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Liver cirrhosis is associated with increased perioperative morbidity. Our study used the Model for End-Stage Liver Disease (MELD) score to assess the impact of cirrhosis severity on postoperative outcomes following total knee arthroplasty (TKA). A retrospective review identified 59 patients with liver cirrhosis who underwent primary TKA at a large, urban, academic center from January 2013 to August 2022. Cirrhosis was categorized as mild (MELD < 10; n = 47) or moderate-severe (MELD ≥ 10; n = 12). Modified Clavien-Dindo classification was used to grade complications, where grade 2+ denoted significant intervention. Hospital length of stay, nonhome discharge, and mortality were collected. A 1:1 propensity matching was used to control for demographics and selected comorbidities. Moderate-severe cirrhosis was associated with significantly higher rates of intrahospital overall (58.33 versus 16.67%, P =.036) complications, 30-day overall complications (75 versus 33.33%, P =.042), and 90-day overall complications (75 versus 33.33%, P =.042) when compared to matched mild cirrhosis patients. Compared to matched noncirrhotic controls, mild cirrhosis patients had no significant increase in complication rate or other outcomes (P >.05). Patients with moderate-severe liver cirrhosis are at risk of short-term complications following primary TKA. Patients with mild cirrhosis have comparable outcomes to matched noncirrhotic patients. Surgeons can use MELD score prior to scheduling TKA to determine which patients require optimization or higher levels of perioperative care. [ABSTRACT FROM AUTHOR]

Removal of primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA) from the inpatient-only list has financial implications for both patients and institutions. The aim of this study was to evaluate and compare financial parameters between patients designated for inpatient versus outpatient total joint arthroplasty. We reviewed all patients who underwent TKA or THA after these procedures were removed from the inpatient-only list. Patients were statistical significance into cohorts based on inpatient or outpatient status, procedure type, and insurance type. This included 5,284 patients, of which 4,279 were designated inpatient while 1,005 were designated outpatient. Patient demographic, perioperative, and financial data including per patient revenues, total and direct costs, and contribution margins (CMs) were collected. Data were compared using t -tests and Chi-squared tests. Among Medicare patients receiving THA, CM was 89.1% lower for the inpatient cohort when compared to outpatient (P <.001), although there was no statistical significance difference between cohorts for TKA (P =.501). Among patients covered by Medicaid or Government-managed plans, CM was 120.8% higher for inpatients receiving THA (P <.001) when compared to outpatients and 136.3% higher for inpatients receiving TKA (P <.001). Our analyses showed that recent costs associated with inpatient stay inconsistently match or outpace additional revenue, causing CM to vary drastically depending on insurance and procedure type. For Medicare patients receiving THA, inpatient surgery is financially disincentivized leaving this vulnerable patient population at a risk of losing access to care. Retrospective Cohort Study. [ABSTRACT FROM AUTHOR]

