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Introduction: Total joint arthroplasty represents the largest expense for a single condition among Medicare beneficiaries. Payment models exist, such as bundled payments, where physicians and hospitals are reimbursed based on providing cost-efficient, high-quality care. There is a need to explicitly define "quality" relevant to hip and knee arthroplasty. Based on prior quality measure research, we hypothesized that less than 20% of developed quality measures are outcome measures., Methods: This study systematically reviewed current and candidate quality measures relevant to total hip and knee arthroplasty using several quality measure databases and an Internet library search., Results: We found a total of 35 quality measures and 81 candidate measures, most of which were process measures (N = 21, 60%), and represented the National Quality Strategy priorities of patient- and caregiver-centered experience and outcomes (31%), effective clinical care (28%), or patient safety (19%)., Conclusion: Various stakeholders have developed quality measures in total joint arthroplasty, with increasing focus on developing outcome measures. The results of this review inform orthopaedic surgeons on quality measures that payers could use value-based payment models like the Merit-based Incentive Payment System and Comprehensive Care for Joint Replacement., Level of Evidence: Level I, systematic review of level I evidence.

Since passage of the Patient Protection and Affordable Care Act of 2010, the current decade has witnessed an explosion of the value-based total hip and knee arthroplasty literature. Total hip arthroplasty and total knee arthroplasty are the most common inpatient surgeries for Medicare beneficiaries, and thus, it is no surprise that total joint arthroplasty is currently a prime target of efforts toward cost reduction and quality improvement. The purpose of this review was to provide a framework for understanding the rapidly growing quality and cost literature. Research efforts toward quality improvement are likely to be effective when they address the structure, process, and most importantly outcomes of total joint arthroplasty. Similarly, cost savings should be evaluated with an understanding of existing accounting methods, relationships to the entire cycle of osteoarthritis care, and the direct effect on the quality of care provided.

Background: Elevated body mass index (BMI) is considered a risk factor for complications after THA and TKA. Stakeholders have proposed BMI cutoffs for those seeking arthroplasty. The research that might substantiate BMI cutoffs is sensitive to the statistical methods used, but the impact of the statistical methods used to model BMI has not been defined., Questions/purposes: (1) How does the estimated postarthroplasty risk of minor and major complications vary as a function of the statistical method used to model BMI? (2) What is the prognostic value of BMI for predicting complications with each statistical method?, Methods: Using the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2012, we investigated the impact of BMI on major and minor complication risk for THA and TKA. Analyses were weighted with covariate-balancing propensity scores to account for the differential rate of comorbidities across the range of BMI. We specified BMI in two ways: (1) categorically by World Health Organization (WHO) BMI classes; and (2) as a smooth, continuous variable using splines. Models of risk for major complications (deep surgical site infection [SSI], pulmonary embolism, stroke, cardiac arrest, myocardial infarction, wound disruption, implant failure, unplanned intubation, > 48 hours on a ventilator, acute renal insufficiency, coma, sepsis, reoperation, or mortality) and minor complications (superficial SSI, pneumonia, urinary tract infection, deep vein thrombosis, or peripheral nerve injury) were constructed and were adjusted for confounding variables known to correlate with complications (eg, American Society of Anesthesiologists classification). Results were compared for different specifications of BMI. Receiver operating characteristic (ROC) curves were compared to determine the additive prognostic value of BMI., Results: The type of BMI parameterization leads to different assessments of risk of postarthroplasty complications for BMIs > 30 kg/m and < 20 kg/m with the spline specification showing better fit in all adjusted models (Akaike Information Criteria favors spline). Modeling BMI categorically using WHO classes indicates that BMI cut points of 40 kg/m for TKA or 35 kg/m for THA are associated with higher risks of major complications. Modeling BMI continuously as a spline suggests that risk of major complications is elevated at a cut point of 44 kg/m for TKA and 35 kg/m for THA. Additionally, in these models, risk does not uniformly increase with increasing BMI. Regardless of the method of modeling, BMI is a poor prognosticator for complications with area under the ROC curves between 0.51 and 0.56, false-positive rates of 96% to 97%, and false-negative rates of 2% to 3%., Conclusions: The statistical assumptions made when modeling the effect of BMI on postarthroplasty complications dictate the results. Simple categorical handling of BMI creates arbitrary cutoff points that should not be used to inform larger policy decisions. Spline modeling of BMI avoids arbitrary cut points and provides a better model fit at extremes of BMI. Regardless of statistical management, BMI is an inadequate independent prognosticator of risk for individual patients considering total joint arthroplasty. Stakeholders should instead perform comprehensive risk assessment and avoid use of BMI as an isolated indicator of risk., Level of Evidence: Level III, diagnostic study.

