioning and lower cost outpatient TKAs are excluded from CJR. Conclusion Although CMS projected a minimal impact on CJR bundle participants, this has not been the case at our institution. We experienced reduced volumes, increased PAC utilization, and a substantial financial impact. We expect a similar outcome when CMS removes total hip arthroplasty from the inpatient-only list.

Background Extensive femoral bone loss poses a challenge in revision total hip arthroplasty (rTHA). Many techniques have been developed to address this problem including fully porous cylindrical stems, impaction bone grafting, and cementation of long stems, which have had varied success. Modular tapered fluted femoral stems (MTFS) show favorable results. We sought to determine the minimum 2-year radiographic and clinical performance of MTFS in rTHA in a population with extensive proximal femoral bone loss. Methods Our clinical database was queried retrospectively for all patients who underwent rTHA with an MTFS. We included patients with Paprosky 3 and 4 femoral bone loss and patients with Vancouver B2 and B3 periprosthetic femur fractures. Patients without 2-year follow-up were invited to return to clinic for X-ray evaluation and to complete clinical questionnaires. We assessed distance of stem subsidence and presence of stem fixation on final X-ray. We recorded all-cause revision and survival of the stem at final follow-up. Results One hundred twenty-nine patients were available for follow-up. Average follow-up time was 3.75 years. One hundred twenty-two stems (95%) remained in place at final follow-up. Median subsidence was 1.4 mm (range 0-21). All-cause revision rate was 16.3% (21 patients). Of the hips revised, 10 were for instability, 6 for infection, 1 for aseptic loosening, and 1 for periprosthetic femur fracture. Three were revised for other reasons. The stem was revised in 7 patients (5.4%), and the most common reason for stem revision was infection (5 patients). The other 2 stems were revised for aseptic loosening in a Paprosky 4 femur and periprosthetic femur fracture. Survival of tapered modular fluted stems with aseptic failure as an endpoint was 98.4%. The mean Hip disability and Osteoarthritis Outcome Score, Joint Replacement score at final follow-up was 73, and mean Veterans Rand 12 item health survey physical and mental scores were 32.8 and 52.2, respectively. Conclusion In patients with Paprosky 3, 4 femoral defects or Vancouver type B2, B3 fractures, modular tapered fluted stems for femoral revision show excellent outcomes at minimum 2-year follow-up.

Background Probability-based computer algorithms that reduce patient burden are currently in high demand. These computer adaptive testing (CAT) methods improve workflow and reduce patient frustration, while achieving high measurement precision. In this study, we evaluated the accuracy and validity of the CAT Hip Disability and Osteoarthritis Outcome Score (HOOS) and the Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS-JR) by comparing them to the full version of these scoring systems in a subset of patients who had undergone total hip arthroplasties. Methods A previously developed CAT HOOS and HOOS-JR was applied to 354 and 1547 HOOS and HOOS-JR patient responses, respectively. Mean, standard deviations, Pearson’s correlation coefficients, interclass correlation coefficients, frequency distribution plots, and Bland-Altman plots were used to compare the precision, validity, and accuracy between CAT scores and full-form scores. Results By modifying the questions to past responses, the CAT HOOS demonstrated a mean reduction of 30% of questions (28 vs 40 questions). There were no significant differences between the full HOOS and CAT HOOS with respect to pain (P = .73), symptoms (P = .94), quality of life (P = .99), activities of daily living (P = .82), and sports (P = .99). There were strong linear relationships between the CAT versions and the standard questionnaires (r > 0.99). The Bland-Altman plot showed that differences between CAT HOOS and full HOOS were independent of the overall scores. Conclusion The CAT HOOS and HOOS-JR have high correlation and require fewer questions to finish compared to the standard full-form questionnaires. This may represent a reliable and practical alternative that may be less burdensome to patients and may help improve compliance for reporting outcome metrics.

Background Achieving appropriate limb length and offset in total hip arthroplasty (THA) is challenging. Target limb length and offset may not always mean equal radiographic measurements bilaterally. The goal of this study is to introduce a method for determining as well as achieving target limb length and offset using digital radiographic measurements. Methods One hundred and two consecutive patients with unilateral hip osteoarthritis undergoing primary THA in the lateral decubitus position were included. Limb length and offset were measured on anterior-posterior pelvic radiographs preoperatively, intraoperatively, and postoperatively. Offset was defined as the length of a line parallel to the inter-teardrop line, extending from the edge of the ischium, at about the lower border of the ipsilateral obturator foramen, to the edge of the femoral cortex, usually at, or just below, the neck resection level. Target limb length was determined for each patient based on patient perception and severity of disease. Target offset equaled the contralateral limb. Using intraoperative digital radiography, adjustments were made until targets were achieved and the hip was stable. Patients were followed for an average of 4.2 years postoperatively. Results Limb length was within 5 mm of target measurements in 100% of patients and offset was within 5 mm of targets in 97.1%. Target measurements differed by >5 mm from the contralateral side in 2.0% of limb length and 2.9% of offset measurements. There were no significant differences between intraoperative and postoperative limb length (P = .261) or offset (P = .747) measurements. At final follow-up, there were no dislocations or reoperations and average Hip disability and Osteoarthritis Outcome Score for Joint Replacement was 95.78. Conclusion Target limb length and offset goals can be determined for most patients undergoing THA. Targets are not always equal to the contralateral side. Intraoperative digital radiography can allow surgeons to accurately achieve target limb length and offset to within 5 mm in a homogenous cohort of patients with unilateral hip osteoarthritis with excellent clinical outcomes.

Background Racial disparities in functional outcomes after total knee arthroplasty (TKA) exist. Whether differences in rehabilitation utilization contribute to these disparities remains to be investigated. Methods Among 8349 women enrolled in the prospective Women's Health Initiative cohort who underwent primary TKA between 2006 and 2013, rehabilitation utilization was determined through linked Medicare claims data. Postacute discharge destination (home, skilled nursing facility, and inpatient rehabilitation facility), facility length of stay, and number of home health physical therapy (HHPT) and outpatient physical therapy (OPPT) sessions were compared between racial groups. Results Non-Hispanic black women had worse physical function (median score, 65 vs 70) and higher likelihood of disability (13.2% vs 6.9%) than non-Hispanic white women before surgery. After TKA, black women were more likely to be discharged postacutely to an institutional facility (64.3% vs 54.5%) than white women, were more likely to receive HHPT services (52.6% vs 47.8%), and received more HHPT and OPPT sessions. After stratification by postacute discharge setting, the likelihood of receipt of HHPT or OPPT services was similar between racial groups. No significant difference in receipt of HHPT or OPPT services was found after use of propensity score weighting to balance health and medical characteristics indicating severity of need for physical therapy services. Conclusion Rehabilitation utilization was generally comparable between black and white women who received TKA when accounting for need. There was no evidence of underutilization of post-TKA rehabilitation services, and thus disparities in post-TKA functional outcomes do not appear to be a result of inequitable receipt of rehabilitation care.