Background: Changes to Medicare's Inpatient Only List (IPO) and factors associated with the COVID pandemic have led to more total joint arthroplasty (TJA) patients to be designated as outpatient (OP). This potentially complicates postoperative care for patients with lower functional status and poor social support. These factors make the decision between OP versus inpatient (IP) designation particularly challenging for healthcare teams. The Risk Assessment and Prediction Tool (RAPT) was designed to indicate patient risk for needing posthospital discharge to facility and considers social and functional factors. The purpose of this study is to 1) evaluate the correlation of RAPT as a clinical tool to aid decision-making regarding OP versus IP for Total Hip and Knee Arthroplasty (THA and TKA), 2) assess the impact of recent changes to the IPO and the COVID pandemic on OP TJA readmission rates, and 3) determine whether 90-day readmissions are correlated with RAPT scores after OP TJA.Methods: We identified all elective TKA and THA patients from 2015 through 2021 in our electronic health record at our large, urban, academic health system. Fracture patients were excluded. For those patients with available RAPT scores, we determined OP and IP designations, with IP defined as those with length-of-stay 2 midnights or more. We performed subanalysis of OP between same-day and next-day discharge. RAPT scores and readmission rates were compared at time points related to changes in the IPO: before TKA removal in 2018 (period A), from 2018 until THA removal in 2020 (Period B), and after January 1, 2020, inclusive of impact from the COVID pandemic (Period C).Results: Reviewed were 11,819 elective TKAs and 10,212 elective THAs. RAPT scores were available for 6,759 TKA patients and 5,589 THA patients. For both TKA and THA, RAPT scores between IP, same-day, and next-day discharged OP were significantly different across all time periods (P < .001). The percentage of OP designation increased across all time periods for TKA and THA. Over these same time periods, mean RAPT scores decreased significantly for both OP TKA and OP THA (P < .01). Concurrent with these changes were significant increases in OP THA 90-day readmission rates across Periods A and B (P = .010) as well as A and C (P = .006). Readmitted OP TKA had significantly lower RAPT scores than OP TKA without readmission during Period B (P < .001). Readmitted OP THA had significantly lower RAPT scores than those without readmission for all periods (P < .05). To facilitate clinical utility, median RAPT scores were also analyzed, and showed that RAPT scores for OP THA patients with readmission were 1 to 2 points lower for all time periods.Conclusion: RAPT scores correlate with IP versus OP status for both TKA and THA and vary significantly with same-day versus next-day discharge. OP TJA RAPT scores may also help predict readmission, and counsel some patients away from OP surgery. Average RAPT scores of 10, 9, and 8 appeared to be separators for same day, next day, and inpatient stay. Changes to the IPO and COVID pandemic correlate with decrease in RAPT scores for both TKA and THA patients within all designations. In addition, a shift toward lower RAPT for OP TJA correlates with increased 90-day readmission rates for OP TJA. Taken together, these results suggest that patients with poorer function and worse social support systems are increasingly being driven toward OP surgery by these changes, which may play a role in increasing readmission rates. Social support and functional factors should be considered for OP elective TKA and THA. Further, any OP TJA value-based payment system must account for these variables. [ABSTRACT FROM AUTHOR]

Background: On December 20, 2020, the Centers for Medicare and Medicaid Services (CMS) finalized its proposed rule: CMS-1734-P. This 2021 Final Rule significantly changed Medicare total joint arthroplasty (TJA) reimbursement. The precise impact on surgeon productivity and reimbursement is unknown. In the present study, we sought to model the potential impact of these changes for multiple unique practice configurations.Methods: A mathematical model was applied to CMS data to determine the impact of CMS-1734-F on multiple, theoretical TJA practice configurations. Variables tested were the annual percentage of revision vs primary arthroplasty cases performed and the annual percentage of operative vs office-based productivity. The model defined baseline annual surgeon productivity as the 2018 Medical Group Management Association hip and knee arthroplasty surgeon median productivity of 10,568 work relative value units (wRVUs).Results: All modeled simulations demonstrated a year-to-year increase in wRVUs independent of practice configuration. However, simulations that demonstrated less than a 3.35% increase in wRVUs from year-to-year saw a decrease in reimbursement. Those simulations with higher wRVU increases tended to have a higher percentage of revision vs primary arthroplasty cases and/or had annual productivity that was derived to a greater extent from office encounters than surgical cases.Conclusion: The impact of CMS-1734-F will vary based on 3 factors: (1) the relative contribution of a surgeon's operative TJA practice compared with their office-based practice to their annual wRVUs; (2) the relative percentage of revision TJAs vs the percentage of primary TJAs performed; and (3) the relative percentage of primary TJA compared to non-arthroplasty surgeries as a component of overall operative practice. The decreased reimbursement will be disproportionately felt by arthroplasty surgeons who perform relatively fewer revision TJA procedures and whose office-based productivity makes up a smaller overall percentage of their annual workload. [ABSTRACT FROM AUTHOR]

