Background. Routine closed suction drainage and postoperative laboratory studies have long been tenets of most TJA protocols. However, recent literature has called into question whether either is necessary with modern outpatient TJA clinical pathways. Methods. Demographic, cost, and readmission data for 2,605 primary unilateral TJA cases was collected retrospectively and analyzed prior to and after a protocol change where routine closed suction drains and postoperative laboratory tests were eliminated. This protocol change was designed to treat all primary TJA like outpatients regardless of their admission status. Drain usage changed from routine to selective based on hemostasis. Lab studies changed from routine to selective for patients on warfarin for VTE prophylaxis (INR), with ASA 4 or 5 status (BMP), and with a hematocrit < 27% in the recovery room after THA (CBC). Results. Drain utilization decreased by 50% and postoperative labs decreased by 70%. Drain and lab test cost per patient decreased from $74.62 before to $19.91 after the change, while charges per patient decreased from $625.23 before to $77.15 after. The 30 and 90-day readmission rates decreased with no readmissions occurring before or after the change that could have been prevented by using a drain or obtaining labs. Conclusion. Selective elimination of routine closed suction drainage and postoperative laboratory studies as part of an outpatient TJA protocol is safe and provides
The debate whether to use cemented or uncemented
components in primary total hip replacement (THR) has not yet been
considered with reference to the cost implications to the National
Health Service. We obtained the number of cemented and uncemented components
implanted in 2009 from the National Joint Registry for England and
Wales. The cost of each component was established. The initial financial
saving if all were cemented was then calculated. Subsequently the
five-year rates of revision for each type of component were reviewed
and the predicted number of revisions at five years for the actual
components used was compared with the predicted number of revisions
for a cemented THR. This was then multiplied by the mean cost of
revision surgery to provide an indication of the savings over the
first five years if all primary THRs were cemented. The saving at primary THR was calculated to be £10 million with
an additional saving during the first five years of between £5 million
and £8.5 million. The use of cemented components in routine primary
THR in the NHS as a whole can be justified on a financial level
but we recognise individual patient factors must be considered when deciding
which components to use.
Implant waste during total hip arthroplasty (THA) represents a significant cost to the USA healthcare system. While studies have explored methods to improve THA cost-effectiveness, the literature comparing the proportions of implant waste by intraoperative technology used during THA is limited. The aims of this study were to: 1) examine whether the use of enabling technologies during THA results in a smaller proportion of wasted implants compared to navigation-guided and conventional manual THA; 2) determine the proportion of wasted implants by implant type; and 3) examine the effects of surgeon experience on rates of implant waste by technology used. We identified 104,420 implants either implanted or wasted during 18,329 primary THAs performed on 16,724 patients between January 2018 and June 2022 at our institution. THAs were separated by technology used: robotic-assisted (n = 4,171), imageless navigation (n = 6,887), and manual (n = 7,721). The primary outcome of interest was the rate of implant waste during primary THA.Aims
Methods
We report the impact of implementing a new short-stay hip and knee arthroplasty pathway in a National Health Service (NHS) hospital. This was enacted due to existing concerns with a long length of stay (LOS) and reduced elective operating capacity each winter due to emergency bed pressures. The overnight introduction of this pathway was aimed to reduce LOS, alleviate bed pressures, minimise readmission rates and generate financial savings, all combining to facilitate full elective activity during the winter. We conducted a prospective study at a regional tertiary arthroplasty centre. The new pathway was introduced across the service overnight. It includes rigorous preoperative optimisation, specific anaesthetic protocols and uniform changes in surgical practice to allow a focus on early mobilization and discharge on the day of surgery where possible. Data collection spanned 17 months, including the initial six months post implementation of the short-stay pathway. LOS data was collected for the full period and data was compared pre- and post-implementation of the new pathway. Patient satisfaction and 30-day readmission data were also collected. There was an immediate and significant decrease in median LOS from 4 days pre-implementation to 1 day post-implementation. Patient satisfaction was high, and the 30-day readmission rate was unchanged (5.95%), with no readmissions directly related to decreased inpatient stay. Financial analyses revealed substantial
Tranexamic Acid (TXA) is now commonly used in major surgical operations including orthopaedics. The TRAC-24 randomised control trial aimed to assess if an additional 24 hours of TXA post – operatively in primary total hip (THA) and total knee arthroplasty (TKA) reduced blood loss. Contrary to other orthopaedic studies to date this trial included high risk patients. This paper presents the results of a cost analysis undertaken alongside this RTC. TRAC-24 was a prospective randomised controlled trial on patients undergoing TKA and THA. Three groups were included, Group 1 received 1 g intravenous (IV) TXA perioperatively and an additional 24-hour post-operative oral regime, group 2 received only the perioperative dose and group 3 did not receive TXA. Cost analysis was performed out to day 90. Group 1 was associated with the lowest mean total costs, followed by group 2 and then group 3. The difference between groups 1 and 3 −£797.77 (95% CI −1478.22, −117.32) were statistically significant. Extended oral dosing reduced costs for patients undergoing THA but not TKA. The reduced costs in groups 1 and 2 resulted from reduced length of stay, readmission rates, Accident and Emergency (A&E) attendances and blood transfusions. This study demonstrated significant