Introduction: The American College of Surgeons' Statements on Principles requires attending surgeons to be present for the "key parts" of surgical procedures, but the term is not defined. The research question addressed in this study is whether a functional definition of the critical or key steps of common orthopaedic surgical procedures can be reliably constructed. We used the examples of hip and knee arthroplasty because these procedures are highly structured and divisible into distinct subroutines., Methods: We surveyed 100 experienced orthopaedic surgeons regarding whether particular steps in knee and hip arthroplasty procedures were considered "key." The patterns of individual surgeons' responses were compared among surgeons for overall reliability. The steps frequently cited as key were also identified., Results: The agreement rates among surgeons for the definitions of the key parts of hip and knee arthroplasty were 3.2% and 8.6%, respectively. For both procedures, five steps were identified as key by >90% of the respondents., Discussion: The agreement rate on what constitutes the key parts of hip and knee arthroplasty was poor, despite the fact that these are highly structured procedures. Accordingly, defining the key parts for a given procedure must rely on either the operating surgeon's discretion or a consensus definition. Imposing a single surgeon's standard on others is not the optimal approach because such a standard is likely to be idiosyncratic., Conclusion: A consensus standard articulated by the orthopaedic surgery community may be the best means for identifying the key parts of orthopaedic surgical operations. The data presented here suggest a foundation upon which a consensus definition for the key parts of arthroplasty procedures may be built.

Total knee arthroplasty is a large contributor to Medicare costs. In an effort to lower costs and improve outcomes, the Centers for Medicaid and Medicare Services has implemented the Comprehensive Care for Joint Replacement model, which incentivizes surgeons to submit both general health and joint-specific patient-reported outcome measures (PROMs). However, in addition to using PROMs for reporting purposes, surgeons should also consider incorporating PROMs into clinical practice. Currently, PROMs are not widely implemented in the clinical setting despite their value in measuring factors such as patients' expectations and mental state, which impact outcomes. Furthermore, as technology improves, PROM collection will become faster and more efficient. The information collected by PROMs can inform treatment decisions and facilitate communication between the surgeon and the patient.

Validated computational models promise a virtual platform to create optimal articular surfaces that best achieve desired implant characteristics. Today, designers can parametrically define the primary geometric features of an implant, and automatically modify design variables until stability/mobility performance objectives are best achieved. This preclinical, virtual design iteration minimizes the development cycle compared with testing physical prototypes and, by evaluating a broader scope of design concepts, likely improves the clinical performance of the final product. However, the scenario described is not without shortcomings and requires thorough understanding of the capabilities and the limitations of the models used. Although models typically represent the articular interface well, the interaction with the patient and the surgical process includes significant variability and increase in complexity. We present current modeling capabilities for the estimation of implant stability/mobility, with further suggestions for answering the difficult question of how an implant might perform throughout the population.

The national Functional and Outcomes Research for Comparative Effectiveness in Total Joint Replacement program routinely collects pre- and postoperative patient-reported outcomes for clinicians to use when making individual patient treatment decisions and monitoring aggregate quality of care and outcomes. When the pre-post gains in pain or function at one site vary from the national norms, the next question is, "how do we improve?" This paper will use the traditional quality management's framework of inputs (patients), processes (clinical care), and outcomes to outline priority research questions to learn how clinicians, hospital managers, and patients can interpret patient-reported outcomes to improve total knee arthroplasty care and outcomes. In summary, research should identify best practices to minimize variation in a patient's health status before surgery, tailor peri-total knee arthroplasty care pathways to match individual patient risks to optimize safe care, and implement patient-reported measures to document optimal outcomes.

Knee stability is the ability for the joint to maintain an appropriate functional position throughout its range of motion. Knee instability can be defined as excessive laxity during activities of daily living. Intraoperative knee laxity can be affected by implant design, alignment of components, and soft-tissue balancing. Soft-tissue balance is a major contributor to knee instability. Mechanical balancing instruments can be classified as spacer blocks or joint-distraction devices. Conventional wisdom favors rectangular and equal flexion-extension gaps. However, knee balance is elusive even with mechanical balancing instruments. First-generation electronic balancing devices are equivalent in concept to spacer blocks instrumented with force sensors. Second-generation electronic balancing devices are equivalent in concept to mechanical distraction devices instrumented with pressure and displacement sensors. Electronic ligament balancers can be useful in documenting intraoperative knee laxity for quantifiable correlation with postoperative outcomes, thus directly relating postoperative stability to surgical balance, and may predict outcomes and knee stability.