Background: Vancomycin is often used as antimicrobial prophylaxis in patients undergoing total hip or knee arthroplasty. Vancomycin requires longer infusion times to avoid associated side effects. We hypothesized that vancomycin infusion is often started too late and that delayed infusion may predispose patients to increased rates of surgical site infections and prosthetic joint infections.Methods: We reviewed clinical data for all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients at our institution between 2013 and 2020 who received intravenous vancomycin as primary perioperative gram-positive antibiotic prophylaxis. We calculated duration of infusion before incision or tourniquet inflation, with a cutoff of 30 minutes defining adequate administration. Patients were divided into two groups: 1) appropriate administration and 2) incomplete administration. Surgical factors and quality outcomes were compared between groups.Results: We reviewed 1047 primary THA and TKA patients (524 THAs and 523 TKAs). The indication for intravenous vancomycin usage was allergy (61%), methicillin-resistant staphylococcus aureus colonization (17%), both allergy and colonization (14%), and other (8%). 50.4% of patients began infusion >30 minutes preoperatively (group A), and 49.6% began infusion <30 minutes preoperatively (group B). Group B had significantly higher rates of readmissions for infectious causes (3.6 vs 1.3%, P = .017). This included a statistically significant increase in confirmed prosthetic joint infections (2.2% vs 0.6%, P = .023). Regression analysis confirmed <30 minutes of vancomycin infusion as an independent risk factor for PJI when controlling for comorbidities (OR 5.22, P = .012).Conclusion: Late infusion of vancomycin is common and associated with increased rates of infectious causes for readmission and PJI. Preoperative protocols should be created to ensure appropriate vancomycin administration when indicated. [ABSTRACT FROM AUTHOR]

Abstract: The shift to value-based care is changing the practice of medicine. In order to prepare our orthopaedic trainees to survive in a value-based health-care environment, we must expose them to and educate them about value-based programs. This creates both challenges and opportunities for training programs. Academic medical centers (AMCs) will need to carefully consider how to adopt value-based programs and agreements, and assess whether they need alternative facilities, partnerships, or processes in order to be successful. Process improvement principles to adapt physician behavior, the introduction of outcome metrics into the surgical decision-making process, and the development of team-based care can greatly enhance the likelihood of success. AMCs should embrace these challenges to ensure that their residents are well-prepared for the future. [ABSTRACT FROM AUTHOR]

Background: The unsustainable rising costs of healthcare, a greater portion of which is being borne by the federal government, has resulted in the government's development of programs aimed to control costs without adversely affecting outcomes.Methods/results: Alternative Payment Models, the shift from inpatient to outpatient and ambulatory surgery centers' surgical venues, and Relative Value Update Committee coding and reimbursement strategies are all designed to achieve the aforementioned goal. These programs will continue to influence our practice patterns.Conclusion: It is clear that we must continue to advocate for access to high quality care reimbursed at a fair price. It is also clear that the successful adult reconstructive surgeon will understand these programs and adjust his/her practice to take full advantage of the opportunities that these programs present. [ABSTRACT FROM AUTHOR]

Background: Medicare's Bundled Payments for Care Initiative (BPCI) is a risk-sharing alternative payment model. There is a concern that BPCI providers may avoid operating on obese patients and active smokers to reduce costs. We sought to understand if increased focus on these patient factors has led to a change in patient demographics in Medicare-insured patients undergoing total knee arthroplasty (TKA).Methods: We retrospectively reviewed all patients who underwent TKA at an academic orthopedic specialty hospital between 1/1/13 and 8/31/19. Surgical date, insurance provider, BMI, and smoking status were collected. Patients were categorized as a current, former, or never smoker. Patients were categorized as obese if their BMI was >30 kg/m2, morbidly obese if their BMI was >40 kg/m2, and super obese if their BMI was >50 kg/m2.Results: In total, 10,979 patients with complete insurance information were analyzed. There was no statistically significant change in the proportion of Medicare patients who were active smokers (4.34% in 2013, 4.85% in 2019, Pearson correlation coefficient = 0.6092, P = .146). The proportion of Medicare patients with BMI >30 kg/m2 increased over the study period (35.84% in 2013, 55.77% in 2019, Pearson correlation coefficient = 0.8505, P = .015). When looking at patients with BMI >40 kg/m2 and >50 kg/m2, there was no significant change.Conclusions: Despite concern that reimbursement payments could alter access to care for patients with certain risk factors, this study did not find a noticeable difference in the representation of patients with obesity and smoking status undergoing TKA following the installation of BPCI.Level Of Evidence: III, retrospective observational analysis. [ABSTRACT FROM AUTHOR]