Background. The Comprehensive Care for Joint Replacement (CJR) model was implemented in April-2016 to standardize cost and improve quality of care for two of the most commonly billed inpatient procedures for Medicare patients, total knee and total hip arthroplasty. The purpose of this study is to compare one institution's predicted savings and losses under the CJR model with actual savings and losses after two years of implementation and discuss new methods to maintain savings. Methods. Using our institution's data, we calculated the mean cost per episode of care. We calculated the percent reduction in target price and percent savings or losses per case for the CJR and Bundle Payment Care Initiative (BPCI) for each Medicare Severity Diagnosis Related Group (MS-DRG) using mean cost per episode and CJR and BPCI target prices. We compared the target prices, annual savings, and losses per episode of care for both CJR and BPCI. All CJR savings, projected and actual, were computed by comparing CJR savings to that of 2018 BPCI savings. Results. We found an average savings of 2.32% under CJR compared to the projected loss of −11.6% for MS-DRG 469 with fracture. There was a 7.97% savings for MS-DRG 470 without fracture compared to the projected 1.9%, a 20.94% savings for MS-DRG 470 with fracture compared to the projected 23.7%, and a loss of −3.98% for MS-DRG 469 without fracture compared to the projected 2.5% savings. Conclusions. The CJR target prices are lower than that of BPCI and this makes maintaining an episode of care at or below the target price increasingly difficult. Discharge disposition and readmission are well established factors that increase hospital cost [7]. However, reduction of these does not seem enough to maintain savings under the CJR model. New
Introduction. Alternative payment models for total hip arthroplasty (THA) were initiated by the Center for Medicare and Medicaid Services (CMS) to decrease overall healthcare cost by optimizing healthcare delivery. The associated shift of financial risk to participating institutions has been criticized to introduce patient selection in order to avoid potentially high cost of care. This study aimed to evaluate the impact of the Comprehensive Care for Joint Replacement (CJR) model on patient selection, care delivery and hospital costs at a single care center. Methods. This is a retrospective review of THA patient from July 2015-December 2017 was performed. Patient were stratified by insurance type (Medicare and commercial insurance) and whether care was provided before or after implementation of the CJR bundle. Patient age, gender, and BMI, as well as Elixhauser comorbidities and ASA scores were analyzed. Delivery of care variables including surgery duration, discharge disposition, length of stay, and direct hospital costs were compared before and after CJR implementation. Results. 751 THA patients (273 Medicare and 478 Commercial Insurance) were evaluated before (29%) and after (71%) CJR bundle implementation. There was no difference in patient demographics (age, gender, or BMI); however, commercially insured patients had less Elxihauser comorbidies pre-bundle (p=0.033). After CJR implementation length of stay (p=0.010) for Medicare patients was reduced with a trend toward discharge to home (p=0.019). However, surgical time and OR service time as well as direct hospital costs were similar before and after the CJR bundle initiation. Conclusions. There was no differential patient selection after CJR bundle implementation, and value-based metrics (surgical time, OR service time) were not affected. Patients were discharged sooner and more often to home. However, overall direct hospital expenses remained unchanged revealing that any
Introduction. There have been significant advancements in postoperative care following total hip arthroplasty (THA) over the past decade and it is essential to quantify the impact of efforts made to better optimize patients and improve postoperative care. The purpose of this study was to assess trends in discharge destination, length of stay (LOS), and readmissions following primary THA. Methods. Patients undergoing primary THA during 2011–2017 were identified in the American College of Surgeons National Quality Improvement Program using CPT code 27130. Non-elective surgery and simultaneous bilateral THA procedures were excluded. Patients were classified as having discharged home or to not home locations. Trends in discharge destination, LOS, 30-day readmission, 30-day reoperation, and American Society of Anesthesiologists (ASA) classification were assessed using the Cochran-Armitage test. Results. Of the 155,638 primary THA patients analyzed, 81% discharged home and 19% did not discharge home. From 2011–2017 there was a 21% increase in percentage of patients discharging home (72% in 2011, 87% in 2017, p<0.001) despite a significantly increasing number of patients with ASA score ≥ 3 (34% to 40%, p<0.001, Figure 1). Over this time period, hospital LOS decreased from 3.1 to 2.0 days for those discharging home (p<0.001) and from 3.8 to 3.6 days those not discharging home (p=0.003). There were no significant changes in 30-day reoperation rates for patients discharging home and readmission rates significantly decreased over time (3.2% in 2011 to 2.6% in 2017, p=0.02). Conclusion. From 2011–2017, patients undergoing THA were more likely to discharge home, had shorter hospital LOS and significantly decreased readmission rates. These trends persisted despite an increasingly comorbid patient population. It is likely these trends have resulted in significant
