Abstract. Introduction. Minimum clinically important differences (MCIDs) are critical to understanding changes in patient-reported outcome measure (PROM) scores after total joint arthroplasty (TJA). The usage and adoption of MCIDs not been well-studied. This study was performed to IDENTIFY trends in PROM and MCID use after TJA over the past decade. Methods. All articles published in the calendar years of 2010 and 2020 in CORR, JBJS, and the Journal of Arthroplasty were reviewed. Articles relating to clinical outcomes in primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) were included. For each article, all reported PROMs and (if present) accompanying MCIDs were recorded. The use of PROMs and MCIDs were compared between articles published in 2010 and 2020. Results. Overall, 263 articles from 2010 and 546 articles from 2020 were included. The total number of articles reporting any PROM after THA and TKA increased from 131 in 2010 to 194 in 2020, but the proportion of articles reporting PROMs decreased from 49.8% (131/263) to 35.5% (194/546). Both the total number and proportion of articles reporting MCIDs increased from 2.3% (3/131) in 2010 to 16.5% (32/194) in 2020. These trends persisted when analyzing THA and TKA articles individually. Conclusions. Both the absolute number and proportion of articles reporting MCIDs in conjunction with PROMs after TJA has increased in the past decade but remains low. We recommend that journal editors and meeting organizers encourage the inclusion of MCID information in all reports on clinical outcomes after joint replacement

Aims. The purpose of this study was to compare outcomes of combined total joint arthroplasty (TJA) (total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed during the same admission) versus bilateral THA, bilateral TKA, single THA, and single TKA. Combined TJAs performed on the same day were compared with those staged within the same admission episode. Patients and Methods. Data from the National (Nationwide) Inpatient Sample recorded between 2005 and 2014 were used for this retrospective cohort study. Postoperative in-hospital complications, total costs, and discharge destination were reviewed. Logistic and linear regression were used to perform the statistical analyses. p-values less than 0.05 were considered statistically significant. Results. Combined TJA was associated with increased risk of deep vein thrombosis, prosthetic joint infection, irrigation and debridement procedures, revision arthroplasty, length of stay (LOS), and in-hospital costs compared with bilateral THA, bilateral TKA, single THA, and single TKA. Combined TJA performed on separate days of the same admission showed no statistically significant differences when compared with same-day combined TJA, but trended towards decreased total costs and total complications despite increased LOS. Conclusion. Combined TJA is associated with increased in-hospital complications, LOS, and costs. We do not recommend performing combined TJA during the same hospital stay. Cite this article: Bone Joint J 2019;101-B:573–581

At our tertiary, large, academic healthcare system, we have access to an academic medical center (AMC), a community based, orthopedic friendly, efficient hospital (CBH) and several ambulatory care centers (ASC) which are being prepared to provide same day discharge (SDD) TJA and UKA. We had a near-capacity AMC with an excellent ability to care for medically and technically complicated TJA patients. However, efficiency was less than desired regardless of case complexity with an average effective case time of 4 hours. Concurrently, the orthopaedically, under-utilized community-based hospital (CBH) wanted to increase volume, improve margins, and become a TJA Center of Excellence with the ability to provide an efficient Hospital Outpatient Department (HOPD) and SDD TJA surgery experience. Methods. The CBH had a main operating floor and a separate floor of four OR suites which were repurposed with the goal of utilizing these rooms for TJA four days per week with an average of 3.5 cases per room per day. We preferentially performed primary, uncomplicated TJA, UKA, and minimally invasive TJA at the CBH. Revision surgeries, patients with extensive medical comorbidities, and complex primary surgeries would be performed at the AMC. Our goals were to decrease costs, readmissions, length of stay, and increase margins at the CBH while increasing efficiency, revenue and volume. Protocols were developed to facilitate SDD UKA and THA at both hospitals as well as rapid recovery protocols for TKA at both hospitals with the understanding that the CBH would perform more of these cases but the efficiency could also be implemented at the AMC when possible. We also needed a strategy to deal with TKA and eventually THA being removed from the Inpatient Only (IPO) list. CMS has utilized the “Two-Midnight Rule” to define outpatient status for both THA and TKA. This has distinct financial implications for the facility's reimbursement with outpatient being $10,123 on average versus $12,380 for inpatient status. A protocol-based system was put in place to make both hospitals compliant with the removal of TKA from the IPO List in order to avoid Quality Improvement Organization (QIO) and Recovery Audit Contractor (RAC) after implementation. Results. Comparing FY 2018 to FY 2019, volume increased 26.4% at the CBH. Outpatient case volume rose substantially from 14 cases to 243. Volumes were slightly decreased at the AMC (−4.57%) resulting in a substantial increase in margin contribution for the parent enterprise. Quality metrics at the CBH (surgical site infections (SSI), length of stay (LOS), readmissions, and mortality) were improved. LOS improved from 52% to 71% discharge before 48 hours. The LOS decreased 12% for THA and 8.1% for TKA. CBH readmission rates decreased from 1.38% to 0.9% with no deaths. Surgeon satisfaction is greatly improved as their volume, efficiency, quality metrics, and finances were enhanced. Financial performance was improved in aggregate and per case for the CBH. Although the CBH per-case revenue was 80.3% and 74.4% of the AMC for THA and TKA: the net margins were 3.6% and 18.8% higher for THA and TKA, respectively. The increased efficiency, lower hospital cost and higher volume at the CBH allowed for an increase in revenue despite lower reimbursement per case. Conclusions. A shifting reimbursement landscape, value-based payment initiatives, and increasing volume have challenged traditional TJA delivery systems. This demonstrates one strategy to help hospital systems improve net margins while improving patient care despite lower net revenue per TJA episode. These strategies will become increasingly important going forward with the transition of higher numbers of TJA patients to outpatient settings including ambulatory surgery centers which will be subjected to even further decreases in net revenue per patient