Background The introduction of new technology in joint replacement surgery requires close monitoring to identify early successes and failures. This monitoring can be effectively performed through the analysis of registry data and radiostereometric analysis studies. This study examined the revision rates of a contemporary knee system for total knee arthroplasty (TKA) using National Joint Replacement Registries. Methods A review of the literature was performed to identify comparative studies and registry databases reporting the revision rates of a specific contemporary knee design between 2013 and 2018. The total number of TKA cases performed using this implant was recorded. The latest follow-up or duration of monitoring through a registry database was used to report implant survivorship. Results There were 4 registry databases and 1 comparative study reporting the revision rates of the contemporary knee system. A total of 41,483 cases were identified with a follow-up range of 1.5-5.0 years. The all-cause revision rate ranged from 0.7% to 2.5% at latest follow-up. This was comparable to all-cause revision rates of other knee systems reported in the registries, ranging from 0.8% to 5.6% over similar follow-up periods. Conclusions Evaluation of data from multiple national joint registries demonstrated the revision rate for this contemporary knee system to be comparable to other TKA systems at latest follow-up. None of the registries have identified any concerning rates of revision compared to other devices at this length of follow-up. National Joint Registries are an important resource in evaluating the short-term, mid-term, and long-term results of new implant designs introduced to the market.

Background For several years, many orthopedic surgeons have been performing total joint replacements in hospital outpatient departments (HOPDs) and more recently in ambulatory surgery centers (ASCs). In a recent shift, the Centers for Medicare and Medicaid Services began reimbursing for total knee replacement surgery in HOPDs. Some observers have expressed concerns over patient safety for the Medicare population particularly if Centers for Medicare and Medicaid Services extends the policy to include total hip replacement surgery and coverage in ASCs. Methods This study used a large claims database of non-Medicare patients to examine inpatient and outpatient total knee replacement and total hip replacement surgery performed on a near-elderly population during 2014-2016. We applied propensity score methods to match inpatients with ASC patients and HOPD patients with ASC patients adjusting for risk using the HHS Hierarchical Condition Categories risk adjustment model. We conducted statistical tests comparing clinical outcomes across the 3 settings and examined relative costs. Results Readmissions, postsurgical complications, and payments were lower for outpatients than for inpatients. Within outpatient settings, readmissions and postsurgical complications were lower in ASCs than in HOPDs but payments for ASC patients were higher than payments for HOPD patients. Conclusion Our findings support the argument that outpatient total joint replacement is appropriate for select patients treated in both HOPDs and ASCs, although in the commercially insured population, the latter services may come at a cost. Until further study of outpatient total joint replacement in the Medicare population becomes available, how this will extrapolate to the Medicare population is unknown.

Background Joint replacement surgery is in increasing demand and is the most common inpatient surgery for Medicare beneficiaries. The venue for post-operative rehabilitation, including early outpatient therapy after surgery, influences recovery and quality of life. As part of a comprehensive total joint program at Kaiser Permanente Colorado, we developed and validated a predictive model to anticipate and plan the disposition for rehabilitation of our patients after total knee arthroplasty (TKA). Methods We analyzed data for TKA patients who completed a pre-operative Total Knee Risk Assessment in 2017 (the model development cohort) or during the first 6 months of 2018 (the model validation cohort). The Total Knee Risk Assessment, which is used to guide disposition for rehabilitation, included questions in mobility, social, and environment domains. Multivariable logistic regression was used to predict discharge to post-acute care facilities (PACFs) (ie, skilled nursing facilities or acute rehabilitation centers). Results Data for a total of 1481 and 631 patients who underwent TKA were analyzed in the development and validation cohorts, respectively. Ninety-three patients (6.3%) in the development cohort and 22 patients (3.5%) in the validation cohort were discharged to PACFs. Eight risk factors for discharge to PACFs were included in the final multivariable model. Patients with a diagnosis of neurological disorder and with a mobility/balance issue had the greatest chance of discharge to PACFs. Conclusion This validated predictive model for discharge disposition following TKA may be used as a tool in shared decision-making and discharge planning for patients undergoing TKA.

BACKGROUND Anterior cruciate ligament (ACL) deficiency is commonly considered a contraindication for unicompartmental knee arthroplasty (UKA). The purpose of this study is to compare the outcomes of UKA after prior ACL reconstruction (rACL cohort) to UKA with an intact native ACL (nACL cohort). METHODS Forty-five patients from 3 institutions who underwent medial UKA after prior rACL were matched by age, gender, preoperative function scores, and body mass index to 90 patients who underwent UKA with an intact nACL. Primary outcomes were Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Oxford Knee Scores, Knee Society Functional Scores, and Kellgren-Lawrence scores in the unresurfaced, lateral tibiofemoral compartment. Secondary outcomes were postoperative complications and the need for revision to TKA. RESULTS At a mean of 3.6 years, all PROMs improved significantly with no differences identified between groups. The incidence of revision TKA was similar between cohorts (P = 1.00); however, the mean time to revision for progressive osteoarthritis was 4.0 years in the nACL group and 2.2 years in the rACL group. Twenty percent of rACL patients had a postoperative complication compared to 8% in the nACL group. Despite presenting with a similar degree of lateral arthritis, a greater percentage of patients developed Kellgren-Lawrence scores of ≥3 in the rACL cohort (9%) than in the nACL cohort (0%). CONCLUSION A previously reconstructed ACL does not appear to compromise the short-term functional outcomes of UKA; however, there is a higher rate of minor complications and progression of lateral compartment arthritis, which should be considered with patients in the shared decision process.

Background In order to reduce the incidence of total hip joint replacement revision for wear, multiple advanced materials and alloys targeting hip replacement tribology have been introduced. Ion implantation of chromium-cobalt heads is thought to reduce wear due to increased surface hardness and lower friction. These advances in technology result in additional manufacturing costs. However, it is unclear whether these attributes result in a decreased rate of revision for wear and when used with modern highly crosslinked polyethylene (XLPE). The aim of this study is to compare the survivorship of stainless steel and ion-implanted chromium-cobalt femoral heads in order to determine whether ion implantation has a lower risk of revision. Methods Data from the Australian Orthopedic Association National Joint Replacement Registry included all stainless steel and low-friction ion-treated (LFIT) femoral heads used in conjunction with a primary Exeter/Trident hip replacement combination and XLPE liners performed for osteoarthritis. Kaplan-Meier estimates of survivorship were used to describe the time to first revision. Hazard ratios (HRs) from Cox proportional hazard models, with adjustment for age and gender, were used to compare revision rates between the 2 groups. Results There were 40,468 total hip replacements that met the inclusion criteria. Stainless steel heads had a lower revision rate compared to LFIT chromium-cobalt heads (HR 0.87, 95% confidence interval 0.76-1.00, P = .048). The difference in the rate of revision was even greater when 32-mm heads were used (HR 0.72, 95% confidence interval 0.58-0.89, P = .002). There was no difference in revision for loosening between head alloys or when stratified by age. Conclusion Given the increased costs associated with LFIT implants and the lower rate of revision for stainless steel heads, we recommend the use of a stainless steel heads when using an Exeter/Trident hybrid hip with an XLPE liner.

Background Self-directed rehabilitation (SDR) after total knee arthroplasty (TKA) has not been traditionally recommended. The purpose of this study was to determine if there was an impact on postoperative outcomes with the use of an SDR program after primary TKA. Methods In this prospective, randomized, multicenter, controlled trial, we paired a smartwatch with a mobile application, providing an SDR program after TKA. Three groups were examined in this level I study: (1) control group (formal physical therapy [PT]), (2) high exercise compliance group, and (3) low exercise compliance group. Patient-reported outcome measures (PROMs) of knee injury and osteoarthritis outcome scores, joint replacement (KOOS, JR), and EuroQol five-dimension five-level (EQ-5D-5L) along with range of motion (ROM) and manipulation rates were evaluated. Results Three hundred thirty-seven patients were enrolled in two groups with 184 in the control group and 153 in the study groups (90 in the high-compliance group and 63 in the low-compliance group). The KOOS, JR score was statistically lower in the low-compliance group in net change from preoperative scores at 3 months (P = .046) and 6 months (P = .032) than that in the control group; difference was noted at 6 months for the high-compliance group, P = .036. However, these did not meet the threshold of 8.02 units for KOOS JR minimal clinically important difference. No differences were seen in PROMs at other time intervals and in manipulation rates or ROM. Conclusion Postoperative outcomes including manipulation under anesthesia, ROM, and PROMs were not different when a smartwatch paired with a self-directed PT mobile application was compared with traditional formal PT. Surgeons can consider this an appropriate alternative to traditional PT programs after TKA.

Opioid prescriptions and subsequent opioid-related deaths have increased substantially in the past several decades. Orthopedic surgery ranks among the highest of all specialties with respect to the amount of opioids prescribed. We present here the outcomes of our opioid-sparing pain management pilot protocol for total hip arthroplasty (THA).A retrospective study was conducted to assess outcomes before and after the implementation of an opioid-sparing pain management protocol for THA. Patients were divided into 2 cohorts for comparison: (1) traditional pain management protocol and (2) opioid-sparing pain management protocol. The Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, pain severity using a Visual Analog Scale, and inpatient morphine milligram equivalents (MMEs) per day were compared between the 2 cohorts.No statistically significant difference was observed in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement between the 2 cohorts at any time point (P.05). Although there was a significant decrease in pain scores over time (P.01), there was no statistically significant difference in the rates of change between the 2 pain management protocols at any time point (P = .463). Inpatient opioid consumption was significantly lower for the opioid-sparing cohort in comparison to the traditional cohort (14.6 ± 16.7 vs 25.7 ± 18.8 MME/d, P.001). Similarly, the opioid-sparing cohort received significantly less opioids than the traditional cohort during the post discharge period (13.9 ± 24.2 vs 80.1 ± 55.9 MME, P.001).The results of this study suggest that an opioid-sparing protocol reduces opioid consumption and provides equivalent pain management and patient-reported outcomes during the 90-day THA episode of care relative to a traditional opioid-based regimen. These findings may help decrease the risk of adverse events associated with postoperative opioid use and provide a means of decreasing the opioid footprint in clinical practice.

Background Multiple papers have purported the superiority of spinal anesthesia used in total joint arthroplasty (TJA). However, there is a paucity of data available for modern general anesthesia (GA) regimens used at high-volume joint replacement centers. Methods We retrospectively reviewed a series of 1527 consecutive primary TJAs (644 total hip arthroplasties and 883 total knee arthroplasties) performed over a 3-year span at a single institution that uses a contemporary GA protocol and report on the length of stay, early recovery rates, perioperative complications, and readmissions. Results From the elective TJAs performed using a modern GA protocol, 96.3% (n = 1471) of patients discharged on postoperative day 1, and 97.2% (n = 1482) of subjects were able to participate with physical therapy on the day of surgery. Only 6 patients (0.4%) required an intensive care unit stay postoperatively. The 90-day readmission rate over this time was 2.4% (n = 36), while the reoperation rate was 1.3% (n = 20). Discussion Neuraxial anesthesia for TJA is commonly preferred in high-volume institutions utilizing contemporary enhanced recovery pathways. Our data support the notion that the utilization of modern GA techniques that limit narcotics and certain inhalants can be successfully used in short-stay primary total joint arthroplasty. Level of Evidence IV– Case series.

Bundled reimbursement models for total knee arthroplasty (TKA) by the Center for Medicare and Medicaid Services have resulted in an effort to decrease the cost of care. However, these models may incentivize bias in patient selection to avoid excess cost of care. We sought to determine the impact of the Comprehensive Care for Joint Replacement (CJR) model at a single center.This is a retrospective review of primary TKA patients from July 2015 to December 2017. Patients were stratified by whether or not their surgery was performed before or after implementation of the CJR bundle. Patient demographic data including age, sex, and body mass index were collected in addition to Elixhauser comorbidities and American Society of Anesthesiologists score. In-hospital outcomes were then examined including surgery duration, length of stay, discharge disposition, and direct cost of care.A total of 1248 TKA patients (546 Medicare and 702 commercial insurance) were evaluated, with 27.0% undergoing surgery before the start of the bundle. Compared to patients following implementation of the bundle, there was no significant difference in age, gender, or body mass index. However, pre-CJR Medicare patients were more likely to have fewer Elixhauser comorbidities (P.001), prolonged length of stay (P.001), and greater discharges to inpatient facilities (P = .019). There was no significant difference in direct hospital costs or operative service time comparing pre-bundle and post-bundle patients.Implementation of the bundled reimbursement model did not result in biased patient selection at our institution; importantly, it also did not result in decreased hospital costs despite apparent improvement in value-based outcome metrics. This should be taken into consideration as future adaptations to reimbursement are made by the Center for Medicare and Medicaid Services.

