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ImportanceDespite the significant contribution of surgical spending to health care costs, most surgeons are unaware of their operating room costs.ObjectiveTo examine the association between providing surgeons with individualized cost feedback and surgical supply costs in the operating room.Design, setting, and participantsThe OR Surgical Cost Reduction (OR SCORE) project was a single-health system, multihospital, multidepartmental prospective controlled study in an urban academic setting. Intervention participants were attending surgeons in orthopedic surgery, otolaryngology-head and neck surgery, and neurological surgery (n = 63). Control participants were attending surgeons in cardiothoracic surgery, general surgery, vascular surgery, pediatric surgery, obstetrics/gynecology, ophthalmology, and urology (n = 186).InterventionsFrom January 1 to December 31, 2015, each surgeon in the intervention group received standardized monthly scorecards showing the median surgical supply direct cost for each procedure type performed in the prior month compared with the surgeon's baseline (July 1, 2012, to November 30, 2014) and compared with all surgeons at the institution performing the same procedure at baseline. All surgical departments were eligible for a financial incentive if they met a 5% cost reduction goal.Main outcomes and measuresThe primary outcome was each group's median surgical supply cost per case. Secondary outcome measures included total departmental surgical supply costs, case mix index-adjusted median surgical supply costs, patient outcomes (30-day readmission, 30-day mortality, and discharge status), and surgeon responses to a postintervention study-specific health care value survey.ResultsThe median surgical supply direct costs per case decreased 6.54% in the intervention group, from $1398 (interquartile range [IQR], $316-$5181) (10 637 cases) in 2014 to $1307 (IQR, $319-$5037) (11 820 cases) in 2015. In contrast, the median surgical supply direct cost increased 7.42% in the control group, from $712 (IQR, $202-$1602) (16 441 cases) in 2014 to $765 (IQR, $233-$1719) (17 227 cases) in 2015. This decrease represents a total savings of $836 147 in the intervention group during the 1-year study. After controlling for surgeon, department, patient demographics, and clinical indicators in a mixed-effects model, there was a 9.95% (95% CI, 3.55%-15.93%; P = .003) surgical supply cost decrease in the intervention group over 1 year. Patient outcomes were equivalent or improved after the intervention, and surgeons who received scorecards reported higher levels of cost awareness on the health care value survey compared with controls.Conclusions and relevanceCost feedback to surgeons, combined with a small departmental financial incentive, was associated with significantly reduced surgical supply costs, without negatively affecting patient outcomes.

