Abstract

Introduction

Quality measures play a substantial role in the Centers for Medicare and Medicaid Services' hospital payment and public reporting programs. The purpose of this study was to assess whether public measurement of total hip and knee arthroplasty risk-standardized readmission (RSRRs) and complication rates (RSCRs) was temporally associated with decreasing rates of adverse outcomes among Medicare beneficiaries.

Background

Prior research has shown that depression negatively impacts outcomes after total hip arthroplasty (THA); however, arthroplasty patients may also have depressive symptoms without an established diagnosis. The purpose of this study was to determine whether the Patient Health Questionnaire-2 (PHQ-2), a two-question depression screener, correlates with joint-specific symptom improvement after primary THA.

Introduction

Patient-reported outcome (PRO) data are variably collected before and after total hip/knee arthroplasty (THA/TKA). We assessed the generalizability of incentivized, prospectively collected PRO data for THA/TKA patient-reported outcome performance measure (PRO-PM) development.

Use of large databases for orthopaedic research has increased exponentially. Each database represents unique patient populations and vary in methodology of data acquisition. The purpose of this study was to evaluate differences in reported demographics, comorbidities and complications following total hip arthroplasty (THA) amongst four commonly used databases.

Patients who underwent primary THA during 2010–2012 were identified within National Surgical Quality Improvement Programs (NSQIP), Nationwide Inpatient Sample (NIS), Medicare Standard Analytic Files (MED) and Humana Claims Database (HAC). NSQIP definitions for comorbidities and surgical complications were queried in NIS, MED, and HAC using coding algorithms. Age, sex, comorbidities, inpatient and 30-day postoperative complications were compared (NIS has inpatient data only).

Primary THAs from each database were 22,644 (HAC), 371,715 (MED), 188,779 (NIS) and 27,818 (NSQIP). Age and gender distribution were similar between databases. There was variability in the prevalence of comorbidities and complications depending upon the database and duration of post-operative follow-up. HAC and MED had twice the prevalence of COPD, coagulopathy and diabetes than NSQIP. NSQIP had more than twice the obesity than NIS. HAC had more than twice the rates of 30-day complications at all endpoints compared to NSQIP and more than twice the DVTs, strokes and deep infection as MED at 30-days post-op. Comparison of inpatient and 30-day complications rates demonstrated more than twice the amount of infections and DVTs are captured when analysis is extended from inpatient stay to 30-days post-op.

Amongst databases commonly used in orthopaedic research, there is considerable variation in complication rates following THA depending upon the database. It will be important to consider these differences when critically evaluating database research. Additionally, with the advent of bundled payments, these differences must be considered in risk adjustment models.

Purpose: Hip arthroscopy has been used at an increasing frequency over the last few years. Majority of patients undergoing hip arthroscopy are young and active individuals who seek definitive therapy for a painful hip condition and wish to avoid undergoing a hip replacement. Although relatively successful, complications following hip arthroscopy occur. This multi-institutional study presents a worrisome and previously unrecognized complication of hip arthroscopy, namely chondrolysis that lead to accelerated development of end-stage arthritis.

Method: Using the computerized database in each institution, patients undergoing total hip arthroplasty between 1999–2008 who had received hip arthroscopy prior to arthroplasty were identified. 39 patients were identified to have undergone at least one hip arthroscopy on the affected hip prior to arthroplasty. There were 21 female and 18 male patients. The mean age of patients at the time of hip arthroscopy was 45.9 years. Data regarding demographics, comorbidities, preoperative diagnosis, number of previous procedures, and the details of the surgical procedure were compiled. Radiographs were evaluated.

Results: The median time from arthroscopy to arthroplasty was 14.8 months (range 2.2 months to 7 years). Fourteen patients (35%) underwent THA within 12 months of a previous hip arthroscopy and in nine of these patients the indication for hip arthroscopy was labral tear debridement. These patients despite having none to minimal arthritis at the time of arthroscopy developed accelerated arthritis within a year that necessitated hip replacement.