Background Postoperative complications are the main consumers of technical, medical, and human resources. Especially in the field of elective joint replacement surgery, a specialized, easy-to-obtain, and cost-efficient preoperative stratification and risk-estimation model is missing. Methods With preoperatively surveyed patient parameters, we identified the most relevant parameters to predict postoperative medical complications. We devised a prospective risk model, measuring the individual probability for intermediate care unit (IMC) or intensive care unit (ICU) admission. The study includes all patients (n = 649) treated with primary or revision total knee arthroplasty in our clinic from 2008 to 2012. Results The association between general comorbidity scores and mortality risk is well known. Among different comorbidity scores, the Charlson Comorbidity Index is not only relevant for overall postoperative complications (odds ratios [OR] = 2.20) but also predictive of specific complications such as the postoperative need for blood transfusion (OR = 1.94) and unexpected adverse events (OR = 1.74). Considering adverse events, c-reactive protein and leukocyte levels are also highly relevant. Upon predicting a necessary postoperative transfer to an IMC or ICU, the preoperative hemoglobin level, the Charlson Comorbidity Index, and the Index of Coexistent Disease stood out. The latter indicates an increased rate for an IMC/ICU stay by 341% per point. Condensing the most influential predictors, the probability for postoperative IMC/ICU transfer can be calculated for each individual patient. Using the routinely assessed patient's variables, no steadier prediction is possible. Conclusion The introduced risk-estimation model offers a specialized preoperative resource-stratification method in knee joint replacement surgery. It condenses the most influential, individual risk factors to avoid clinical test redundancy and improve resource efficiency and presurgical care planning. A prospective follow-up study could help validating the risk model in clinical routine.

With improved materials and bearing surfaces, the use of total hip arthroplasty (THA) in young patients is increasing. Functional outcomes and activity level are particularly relevant in this higher-demand patient population. There is a paucity of data on patient-reported outcomes and activity levels after THA in extremely young (21 years old) patients.We identified 196 patients (222 hips) who underwent THA at age21 years at our institution from 1982 to 2018. After applying exclusion criteria, 113 of 160 (70.6%) patients (129 hips) were available for follow-up. Patient activity levels and functional outcomes were evaluated using the UCLA activity score, Forgotten Joint Score (FJS), Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, and a validated 5-question satisfaction survey. Survivorship and reasons for revision were recorded.The mean age at surgery was 17.0 ± 2.8 years, and the mean follow-up was 13.2 years (range 2-38 years). The most common indications for THA were osteonecrosis (34%) and juvenile idiopathic arthritis (30%). The mean UCLA activity score was 5.9 ± 2.0, and 64% of patients reported a score ≥6. The mean FJS was 57.9 ± 31.0. The mean Hip Disability and Osteoarthritis Outcome Score for Joint Replacement score was 84.6 ± 16.6. Ninety percent of patients reported that they were very or somewhat satisfied with their surgery. At final follow-up, 27 of 129 (20.9%) hips had undergone revision surgery.THA performed in patients under 21 years of age with end-stage hip disease allows for high levels of activity and satisfaction postoperatively, with most patients being able to participate in moderate recreational activities. These data may be useful for surgeons in planning for and counseling extremely young patients indicated for THA.

Background Digital patient engagement has been suggested as a mean to increase patient activation and patient satisfaction after total joint arthroplasty. The purpose of this study was to assess patient engagement with application-based educational tools and to explore what content was most useful to patients in the perioperative period surrounding total hip arthroplasty (THA) and total knee arthroplasty (TKA), respectively. Methods Patients undergoing THA and TKA between October 2017 and January 2020 were enrolled to use an application-based digital technology. The App provides comprehensive patient education using a series of modules delivered at set intervals preoperatively and postoperatively. Patient engagement was defined as patients viewing at least one time the modules that were sent, or marking them as completed. Patient satisfaction was assessed using an in-application survey. Results Complete data were available on 207 patients of which 95 (46%) underwent THA and 112 (54%) underwent TKA. The average age was 60 years. 54% with patients invited to the program completed registration. An average compliance rate of 48% (41 modules engaged out of 83) was observed. Of all modules completed, the top three most popular categories included physical therapy/exercise videos, health literacy, and anxiety/stress/pain management. The least viewed category was nutrition planning and education. Conclusion When presented educational material related to THA and TKA, patients had a high rate of compliance. Digital technology platforms provide a scalable, meaningful approach to engaging patients throughout the continuum of joint replacement care and may serve as a cost-effective adjunct to traditional methods.

The use of technology such as navigation and robotic systems may improve the accuracy of component positioning in total hip arthroplasty (THA), but its impact on patient-reported outcome measures (PROMs) remains unclear. This study aims to elucidate the association between the use of intraoperative technology and PROMs in patients who underwent primary THA.We retrospectively reviewed a consecutive series of patients who underwent primary THA between 2016 and 2020 and answered PROM questionnaires. Patients were separated into 3 groups depending on intraoperative technology utilization: computer-assisted navigation, robotic-assisted, or no technology (conventional) THA. Forgotten Joint Score-12 and Hip disability and Osteoarthritis Outcome Score, Joint Replacemen scores were collected at various time points. Demographic differences were assessed with chi-square and analysis of variance. Mean scores between groups were compared using univariate analysis of covariance, controlling for all significant demographic differences.Of the 1960 cases identified, 896 used navigation, 135 used robotics, and 929 used no technology. There were significant statistical differences in one-year Hip disability and Osteoarthritis Outcome Score, Joint Replacement scores (85.23 vs 85.95 vs 86.76, respectively; P = .014) and two-year Forgotten Joint Score-12 scores (64.72 vs 73.35 vs 74.63, respectively; P = .004) between the 3 groups. However, these differences did not exceed the mean clinically important differences. Length of stay was statistically longest for patients who underwent conventionally performed THA versus navigation and robotics (2.22 vs 1.46 vs 1.91, respectively; P.001). Surgical time was significantly longer for cases performed using robotics versus navigation and conventionally (119.61 vs 90.35 vs 95.35, respectively; P.001).Statistical differences observed between all modalities are not likely to be clinically meaningful with regard to early patient-reported outcomes. Although intraoperative use of technology may improve the accuracy of implant placement, these modalities have not yet translated into improved early reported functional outcomes.Retrospective cohort.