Background: Alternative payment models were set up to increase the value of care for total joint arthroplasty. Currently, total knee arthroplasty (TKA) and total hip arthroplasty (THA) are reimbursed within the same bundle. We sought to determine whether it was appropriate for these cases to be included within the same bundle.Methods: The data were collected from consecutive patients in a bundled payment program at a single large academic institution. All payments for 90 days postoperatively were included in the episode of care. Readmission rates, demographics, and length of stay were collected for each episode of care.Results: There was a significant difference in cost of episode of care between TKA and THA, with the average TKA episode-of-care cost being higher than the average THA episode-of-care cost ($25803 vs $23805, P < .0001). There was a statistically significant difference between the 2 groups between gender, race, medical complexity, disposition outcome, and length of stay. The TKA group trended toward a lower readmission rate (5.3%) compared to the THA group (6.6%).Conclusion: The cost of an episode of care for patients within the bundled payment model is significantly higher for patients undergoing TKA compared with those undergoing a THA. This should be taken into consideration when determining payment plans for patients in alternative payment plans, along with other aspects of risk that need to be considered in order to allow for hospitals to be successful under the bundled payment model. [ABSTRACT FROM AUTHOR]

There has been an upsurge in the number of practices owned by non-physicians. With orthopaedic surgery as the next frontier in this market, orthopaedists need to consider the ethical consequences of such acquisitions. The history and trends of practice ownership are reviewed alongside how laws shifted to reflect a changing health-care climate. The 4 tenets of bioethics (beneficence, nonmaleficence, autonomy, and justice) are explored with regard to practice acquisition by non-physician entities. Although non-physician-owned corporations and private equity firms provide liquidity to the health-care sector, there are ethical concerns that may ultimately impact patient care. Orthopaedic surgeons must be cautious when engaging in acquisitions with non-physician-owned entities, as the goals of each party may not align. This may yield situations that infringe on the basic principles of bioethics for both physician and patient. [ABSTRACT FROM AUTHOR]

The aims of this study were to examine variances in inpatient opioid consumption after total shoulder arthroplasty (TSA) and to determine factors influencing inpatient opioid utilization. The sample included patients undergoing elective TSA at a tertiary-level institution between January 2016 and April 2018. Opioid consumption during the inpatient stay was converted into morphine milligram equivalents (MMEs), accounting for dosage and route of administration. The MMEs were calculated per patient encounter and used to calculate mean opioid consumption. Bivariate linear regression analysis was performed to assess the impact of patient-related factors and surgery-related factors on inpatient opioid consumption. Altogether 20 surgeons performed 622 TSAs. The average opioid dose per encounter was 47.4 ± 65.7 MME/d. MMEs prescribed varied significantly among surgeon providers (P <.01). Pre-existing psychiatric disorders (P =.00012), preoperative opioid use (P =.0013), highest quartile of median household income (P =.048), current-smoker status (P <.001), age < 60 years (P <.01), and general anesthesia (vs. regional anesthesia, P =.005) were associated with significant inpatient opioid consumption after TSA. Sex, race, American Society of Anesthesiologists status, replacement type (anatomic TSA vs. reverse TSA), and prior shoulder surgery did not show any significant differences. There is considerable variation in inpatient opioid consumption after TSA at the same institution. Knowledge of modifiable and nonmodifiable risk factors that increase inpatient opioid consumption will help to optimize multimodal analgesia protocols for TSA. [ABSTRACT FROM AUTHOR]

Background: Opioid addiction affects patients of every race, sex, and socioeconomic status. Overprescribing is a known cause of the opioid crisis. Various agencies have implemented requirements and programs to combat practitioner overprescribing; however, there can be adverse ethical consequences when regulations are used to influence physician behavior. We aimed to explore the ethical aspects of some of these interventions. Methods: We reviewed various interventions for opioid prescribing through the lens of ethical inquiry. Specifically, we evaluated (1) requirements for educational programs for prescribers and patients, (2) prescription monitoring programs, (3) prescription limits, (4) development of condition-specific pain management guidelines, (5) increased utilization of naloxone, and (6) opioid disposal programs. We also evaluated patient satisfaction survey questions relating to pain. Results: The present analysis demonstrated that the following regulatory interventions are ethically sound: requirements for educational programs for prescribers and patients, robust prescription monitoring programs that cross state lines, increased prescribing of naloxone for at-risk patients, development of condition-specific pain management guidelines, improvement of opioid disposal programs, and elimination of pain-control questions from patient satisfaction surveys. However, implementation of strict prescribing limits without accommodation for procedure and patient characteristics may have negative ethical consequences. Conclusions: Although the importance of addressing the current opioid crisis cannot be understated, as surgeons, we must examine ethical implications of any new regulations that affect musculoskeletal patient care. [ABSTRACT FROM AUTHOR]

Introduction: Magnet Recognition is the highest distinction a healthcare organization can receive for excellence in nursing. Although Magnet status is generally associated with superior clinical outcomes and patient satisfaction, its association with performance on nationwide quality metrics is currently unknown. Methods: Within a propensity score–matched cohort, we compared performance on the Hospital-Acquired Condition Reduction Program (HACRP), Hospital Value-Based Purchasing (VBP), and Hospital Readmissions Reduction Program (RRP) initiatives. Results: The mean HACRP total performance score was inferior at Magnet versus non-Magnet hospitals (p <.001), and HACRP penalties were more likely to be levied against Magnet hospitals (p =.003). There was no significant difference according to Magnet status for VBP penalties after correcting for multiple comparisons (p =.049). There were no significant difference in RRP penalties according to Magnet status (p =.999). Conclusions: Magnet hospitals performed worse on a number of hospitalwide quality metrics tied to reimbursement by the Centers for Medicare and Medicaid Service. Although Magnet hospitals are known for superior nursing care and organizational support for safety and quality improvement, this is not captured within these composite measures of quality, which can be influenced at many levels of care. These data underscore the need for comprehensive quality improvement across multiple domains of care outside of nursing. Level of Evidence: Level III, retrospective study. [ABSTRACT FROM AUTHOR]

As soon as it became clear that our economy was going to be paralyzed by the SARS-CoV-2 pandemic, the American Association of Hip and Knee Surgeons leadership acted swiftly to ensure that our members were going to be eligible for the anticipated federal economic stimulus. The cessation of elective surgery, enacted in mid-March and necessary to stop the spread of the SARS-CoV-2 virus, would surely challenge the solvency of many of our members' practices. Although our advocacy efforts discussed further have helped, clearly more relief is needed. Fortunately, our mitigation efforts have led to a "flattening of the curve" and discussions have begun on when, where, and how to safely start elective surgery again. [ABSTRACT FROM AUTHOR]

Background: Smoking is associated with adverse outcomes after total joint arthroplasty (TJA), including periprosthetic joint infection (PJI). Although preoperative smoking cessation interventions may help reduce the risk PJI, the short-term cost-effectiveness of these programs remains unclear.Methods: Decision analysis was used to evaluate the cost-effectiveness of a preoperative smoking cessation intervention over a 90-day TJA episode of care. Costs and probabilities were derived from literature review and published Medicare data. Thresholds for cost and efficacy of the intervention were determined using sensitivity analysis.Results: In our model, the average 90-day cost was $32 less for patients enrolled in a mandatory smoking cessation intervention ($23,457) compared with patients who were not ($23,489). In sensitivity analyses, the smoking cessation intervention was cost-saving vs no intervention when the short-term cost of PJI was greater than $95,410, the rate of PJI was reduced by at least 25% for former vs current smokers, the cost of the intervention was less than $219, or the success rate of the intervention was greater than 56%.Conclusion: Smoking cessation interventions prior to TJA can increase the value of care and are an important public health initiative. Routine referral to smoking cessation interventions should be considered for smokers indicated for TJA.Level Of Evidence: Level II, economic and decision analyses. [ABSTRACT FROM AUTHOR]

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

Introduction: The Federal Government, the largest payer of health care, considers readmission within 30 days of discharge an indicator of quality of care. Many studies have focused on causes for and strategies to reduce readmissions following medical admissions. However, few studies have focused on the differences between them. We believe that the causes for readmission following orthopaedic surgery are markedly different than those following medical admissions, and therefore, the strategies developed to reduce medical readmissions will not be as effective in reducing readmissions after elective orthopaedic surgery. Methods: All unplanned 30-day readmissions following an index hospitalization for an elective orthopaedic procedure (primary and revision total joint arthroplasty and spine procedure) or for one of the three publicly reported medical conditions (AMI, HF, and pneumonia, which accounted for 11% of readmissions) were identified at our institution from 2010 through 2012. A total of 268 patients and 390 medical patients were identified as having an unplanned 30-day readmission. We reviewed a prospectively collected data base to determine the reason for readmission in each encounter. Results: A total of 233 (86.9%) orthopaedic patients were readmitted for surgical complications, most commonly for a wound infection (56.0%) or wound complication (11.6%). Following an index admission of HF or AMI, the primary reason for readmission was a disease of the circulatory system (55.9% and 57.4%, respectively). Following an index admission for pneumonia, the primary reason for readmission was a disease of the respiratory system (34.5%). Conclusion: The causes of readmissions following orthopaedic surgery and medical admissions are different. Patients undergoing orthopaedic procedures are readmitted for surgical complications, frequently unrelated to aftercare, and medicine patients are readmitted for reasons related to the index diagnosis. Interventions designed to reduce orthopaedic readmissions must focus on reducing surgical complications, differing from interventions designed to reduce readmissions following medical admissions, which focus on medical diagnoses. [ABSTRACT FROM AUTHOR]

Staphylococcus aureus nasal colonization is a risk factor for surgical site infection. We conducted a retrospective case-control study of 1,708 consecutively enrolled patients to identify criteria that places orthopaedic surgery patients undergoing spine and total joint arthroplasty surgery at risk for nasal colonization by MRSA and MSSA. Multivariate analysis showed obesity and asthma as significant risk factors for MRSA colonization. The identification of these two risk factors for MRSA colonization may help decolonization programs target patients with these factors for treatment prior to surgery, which could potentially lead to reductions in the rates of surgical site infections. [ABSTRACT FROM AUTHOR]

Favorable patient experience and low complication rates have been proposed as essential components of patient-centered medical care. Patients' perception of care is a key performance metric and is used to determine payments to hospitals. It is unclear if there is a correlation between technical quality of care and patient satisfaction. The study authors correlated patient perceptions of care measured by the Hospital Consumer Assessment of Healthcare Providers and Systems scores with accepted quality of care indicators. The Hospital Compare database (4605 hospitals) was used to examine complication rates and patient-reported experience for hospitals across the nation in 2011. The majority of the correlations demonstrated an inverse relationship between patient experience and complication rates. This negative correlation suggests that reducing these complications can lead to a better hospital experience. Overall, these results suggest that patient experience is generally correlated with the quality of care provided. [ABSTRACT FROM AUTHOR]

"The purpose of our pre-post intervention study was to reduce the number of near-miss events pertaining to wrong-site surgery, including incorrectly sided surgical bookings and incorrectly performed preoperative time-out procedures. Pre- and postintervention, incorrectly booked cases, and improperly performed presurgical time-out procedures were recorded. We then educated each surgeon and their staff regarding the importance of and proper way to perform these tasks. Subsequently, the monthly percentage of incorrectly booked surgical procedures and improperly performed time-outs were significantly decreased.~Unlabelled~In 2004, the Joint Commission published comprehensive guidelines to prevent wrong-site surgery. Seven years have passed, and the incidence has not declined. The Joint Commission estimates that in the United States, wrong-site procedures including surgeries occur at least 40 times a week. ""Near misses"" are events that could have harmed a patient, but did not due to chance or mitigation. Improperly performed time-out procedures and inaccurate surgical bookings are considered near misses and could ultimately lead to ""never events,"" such as wrong-site surgery. Near-miss analysis is a highly effective method of preventing rare, ""never events."" We hypothesize that proper education of surgeons and staff will be effective in reducing the number of near misses.~Introduction~Background~All cases analyzed were performed at an academic, orthopedic surgery specialty institution. From August 2010 to May 2011, near misses were identified and stored in Patient Safety Net (PSN), an electronic database. We tracked these cases and educated each offending attending physician and his or her staff about the importance of accurate surgical bookings. Additionally, we began an observational program to carefully review presurgical time-out procedures as they occurred. We tracked the percentage of these improperly performed time-outs and counseled offenders (attending surgeon, or any member of the operating room staff who made the error) regarding the deficiencies that caused the time-out to be ineffective. The number of near misses that occurred before and after the interventions were recorded and analyzed.~Methods~Methods~Of the 12,215 cases included in this study, 6,126 cases formulated the ""pre-education"" cohort, while a total of 6,089 cases formulated the ""post-education"" cohort. In the first four months of the study, the monthly rate of incorrectly booked cases was 0.75%. Since the intervention, the rate decreased to 0.41% (p = .0139). The percentage of improperly performed time-out procedures decreased from 18.7% to 5.9% after the educational interventions were performed (p < .0001).~Results~Results~A program designed to educate physicians to the importance of decreasing near misses for wrong-site surgery is effective. When analyzing the literature, it is clear that the reduction in near misses observed in this study decreases the likelihood of a wrong-site surgery.~Conclusion~Conclusions" [ABSTRACT FROM AUTHOR]

Background: Regulatory change has created a growing demand to decrease the hospital costs associated with primary total joint arthroplasty (TJA). Concurrently, the removal of lower extremity TJA from the in-patient only list has affected hospital reimbursement. The purpose of this study is to investigate trends in hospital revenue versus costs in primary TJA.Methods: We retrospectively reviewed all patients who underwent primary TJA from June 2011 to May 2021 at our institution. Patient demographics, revenue, total cost, direct cost, and contribution margin were collected. Changes over time as a percentage of 2011 numbers were analyzed. Linear regression analysis was used to determine overall trend significance and develop projection models.Results: Total knee arthroplasty (TKA) insured by government-managed/Medicaid (GMM) plans showed a significant upward trend (P = .013) in total costs. Direct costs of TKA across all insurance providers (P = .001 and P < .001) and total hip arthroplasty (THA) for Medicare (P = .009) and GMM (P = .001) plans demonstrated significant upward trends. Despite this, 2011-2021 modeling found no significant change in contribution margin for TKA and THA covered under all insurance plans. However, models based on 2018-2021 financial data demonstrated a significant downward trend in contribution margin across Medicare (P < .001) and GMM (P < .001) insurers for both TKA and THA.Conclusion: Physician-led innovation in cost-saving strategies has maintained contribution margin over the past decade. However, the increase in direct costs seen over the past few years could lead to negative contribution margins over time, if further efficiency and cost-saving measures are not developed.Level Iii Evidence: Retrospective Cohort Study. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to determine the incidence of venous thromboembolism (VTE) after hip arthroscopy. Methods: Over the course of 13 months, four surgeons that routinely perform hip arthroscopy participated in a protocol to screen all patients postoperatively for deep venous thrombosis (DVT) using bilateral venous duplex ultrasound at or about the 2 week postoperative time point. All patients were assessed and stratified for VTE risk prior to surgery. Mechanical intraoperative and postoperative chemoprophylaxis were not administered. Perioperative factors, such as weightbearing status after surgery, traction time, and anesthesia type, were recorded. Results: We identified 139 eligible patients (average age 37.7, SD = 12.0) that underwent hip arthroscopy. The incidence of symptomatic VTE was 1.4 percent (2/139). Of the entire patient pool, 81 obtained a follow-up ultrasound. There were no cases of asymptomatic deep vein thrombosis (DVT). There were two symptomatic venous thromboembolic events noted; one DVT and one pulmonary embolus. One patient had no risk factors; the other was overweight and routinely took oral contraceptives. Amongst the patient cohort, the mean BMI was 25.9 (SD = 4.8). The mean traction time was 58.9 minutes (SD = 23.1). Most patients (71%) were partial weightbearing after the procedure. Conclusion and Clinical Relevance: In patients undergoing hip arthroscopy, the rate of postoperative VTE was low, despite the use of prolonged axial traction and surgical proximity to the pelvic veins. Although patients should be counseledpreoperatively regarding the risk of VTE, we believe that routine use of pharmacologic prophylaxis is not indicated following hip arthroscopy if patients are properly risk stratified prior to surgery and found to be at low risk for VTE. [ABSTRACT FROM AUTHOR]