Prompted by the aims to improve the patient experience of care (including quality and satisfaction), improve the health of populations, and reduce the per capita cost of health care, the US healthcare system is embarking upon a new era in care delivery that seeks to optimize healthcare value. Value, the consideration of quality relative to cost, can be increased by improving quality, reducing cost, or doing both. Given that patient-reported outcomes related to pain, function, and quality of life underlay both the reason patients seek care for and the benchmarks by which treatment success is measured for osteoarthritis, measures of these patient-reported outcomes figure prominently in understanding the quality and hence value. Directed attention to patient-reported outcomes has the potential to drive quality and efficiency improvements, but only if the quality measures that are developed from them are clinically important, scientifically acceptable, usable, and feasible.

Patient-reported outcome measures (PROMs) has emerged as a strategy to improve the outcome of total knee arthroplasty. The use of PROMs in routine clinical practice has accelerated because health care in the United States is shifting from a volume-based to a value-based reimbursement system in which quality is increasingly being measured using PROMs. Electronic, internet-based platforms, such as Functional and Outcomes Research for Comparative Effectiveness in Total Joint Replacement, currently exist which offer turn-key solutions for PROM collection, trending, analysis, and benchmarking for busy clinicians. Successful systems provide real-time trended PROM scores that inform shared decision making, optimize patient care, and enable comparisons among practices.

Instability remains a common cause of failure in total knee arthroplasty. Although approaches for surgical treatment of instability exist, the target for initial stability remains elusive, increasing the likelihood that failures will persist because adequate stability is not restored when performing the primary arthroplasty. Although the mechanisms that stabilize the knee joint-contact between the articular surfaces, ligamentous constraints, and muscle forces-are well-defined, their relative importance and the interplay among them throughout functions of daily living are poorly understood. The problem is exacerbated by the complex multiplanar motions that occur across the joint and the large variations in these motions across the population, suggesting that stability targets may need to be patient-specific.

Surgical Management of Osteoarthritis of the Knee: Evidence-based Guideline is based on a systematic review of the current scientific and clinical research. The guideline contains 38 recommendations pertaining to the preoperative, perioperative, and postoperative care of patients with osteoarthritis (OA) of the knee who are considering surgical treatment. The purpose of this clinical practice guideline is to help improve surgical management of patients with OA of the knee based on current best evidence. In addition to guideline recommendations, the work group highlighted the need for better research on the surgical management of OA of the knee.

Background: Standardized care plans are effective at controlling cost and quality. Registries provide insights into quality and outcomes for use of implants, but most registries do not combine implant and care quality data. In 2012, several Michigan area hospitals and a major insurance provider formed a voluntary statewide total joint database/registry, the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI), to collect procedural, hospital, discharge, and readmission data. Noting substantial variation in transfusion practices after total joint arthroplasty (TJA) in our institutions, we used these prospectively collected data to examine whether awareness and education of the American Association of Blood Banks' (AABB) transfusion guidelines would result in decreased transfusions., Questions/purposes: (1) Can an established arthroplasty registry help implement a quality initiative (QI) designed to decrease the proportion of transfused postoperative patients undergoing TJA? (2) Do data-driven transfusion protocols decrease length of stay without increasing ischemic complications (myocardial infarctions and cerebrovascular accidents)? (3) Are decreased transfusion proportions associated with decreased readmissions, nonischemic morbidity (including deep vein thrombosis and deep prosthetic infection), and mortality in postoperative patients who had undergone TJA?, Methods: After reviewing data from the recently established MARCQI registry, the orthopaedic department noticed many discrepancies and practice variances regarding blood transfusions among their providers. In October 2013, a QI was implemented to raise awareness of the discrepancies and education about the AABB guidelines was presented at the monthly orthopaedic service line meeting. A total of 1872 TJA cases were reviewed; 50 were excluded for incomplete data and two for intraoperative transfusions for the period before education (May 2012 to June 2013, n = 1240) and after education (November 2013 to April 2014, n = 580). Data collected included gender, age, length of stay, body mass index, preoperative hemoglobin level, lowest postoperative hemoglobin level during admission, transfusion status, number of units transfused, ischemic and nonischemic morbidity, hospital readmissions within 90 days, and mortality. Pre- and post-QI transfusion proportions were calculated. Chi-square test, Student's t-test, and a multivariate analysis were performed to compare differences in transfusion proportions for patients with a postoperative hemoglobin ≥ 8 g/dL., Results: Overall, the percentage of patients transfused with a postoperative hemoglobin ≥ 8 g/dL decreased 80% (6.5% [71 of 1092] versus 1.3% [seven of 538]; odds ratio, 5.3; 95% confidence interval, 2.4-11.6; p < 0.001) after the educational intervention. Before education, 16% (195 of 1240) of all patients undergoing TJA were transfused, whereas 6.5% (71 of 1092) were outside recommended AABB guidelines (hemoglobin ≥ 8 g/dL). In the 6 months after QI initiation, overall transfusions decreased to 6% (35 of 580) with 1.3% (seven of 538) having a hemoglobin ≥ 8 g/dL. The mean length of stay for nontransfused patients was shorter (2.4 days ± 0.9 versus 3.3 days ± 1.1, p < 0.001) and ischemic complications did not differ between groups (0.32% [four of 1240] versus 0.34% [two of 580], p = 0.61). Before and after education, neither the number of readmissions (5.4% [67 of 1240] versus 4.7% [27 of 580], p = 0.50) nor morbidity (3.6% [45 of 1240] versus 2.4% [14 of 580], p = 0.17) differed between time periods. There were no deaths., Conclusions: Simple education and awareness of quality practices drive safety and compliance. The impact can be immediate and lasting. Arthroplasty registries that combine procedural and care quality data are vital and may be used for important data-driven QIs., Level of Evidence: Level III, therapeutic study.