IntroductionAdvances in surgical technique, implant design, and clinical care pathways have resulted in higher expectations for improved clinical outcomes after primary THA; however, despite these advances, it is unclear whether the risk of revision THA actually has decreased with time. Understanding trends in short- and mid-term risks of revision will be helpful in directing clinical, research, and policy efforts to improve THA outcomes.Question/purposesWe therefore asked (1) whether there have been changes in overall short- and mid-term risks of revision THA among patients in the Medicare population who underwent primary THA between 1998 and 2010; and (2) whether there are different demographic factors associated with short- and mid- term risks of revision THA.MethodsUsing the Medicare 5% national sample database, patients who underwent primary THA between 1998 and 2010 followed by subsequent revision through 2011 were identified by ICD-9-CM procedure codes 81.51 and 81.53/80.05/00.70-00.73, respectively. This dataset included a random sample of Medicare beneficiaries based on their social security number. Only patients with minimum 1-year followup after primary THA were included in our analysis. A total of 64,260 patients who underwent primary THA were identified from the 1998 to 2010 Medicare 5% dataset. Eighty-eight percent of the patients had 1-year followup providing a final study cohort of 56,700 patients. The risk of revision was evaluated at 1, 3, 5, and 7 years. Multivariate Cox regression was used to evaluate temporal trends in revision risk using two methods to account for time effects with periods 1998 to 2002, 2003 to 2007, and 2008 to 2010 for the index year of primary THA, and individual year of index of primary THA as independent variables. The analysis adjusted for patient age, sex, race, census region, Charlson score, and socioeconomic status.ResultsThe 7-year crude risk of revision THA declined from 7.10% in 1998 to 2002 to 6.09% in 2008 to 2010, representing a 14.4% overall reduction in adjusted risk of revision (p = 0.0058; 95% CI, 4.4%-23%). Similarly, the 5-year crude risk of revision THA declined from 5.96% in 1998 to 2002 to 5.11% in 2008 to 2010, representing a 14.2% overall reduction in adjusted risk of revision (p = 0.0069; 95% CI, 4.1%-23%). However, the adjusted risk of revision THA at 3 years was not different from 1998 to 2002 (4.70%) and 2008 to 2010 (4.03%; p = 0.1176). Similarly, the adjusted risk of revision at 1 year did not differ from 1998 to 2002 (2.83%) and 2008 to 2010 (2.42%; p = 0.3386). Patients with more comorbidities had a greater adjusted risk of revision (p < 0.001) at all times: 94% (95% CI, 58%-138%) and 56% (95% CI, 33%-84%) at 1 year and 7 years, respectively, for Charlson score of 5+ vs 0).ConclusionsAlthough the mid-term (5 and 7 years) risk of revision THA has decreased during the past 14 years among Medicare beneficiaries who underwent primary THA, the short-term risk has not. These findings suggest that greater clinical, research, and policy emphasis is needed to identify potentially avoidable causes of early failure after primary THA in patients in the Medicare population, and multistakeholder solutions are needed to optimize short-term outcomes.Level of evidenceLevel III, therapeutic study.

BackgroundRevision THA and TKA are growing and important clinical and economic challenges. Healthcare systems tend to combine revision joint replacement procedures into a single service line, and differences between revision THA and revision TKA remain incompletely characterized. These differences carry implications for guiding care and resource allocation. We therefore evaluated epidemiologic trends associated with revision THAs and TKAs.Questions/purposesWe sought to determine differences in (1) the number of patients undergoing revision TKA and THA and respective demographic trends; (2) differences in the indications for and types of revision TKA and THA; (3) differences in patient severity of illness scoring between THA and TKA; and (4) differences in resource utilization (including cost and length of stay [LOS]) between revision THA and TKA.MethodsThe Nationwide Inpatient Sample (NIS) was used to evaluate 235,857 revision THAs and 301,718 revision TKAs between October 1, 2005 and December 31, 2010. Patient characteristics, procedure information, and resource utilization were compared across revision THAs and TKAs. A revision burden (ratio of number of revisions to total number of revision and primary surgeries) was calculated for hip and knee procedures. Severity of illness scoring and cost calculations were derived from the NIS. As our study was principally descriptive, statistical analyses generally were not performed; however, owing to the large sample size available to us through this NIS analysis, even small observed differences presented are likely to be highly statistically significant.ResultsRevision TKAs increased by 39% (revision burden, 9.1%-9.6%) and THAs increased by 23% (revision burden, 15.4%-14.6%). Revision THAs were performed more often in older patients compared with revision TKAs. Periprosthetic joint infection (25%) and mechanical loosening (19%) were the most common reasons for revision TKA compared with dislocation (22%) and mechanical loosening (20%) for revision THA. Full (all-component) revision was more common in revision THAs (43%) than in TKAs (37%). Patients who underwent revision THA generally were sicker (> 50% major severity of illness score) than patients who underwent revision TKA (65% moderate severity of illness score). Mean LOS was longer for revision THAs than for TKAs. Mean hospitalization costs were slightly higher for revision THA (USD 24,697 +/- USD 40,489 [SD]) than revision TKA (USD 23,130 +/- USD 36,643 [SD]). Periprosthetic joint infection and periprosthetic fracture were associated with the greatest LOS and costs for revision THAs and TKAs.ConclusionsThese data could prove important for healthcare systems to appropriately allocate resources to hip and knee procedures: the revision burden for THA is 52% greater than for TKA, but revision TKAs are increasing at a faster rate. Likewise, the treating clinician should understand that while both revision THAs and TKAs bear significant clinical and economic costs, patients undergoing revision THA tend to be older, sicker, and have greater costs of care.