Introduction. Patients undergoing TJA have higher rates of anxiety and/or depression than the general population and higher costs of care. These preoperative diagnoses lead to higher levels of postoperative dissatisfaction and depression patients alone have higher readmission rates. There is significant crossover between anxiety and depressive disorders, and many patients are classed as combined. Our goal was to evaluate readmission rates of patients undergoing total hip or knee arthroplasty with diagnoses of anxiety, depression or both. Methods. Our hospital's prospectively collected data from our statewide total joint database (MARCQI) was reviewed from 2013–2018. Rates of anxiety and/or depression were determined based preoperative anxiolytic or antidepressant medications using national drug codes. Independent sample t-tests compared continuous variables and Chi-square tests (or Fisher's exact tests) compared categorical variables. Potential risk factors were identified by multivariable logistic regression modeling. Results. 4,107 cases (1,261 THA and 2,846 TKA) were included. 176 patients (4.28%) had a readmission within the 90-day global period. 476 patients (12%) had history of depression or anxiety or both. For the entire cohort, those on anxiolytic medication were 153% more likely to be readmitted than those not on medication (p=0.017). When patients were stratified based on THA or TKA, patients taking anxiolytic medication undergoing TKA were 120% more likely to undergo readmission within 90 days (p=0.021). Patients on depression medication alone were not at increased risk of readmission in the TKA cohort (p=0.991). For THA patients neither diagnosis appeared a risk factor for readmission (p=0.852). Conclusions. Patients with depression, anxiety, or both undergoing TKA were at a statistically significant risk of readmission within 90-days compared to patients without these diagnoses. Anxiety and depression were both risk factors for readmission, but anxiety appeared to have a more significant impact. THA on the other hand did not appear to share this risk profile

Aims. There is little information regarding the risk of a patient developing prosthetic joint infection (PJI) after primary total knee arthroplasty (TKA) when the patient has previously experienced PJI of a TKA or total hip arthroplasty (THA) in another joint. The goal of this study was to compare the risk of PJI of primary TKA in this patient population against matched controls. Patients and Methods. We retrospectively reviewed 95 patients (102 primary TKAs) treated between 2000 and 2014 with a history of PJI in another TKA or THA. A total of 50 patients (53%) were female. Mean age was 69 years (45 to 88) with a mean body mass index (BMI) of 36 kg/m. 2. (22 to 59). In total, 27% of patients were on chronic antibiotic suppression. Mean follow-up was six years (2 to 16). We 1:3 matched these (for age, sex, BMI, and surgical year) to 306 primary TKAs performed in 306 patients with a THA or TKA of another joint without a subsequent PJI. Competing risk with death was used for statistical analysis. Multivariate analysis was followed to evaluate risk factors for PJI in the study cohort. Results. The cumulative incidence of PJI in the study cohort (6.1%) was significantly higher than the matched cohort (2.6%) at ten years (hazard ratio (HR) 3.3; 95% confidence interval 1.18 to 8.97; p = 0.02). Host grade in the study group was not a significant risk factor for PJI. Patients on chronic suppression had a higher rate of PJI (HR 15; p = 0.002), with six of the seven patients developing PJI in the study group being on chronic suppression. The new infecting microorganism was the same as the previous in only two of seven patients. Conclusion. In this matched cohort study, patients undergoing a clean primary TKA with a history of TKA or THA PJI in another joint had a three-fold higher risk of PJI compared with matched controls with ten-year cumulative incidence of 6.1%. The risk of PJI was 15-fold higher in patients on chronic antibiotic suppression; further investigation into reasons for this and mitigation strategies are recommended. Cite this article: Bone Joint J 2019;101-B(7 Supple C):91–97