Conclusion: Hip arthroscopy can cause accelerated degenerative arthritis of the hip in some patients. We believe the subset of our patients who developed arthritis so early after hip arthroscopy may have suffered chondrolysis and/or chondral injury during the arthroscopy that resulted in progressive and aggressive arthritis of the hip within 12 months. Hip arthroscopy should be reserved for a select group of patients. All measures to minimize the possibility of chondrolysis and/or chondral injury should be exercised.

Background: The rates of primary and revision knee arthroplasty in the United States have been increasing. Simultaneously, several studies have reported increased complication rates when these procedures are performed at low-volume centers. One innovation designed to improve knee arthroplasty outcomes is computer navigation, which aims to reduce revision rates by improving the alignment achieved at surgery. The purpose of this study was to examine the impact of hospital volume on the costeffectiveness of this new technology in order to determine its feasibility and the level of evidence that should be sought prior to its adoption.

Methods: A Markov decision model was used to evaluate the cost-effectiveness of computer-assisted knee arthroplasty, in relation to hospital volume. Transition probabilities were estimated from the arthroplasty literature, and costs were based on the average reimbursement for primary and revision knee arthroplasty at out institution. Outcomes were measured in quality adjusted life years.

Results: The results demonstrate that computer-assisted surgery becomes less cost-effective as the annual hospital volume decreases, as the cost of navigation increases, and as the impact on revision rates decreases. If a center performs 250 cases per year, computer navigation will be cost-effective if the annual revision rate is reduced by 2% per year over a twenty-year period. If a center performs 150 cases per year, computer navigation is cost-effective if it results in a 2.5% reduction in the annual revision rate over a twenty-year period. If a center performs only 25 cases per year, the annual reduction in revision rates must be 13% for computer navigation to be cost-effective.

Conclusion: This analysis demonstrates that computer navigation is not likely to be a cost-effective investment in health care improvement in low volume joint replacement centers, where its benefit is most likely to be realized. However, it may be a cost-effective technology for higher volume joint replacement centers, where the decrease in the rate of knee revision needed to make the investment cost-effective is modest, if improvements in revisions rates with the use of this technology can be realized. This illustrates that hospital volume can have a substantial impact on the cost-effectiveness of new technology in surgery, and this should be carefully considered by any center considering such a large capital investment.

Purpose: Few reports are available at minimum 15 year follow-up of cemented modular cruciate retaining TKA, especially where all polyethylene patella components were utilized. This paper addresses the questions “What is the durability of cemented modular cruciate retaining TKA with all polyethylene patella components at 15 years?” and “Did modular tibial trays demonstrate their utility in terms of the potential for less costly and less complex revisions?”

Method: 101 Press Fit Condylar TKA’s were performed consecutively over a 27 month interval and followed prospectively for a minimum of 15 years. The average age at surgery was 72 years. Clinical Knee Society scores, need for revision, radiographic evidence of loosening, and osteolysis were recorded. All patients were recalled at 5 year intervals.

Results: At minimum 15 year follow-up, 34 patients with 45 knees were living and 40 patients with 54 knees were deceased (one patient [2 knees] was lost to follow-up). 81% of living patients had 15 year radiographs. 6 knees were revised (all related to wear and osteolysis). Average Knee Society clinical scores only deteroriated from 92 points to 89 points between 10 and 15 years.

Conclusion: This cemented modular CR TKA performed well at 15 years with only 6% of knees requiring revision. All revisions occurred after 10 years and were related to wear and osteolysis. 2/3 of the revisions could be salvaged without tibial component revision in this closely followed series. Hopefully these results can be improved with better wear-resistant designs and better quality polyethylene. Especially into the second decade, patients with modular tibial tray TKA constructs should be closely followed to optimize their utility allowing less costly and less complex revisions in cases with polyethylene wear.