BackgroundOutcomes research in THA has focused largely on long-term implant survivorship as a primary outcome and emphasized the development of new implant technologies. In contrast, strategies to improve short-term outcomes, such as the frequencies of periprosthetic joint infections and unplanned readmissions, have received less attention.Questions/purposesWe asked whether reductions in periprosthetic joint infections and early readmissions would have greater influence on the net monetary benefit (a summation of lifetime cost and quality of life) for THA compared with equivalent reductions in aseptic loosening.MethodsA Markov model was created using decision-analysis software with six health states and death to represent seven major potential outcomes of THA. We compared the effect of a 10% reduction in each of the following outcomes: (1) periprosthetic joint infection, (2) hospital readmission, and (3) aseptic loosening. Procedure costs (not charges) were derived from our hospital cost-accounting system. Probabilities were derived primarily from the Australian Orthopaedic Association National Joint Replacement Registry, and utilities were estimated from a previous study at our institution using the time trade-off method. The primary outcome of the study is the net monetary benefit, which combines the reductions in cost and improvement in health-related quality of life in a single metric. Quality of life is expressed in quality-adjusted life years (QALYs), which are calculated by multiplying the utility of a health state (ranging from 0 to 1) by the duration of time in the health state. The cost and QALYs are reported separately as secondary outcomes. One-way and multivariate sensitivity analyses were performed including a probabilistic sensitivity analysis to account for uncertainty in model inputs.ResultsThe net monetary benefit for a 10% reduction in periprosthetic joint infections was USD 278 (95% CI, USD 239-295) per index procedure compared with USD 174 (95% CI, USD 150-185) and USD 113 (95% CI, USD 94-129) for reductions in aseptic loosening and early readmission, respectively. Compared with the base case, reductions in cost associated with a 10% reduction in periprosthetic joint infections, early readmissions, and aseptic loosening were USD 98, USD 93, and USD 75 per index procedure, respectively. The increase in QALYs for an equivalent reduction in periprosthetic joint infections, aseptic loosening, and early readmissions were 0.0036, 0.002, and 0.0004 QALYs, respectively. Results were most sensitive to age, baseline rate of readmission, periprosthetic joint infection, aseptic loosening, and the costs of readmission and revision THA.ConclusionsStrategies to reduce periprosthetic joint infections may have a greater effect on the cost and long-term effectiveness of THA than further enhancements in implant longevity. Reductions in the rate of readmission resulted in greater reductions in cost but not quality-of-life, and therefore had smaller effect on the net monetary benefit compared with aseptic loosening. Surgeons preferentially should engage in strategies focusing on periprosthetic joint infections to improve the value of THA care.Level of evidenceLevel II, economic and decision analysis.

BackgroundTotal hip arthroplasty (THA) is a beneficial and cost-effective procedure for patients with osteoarthritis. Recent initiatives to improve hospital quality of care include assessing unplanned hospital readmission rates. Patients presenting for THA have different indications and medical comorbidities that may impact rates of readmission.Questions/purposesThis study measured (1) the unplanned hospital readmission rate in primary THA, revision THA, and antibiotic-spacer staged revision THA to treat infection. Additionally, we determined (2) the medical and surgical causes of readmission; and (3) the risk factors associated with unplanned readmission.MethodsA total of 1415 patients (988 primary THA, 344 revision THA, 82 antibiotic-spacer staged revision THA to treat infection) from a single institution were included. All hospital readmissions within 90 days of discharge were reviewed. Patient demographics and medical comorbidities were included in a Cox proportional hazards model to assess risk of readmission.ResultsThe overall unplanned readmission rate was 4% at 30 days and 7% at 90 days. At 90 days, primary THA (5%) had a lower unplanned readmission rate than revision THA (10%, p < 0.001) and antibiotic-spacer staged revision THA (18%, p < 0.001). Medical diagnoses were responsible for almost one-fourth of unplanned readmissions, whereas over half of surgical readmissions were the result of dislocation, surgical site infection, and postoperative hematoma. Type of procedure, hospital stay greater than 5 days, cardiac valvular disease, diabetes with end-organ complications, and substance abuse were each associated with increased risk of unplanned readmission.ConclusionsHigher rates of unplanned hospital readmissions in revision THA rather than primary THA suggest that healthcare quality measures that incorporate readmission rates as a proxy for quality of care should distinguish between primary and revision procedures. Failure to do so may negatively impact tertiary referral hospitals that often care for patients requiring complex revision procedures.