Widespread use of XLPE has reduced the incidence of both revision surgery and dislocations. This paper aims to create gross estimates of the magnitude of the resulting
Hip dysplasia (HD) leads to premature osteoarthritis. Timely detection and correction of HD has been shown to improve pain, functional status, and hip longevity. Several time-consuming radiological measurements are currently used to confirm HD. An artificial intelligence (AI) software named HIPPO automatically locates anatomical landmarks on anteroposterior pelvis radiographs and performs the needed measurements. The primary aim of this study was to assess the reliability of this tool as compared to multi-reader evaluation in clinically proven cases of adult HD. The secondary aims were to assess the time savings achieved and evaluate inter-reader assessment. A consecutive preoperative sample of 130 HD patients (256 hips) was used. This cohort included 82.3% females (n = 107) and 17.7% males (n = 23) with median patient age of 28.6 years (interquartile range (IQR) 22.5 to 37.2). Three trained readers’ measurements were compared to AI outputs of lateral centre-edge angle (LCEA), caput-collum-diaphyseal (CCD) angle, pelvic obliquity, Tönnis angle, Sharp’s angle, and femoral head coverage. Intraclass correlation coefficients (ICC) and Bland-Altman analyses were obtained.Aims
Methods
Total hip arthroplasty (THA) with dual-mobility components (DM-THA) has been shown to decrease the risk of dislocation in the setting of a displaced neck of femur fracture compared to conventional single-bearing THA (SB-THA). This study assesses if the clinical benefit of a reduced dislocation rate can justify the incremental cost increase of DM-THA compared to SB-THA. Costs and benefits were established for patients aged 75 to 79 years over a five-year time period in the base case from the Canadian Health Payer’s perspective. One-way and probabilistic sensitivity analysis assessed the robustness of the base case model conclusions.Aims
Methods
To examine incidence of complications associated with outpatient
total hip arthroplasty (THA), and to see if medical comorbidities
are associated with complications or extended length of stay. From June 2013 to December 2016, 1279 patients underwent 1472
outpatient THAs at our free-standing ambulatory surgery centre.
Records were reviewed to determine frequency of pre-operative medical
comorbidities and post-operative need for overnight stay and complications
which arose.Aims
Patients and Methods
The aim of this systematic review was to report the rate of dislocation
following the use of dual mobility (DM) acetabular components in
primary and revision total hip arthroplasty (THA). A systematic review of the literature according to the Preferred
Reporting Items for Systematic Reviews and Meta-analyses guidelines
was performed. A comprehensive search of Pubmed/Medline, Cochrane
Library and Embase (Scopus) was conducted for English articles between
January 1974 and March 2016 using various combinations of the keywords “dual
mobility”, “dual-mobility”, “tripolar”, “double-mobility”, “double
mobility”, “hip”, “cup”, “socket”. The following data were extracted
by two investigators independently: demographics, whether the operation
was a primary or revision THA, length of follow-up, the design of
the components, diameter of the femoral head, and type of fixation
of the acetabular component.Aims
Materials and Methods
In March 2012, an algorithm for the treatment
of intertrochanteric fractures of the hip was introduced in our academic
department of Orthopaedic Surgery. It included the use of specified
implants for particular patterns of fracture. In this cohort study,
102 consecutive patients presenting with an intertrochanteric fracture
were followed prospectively (post-algorithm group). Another 117
consecutive patients who had been treated immediately prior to the
implementation of the algorithm were identified retrospectively
as a control group (pre-algorithm group). The total cost of the
implants prior to implementation of the algorithm was $357 457 (mean:
$3055 (1947 to 4133)); compared with $255 120 (mean: $2501 (1052
to 4133)) after its implementation. There was a trend toward fewer complications
in patients who were treated using the algorithm (33% pre- The implementation of an evidence-based algorithm for the treatment
of intertrochanteric fractures reduced costs while maintaining quality
of care with a lower rate of complications and re-admissions. Cite this article:
A retrospective review was performed of patients
undergoing primary cementless total knee replacement (TKR) using
porous tantalum performed by a group of surgical trainees. Clinical
and radiological follow-up involved 79 females and 26 males encompassing
115 knees. The mean age was 66.9 years (36 to 85). Mean follow-up
was 7 years (2 to 11). Tibial and patellar components were porous
tantalum monoblock implants, and femoral components were posterior
stabilised (PS) in design with cobalt–chromium fibre mesh. Radiological
assessments were made for implant positioning, alignment, radiolucencies,
lysis, and loosening. There was 95.7% survival of implants. There
was no radiological evidence of loosening and no osteolysis found.
No revisions were performed for aseptic loosening. Average tibial
component alignment was 1.4° of varus (4°of valgus to 9° varus),
and 6.2° (3° anterior to 15° posterior) of posterior slope. Mean
femoral component alignment was 6.6° (1° to 11°) of valgus. Mean tibiofemoral
alignment was 5.6° of valgus (7° varus to 16° valgus). Patellar
tilt was a mean of 2.4° lateral (5° medial to 28° lateral). Patient
satisfaction with improvement in pain was 91%. Cementless TKR incorporating
porous tantalum yielded good clinical and radiological outcomes
at a mean of follow-up of seven-years. Cite this article: