Introduction. Cardiac events have been found to occur with increased frequency in total joint arthroplasty (TJA) patients >65 y/o without known coronary artery disease (CAD). Avoidance of readmissions for cardiac events is paramount with
Introduction. Bundled budgeting of payments for joint replacement services has become increasing common in an effort to improve quality while lowering cost. In the US, some Medicare
The high and ever increasing cost of medical care worldwide has driven a trend toward new payment models. Event based models (such as
Wound closure is not often an area that is discussed by orthopaedic surgeons. We commonly attend meetings and talks related to different types of implants and surgical technique but in reality the wound and how we close it maybe one of the most important aspects of a surgical procedure. The avoidance of wound complications such as unplanned clinic visits, readmissions, reoperations and deep infections are very important as we move into a world of
Background. In surgeon controlled
Introduction. Close to 30% of the surgical causes of readmission within 90 days post-total knee arthroplasty (TKA) and nearly half of those occurring in the first 2 years are caused by instability, arthrofibrosis, and malalignment, all of which may be addressed by improving knee balance. Furthermore, the recently launched Comprehensive Care for Joint Replacement (CJR) initiative mandates that any increase in post-acute care costs through 90-days post-discharge will come directly from the
As the American population ages and a trend toward performing total hip arthroplasty (THA) in younger patients continues, the number of Americans undergoing THA is projected to increase over time. The advent of the
Introduction. Alternative payment models, such as
Introduction. Hip and knee device sales representatives (reps) can provide intra-operative guidance through their knowledge of the products, especially in complicated cases such as revision hip and knee arthroplasty. However, for an experienced arthroplasty surgeon in the majority of straightforward primary cases, the rep's presence may not be required for clinical decision-makings. With recent challenges in cost savings and
BACKGROUND. As the climate of medicine continues to change, physicians and healthcare administrations seek to improve both the quality of the care we provide patients, as well as reducing the cost at which we provide that care. Delivering value based care is of the utmost importance. The Perioperative Surgical Home (PSH) model is a multidisciplinary team approach to care that has shown success in reducing cost, length of stay, and admission to after care facilities. We sought to compare the results of total knee arthroplasty patients managed in the PSH rapid recovery model, to patients managed in a more traditional fashion. METHODS. We compared 451 patients managed in the PSH model from January 1 to December 31, 2015 to 453 patients managed in a more traditional fashion from January 1 to December 31, 2014. Preoperative. Once identified as potential candidates for total knee arthroplasty, a thorough triage process to optimize patients' medical co-morbidities, educate, and set expectations begins with an evaluation by the preoperative staff and mandatory attendance at a total joint class. Patients were sent for pre-operative physical therapy. Intraoperative. Neuraxial anesthesia was the anesthetic of choice, and perineural analgesia in the form of an adductor canal catheter and single shot posterior capsular injection were used to minimize pain and narcotic usage while maintaining the patient's ability to ambulate with physical therapy early in the post operative course. Additionally, multimodal analgesia was achieved with non- opioid analgesics (acetaminophen, NSAIDS, and gabapentanoids) and limited opioids. Aggressive fluid management and administration of steroids and ketamine also took place intraoperatively. Postoperatively. A multi-disciplinary team led by an orthopaedic surgeon and an anesthesiologist managed the patients throughout their stay. Multimodal analgesia was continued, and there was a rapid de-escalation of care. Physical therapy was initiated in PACU and continued at a minimum of BID thereafter. Patients were eligible for discharge on POD 1 after meeting physical therapy criteria. RESULTS. Average Length of Stay (LOS): 2.86 days in 2014 down to 2.1 in 2015 for an over 25% reduction. Discharge Mix: 71% to home independently or with home health in 2014 increased to 80% in 2015, with a reduction in discharges to a Skilled Nursing Facility from 24% to 16% respectively. 30 Day Readmissions: remained constant at 8 per year. Hospital Cost: $11,126.00 in 2014 vs $10,703.00 in 2015. CONCLUSION. As
Introduction. CMS is now publicly reporting 30-day readmission rates following total joint replacement (TJR) by hospital and is planning the collection of patient-reported function and pain after TJR. Nationally, 5% of patients are readmitted to the hospital after TJR for both medical and orthopedic-related issues. However, the relationship between readmission and functional gain and pain relief after TJR has not been evaluated. Methods. Clinical data on 2990 CMS patients from over 150 surgeons practicing in 22 US states who elected primary unilateral TJR in 2011–2012 were identified. Measures include pre-operative demographics, BMI, medical and musculoskeletal comorbidities, pain and function (KOOS/HOOS; SF36) and 6 month post-TJR pain and function. Data were merged with CMS claims to verify 30-day readmissions. Descriptive statistics and multivariate models adjusted for covariates and clustering within site were performed. Results. Overall 4.7% of patients were readmitted; 2.0% due to limb related diagnoses. Readmitted patients had significantly greater number of medical comorbidities; more severe OA in non-operated knees and hips; were more likely to smoke; and have poorer pre-TJR function (all p<0.05). After TJR, a greater proportion of readmitted patients had poor global function (PCS<30= 14% vs. 8%; p<0.008) but knee/hip function was similar in both groups. Joint pain improvement did not differ by readmit status. Conclusion. In this national representative cohort of CMS patients, patients readmitted within 30 days after TJR had poorer global function but similar joint specific function as non-readmitted patients. Readmitted patients also had significantly more medical comorbidities, more severe osteoarthritis in non-operated knees and hips; were more likely to smoke; and have poorer pre-TJR function. The overall rate of FORCE-TJR CMS patients readmitted within 30 days (4.7%) is consistent with national CMS analyses (5%). Of interest, in our cohort, readmitted patients had poorer global function after surgery, but similar joint specific (hip/knee) function compared to patients who were not readmitted. They also had poorer pre-THR function, and more severe OA in other joints, which may contribute to their overall lower global function scores. As CMS moves to use PROs in its