Background: Physiotherapy after total joint replacement enhances postoperative recovery. Implementing a pathway to include earlier postoperative mobilization can reduce the hospital length-of-stay as well as cost. Questions: Does a rapid rehabilitation program consisting of physical therapy on the day of surgery affect the hospital length-of-stay on patients undergoing either total hip or total knee replacements? Is there a difference in the effectiveness of rapid rehabilitation between patients undergoing Total Hip and Total Knee Replacements? Can these patients tolerate day of surgery physical therapy sessions? Patients and Methods: Nine-hundred hip and knee arthroplasty patients were divided into two groups for analysis. Group 1 participated in a rapid rehabilitation physical therapy program that began with physical therapists in the recovery room. Group 2 received a standard physical therapy protocol starting the day after surgery. Progression with rehabilitation was followed, and length of hospital stay between the two groups was compared. Results: Total length-of-stay was 3.9 days for the rapid rehabilitation group and was 4.4 days (p < 0.001) for the standard therapy group. We found the rapid rehabilitation group had a significantly shorter length-of-stay than patients who began therapy on postoperative day one. In addition to decreased length-of-stay, rapid rehabilitation also resulted in direct savings considering fewer hospital resources were utilized over the decreased time in-house. Conclusions: Rapid mobilization of total joint replacement patients in the recovery room can be accomplished safely and reduces the overall length of hospital stay for over 70 % of patients. [ABSTRACT FROM AUTHOR]

The outcomes of ACL reconstructions in terms of patient satisfaction and function are well known. Most orthopaedic surgeons feel that Medicare and other payors do not reimburse enough for this surgery. The purpose of this study is to determine how much patients are willing to pay for this surgery and compare it to reimbursement rates. Methods: We constructed a survey which described the function and limitations of an ACL deficient knee and the expected function of that knee after an ACL reconstruction. We then asked the volunteers how much they would be willing to pay for an ACL reconstruction if it were their knee. We also gathered data on the yearly earnings and Tegner activity level of the volunteers. In all, 143 volunteers completed the survey. We computed correlation coefficients between willingness to pay and both yearly earnings and Tegner activity level. Results: The average amount that the volunteers were willing to pay for an ACL reconstruction was $4,867.00. There was no correlation between yearly earnings and willingness to pay. The correlation coefficient was 0.34. There was a weak correlation between Tegner activity level and willingness to pay. This correlation coefficient was 0.81. The Medicare allowable rate for ACL reconstruction (CPT 29888) in the geographic area of the study was $1,132.00. Conclusion: The data demonstrates that patients are willing to pay much more than traditional payors for ACL reconstruction. These payors undervalue the benefit of this surgery to the patient. There is increasing pressure on orthopaedic surgeons to not participate in insurance plans that reimburse poorly. This places an increasing financial burden on the patient. This study suggests that patients may be willing to pay more for their surgery than their insurance plan and accept more of this burden. [ABSTRACT FROM AUTHOR]

The article outlines several perioperative strategies for decreasing the rates of surgical site infections associated with orthopaedic surgical procedures. These strategies include preoperative preparation of a patient with chlorhexidine gluconate, identification of high-risk patients, and addressing nutritional issues prior to surgery. It notes that the reduction of the incidence of infections is a major focus of patients and surgeons, as well as several groups of interested parties.

The subscapularis tendon, coracohumeral ligament, and transverse humeral ligament are all believed to contribute to biceps tendon stability within the bicipital groove. In order to examine the relative contribution of these soft tissue structures to proximal biceps tendon stability, 11 fresh frozen cadaveric shoulder specimens were prepared and mounted onto a custom jig. A three-dimensional digitizer was utilized to record biceps tendon excursion in various shoulder positions. In sequential order, these structures were then sectioned, and biceps tendon excursion was again recorded. We found that sectioning of the subscapularis tendon significantly increased biceps tendon excursion, compared to intact specimens (8.1 ± 4.1 mm vs. 4.3 ± 3.6 mm; p < 0.006). In contrast, isolated sectioning of the transverse humeral ligament or the coracohumeral ligament did not significantly increase biceps excursion (5.4 ± 2.5 mm, p = 0.26; 5.6 ± 1.3 mm, p - 0.24). When two structures were sectioned, significant excursion in the biceps tendon only occurred in specimens where the subscapularis tendon was one of the sectioned structures. The preliminary data suggest that, of the three tested soft tissue structures, the subscapularis tendon is the most important stabilizer of the proximal biceps and that clinically significant lesions of the proximal biceps tendon may be associated with a defect in the subscapularis tendon. [ABSTRACT FROM AUTHOR]

Patellofemoral joint arthritis is a common condition which can be extremely debilitating. Although it is a common condition, the treatment of isolated patellofemoral arthritis varies and remains controversial. The objective of this review is to provide an overview of the current understanding of patellofemoral arthritis and various different surgical options, indications, and their respective outcomes. [ABSTRACT FROM AUTHOR]