BackgroundPatient, surgeon, health system, and device factors are all known to influence outcomes in THA. However, patient-related factors associated with an increased risk of early failure are poorly understood, particularly in elderly patients.Questions/purposesWe identified specific demographic and clinical characteristics associated with increased risk of early revision in Medicare patients with THA.MethodsThe Medicare 5% national sample administrative database was used to calculate the relative risk of revision within 12 months following primary THA as a function of baseline medical comorbidities in 56,030 Medicare patients who underwent primary THA between 1998 and 2010. The impact of 29 comorbid conditions on risk of early revision was examined using Cox regression, controlling for age, sex, race, US Census region, socioeconomic status, and all other baseline comorbidities.ResultsDepression, rheumatologic disease, psychoses, renal disease, chronic urinary tract infection, and congestive heart failure were associated with revision THA within 12 months of the index arthroplasty (p ≤ 0.038 for all comparisons; risk factors listed in order of significance).ConclusionsThis information is important when counseling elderly patients with THA regarding the risk of early failure and for risk stratifying publicly reported outcomes in Medicare patients with THA.

BackgroundTotal knee arthroplasty (TKA) and related interventions such as revision TKA and the treatment of infected TKAs are commonly performed procedures. Hospital readmission rates are used to measure hospital performance, but risk factors (both medical and surgical) for readmission after TKA, revision TKA, and treatment for the infected TKA have not been well characterized.Questions/purposesWe measured (1) the unplanned hospital readmission rate in primary TKA and revision TKA, including antibiotic-spacer staged revision TKA to treat infection. We also evaluated (2) the medical and surgical causes of readmission and (3) risk factors associated with unplanned hospital readmission.MethodsThis retrospective cohort study included a total of 1408 patients (1032 primary TKAs, 262 revision TKAs, 113 revision of infected TKAs) from one institution. All hospital readmissions within 90 days of discharge were evaluated for timing and cause. Diagnoses at readmission were categorized as surgical or medical. Readmission risk was assessed using a Cox proportional hazards model that incorporated patient demographics and medical comorbidities.ResultsThe unplanned readmission rate for the entire cohort was 4% at 30 days and 8% at 90 days. At 90 days postoperatively, revision of an infected TKA had the highest readmission rate, followed by revision TKA, with primary TKA having the lowest rate. Approximately three-fourths of readmissions were the result of surgical causes, mostly infection, arthrofibrosis, and cellulitis, whereas the remainder of readmissions were the result of medical causes. Procedure type (primary TKA versus revision TKA or staged treatment for infected TKA), hospital stay more than 5 days, discharge destination, and a fluid/electrolyte abnormality were each associated with risk of unplanned readmission.ConclusionsPatients having revision TKA, whether for infection or other causes, are more likely to have an unplanned readmission to the hospital than are patients having primary TKA. When assessing hospital performance for TKA, it is important to distinguish among these surgical procedures.