Aims. The aim of this study was to evaluate the ability of a machine-learning algorithm to diagnose prosthetic loosening from preoperative radiographs and to investigate the inputs that might improve its performance. Methods. A group of 697 patients underwent a first-time revision of a total hip (THA) or total knee arthroplasty (TKA) at our institution between 2012 and 2018. Preoperative anteroposterior (AP) and lateral radiographs, and historical and comorbidity information were collected from their electronic records. Each patient was defined as having loose or fixed components based on the operation notes. We trained a series of convolutional neural network (CNN) models to predict a diagnosis of loosening at the time of surgery from the preoperative radiographs. We then added historical data about the patients to the best performing model to create a final model and tested it on an independent dataset. Results. The convolutional neural network we built performed well when detecting loosening from radiographs alone. The first model built de novo with only the radiological image as input had an accuracy of 70%. The final model, which was built by fine-tuning a publicly available model named DenseNet, combining the AP and lateral radiographs, and incorporating information from the patient’s history, had an accuracy, sensitivity, and specificity of 88.3%, 70.2%, and 95.6% on the independent test dataset. It performed better for cases of revision THA with an accuracy of 90.1%, than for cases of revision TKA with an accuracy of 85.8%. Conclusion. This study showed that machine learning can detect prosthetic loosening from radiographs. Its accuracy is enhanced when using highly trained public algorithms, and when adding clinical data to the algorithm. While this algorithm may not be sufficient in its present state of development as a standalone metric of loosening, it is currently a useful augment for clinical decision making. Cite this article: Bone Joint J 2020;102-B(6 Supple A):101–106

Aims. In patients with a “dry” aspiration during the investigation of prosthetic joint infection (PJI), saline lavage is commonly used to obtain a sample for analysis. The aim of this study was to investigate prospectively the impact of saline lavage on synovial fluid analysis in revision arthroplasty. Methods. Patients undergoing revision hip (THA) or knee arthroplasty (TKA) for any septic or aseptic indication were enrolled. Intraoperatively, prior to arthrotomy, the maximum amount of fluid possible was aspirated to simulate a dry tap (pre-lavage) followed by the injection with 20 ml of normal saline and re-aspiration (post-lavage). Pre- and post-lavage synovial white blood cell (WBC) count, percent polymorphonuclear cells (%PMN), and cultures were compared. Results. A total of 78 patients had data available for analysis; 17 underwent revision THA and 61 underwent revision TKA. A total of 16 patients met modified Musculoskeletal Infection Society (MSIS) criteria for PJI. Pre- and post-lavage %PMNs were similar in septic patients (87% vs 85%) and aseptic patients (35% vs 39%). Pre- and post-lavage synovial fluid WBC count were far more disparate in septic (53,553 vs 8,275 WBCs) and aseptic (1,103 vs 268 WBCs) cohorts. At a cutoff of 80% PMN, the post-lavage aspirate had a sensitivity of 75% and specificity of 95%. At a cutoff of 3,000 WBCs, the post-lavage aspirate had a sensitivity of 63% and specificity of 98%. As the post-lavage synovial WBC count increased, the difference between pre- and post-lavage %PMN decreased (mean difference of 5% PMN in WBC < 3,000 vs mean difference 2% PMN in WBC > 3,000, p = 0.013). Of ten positive pre-lavage fluid cultures, only six remained positive post-lavage. Conclusion. While saline lavage aspiration significantly lowered the synovial WBC count, the %PMN remained similar, particularly at WBC counts of > 3,000. These findings suggest that in patients with a dry-tap, the %PMN of a saline lavage aspiration has reasonable sensitivity (75%) for the detection of PJI. Cite this article: Bone Joint J 2020;102-B(6 Supple A):138–144

Aims

The diagnosis of periprosthetic joint infection (PJI) can be challenging as the symptoms are similar to other conditions, and the markers used for diagnosis have limited sensitivity and specificity. Recent research has suggested using blood cell ratios, such as platelet-to-volume ratio (PVR) and platelet-to-lymphocyte ratio (PLR), to improve diagnostic accuracy. The aim of the study was to further validate the effectiveness of PVR and PLR in diagnosing PJI.

Aims

Aseptic loosening is the most common cause of failure following cemented total knee arthroplasty (TKA), and has been linked to poor cementation technique. We aimed to develop a consensus on the optimal technique for component cementation in TKA.

Introduction. There is no literature regarding the risk of a patient developing PJI after primary TKA if the patient has previously experienced PJI of a TKA or THA in another joint. The goal of this study was to compare the risk of PJI of primary TKA in this patient population compared to matched controls. Methods. We retrospectively reviewed 95 patients (102 primary TKAs) from 2000–2014 with a history of a TKA or THA PJI in another joint. Mean age was 69 years; mean BMI was 36 kg/m2. 27% high-risk patients were on chronic antibiotic suppression. Mean follow-up was 6 years. We 1:3 matched (to age, sex, BMI, and surgical year) these to 306 primary TKAs performed in patients with a THA or TKA of another joint without a subsequent PJI. Competing risk with death was used for statistical analysis. Multivariate analysis was utilized to evaluate risk factors for PJI in the study cohort. Results. The cumulative incidence of PJI in the study cohort (6.1%) was significantly higher than the matched cohort (2.6%) at 10 years (HR=3.3, p=0.02). Host grade in the study group was not a significant risk factor for PJI. Patients on chronic suppression had a higher rate of PJI (HR=15, p=0.002), with 6 of 7 patients developing a PJI being on chronic suppression. The new infecting microorganism was the same as the previous in only 2 of 7 patients. Conclusion. In this matched cohort study, patients undergoing a clean primary TKA with a history of a TKA or THA PJI in another joint had a 3-fold higher risk of PJI compared to matched controls with a 10-year cumulative incidence of 6.1%. The risk of PJI was 15-fold higher in patients on chronic suppression; further investigation into reasons for this and mitigation strategies is recommended

Introduction. First generation cephalosporins remain the gold standard perioperative antibiotic for total hip and knee arthroplasty (THA, TKA). However, some patients have documented or self-reported allergies to antibiotics, most commonly penicillin, that result in changes to perioperative antibiotic coverage. Furthermore, patients testing positive for methicillin resistant staphylococcus aureus (MRSA) represent another group where an alternative to cefazolin, typically vancomycin, is often chosen for perioperative prophylaxis. The aims of this study were to 1) characterize the antibiotic choices for perioperative prophylaxis at the time of primary TKA and THA, 2) assess the efficacy of a preoperative antibiotic allergy testing program, and 3) determine rates of periprosthetic joint infection (PJI) based on perioperative antibiotic regimen. Methods. We evaluated all patients undergoing primary TKA or THA at a single academic institution from January 2004-May 2017, yielding a cohort of 29,695 patients. A series of institutional databases were combined to determine which patients underwent antibiotic allergy testing prior to surgery, outcomes from the allergy consultation, perioperative antibiotic management strategy, and survivorship free of infection until final follow-up. Results. Antibiotic allergy testing was performed in 3,411 patients (11.5%) on the basis of a patient provided history of possible penicillin or cephalosporin allergy. Among those tested, 3,310 patients (97.0%) were cleared by the allergist to use cephalosporins in the perioperative period and 2,883 patients (87.1%) eventually received cefazolin. For the entire cohort, 28,174 patients (94.9%) received an operative antibiotic regimen including cefazolin and 1,521 patients (5.1%) received non-cefazolin antibiotics, most commonly vancomycin or clindamycin. Survivorship free of PJI was significantly higher among patients receiving cefazolin compared to non-cefazolin antibiotics with the most rapid divergence occurring within 2 months of surgery (p<0.001) (Figure 1). Survivorship free of PJI in the cefazolin compared to the non-cefazolin groups was 99.40% vs 99.34% at 1 month, 99.11% vs 98.55% at 2 months, 98.83% vs 98.22% at 1 year, and 98.15% vs 96.96% at 10 years (Table 1). Notably, the increased PJI rate observed in the non-cefazolin group was not attributable to high preoperative MRSA prevalence as 0 of the 38 PJIs grew MRSA on culture. The number needed to treat with cefazolin to prevent 1 PJI was 164 patients at 1-year and 84 patients at 10-years. Therefore, potentially 6,098 PJIs could be prevented by 1-year and 11,905 by 10-years in a cohort of 1,000,000 primary TKA and THA patients. Conclusions. This study demonstrates a significantly higher rate of PJI when non-cefazolin antibiotics are used for prophylaxis during primary TKA and THA, which is likely attributable to the superior spectrum of coverage for common PJI organisms compared to vancomycin or clindamycin. This is supported by the increased rate of non-MRSA PJI observed in the non-cefazolin cohort. Furthermore, cefazolin has been shown to act synergistically with vancomycin against MRSA. This work highlights the positive impact of a formal preoperative antibiotic allergy testing program to increase cefazolin usage. Also, surgeons may consider using cefazolin as a dual agent in the case of known MRSA colonization, whenever possible for PJI prophylaxis during TKA and THA. For any figures or tables, please contact authors directly

Aims. 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). Materials and Methods. 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. Results. A total of 4205 UKA patients were analysed. Of these, 1362 patients (32.4%) were users of opioids. Pre-operative opioid use was the strongest predictor of prolonged opioid use after UKA. Opioid users were 1.4 (81.6% versus 57.7%), 3.7 (49.5% versus 13.3%) and 5.5 (35.8% versus 6.5%) times more likely to be taking opioids at one, two and three months post-operatively, respectively (p < 0.05 for all). Younger age and specific comorbidities such as anxiety/depression, smoking, back pain and substance abuse were found to significantly increase the rate of repeat prescription for opioids after UKA. Overall, UKA patients required significantly less opioid prescriptions than patients who had undergone THA and TKA. Conclusion. One-third of patients who undergo UKA are given opioids in the three months pre-operatively. Pre-operative opioid use is the best predictor of increased repeat prescriptions after UKA. However, other intrinsic patient characteristics are also predictive. Cite this article: Bone Joint J 2018;100-B(1 Supple A):62–7

Introduction. Despite several preventive strategies, periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) is still a devastating complication. Early diagnosis and appropriate treatment are crucial to achieve successful infection control, but challenging since there is no test with 100% sensitivity and 100%. Therefore, several national and international guidelines include synovial analysis of joint aspirates as important diagnostic criteria, but cut-off levels for synovial cell count (CC) and polymorphonuclear (granulocyte) percentage (PMN%) are still debatable. The current investigation was performed to analyze the overall accuracy and optimal cut-off of synovial CC and PMN% following total knee (TKA) and total hip arthroplasty (THA). Methods. Between October 2012 and June 2017, all patients with painful TKA or THA, who underwent joint aspiration before revision arthroplasty were included in this retrospective study. From aspirated synovial fluid, leukocyte esterase activity, leukocyte CC and PMN% were determined, and specimens were sent for bacterial culture. A total of 524 preoperative joint aspirations (255 hips, 269 knees) were enrolled for final analysis. For 337 patients, the synovial CC and PMN% could be measured by the laboratory. From those patients, 203 patients were scheduled for aseptic revision, and 134 patients for septic revision arthroplasty according to the MSIS criteria for PJI. Specificity (SP), sensitivity (SE), positive predictive value (PPV), negative predictive and overall accuracy were measured for CC and PMN%. The optimum cut-off value was calculated by the ROC and the value giving the AUC, achieving the best possible level of sensitivity and specificity. Results. The best cut-off level for PJI of all study patients was 2582 leukocytes/μL (Se 80.6%, Sp 85.2%) and a PMN% of 66.1% (Se 80.6%, Sp 83.3%). The chosen cut-off levels for PJI of TKA was 1630 leukocytes/μL (Se 83.6%, Sp 82.2%) and a PMN% of 60.5% (Se 80.3%, Sp 77.1%). The optimal cut-off values for PJI of THA was 3063 leukocytes/μL (Se 78.1%, Sp 80.0%) and a PMN% of 66.1% (Se 82.2%, Sp 82.4%). Conclusions. Synovial cell count and polymorphonuclear percentage are sensitive methods for diagnosing PJI with differences in cut-off levels for THA and TKA. We suggest considering the cut-off levels of CC and PMN% from aspirates of TKA at 1600/μL and 60%, respectively, as possible PJI. For THA, the cut-off levels of CC and PMN% are at 3000/μL and 66%, respectively

Introduction. Employer-sponsored travel surgery programs for commonly performed procedures like total joint arthroplasty (TJA) are increasing, as employers try to more effectively manage the healthcare costs of their employees. This new approach by employers to direct their employees to designated “Centers of Excellence” (COEs) creates a need to characterize the “travel patient” population that commutes long distances to receive their surgical care and returns home for their rehab shortly after surgery. Electronic patient rehabilitation platforms (EPRA) facilitate communication, patient navigation, and care coordination across this complex episode of care and may contribute to improved outcomes after TJA. The aim of this study is to evaluate patient satisfaction, functional outcomes and engagement with the use of an EPRA among two TJA cohorts: 1) travel and 2) non-travel TJA patients. Methods. A retrospective review was performed on total knee (TKA) and total hip (THA) arthroplasty patients at a single institution during the first 6 months following implementation of an EPRA. All patients were offered internet based access to an EPRA which provided instant messaging with the care team, algorithmic navigation of the patient during the pre and post-op phases, and access to an extensive library of educational videos regarding their surgery, rehab, and FAQs. Primary outcome measures were the pre-op and 12 week post op HOOS Jr. and KOOS Jr. Patient satisfaction at 12 weeks after surgery and engagement metrics for the EPRA were also examined. Cases were separated into two groups: travel and non-travel, and the groups were compared in terms of engagement, improvement in functional outcomes, and patient satisfaction. Chi-square test and t-test statistics were used for analysis. Results. 634 TJA cases (100 travel; 534 non-travel) were included in this study. Age and BMI differed significantly between these cohorts (p<0.001). The mean age and BMI were 59.17 and 33.01, respectively for travel patients and 69.27 and 29.56, respectively for non-travel patients. 97% of the travel patients initially opted-in to use the electronic rehabilitation program compared to 87.6% of the non-travel patients. The number of travel patients logging in, watching videos, and messaging was significantly higher than that of non-travel patients (p<0.01). On average, travel patients generated double the number of sessions than non-travel patients (71.5 vs 31.5, p<0.001). Among TKA cases, travel patients reported significantly lower pre-op mean KOOS Jr. scores than non-travel patients (43.11 vs. 47.78, p< 0.01). By 12 weeks, there was no difference between the groups (67.11 vs. 70.05, p=0.15). THA cases exhibited similar increases in patient reported outcomes(PROs). Mean pre-op HOOS Jr scores for travel and non-travel patients were 42.64 and 48.16 respectively (p=0.07) and mean post-op HOOS Jr. scores at 12 weeks were 75.93 and 80.12, respectively (p=0.15). Comparing 12 week procedure satisfaction (0–5), travel THA patients reported significantly higher mean satisfaction than non-travel THA cases (4.93 vs 4.32, p<0.001). There was no difference in satisfaction between travel TKA and non-travel TKA cases (4.31 vs 4.35, p=0.85). Conclusion. This study revealed higher engagement among travel patients in comparison to non-travel patients as measured by utilization of EPRA. Patients participating in these programs are typically incentivized financially in terms of enhanced insurance coverage and elimination of out-of-pocket expenses when they obtain care at an employer designated COE which may contribute to this increased degree of engagement. Increased utilization of EPRA may have also contributed to higher 12 week patient satisfaction. Despite the logistical challenges of travel TJA surgery, the EPRA used in this study appears to facilitate effective patient navigation and care coordination in the travel patient population, resulting in patient reported outcomes and satisfaction that is comparable to our non-travel patient population. Considering the projected increased growth of these employer directed COE programs, further understanding of these travel surgery patients and the role of electronic patient engagement platforms and telehealth technologies is warranted. For figures, tables, or references, please contact authors directly

Aims

Metal particles detached from metal-on-metal hip prostheses (MoM-THA) have been shown to cause inflammation and destruction of tissues. To further explore this, we investigated the histopathology (aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL) score) and metal concentrations of the periprosthetic tissues obtained from patients who underwent revision knee arthroplasty. We also aimed to investigate whether accumulated metal debris was associated with ALVAL-type reactions in the synovium.

Aims

Patient dissatisfaction following primary total knee arthroplasty (TKA) with manual jig-based instruments has been reported to be as high as 30%. Robotic-assisted total knee arthroplasty (RA-TKA) has been increasingly used in an effort to improve patient outcomes, however there is a paucity of literature examining patient satisfaction after RA-TKA. This study aims to identify the incidence of patients who were not satisfied following RA-TKA and to determine factors associated with higher levels of dissatisfaction.

Aims

Micromotion of the polyethylene (PE) inlay may contribute to backside PE wear in addition to articulate wear of total knee arthroplasty (TKA). Using radiostereometric analysis (RSA) with tantalum beads in the PE inlay, we evaluated PE micromotion and its relationship to PE wear.

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. Methods. The Centers for Medicare & Medicaid Services (CMS) received PRO data voluntarily submitted by hospitals in a bundled payment model for THA/TKA procedures. Participating hospitals who collected and successfully submitted these data received an increase in their overall quality score, possibly resulting in a positive impact on model reconciliation payments. PRO data were collected from Medicare Fee-For-Service beneficiaries >= 65 years undergoing elective primary THA/TKA procedures from July 1 to August 31, 2016 at hospitals participating in the model. Pre-operative PRO and risk variable data were collected 0 – 90 days prior to surgery, while post-operative PRO data were collected 270 – 365 days following elective THA/TKA. PRO pre-op and post-op data were matched to Medicare claims data for determination of clinically eligible procedures and clinical comorbidities. We compared the characteristics of patients submitting PRO data to other elective primary THA/TKA recipients in the US. Results. Four patient characteristics were associated with HOOS Jr. mean change scores (sex, narcotic use in past 90 days, other joint pain, and back pain) and four with KOOS Jr. mean change scores (sex, Hispanic ethnicity, other joint pain, and back pain). The frequency of simultaneous bilateral procedures, dementia, trauma, and dialysis were statistically significantly lower in patients submitting PRO data compared to other US Medicare beneficiaries undergoing elective primary THA/TKA, but no difference was greater than 1.5% absolute percentage points between groups. Conclusions. Offering financial incentives in alternative payment models to encourage PRO data collection and submission can produce generalizable data for PRO measure development. The possibility of non-respondent biases will need to be specifically considered in measure development

Introduction. Pulmonary embolism (PE) complicates up to 1% of total joint arthroplasties (TJA). Many PE treatment guidelines call for immediate initiation of therapeutic anticoagulation. Options include Xa inhibitors, Enoxaparin, and Warfarin. Deciding between these is a balance of the efficacy and the risks. Little data exists regarding the risks of each of these treatment options for treating PE in arthroplasty patients. Methods. We examined the records of 29,270 patients who underwent a primary total joint arthroplasty (TJA), defined as a unilateral total knee arthroplasty (TKA) (18,987) or total hip arthroplasty (THA) (10,283), between 2/2016 and 12/2018 at our institution and identified 338 (242 TKA, 96 THA) patients who developed an in-hospital PE treated with therapeutic anticoagulation. The patients were treated with therapeutic doses of Xa inhibitors, enoxaparin or warfarin. The type and frequency of complications were determined and classified as major or minor. Major complication included: bleeding requiring surgery, GI bleed requiring treatment, >2 unit transfusion and mortality. Minor complications included wound drainage, bleeding not requiring surgery, and thrombocytopenia. Results. Overall complication rates were high for all treatments. Xa inhibitors had the lowest complication rate at 14% compared to 20% for enoxaparin and 20.7% for warfarin though the difference did not quite reach statistical significance (p=.054). Both major and minor complication were lower with Xa inhibitors, but again the difference was not statistically significant (p=0.67). There was no significant difference in complications between TKA groups (p=0.73) or THA groups (p=0.83). Gender and body mass index were not predictive of major or minor complications. Discussion. Our results demonstrate high complication rates associated with modern therapeutic anticoagulation protocols for perioperative PE following TJA. Patients who receive therapeutic anticoagulation postoperatively are at high risk for complication. Xa inhibitors may decrease these risks, but larger studies are required

Aims

The aims of this study were to assess mapping models to predict the three-level version of EuroQoL five-dimension utility index (EQ-5D-3L) from the Oxford Knee Score (OKS) and validate these before and after total knee arthroplasty (TKA).