BACKGROUND Most studies on cementless total knee arthroplasty (TKA) have excluded patients >75 years due to concerns that older patients have poorer bone mineral density and osteogenic activity. This study compared the midterm outcomes and survivorship of cemented and cementless TKA of the same modern design performed in patients >75 years. METHODS We identified a consecutive series of 120 primary cementless TKA performed in patients >75 years. Each case was propensity score matched 1:3 with 360 cemented TKA of the same modern design based on age, sex, body mass index, Charlson Comorbidity Index, bilateral procedures, liner type and year of surgery. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and Short Form-12 (SF-12) were collected preoperatively, at 6 months and 2 years. Implant survivorship was recorded at mean 4.2 years (range, 2.0-7.9). RESULTS Mean age was 79.0±3.4 years (range, 75-92) in the cemented cohort and 78.9±3.5 (range, 75-91) in the cementless cohort (p=0.769). There was no difference in final postoperative scores or improvement in scores at 2 years. The percentage of patients that met the minimal clinically important difference was also similar (KOOS-JR, 68.9% vs. 69.2%, p=0.955; SF-12 Physical, 71.7% vs. 66.7%, p=0.299). Seven-year survivorship free from aseptic revision was 99.4% for cemented knees and 100% for cementless knees (log-rank, p=0.453). CONCLUSION Patients over 75 years undergoing cementless or cemented TKA of the same modern design had comparable outcomes and survivorship in the midterm. The theoretical risks of cementless fixation in this age group were not realized in this study.

The purpose of this study was to determine whether robotic total knee arthroplasty (R-TKA) demonstrated evidence of improvement in minimal clinically important difference (MCID) in early (4 weeks) and intermittent (4-8 month) patient-reported outcomes compared with manual total knee arthroplasty (M-TKA).A prospectively collected database was reviewed of 1160 consecutive patients undergoing R-TKA or M-TKA from December 2017 to October 2019. Primary outcomes consisted of Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and Patient-Reported Outcomes Measurement Information System Global Health Measures of Physical Health (PH) and Mental Health (MH). Statistical analysis included MCID via the distribution method.Univariate analysis demonstrated conflicting results for early MCID achievement favoring M-TKA (4-week KOOS-JR, P = .03) for the multisurgeon cohort, but favored R-TKA (4-week Patient-Reported Outcomes Measurement Information System-PH, P = .04) in the single-surgeon analysis, and the remaining outcome scores were similar. Ultimately, multivariate analysis demonstrated similar 4-week and 6-month MCID achievement in all measures. Lower preoperative scores consistently achieved MCID at a higher rate in M-TKA, although in R-TKA, the higher baseline scores improved at a rate comparable with those with lower scores in all but the short-term postoperative KOOS-JR.R-TKA demonstrated comparable MCID achievement to M-TKA across the larger cohort. Single-surgeon comparison did show some early benefit. Confounding variables such as surgical technique, implant fixation, and responsiveness of an outcome measure may be as important as simply what tools are used during surgery. Such granular data should be sought out in future studies.

Background Enhanced implant longevity through biological fixation is achievable using cementless total knee arthroplasty but concerns about patellar component failure have lingered because of prior experiences with older component designs. A new metal-backed patella (MBP) design was released which features a 3-dimensional printed porous titanium metal backing to improve biologic fixation potential and a unique compression molding technique to create a stronger interlock layer between the polyethylene and metal backing. Our study purpose was to determine the clinical and radiographic outcomes and survivorship of this novel cementless MBP. Methods Our institutional registry identified 388 cementless MBP with minimum 2-year and 80 with minimum 5-year follow-up. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement and 12-item Veterans RAND/Short Form Health Survey (VR/SF-12) scores were used to evaluate clinical outcomes. Aseptic loosening noted on radiographs as well as revision for any reason were the end points used to determine survivorship. Results Improvement in the preoperative Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, VR/SF-12 physical health and mental health scores were all statistically significant at 2-year follow-up and the VR/SF-12 mental health score at 5-year follow-up. By radiologic criteria, biologic fixation of the patellar component was present in all except 1 case at 2 years (99.6%) and at 5 years (97.7%). Radiolucent lines were present in 15 cases (6.2%) at 2 years and in 6 cases (14%) at 5 years, but progressive increase in radiolucent lines was seen in only 4 cases. No component was revised for loosening; aseptic survivorship was 100%. Conclusion This 3-dimensional printed cementless patellar component shows excellent survivorship at 2-year and 5-year follow-up. We are hopeful about the long-term durability of this implant.

Identifying predictors of failed same-day discharge (SDD) is critical for patient selection. We evaluated patient factors associated with failure of SDD in patients undergoing elective total joint arthroplasty (TJA) in a hospital setting.We retrospectively reviewed consecutive patients who underwent primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) between January 31, 2018 and February 1, 2020 by one of the 3 fellowship-trained arthroplasty surgeons. Patient demographics, comorbidities, and clinical data were collected. Analysis was performed to assess risk factors for failed SDD.In total, 2615 TJAs (1425 TKAs, 1190 THAs) were performed over the study period. Two hundred seventy-one (10.4%) were SDDs (80 TKAs, 191 THAs). There were fewer TKAs than THAs (5.6% vs 16.1%, P.001). Forty-five patients failed SDD (16.6%). Failure rates were similar in TKA and THA (18.8%, 15.7%, P = .54). The most common reasons for failure of SDD were hypotension (11, 24.4%), delayed resolution of spinal anesthesia (11, 24.4%), and nausea (5, 11.1%). Age over 70 years (P = .007), greater than 2 self-reported allergies (P.001), and preoperative narcotic use (P = .01) were associated with failure of SDD. Gender, body mass index, American Society of Anesthesiologists class, and prior TJA were not significantly associated (P.05).Success of SDD was greater than 80%. Hypotension, delayed resolution of spinal anesthesia, and nausea accounted for 60% of failures of SDD. Patients70 years, those with2 self-reported drug allergies, or patients who used preoperative narcotics were at high risk for failure of SDD after THA or TKA.

Tibial component loosening is one of the most common modes of failure in contemporary total knee arthroplasty (TKA). Limited literature is available on the outcomes of isolated tibial revision with retention of the cruciate retaining (CR) femoral component. The purpose of this study was to determine the results of isolated tibial revisions in CR TKA.We identified 135 patients who underwent an isolated tibial revision after a primary CR TKA from our institutional registry between January 2007 and January 2017. The mean time between the primary and revision was 2.9 years (range 0.1-15.4). Revision with a press-fit stem was performed in 79 patients and 56 patients were revised with a fully cemented stem. Patients were evaluated at a minimum of two years using Knee Society Score, Knee Injury and Osteoarthritis Score for Joint Replacement, and radiography. Implant survivorship was determined using Kaplan-Meier survival analysis.At a mean follow-up of 5.1 years, there were six (4.4%) repeat revisions: three for periprosthetic infection (2.2%), two for instability (1.5%), and one for a fractured tibial stem (0.7%). The mean Knee Society Score and Knee Injury and Osteoarthritis Score for Joint Replacement increased from 51.6 and 56.1 preoperatively to 90.1 and 89.7 after surgery (P.001). Survivorship free of repeat revision for any cause was 93.3% at 5 years, and aseptic revision survivorship was 95.8% at 5 years. No implants were radiographically loose.In patients with isolated tibial loosening and a well-fixed and well-positioned CR femoral component, isolated tibial revision provides excellent early to midterm implant survivorship and clinical outcomes with a low risk of instability and recurrent tibial loosening.

Background Overlap between Medicare’s Comprehensive Care for Joint Replacement (CJR) and accountable care organizations (ACOs) may result in positive or negative synergies. In this study, we describe the overlap between the programs at the beneficiary and hospital levels. Methods We conducted a retrospective study of patient and hospital characteristics using data from 2016 Medicare claims, the US Census Bureau, the American Hospital Association annual survey, Hospital Compare, and the Centers for Medicare & Medicaid Services Improving Medicare Post–Acute Care Transformation file. On the beneficiary level, we conducted two comparisons: 1) among patients who received joint replacement at CJR hospitals, ACO patients (Overlap) versus not (CJR-only) and 2) among patients who received joint replacement elsewhere, ACO patients (ACO-only) versus not (Neither). On the hospital level, we compared hospitals in the top quartile of overlap rate (High Overlap) versus those in the bottom three (Low Overlap). Results We studied 14,519 Overlap, 38,972 CJR-only, 26,872 ACO-only, and 68,945 Neither beneficiaries. Compared to CJR-only patients, the Overlap group was less likely to be older than 85, of Black race, of low socioeconomic status, and burdened with clinical complications. Similar results were observed when the ACO-only group was compared to the Neither group. Compared to Low Overlap hospitals, High Overlap ones were more likely to be non-profit and less likely to be safety-net. Conclusions CJR-ACO overlap is associated with differences in beneficiary and hospital characteristics, which raises key issues for providers and policymakers.

Background: Kinematic alignment (KA) in total knee arthroplasty (TKA) replicates individual knee joint line orientation and physiological soft tissue balance. There are limited data on the effect of KA on survivorship compared with other methods of implanting a TKA. The aim of this study was to compare the survivorship of the same design of TKA implanted with either patient-specific instrument (PSI) KA or with computer-assisted surgery and conventionally instrumented. Methods: We performed an observational study of data from 2 national joint registries on all patients who underwent a TKA with a Triathlon cruciate-retaining TKA (Stryker, Mahwah, NJ) from January 2011 to December 31, 2013. The outcomes of knees performed with unrestricted KA using patient-specific instrument were compared with computer-assisted surgery and conventionally instrumented Triathlon cruciate-retaining TKA. The principal outcome measure was time to first revision using Kaplan-Meier estimates of survivorship. Cox proportional hazard ratios, adjusted for age and gender, were used to compare the 2 groups. Results: There were 20,512 TKA procedures recorded, of which 416 were performed using KA-PSI. The KA-PSI group was younger (66.8 ± 8.2 vs 68.3 ± 9.2, P = .001), with an identical gender distribution. The cumulative revision rate at 7 years was 3.1% for the KA-PSI Triathlon cohort and 3.0% for the other Triathlon TKA cohort (P = .89). The most common reasons for revision in the KA-PSI group were maltracking, patella erosion, and arthrofibrosis. Conclusion: Kinematically aligned Triathlon TKA using PSI has similar revision rate as all other Triathlon TKA.

It is vital for orthopedic residents and residency programs to have a current understanding of the materials and resources utilized on the Orthopedic In-Training Examination (OITE) to tailor resident educational curricula accordingly. This study presents an updated analysis of the hip and knee section of the OITE.All OITE questions related to hip and knee reconstruction over six examinations between 2014 and 2019 were analyzed for topic, subtopic, taxonomy, imaging modalities, resident performance, and references.There were 166 hip and knee reconstruction questions of 1600 OITE questions (10.4%) over a six-year period. The most commonly tested topics include mechanical properties of total knee and hip implants (10.8%), instability after THA (10.8%), periprosthetic fracture (10.2%), and prosthetic joint infection (10.2%). A total of 362 references were cited from 68 different sources. The most common sources were JOA, JBJS, JAAOS, and CORR, which were collectively responsible for 68% of all citations. There was an average publication lag of 7.1 years, with 75% of all citations falling within 10 years of the question date. Compared with a prior analysis from 2005 and 2009, there were significantly more complex multistep questions regarding treatment and fewer one-step knowledge recall questions (P = .003). Similarly, recent tests had significantly more questions involving interpretation of radiographs (55%, P.001) and advanced imaging (9.6%, P.001), compared with a decade ago.The OITE continues to evolve over time, incorporating recent literature and topics. The current analysis identifies high-yield topics and resources that can guide resident preparation for the OITE hip and knee section.

Background Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age. They are associated with disparities in outcomes following total joint arthroplasty (TJA). These disparities occur even in equal-access healthcare systems such as the Veterans Health Administration (VHA). Our goal was to determine whether SDOH affect patient-reported outcome measures (PROMs) following TJA in VHA patients. Methods Patients scheduled to undergo total hip or knee arthroplasty at VHA Hospitals in Minneapolis, MN, Palo Alto, CA, and San Francisco, CA, prospectively completed PROMs before and 1 year after surgery. PROMs included the Hip disability and Osteoarthritis Outcome Score, the Knee injury and Osteoarthritis Outcome Score, and their Joint Replacement subscores. SDOH included race, ethnicity, marital status, education, and employment status. The level of poverty in each patient’s neighborhood was determined. Medical comorbidities were recorded. Univariate and multivariate analyses were performed to determine whether SDOH were significantly associated with PROM improvement after surgery. Results On multivariate analysis, black race was significantly negatively correlated with knee PROM improvement and Hispanic ethnicity was significantly negatively correlated with hip PROM improvement compared to whites. Higher baseline PROM scores and lower age were significantly associated with lower PROM improvement. Significant associations were also found based on education, gender, comorbidities, and neighborhood poverty. Conclusion Minority VHA patients have lower improvement in PROM scores after TJA than white patients. Further research is required to identify the reasons for these disparities and to design interventions to reduce them.

Background The knee injury osteoarthritis outcomes survey, Joint Replacement (KOOS, JR) is a reliable, responsive and validated patient-reported outcome measure (PROM) of knee health in patients with knee osteoarthritis undergoing unilateral primary total knee arthroplasty (TKA). The validity of the KOOS, JR for revision TKA remains unknown. Methods We identified 314 patients who underwent revision TKA and had completed preoperative and 2-year postoperative PROMs. Validation included assessment of: local dependence, unidimensionality, internal consistency, external construct validity, responsiveness, and floor effects preoperatively and ceiling effects at 2 years postoperatively. Results Among patients undergoing revision TKA, the KOOS, JR demonstrated an absence of residual item correlation, adequate unidimensionality, high internal consistency (Person Separation Index 0.897), and high external construct validity with existing validated PROMs, including KOOS Pain (Spearman’s correlation coefficient 0.89) and KOOS Activities of Daily Living (0.90) domains. The KOOS, JR was more responsive (standardized response means: 1.14) to revision TKA than other common knee PROMs. Three percent of revision TKA patients were at the floor (lowest score) pre-operatively and 9% reached the ceiling (highest possible score) post-operatively. Conclusions KOOS, JR performs well in revision TKA patients with regard to internal consistency, external validity, responsiveness, and floor & ceiling effects. Our results support extending its use to revision TKA in both clinical and research settings.

Bundled payments are meant to reduce costs and improve quality of care. Without adequate risk adjustment, bundling may be inequitable to providers and restrict access for certain patients. This study examines patient factors that could improve risk stratification for the Comprehensive Care for Joint Replacement (CJR) bundled-payment program.Ninety-five thousand twenty-four patients meeting the CJR criteria were retrospectively reviewed using administrative Medicare data. Multivariable regression was used to identify associations between patient factors and traditional (fee-for-service) Medicare reimbursement over the bundle period.Average reimbursement was $18,786 ± $12,386. Older age, male gender, cases performed for hip fractures, and most comorbidities were associated with higher reimbursement (P.05), except dementia (lower reimbursement; P.01). Stratification incorporating these factors displayed greater accuracy than the current CJR risk adjustment methods (RMore robust risk stratification could provide more equitable reimbursement in the CJR program.Large database analysis; Level III.

Background The Comprehensive Care for Joint Replacement bundle was created to decrease total knee arthroplasty (TKA) cost. To help accomplish this, there is a focus on reducing TKA readmissions. However, there is a lack of national representative sample of all-payer hospital admissions to direct strategy, identify risk factors for readmission, and understand actual readmission cost. Methods We used the Nationwide Readmission Database to examine national readmission rates, predictors of readmission, and associated readmission costs for elective TKA procedures. We fit a multivariable logistic regression model to examine factors associated with readmission. Then, we determined mean readmission costs and calculated the readmission cost when distributed across the entire TKA population. Results We identified 224,465 patients having TKA across all states participating in the Nationwide Readmission Database. The mean unadjusted 30-day TKA readmission rate was 4%. The greatest predictors of readmission were congestive heart failure (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.62-2.80), renal disease (OR 2.19, 95% CI 2.03-2.37), and length of stay greater than 4 days (OR 2.4, 95% CI 2.25-2.61). The overall median cost for each readmission was $6753 ± 175. Extrapolating the readmission cost for the entire TKA population resulted in the readmission cost being 2% of the overall 30-day procedure cost. Conclusions A major focus of the Comprehensive Care for Joint Replacement bundle is improving cost and quality by limiting readmission rates. TKA readmissions are low and comprise a small percentage of total TKA cost, suggesting that they may not be the optimal measure of quality care or a significant driver of overall cost.

Background UK hospitals nationally report venous thromboembolism (VTE) within 90 days of hospital admission, with hospital-acquired thrombosis (HAT) registers at each center used for this. We assessed the accuracy of our HAT register in identifying VTE following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods We assessed 982 elective admissions for primary THA and TKA at a large tertiary center during 2018. The primary outcome was any VTE (deep vein thrombosis and/or pulmonary embolism) within 90 days postsurgery. VTEs were identified by systematically searching hospital databases (including discharge and outpatient letters, readmissions, emergency department visits, and imaging) for every patient. VTEs were also collected using the HAT database at our center, which is maintained regularly by a specialist nursing team and used to report VTEs nationally. Diagnostic test characteristics were assessed for HAT in identifying VTEs compared to the gold standard (ie, VTEs from the hospital databases). Results The prevalence of VTE was 2.7% (n = 27), with 20 VTEs identified by HAT. The accuracy of HAT in identifying VTEs were as follows: sensitivity = 74.1% (95% confidence interval [CI] = 53.7-88.9), specificity = 100% (CI = 99.6-100), positive predictive value = 100% (CI = 83.2-100), and negative predictive value = 99.3% (CI = 98.5-99.7). Conclusion One-quarter of VTEs occurring after THA and TKA were not identified by the HAT register. These cases would be missing when our hospital’s data are sent for national VTE reporting, and therefore would have substantial implications if HAT was primarily used to identify VTEs in a trial. Further work is needed to improve the accuracy of HAT VTE reporting before this could be relied upon in this setting.

Background This prospective cohort study evaluates the impact of total hip arthroplasty and total knee arthroplasty on patient’s spouses/significant others (SSOs). Methods Patients and SSOs were provided similar outcome metrics (Global Health Patient-Reported Outcomes Measurement Information System, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement) at preoperative and postoperative visits. Pearson correlation was used to evaluate scores. Results Our sample included 99 patients (58 total hip arthroplasties and 41 total knee arthroplasties). We found strong correlation between patient and SSO mental status scores. We found moderate correlation for some physical function domains. Conclusion SSOs closely share total joint arthroplasty patient’s mental and even some of the physical burden of disease and recovery.

Background We developed an orthopedic hospitalist fellowship program for our total joint replacement program at a large urban academic medical center. The goal of the program was to improve patient outcomes, quality, and healthcare value through collaborative perioperative care and improved care coordination. This study evaluates the implementation and impact of our modified Hospitalist-Orthopaedic Team Co-management model on quality and performance metrics. Methods We reviewed our Quality Institute data using 3 databases for the 16 months before (PreOH) and 18 months after (PostOH) implementation. Procedural volume was identical during period 1 (1100 cases) vs period 2 (1119 cases). Metrics included mean LOS (length of stay), % patients discharged home, mean observed and expected LOS and LOS index, LOS variance, % ICU (intensive care unit) admissions, mean ICU days, % cases with complications, % mortality, 30-day readmission rate, and Hospital Consumer Assessment of Healthcare Providers and Systems scores. Statistical analysis was performed using the software imbedded in the database software. Results Statistically significant improvements occurred in multiple performance and quality metrics including mean hospital LOS for total knee replacement, percentage of total knee replacement patients discharged home, and percentage of patients discharged home for primary total hip arthroplasty, complication rate, and 30-day readmission rate. Reductions in % ICU admission and ICU LOS were seen but not statistically significant. HCAPHS scores improved in 6 of 8 categories, and was statistically significant in 3 of 8. Conclusion The results of this study demonstrate that the modified Hospitalist-Orthopaedic Team Co-management model described above improves quality, cost effectiveness, and value for elective total joint replacement patients in comparison to the traditional consultation only model.