BackgroundPatient, surgeon, health system, and device factors are all known to influence outcomes in total knee arthroplasty (TKA). However, patient-related factors associated with an increased risk of early failure are not well understood, particularly in elderly patients.Questions/purposesThe purpose of this study was to identify specific comorbid conditions associated with increased risk of early revision in Medicare patients undergoing TKA.MethodsA total of 117,903 Medicare patients who underwent primary TKA between 1998 and 2010 were identified from the Medicare 5% national sample administrative database and used to determine the relative risk of revision within 12 months after primary TKA as a function of baseline medical comorbidities. Cox regression was used to evaluate the impact of 29 comorbid conditions on risk of early failure controlling for age, sex, race, census region, socioeconomic status, and all other baseline comorbidities.ResultsThe most significant independent risk factors for revision TKA within 12 months were chronic pulmonary disease, depression, alcohol abuse, drug abuse, renal disease, hemiplegia or paraplegia, and obesity.ConclusionsThis information could be valuable to patients and their surgeons when making shared medical decisions regarding elective TKA and for risk-stratifying publicly reported outcomes in Medicare patients undergoing TKA.

BackgroundThe role of vancomycin in surgical antimicrobial prophylaxis and high-risk patients who are most likely to benefit remains unclear.Questions/purposesWe determined the impact of targeted use of vancomycin on (1) the incidence of periprosthetic joint infection (PJI); and (2) the incidence of PJI from methicillin-resistant organisms in patients undergoing revision total knee arthroplasty (TKA) at our institution.MethodsIn an effort to reduce PJI rates, we added vancomycin to cefazolin as surgical antimicrobial prophylaxis for patients undergoing revision TKA in October 2010. Internal data indicated a high rate of PJI in revision TKA and in particular PJI resulting from methicillin-resistant organisms, including methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant Staphylococcus epidermidis (MRSE). We retrospectively reviewed infection control surveillance data on 414 revision TKAs performed between July 2008 and June 2012 (fiscal years 2009-2012).ResultsThe overall rate of PJI in fiscal years 2009-2010 among 190 patients undergoing revision TKA was 7.89%. After the change in surgical antimicrobial prophylaxis, there was a significant reduction in PJI among patients undergoing revision TKA in fiscal years 2011-2012 to 3.13% (p = 0.046). In particular, we observed a reduction in PJI resulting from methicillin-resistant organisms over this same time period, from 4.21% to 0.89% (p = 0.049).ConclusionsTargeted use of vancomycin in patients undergoing revision TKA was effective in reducing the rate of PJI and PJI resulting from methicillin-resistant organisms in an institution with a high baseline rate of PJI due to MRSA and MRSE. Identification of high-risk subgroups of patients within a surgical population can help target infection prevention strategies to those who are most likely to benefit and thus minimize potential risks (eg, selection of resistant organisms, adverse drug events) associated with broader application of such an intervention.

BackgroundUnderstanding the type and magnitude of services that patients receive postdischarge and the financial impact of readmissions is crucial to assessing the feasibility of accepting bundled payments.Questions/purposesThe purposes of this study were to (1) determine the cost and service components of a 30-day total joint arthroplasty (TJA) episode of care; (2) analyze the portion of the total payment that is used for postdischarge services, including home care; and (3) to evaluate the frequency of readmissions and their impact on total episode-of-care payments.MethodsAll payments to Medicare providers (hospitals, postacute care facilities, physicians, and other healthcare providers) for services beginning with the index procedure and extending 30-days postdischarge were analyzed for 250 Medicare beneficiaries undergoing primary or revision TJA from a single institution over a 12 months. Payments and services were aggregated by procedure type and categorized as index procedure, postacute care, and related hospital readmissions.ResultsMean episode-of-care payments ranged from USD 25,568 for primary TJA in patients with no comorbidities to USD 50,648 for revision TJA in patients with major comorbidities or complications, with wide variability within and across procedures. Postdischarge payments accounted for 36% of total payments. A total of 49% of patients were transferred to postacute care facilities, accounting for 70% of postdischarge payments. The overall 30-day unplanned readmission rate was 10%, accounting for 11% of postdischarge payments.ConclusionsEpisode-of-care payments for TJAs vary widely depending on the type of procedure, patient comorbidities and complications, discharge disposition, and readmission rates. Postdischarge care accounted for more than one-third of total episode payments and varied substantially across patients and procedures.

BackgroundAlthough risk factors for periprosthetic joint infection (PJI) and mortality after total hip arthroplasty (THA) have been identified, interactions between specific patient risk factors are poorly understood. Therefore, it is difficult for surgeons to counsel patients on their individual risk of PJI or mortality after THA.Questions/purposesWe evaluated the interaction between patient clinical and demographic factors on the risk of PJI and mortality after THA and developed an electronic risk calculator for estimating the patient-specific risk of PJI and mortality in Medicare patients with THA.MethodsWe used the Medicare 5% sample claims database to calculate the risk of PJI within 2 years and mortality within 90 days after THA in 53,252 Medicare patients with primary THAs between 1998 and 2009. Logistic regression using 29 comorbid conditions, age, sex, race, and socioeconomic status were used as inputs to develop an electronic risk calculator to estimate patient-specific risk of PJI and mortality after THA.ResultsThe overall 2-year risk of PJI and 90-day risk of mortality after primary THA were 2.07% and 1.30%, respectively. White women aged 70 to 74 years with alcohol abuse, depression, electrolyte disorder, peptic ulcer disease, urinary tract infection, rheumatologic disease, preoperative anemia, cardiopulmonary (cardiac arrhythmia, congestive heart failure, ischemic heart disease, chronic pulmonary disease) comorbidities, and peripheral vascular disease were at highest risk for PJI. White women aged 65 to 69 years with electrolyte disorder, hemiplegia/paraplegia, hypertension, hypothyroidism, metastatic tumor, preoperative anemia, coagulopathy, cardiopulmonary (congestive heart failure, chronic pulmonary disease) and psychiatric (psychoses, depression) comorbidities, malignancies, and peripheral vascular disease were at highest risk for mortality. An electronic risk calculator was developed to estimate the risk of PJI and mortality in Medicare patients with THA.ConclusionsThis electronic risk calculator can be used to counsel Medicare patients regarding their patient-specific risks of PJI and mortality after THA.Level of evidenceLevel II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Abstract Background The purpose of this study was to compare pre- and post-surgical healthcare costs in commercially insured total joint arthroplasty (TJA) patients with osteoarthritis (OA) in the United States (U.S.). Methods Using a large healthcare claims database, we identified patients over age 39 with hip or knee OA who underwent unilateral primary TJA (hip or knee) between 1/1/2006 and 9/30/2007. Utilization of healthcare services and costs were aggregated into three periods: 12 months "pre-surgery," 91 days "peri-operative," and 3 to 15 month "follow-up," Mean total pre-surgery costs were compared with follow-up costs using Wilcoxon signed-rank test. Results 14,912 patients met inclusion criteria for the study. The mean total number of outpatient visits declined from pre-surgery to follow-up (18.0 visits vs 17.1), while the percentage of patients hospitalized increased (from 7.5% to 9.8%) (both p < 0.01). Mean total costs during the follow-up period were 18% higher than during pre-surgery ($11,043 vs. $9,632, p < 0.01), largely due to an increase in the costs of inpatient care associated with hospital readmissions ($3,300 vs. $1,817, p < 0.01). Pharmacotherapy costs were similar for both periods ($2013 [follow-up] vs. $1922 [pre-surgery], p = 0.33); outpatient care costs were slightly lower in the follow-up period ($4338 vs. $4571, p < 0.01). Mean total costs for the peri-operative period were $36,553. Conclusions Mean total utilization of outpatient healthcare services declined slightly in the first year following TJA (exclusive of the peri-operative period), while mean total healthcare costs increased during the same time period, largely due to increased costs associated with hospital readmissions. Further study is necessary to determine whether healthcare costs decrease in subsequent years.

Abstract Background The effect of peripheral nerve blocks on postoperative delirium in older patients has not been studied. Peripheral nerve blocks may reduce the incidence of postoperative opioid use and its side effects such as delirium via opioid-sparing effect. Methods A prospective cohort study was conducted in patients who underwent total knee replacement. Baseline cognitive function was assessed using the Telephone Interview for Cognitive Status. Postoperative delirium was measured using the Confusion Assessment Method postoperatively. Incidence of postoperative delirium was compared in two postoperative management groups: femoral nerve block ± patient-controlled analgesia and patient-controlled analgesia only. In addition, pain levels (using numeric rating scales) and opioid use were compared in two groups. Results 85 patients were studied. The overall incidence of postoperative delirium either on postoperative day one or day two was 48.1%. Incidence of postoperative delirium in the femoral nerve block group was lower than patient controlled analgesia only group (25% vs. 61%, P = 0.002). However, there was no significant difference between the groups with respect to postoperative pain level or the amount of intravenous opioid use. Conclusions Femoral nerve block reduces the incidence of postoperative delirium. These results suggest that a larger randomized control trial is necessary to confirm these preliminary findings.

Metal-on-metal hip resurfacing arthroplasty (MoM HRA) may offer potential advantages over total hip arthroplasty (THA) for certain patients with advanced osteoarthritis of the hip. However, the cost effectiveness of MoM HRA compared with THA is unclear.The purpose of this study was to compare the clinical effectiveness and cost-effectiveness of MoM HRA to THA.A Markov decision model was constructed to compare the quality-adjusted life-years (QALYs) and costs associated with HRA versus THA from the healthcare system perspective over a 30-year time horizon. We performed sensitivity analyses to evaluate the impact of patient characteristics, clinical outcome probabilities, quality of life and costs on the discounted incremental costs, incremental clinical effectiveness, and the incremental cost-effectiveness ratio (ICER) of HRA compared to THA.MoM HRA was associated with modest improvements in QALYs at a small incremental cost, and had an ICER less than $50,000 per QALY gained for men younger than 65 and for women younger than 55. MoM HRA and THA failure rates, device costs, and the difference in quality of life after conversion from HRA to THA compared to primary THA had the largest impact on costs and quality of life.MoM HRA could be clinically advantageous and cost-effective in younger men and women. Further research on the comparative effectiveness of MoM HRA versus THA should include assessments of the quality of life and resource use in addition to the clinical outcomes associated with both procedures.Level I, economic and decision analysis. See Guidelines for Authors for a complete description of levels of evidence.

To address the long-term problems of bearing surface wear and osteolysis associated with conventional metal-polyethylene (M-PE) total hip arthroplasty (THA), metal-metal (M-M), and ceramic-ceramic (C-C) bearings have been introduced. These bearing surfaces are associated with unique risks and benefits and higher costs. However the relative risks of these three bearings in an older population is unknown.We compared the short-term risk of complication and revision THA among Medicare patients having a primary THA with metal-polyethylene (M-PE), metal-metal (M-M), and ceramic-ceramic (C-C) bearings.We used the 2005 to 2007 100% Medicare inpatient claim files to perform a matched cohort analysis in three separate cohorts of THA patients (M-PE, M-M, and C-C) who were matched by age, gender, and US census region. Multivariate Cox proportional-hazards models were constructed to compare complication and revision THA risk among cohorts, adjusting for medical comorbidities, race, socioeconomic status, and hospital factors.After adjusting for patient and hospital factors, M-M bearings were associated with a higher risk of periprosthetic joint infection (hazard ratio, 3.03; confidence interval, 1.02–9.09) when compared with C-C bearings (0.59% versus 0.32%, respectively). There were no other differences among bearing cohorts in the adjusted risk of revision THA or any other complication.The risk of short-term complication (including dislocation) and revision THA were similar among appropriately matched Medicare THA patients regardless of bearing surface. Hard-on-hard THA bearings are of questionable value in Medicare patients, given the higher cost associated with their use and uncertain long-term benefits in older patients.Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Understanding the cause of failure and type of revision total knee arthroplasty (TKA) procedures performed in the United States is essential in guiding research, implant design, and clinical decision making in TKA. We assessed the causes of failure and specific types of revision TKA procedures performed in the United States using newly implemented ICD-9-CM diagnosis and procedure codes related to revision TKA data from the Nationwide Inpatient Sample (NIS) database. Clinical, demographic, and economic data were reviewed and analyzed from 60,355 revision TKA procedures performed in the United States between October 1, 2005 and December 31, 2006. The most common causes of revision TKA were infection (25.2%) and implant loosening (16.1%), and the most common type of revision TKA procedure reported was all component revision (35.2%). Revision TKA procedures were most commonly performed in large, urban, nonteaching hospitals in Medicare patients ages 65 to 74. The average length of hospital stay (LOS) for all revision TKA procedures was 5.1 days, and the average total charges were $49,360. However, average LOS, average charges, and procedure frequencies varied considerably by census region, hospital type, and procedure performed. Level of Evidence: Level II, economic and decision analysis. See Guidelines for Authors for a complete description of levels of evidence.