Preoperative identification of the risk factors for surgical site infection and patient risk stratification are essential for deciding whether surgery is appropriate, educating patients on their individual risk of complications, and managing postoperative expectations. Early identification of these factors is also necessary to help guide both patient medical optimization and perioperative care planning. Several resources are currently available to track and analyze healthcare-associated infections, including the Centers for Disease Control and Prevention's National Healthcare Safety Network. In addition, the Centers for Disease Control and Prevention and the American Academy of Orthopaedic Surgeons are exploring collaborative opportunities for the codevelopment of a hip and/or knee arthroplasty national quality measure for periprosthetic joint infection., (Copyright 2015 by the American Academy of Orthopaedic Surgeons.)

Background: Controversy exists regarding many aspects of decision making pertaining to same-day versus staged bilateral TKA (BTKAs), including patient selection, perioperative management decisions, and other important choices., Questions/purposes: In the absence of suitable randomized trials, we sought to determine areas of consensus among national experts on the following questions: (1) What are the comparative risks of same-day BTKAs compared with unilateral TKA (UTKA) and staged BTKAs? (2) Who should be considered an appropriate candidate for same-day BTKAs? (3) What constitutes appropriate workup and perioperative management for BTKAs? (4) What is the optimal time between procedures if same-day BTKAs are not deemed appropriate? (5) Are there orthopaedic or rehabilitation considerations for BTKAs that might outweigh medical contraindications?, Methods: In the setting of a consensus conference of national experts in orthopaedic surgery, anesthesiology, perioperative medicine, and epidemiology, the major questions surrounding same-day BTKAs were addressed by using an extensive literature review and the modified Delphi process. The process concluded with a meeting of participants and formulation of consensus statements., Results: Eighty-one percent of participants agreed that BTKAs are more invasive and complex procedures associated with increased risk for perioperative adverse events compared with UTKA in an unselected group of patients. The consensus group agreed that physicians and hospitals should consider using more restrictive patient selection criteria and exclude those with a modified cardiac risk index greater than 3 to mitigate the potentially increased risk. The majority of the group agreed that perioperative assessment and management should reflect the higher level of acuity of same-day BTKAs. Eighty-one percent of participants agreed that if a patient is not deemed a candidate for same-day BTKAs, a second TKA should be scheduled no sooner than 3 months after the first. The entire group agreed that when there is a conflict between the orthopaedic need and the medical adequacy of same-day BTKAs, the medical concern for the patient's safety should prevail over the orthopaedic need., Conclusions: Experts perceived that same-day BTKAs increase medical risk, and thus a systematic approach to the management of patients should be taken to minimize complications.

Background: Joint function and durability after TKA depends on many factors, but component alignment is particularly important. Although the transepicondylar axis is regarded as the gold standard for rotationally aligning the femoral component, various techniques exist for tibial component rotational alignment. The impact of this variability on joint kinematics and stability is unknown., Questions/purposes: We determined how rotationally aligning the tibial component to four different axes changes knee stability and passive tibiofemoral kinematics in a knee after TKA., Methods: Using a custom surgical navigation system and stability device to measure stability and passive tibiofemoral motion, we tested 10 cadaveric knees from five hemicorpses before TKA and then with the tibial component aligned to four axes using a modified tibial tray., Results: No changes in knee stability or passive kinematics occurred as a result of the four techniques of tibial rotational alignment. TKA produces a 'looser' knee over the native condition by increasing mean laxity by 5.2°, decreasing mean maximum stiffness by 4.5 N·m/°, increasing mean anterior femoral translation during passive flexion by 5.4 mm, and increasing mean internal-external tibial rotation during passive flexion by 4.8°. However, no statistically or clinically important differences occurred between the four TKA conditions., Conclusions: For all tibial rotations, TKA increased laxity, decreased stiffness, and increased tibiofemoral motion during passive flexion but showed little change based on the tibial alignment., Clinical Relevance: Our observations suggest surgeons who align the tibial component to any of the axes we examined are expected to have results consistent with those who may use a different axis.

Unlabelled: Increasing evidence suggests performing total knee arthroplasty using computer navigation can lead to more accurate surgical positioning of the components and knee alignment compared to a conventional operating technique without computer assistance. The use of robotic technology could theoretically take this accuracy one level further because it uses navigation in combination with ultimate mechanical precision, which could eliminate or reduce the inevitable margin of error during mechanical preparation of the bony cuts of total knee arthroplasty by the surgeon. We prospectively followed 25 consecutive cases using an active surgical robot. The minimum followup was 5.1 years (mean, 5.5 years; range, 5.1-5.8 years). Our results demonstrate excellent implant positioning and alignment was achieved within the 1 degree error of neutral alignment in all three planes in all cases. Despite this technical precision, the excessive operating time required for the robotic implantation, the technical complexity of the system, and the extremely high operational costs have led us to abandon this procedure and direct our interest more toward smart semiactive robotic systems., Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

In computer-assisted surgery, efficacy relies on the overall precision of the method, of which the tracking technology is an integral feature. Does electromagnetic tracking perform clinically as well as standard optical tracking technologies? A pilot study using a computer-assisted surgery system and one lower extremity from an embalmed cadaver evaluated the mechanical axis, the transepicondylar axis, and the anteroposterior axis of Whiteside (anteroposterior axis). Using three-dimensional computed tomography and direct anatomic measurements, the baseline value for the mechanical axis was 4.9 degrees varus and the tibial shaft axis was 4.6 degrees varus. All tests were performed in a standard operating room using an imageless referencing protocol. Repeatability of one surgeon performing eight trials revealed optical mechanical axis mean of 5.8 degrees varus (standard deviation, 0.3 degree) and electromagnetic mechanical axis mean of 5.3 degrees varus (standard deviation, 0.9 degree); reproducibility of three surgeons performing eight trials each revealed optical mechanical axis mean of 6.3 degrees varus (standard deviation, 0.6 degree) and electromagnetic mechanical axis mean of 5.2 degrees varus (standard deviation, 0.8 degree). Precision was satisfactory for both optical and electromagnetic tracking for mechanical axis assessment, but outliers were identified with electromagnetic tracking causing concern for efficacy. Assessment of the transepicondylar or the anteroposterior axis measurements was not satisfactory with either the optical or electromagnetic system.

When compared to standard intramedullary and extramedullary referencing systems, computer-assisted navigation systems have been shown in multiple randomized studies to increase the accuracy of bone resections in total knee arthroplasty. Accuracy to within 1 degrees in the coronal plane resections can routinely be obtained. Recent modifications of the software programs address the problem of proper soft tissue balance. Newer techniques of bone morphing have obviated the use of preoperative imaging in most cases. Despite these advances, the systems remain somewhat cumbersome to use and costly to acquire. As these limitations are addressed, computer-assisted navigation may become a valuable part of the knee surgeon's armamentarium, especially for the patient with a deformed femur or tibia in whom conventional navigation instruments are difficult to use accurately.

Hip and knee arthroplasties usually are satisfying for the patient and the surgeon; however, these procedures also have considerable risks for generating a medical malpractice lawsuit. Strict adherence to the standard of care and recently implemented patient safety strategies should reduce the surgeon's liability. Expert technical execution of the surgery, timely evidence-based patient treatment, and detailed documentation in the medical record will not only improve the quality of patient care but also will serve as a strong legal defense should the need arise.