Introduction. The purpose of bundled payment programs is to reduce cost via risk sharing, while still maintaining quality. If savings are achieved under a historic target price, the orthopedic surgeon will receive a monetary bonus. If costs are higher, a portion is deducted from payment to the orthopedic surgeon. The purpose of this study was to evaluate our experience with the Bundled Payments for Care Improvement Program (BPCI) when run by an orthopedic surgeon group to determine patient safety and who benefited the most financially. Methods. This program ran from January 2015 through September 2018. 3,186 Medicare total hip and knee replacements, elective (DRG 470) and for fracture (DRG 469), performed by our group were included. 90 day hospital and all postoperative expenditures were reconciled against our historic cost. All patients were medically optimized with discharge plans established preoperatively. We developed preferred skilled nursing facilities and home health care agencies with synergistic medical providers so that discharges were recommended as soon as appropriate. We hired two full-time case managers to have direct contact with patients pre-and post-operatively. Waiver assistance such as house and pet sitters were used if necessary at our expense. 35% of savings went to the convener, who acted as a liaison between our group and CMS. Expenditures for the 90-day period for all patients were calculated to determine where savings occurred and which entity benefitted financially. Results. There was an average 9.2% reduction in hospital readmissions. An estimated total savings of $5,100,000 occurred. There was a 17% reduction in hospital costs, a 12.1% reduction in admissions to skilled nursing facilities with a 34% reduction in length of stay, and a 5% reduction in admissions to inpatient rehabilitation facilities. There was a 35% reduction in home health visits, but no change in outpatient physical therapy visits. After group expenses, final bonus to the orthopedic provider was on average $262 per patient. Conclusion. The physician managed program was very successful from Medicare's standpoint, achieving significant monetary savings without reducing quality of care. However, the bonus to the providing and managing physicians was nominal. It also does not take into consideration the 50 plus hours spent in meetings to develop this program. Participation could be considered a defensive posture so as not to lose more reimbursement. However, experience was gained which will be valuable for future gain sharing programs.
To identify variables independently associated with same-day discharge (SDD) of patients following revision total knee arthroplasty (rTKA) and to develop machine learning algorithms to predict suitable candidates for outpatient rTKA. Data were obtained from the American College of Surgeons National Quality Improvement Programme (ACS-NSQIP) database from the years 2018 to 2020. Patients with elective, unilateral rTKA procedures and a total hospital length of stay between zero and four days were included. Demographic, preoperative, and intraoperative variables were analyzed. A multivariable logistic regression (MLR) model and various machine learning techniques were compared using area under the curve (AUC), calibration, and decision curve analysis. Important and significant variables were identified from the models.Aims
Methods
Aim. To evaluate safety and efficacy of performing a total knee arthroplasty (TKA) on patients receiving continuous Warfarin therapy. Methods. We identified 24 consecutive patients receiving long term warfarin therapy who underwent total knee arthroplasty between 2006 and 2008. As a control, we collected the same data from a group of age and sex matched patients not on warfarin. Primary observations were changes in haemoglobin, transfusion rates and complications. Secondary observations were fluctuations in the INR and post operative range of motion (ROM). All procedures were performed by the senior author in a single centre using the same TKA technique. Results. There was no significant difference between the warfarinised and non warfarinised groups in preoperative or postoperative haemoglobin. After unilateral TKA 38% of non warfarinised patients and 24% of warfarinised patients required a blood transfusion. Both the warfarin and non warfarin groups had a bilateral TKA transfusion rate of 67%. In the warfarin group the mean preoperative INR was 2.2 (SD=0.46; range 1.0 to 3.0) and mean postoperative INR was 2.6 (SD=0.8; range 1.5 to 5.0). There were no surgical delays due to a high INR level. The mean change in INR during the perioperative phase was minimal (mean 0.4; SD=0.7). In the warfarin group the mean flexion range of motion was 116° preoperatively, 88° at 5 days, 107° at 6 weeks and 117° at 12 months after surgery. There was no significant ROM difference between the warfarin and non warfarin groups. There were no post operative bleeding complications. Conclusions. Current American College of Chest
Purpose. To study the initial presentation and subsequent investigation and management of acute knee dislocations at a regional trauma centre. Introduction. Knee dislocation requires high energy trauma, and often affects young working adults. The high incidence of associated arterial, neurological, ligamentous, and other soft tissue injuries, can produce potentially devastating outcomes. Rapid mobilisation of traditionally distinct surgical teams, with urgent vascular imaging and emergency surgery are often necessary. The extent and severity of ligamentous damage may require multiple operations to repair. Methods. A retrospective nine-year study of knee dislocations managed in the Trauma and Orthopaedic Department of the Royal Hospitals, Belfast was performed using a Fractures Outcomes Research Database (FORD), a chart review, and a review of relevant radiology. Demographic data, mechanisms of injury, associated neurovascular injuries, ligamentous damage, and operative intervention were recorded. Results. 