Background We sought to evaluate the outcomes of cementless acetabular components used in patients with Crowe II and III dysplasia, and to compare outcomes between cups placed within vs outside of an “anatomic” zone. Our specific aims were to (1) plot hip centers in these patients at our institution to characterize “anatomic” vs “nonanatomic” positions, (2) evaluate the association between hip center and radiographic loosening, (3) determine whether hip center was associated with acetabular component revision, and (4) compare patient-reported outcome scores between groups. Methods We retrospectively reviewed 88 primary cementless total hip arthroplasties at a mean follow-up of 10 years (range 2-26 years). Patients were 85% female, with a mean age of 44 years (range 28-61 years) and a body mass index of 27 kg/m2 (range 19-42 kg/m2). Medical records and radiographs were reviewed, and a survey was conducted for all patients. Anatomic hip center was defined using the 4-zone system, wherein centers are “anatomic” if they are Results Seventy hips (80%) had an anatomic hip center. Anatomic hips had a lower incidence of radiographic acetabular loosening (0% vs 17%, P = .007) and cup revision (0% vs 28%, P = .0002). There were no differences in Hip Disability and Osteoarthritis Outcome and Joint Replacement Scores (96.2 ± 5 vs 91.9 ± 12, P = .7). Conclusion The incidence of aseptic loosening and cup revision were lower when hip center was

Background When critically analyzing our hospital system's rate of hypotension and acute kidney injury (AKI) after total joint arthroplasty, our incidence rates (14.54%, 6.02%) were much higher than our peers (7.17%, 2.03%) and national rates (2.0%, 3.3%). We present a multi-disciplinary management intervention that aimed to decrease overall complication rates. Method A multi-disciplinary team implemented a protocol at our suburban hospital to limit complication rates after joint replacement surgery. Hypotension, AKI, length of stay (LOS), re-admission rates, and mortality rates were compared before the protocol was implemented, after protocol implementation, and after protocol integration into our EMR (electronic medical record). Results In total, 1233 patients over 36 months were followed. Hypotension rates after protocol implementation into EMR (group 3) were significantly lower than rates before the protocol (group 1) (P = .002), with rates after protocol implementation without EMR (group 2) trending toward a significant decrease from group 1 (P = .064). AKI rates in group 3 were significantly lower than group 1 (P = .000) and group 2 (P = .006). No difference was seen in hypotension rates between group 2 and 3 (P = .792) or AKI rates between group 1 and 2 (P = .533). Finally, no significant difference was seen between groups in LOS (P = .560), re-admission rates (P = .378), and mortality rates (all 0.0%). Conclusion By implementing a comprehensive electronic protocol consisting of pre-operative risk stratification, multi-disciplinary medical optimization, and an evolving post-operative management plan, significant decreases in hypotension and AKI can be seen.

Background Attempts to control costs associated with total joint arthroplasty have included efforts to shorten hospital length of stay (LOS). Concerns related to patient outcomes and safety with decreased LOS persist. The purpose of this study was to investigate whether discharge on postoperative day (POD) 1 after joint replacement is associated with increased rates of 90-day return to the operating room, and 30-day readmissions and emergency department (ED) visits. Methods After chart review, 447 patients admitted between January 2, 2013 and September 16, 2016 met inclusion criteria. All patients underwent one total joint arthroplasty. Patients were either discharged on POD 1 (subgroup 1) or POD 2 or 3 (subgroup 2). Statistical evaluation was performed using Wilcoxon-Mann-Whitney tests for continuous variables, and Fisher exact tests for categorical and frequency data. Statistical significance was established at P ≤ .05. Results Subgroup 1 had significantly fewer return trips to the operating room (P = .043) and significantly fewer 30-day readmissions (P = .033). ED visits were not significantly different between groups (P = .901). Conclusion Early discharge after joint arthroplasty appears to be a viable practice and did not result in increased rates of reoperation within the 90-day global period, or rates of 30-day readmission and ED visits. Our results support the utilization of an early discharge protocol on POD 1, with no evidence that shorter LOS results in higher rates of short-term complications.

Although previous studies have compared radiological, pain, and function scores in kinematically aligned (KA) and mechanically aligned (MA) total knee arthroplasty (TKA), no previous studies have undertaken a three-dimensional (3D) gait analysis in these groups. This study compared kinematic and kinetic variables recorded during level walking in patients at least 2 years post-surgery who underwent an MA or KA procedure.Utilizing a 9-camera motion analysis system, gait analysis was undertaken on 29 patients (MA = 15, KA = 14). A 9-camera motion analysis system was used to collect 3D kinematic data of the involved and uninvolved limbs during walking at a self-selected speed. Additionally, 3D ground reaction forces and moments during the stance phase were recorded, and an inverse dynamics approach was utilized to analyze these data.There were no significant differences in spatial-temporal variables between MA and KA groups (P.05). Local minima and maxima for knee joint angles were not significantly different (P.05) across involved and uninvolved legs and MA/KA groups in any of the 3 planes of motion. Principal component analysis revealed a significant difference (P.05) in the transverse plane moment in late stance. No other significant differences were observed for knee, hip, or ankle joint moments.Differences in gait parameters across the KA and MA groups at 2 years post-surgery were insufficient to support either one of the operative procedures over the other.

Total hip and knee replacements are frequently performed curative treatment options in end-stage arthritis. In this study, we analyzed clinical outcome, complications, and predictors of outcome in modern joint replacement.In a retrospective analysis of over 2000 primary total hip and knee replacements from our institutional joint registry, responder rates for positive outcome as defined by the OMERACT-OARSI criteria, postoperative complication rates, and patient-reported outcome measures (EQ-5D, WOMAC) within the first year were compared between hip and knee replacements. Furthermore, preoperative risk factors associated with nonresponder rate were evaluated.Positive responder rate was higher for hip replacements with 92.8% (1145/1234) than for knee replacements with 86.1% (839/975, P.001). Infection rates were lower (P = .04), whereas intraoperative fracture occurred more frequently (P = .001) in hip than in knee replacements. Patient-reported outcome measures 1 year after surgery were higher in hip than in knee replacements with EQ-5D (0.88 ± 0.17 to 0.81 ± 0.19, P.001) and WOMAC (84.58 ± 16.73 to 74.31 ± 18.94, P.001). Besides the type of joint replacement (hazard ratio [HR] 2.0, P.001), high preoperative outcome measures (HR 7.4, P.001) and male gender (HR 1.4, P = .05) were independent risk factors of nonresponders after joint replacement.Both total hip and knee replacements are safe procedures with low complication rates. Still, postoperative outcome is higher in hip than in knee arthroplasty. High preoperative clinical scores are a risk factor for poor clinical improvement following total joint replacement and can be used in counseling patients in the office.