The US healthcare system is currently facing daunting demographic and economic challenges. Because musculoskeletal disorders and disease represent a substantial and growing portion of this healthcare burden, novel approaches will be needed to continue to provide high-quality, affordable, and accessible orthopaedic care to our population. The concept of “disruptive innovations,” which has been studied and popularized by Harvard Business School Professor Clayton Christensen, may offer a potential framework for developing strategies to improve quality and control costs associated with musculoskeletal care. The introduction of mobile fluoroscopic imaging systems, the development of the Surgical Implant Generation Network intramedullary nail for treatment of long bone fractures in the developing world, the expanding role and contributions of physician assistants and nurse practitioners to the orthopaedic team, and the rise of ambulatory surgery centers are all examples of disruptive innovations in the field of orthopaedics. Although numerous cultural and regulatory barriers have limited the widespread adoption of these “disruptive innovations,” we believe they represent an opportunity for clinicians to regain leadership in health care while at the same time improving quality and access to care for patients with musculoskeletal disease.

Background: Total knee arthroplasty is one of the most clinically successful and cost-effective interventions in medicine. However, implant malalignment, especially in the coronal plane, is a common cause of early failure following total knee arthroplasty. Computer-assisted surgery has been employed during total knee arthroplasty to improve the precision of component alignment. The purpose of the present study was to evaluate the cost-effectiveness of computer-assisted surgery to determine whether the improved alignment achieved with computer navigation provides a sufficient decrease in failure rates and revisions to justify the added cost.Methods: A decision-analysis model was used to estimate the cost-effectiveness of computer-assisted surgery in total knee arthroplasty. Model inputs, including costs, effectiveness, and clinical outcome probabilities, were obtained from a review of the literature. Sensitivity analyses were performed to evaluate the impact of component-alignment precision with use of computer-assisted and mechanical alignment guides, total knee arthroplasty failure rates secondary to malalignment, and costs of computer-assisted surgery systems on the cost-effectiveness of computer navigation in total knee arthroplasty.Results: Computer-assisted surgery is both more effective and more expensive than mechanical alignment systems. Given an additional cost of $1500 per operation, a 14% improvement in coronal alignment precision (within 3 degrees of neutral mechanical axis), and an elevenfold increase in revision rates at fifteen years with coronal malalignment (54% compared with 4.7%), the incremental cost of using computer-assisted surgery is $45,554 per quality-adjusted life-year gained. Cost-savings is achieved if the added cost of computer-assisted surgery is $629 or less per operation. Variability in published clinical outcomes, however, introduces uncertainty in determining the cost-effectiveness.Conclusions: Computer-assisted surgery is potentially a cost-effective or cost-saving addition to total knee arthroplasty. However, the cost-effectiveness is sensitive to variability in the costs of computer navigation systems, the accuracy of alignment achieved with computer navigation, and the probability of revision total knee arthroplasty with malalignment.