15 patients were identified over 9 years (2000-2008 inclusive). Mean age at injury was 38 years, median 37. 14 (93%) of patients were male, 1 (7%) was female. 6 injuries (40%) were sport-related, 3 (20%) occurred as a result of road traffic collisions, 5 (33%) were accidents in the workplace, and 1 (7%) was a result of a fall while intoxicated with alcohol. 5 (33%) patients experienced a common peroneal nerve palsy. 10 (67%) received vascular imaging, and 2 (13%) underwent vascular surgery as part of the initial theatre episode. All 15 dislocations led to some degree of structural soft tissue knee injuries. These included 12 (80%) anterior cruciate ligaments, 8 (53%) posterior cruciate ligaments, 7 (47%) lateral collateral ligaments, and 5 (33%) medial collateral ligaments. 3 posterolateral corner injuries required repair. Of the 15 patients, 2 (13%) underwent no operative procedures following closed reduction, and the remaining 13 patients had 21 distinct theatre episodes recorded between them. 2 fasciotomies for compartment syndrome, and 2 common peroneal nerve decompression/explorations were performed in the initial theatre episode. 3 patients (20%) were managed with an external fixator initially. 1 patient (7%) developed complications and required trans-femoral amputation. Conclusions. Knee dislocation remains uncommon, and even major centres may receive only a few injuries per year. Orthopaedic, Vascular and Plastic surgeons, as well as Emergency
The optimal management of an infrapopliteal deep venous thrombosis (IDVT) following total knee arthroplasty (TKA) remains unknown. The risk of DVT propagation and symptom progression must be balanced against potential haemorrhagic complications associated with administration of anticoagulation therapy. The current study reports on a cohort of patients diagnosed with IDVT following TKA who were treated with aspirin, followed closely for development of symptoms, and scanned with ultrasound to determine resolution of IDVT. Among a cohort of 5,078 patients undergoing TKA, 532 patients (695 TKAs, 12.6%) developed an IDVT between 1 January 2014 to 31 December 2019 at a single institution, as diagnosed using Doppler ultrasound at the first postoperative visit. Of the entire cohort of 532 patients with IDVT, 91.4% (486/532) were treated with aspirin (325 mg twice daily) and followed closely. Repeat lower limb ultrasound was performed four weeks later to evaluate the status of IDVT.Aims
Methods
Cementless total knee arthroplasty (TKA) offers the potential for strong biological fixation compared with cemented TKA where fixation is achieved by the mechanical integration of the cement. Few mid-term results are available for newer cementless TKA designs, which have used additive manufacturing (3D printing). The aim of this study was to present mid-term clinical outcomes and implant survivorship of the cementless Stryker Triathlon Tritanium TKA. This was a single institution registry review of prospectively gathered data from 341 cementless Triathlon Tritanium TKAs at four to 6.8 years follow-up. Outcomes were determined by comparing pre- and postoperative Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) scores, and pre- and postoperative 12-item Veterans RAND/Short Form Health Survey (VR/SF-12) scores. Aseptic loosening and revision for any reason were the endpoints which were used to determine survivorship at five years.Aims
Methods
The aim of this study was to investigate the incidence, risk factors, and outcome of venous thromboembolism (VTE) following anterior cruciate ligament (ACL) reconstruction in a nationwide cohort. All ACL reconstructions, primary and revision, that were recorded in the Swedish Knee Ligament Register (SKLR) between 2006 and 2013 were linked with data from the Swedish National Board of Health and Welfare. The incidence of VTE was determined by entries between the day of surgery until 90 days postoperatively based on diagnosis codes and the prescription of anticoagulants. Risk factors, outcome, and the use of thromboprophylaxis were analyzed. Descriptive statistics with multivariate analysis were used to describe the findings.Aims
Patients and Methods
The purpose of this study was to evaluate trends in opioid use
after unicompartmental knee arthroplasty (UKA), to identify predictors
of prolonged use and to compare the rates of opioid use after UKA,
total knee arthroplasty (TKA) and total hip arthroplasty (THA). We identified 4205 patients who had undergone UKA between 2007
and 2015 from the Humana Inc. administrative claims database. Post-operative
opioid use for one year post-operatively was assessed using the
rates of monthly repeat prescription. These were then compared between
patients with and without a specific variable of interest and with
those of patients who had undergone TKA and THA.Aims
Materials and Methods
We compared thromboembolic events, major haemorrhage
and death after knee replacement in patients receiving either aspirin
or low-molecular-weight heparin (LMWH). Data from the National Joint
Registry for England and Wales were linked to an administrative
database of hospital admissions in the English National Health Service.
A total of 156 798 patients between April 2003 and September 2008
were included and followed for 90 days. Multivariable risk modelling
was used to estimate odds ratios adjusted for baseline risk factors
(AOR). An AOR <
1 indicates that risk rates are lower with LMWH
than with aspirin. In all, 36 159 patients (23.1%) were prescribed aspirin
and 120 639 patients (76.9%) were prescribed LMWH. We found no statistically
significant differences between the aspirin and LMWH groups in the
rate of pulmonary embolism (0.49% These results should be considered when the existing guidelines
for thromboprophylaxis after knee replacement are reviewed.