Several design principles were considered paramount when the surgical technique of performing total hip arthroplasty through an incision in the superior capsule without dislocation of the hip joint was developed. These design principles include: Preservation of the abductors; Preservation of the posterior capsule and short external rotators; Preparation of the femur in situ without dislocation of the hip; In-line access to the femoral shaft axis; Ability to perform a trial reduction; Independence from intraoperative imaging; Independence from a traction table; Applicable to at least 99% of THA procedures. Personal experience with more than 1950 THA using the superior capsulotomy technique over a 12-year period has demonstrated several observations: Dislocation rate of 0.15% (3 in 1950); Acute deep infection rate of 0% (0 in 1950); Universal applicability: used in 99.7% of primary THA; Lateral femoral cutaneous nerve palsy incidence: 0/1950; Femoral nerve palsy incidence: 0/1950; Transient peroneal palsy incidence: 2/1950; Length of stay (since 2010): 1.55 days; Discharge to home: 98%; 90-day cost (2/13 to 2/14) compared to other exposures in CMS patients in the same institution: $24,200 vs $30,100; Readmission costs (CMS 2/13 to 2/14) at 90 days: $0. Conclusion: Performing total hip arthroplasty without dislocation and with preservation of the abductors, posterior capsule and short external rotations has proven to have a low dislocation rate, a low infection rate, and wide applicability. CMS 12-month expenditure data documenting ZERO dollars spent on readmission for any reason within 90 days of surgery demonstrates the potential for simultaneously improving incomes and reducing cost, with particular benefit within the CMS BPCI and private
Numerous studies have shown highly cross-linked polyethylene (XLPE) to be an extremely low wear bearing surface for total hip arthroplasty (THA) at intermediate term follow-up. Wear rates and the incidence of osteolysis for CoCr femoral heads on XLPE liners appears to be considerably less than what is observed for conventional polyethylene (PE). This has been demonstrated even in younger, more active patients. Nevertheless, polyethylene wear and associated osteolysis are still a concern, since the indications for THA have been expanded to include younger and more active patients. Both wear simulator and clinical data suggest that ceramic femoral heads can reduce bearing surface wear of conventional PE. There is, however, extremely limited evidence supporting any advantage of ceramic femoral heads over CoCr femoral heads with regards to bearing surface wear of XLPE. This is perhaps due to the relative difficulty in measuring the low wear rates of XLPE bearings in general, regardless of material composition of the femoral head. Although ceramic femoral heads are more scratch resistant and less susceptible to third body wear, their current clinical use to reduce wear of XLPE bearings is, in reality, based on the unproven assumption that use of ceramic femoral heads will have a similar effect on wear reduction as is seen with ceramic on conventional PE bearing couples. Nevertheless, the use of ceramic femoral heads has become common in younger, more active patients. Recently, corrosion at the head neck junction of modular THA (trunnionosis), has been determined to be the possible source of metal debris and metal ions associated with adverse local tissue reactions (ALTR or ARMD) in THA, including ALVAL and pseudotumors. There is general agreement that trunnionosis results from mechanically assisted crevice corrosion (fretting) of the modular junctions common to nearly all contemporary THA designs. Several design, material and patient factors have been implicated as contributors to this problem including larger diameter femoral heads (>36 mm), reduced femoral neck and taper geometry, flexural rigidity of the taper, and patient body weight and activity level. Data from our multicenter implant retrieval program has shown that corrosion at the head-neck junction of contemporary modular THAs may be reduced with use of ceramic femoral heads. The use of ceramic femoral heads also eliminates the potential for release of cobalt and chromium ions from the taper junctions of titanium alloy stems. In younger patients, the long term effects of cobalt ions released from corrosion at the modular neck junction are still unknown. Although the surgeon's selection of a ceramic femoral head in combination with a XLPE acetabular liner is likely based on the desire to minimise PE wear, the impact of femoral head composition on taper neck corrosion and ALTR is perhaps more of a concern in 2015. Until the problem of taper neck corrosion is more thoroughly understood and effectively addressed by implant manufacturers, the use of ceramic femoral heads in THA should be considered in the younger or more active patient. The increased cost of ceramic femoral heads creates a dilemma in defining who is “young” enough and “active” enough to be considered an appropriate candidate for a ceramic femoral head in our current environment of
Medical comorbidities are a critical factor in the decision-making process for operative management and risk-stratification. The Hierarchical Condition Categories (HCC) risk adjustment model is a powerful measure of illness severity for patients treated by surgeons. The HCC is utilized by Medicare to predict medical expenditure risk and to reimburse physicians accordingly. HCC weighs comorbidities differently to calculate risk. This study determines the prevalence of medical comorbidities and the average HCC score in Medicare patients being evaluated by neurosurgeons and orthopaedic surgeon, as well as a subset of academic spine surgeons within both specialities, in the USA. The Medicare Provider Utilization and Payment Database, which is based on data from the Centers for Medicare and Medicaid Services’ National Claims History Standard Analytic Files, was analyzed for this study. Every surgeon who submitted a valid Medicare Part B non-institutional claim during the 2013 calendar year was included in this study. This database was queried for medical comorbidities and HCC scores of each patient who had, at minimum, a single office visit with a surgeon. This data included 21,204 orthopaedic surgeons and 4,372 neurosurgeons across 54 states/territories in the USA.Aims
Methods