Abstract

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).

Abstract

Introduction

Bundled Payments (BP) were a revolutionary new experiment for CMS that tested whether risk sharing for an episode of care would improve quality and reduce costs. The initial success of BP accelerated their growth as evidence by the launch of both mandatory and commercial bundles. Success in BP is dependent on the target price and the opportunity to reduce avoidable costs during the episode of care. There is concern that the aggressive target pricing methodology in the new model (BPCI-Advanced) penalizes high performing groups that already achieved low episode costs through prior experience and investment in BP. We hypothesize that this methodology incorporates unsustainable downward trends on target prices to a point beyond reasonableness for efficient groups to reduce additional costs and will lead to a large percentage of groups opting out of BPCI-A in favor of a return to fee for service (FFS) reimbursement.

A 5 year review of factors instigating malpractice claims and likely to result in a payout. Possible lessons for the future.

The Oxford knee score (OKS) is a validated and widely accepted disease-specific patient-reported outcome measure, but there is limited evidence regarding any long-term trends in the score. We reviewed 5600 individual OKS questionnaires (1547 patients) from a prospectively-collected knee replacement database, to determine the trends in OKS over a ten-year period following total knee replacement. The mean OKS pre-operatively was 19.5 (95% confidence interval (CI) 18.8 to 20.2). The maximum post-operative OKS was observed at two years (mean score 34.4 (95% CI 33.7 to 35.2)), following which a gradual but significant decline was observed through to the ten-year assessment (mean score 30.1 (95% CI 29.1 to 31.1)) (p < 0.001). A similar trend was observed for most of the individual OKS components (p < 0.001). Kneeling ability initially improved in the first year but was then followed by rapid deterioration (p < 0.001). Pain severity exhibited the greatest improvement, although residual pain was reported in over two-thirds of patients post-operatively, and peak improvement in the night pain component did not occur until year four. Post-operative OKS was lower for women (p < 0.001), those aged < 60 years (p < 0.003) and those with a body mass index > 35 kg/m² (p < 0.014), although similar changes in scores were observed. This information may assist surgeons in advising patients of their expected outcomes, as well as providing a comparative benchmark for evaluating longer-term outcomes following knee replacement.

Cite this article: Bone Joint J 2013;95-B:45–51.

Aims. The purpose of this study was to assess total knee arthroplasty (TKA) volume and rates of early complications in morbidly obese patients over the last decade, where the introduction of quality models influencing perioperative care pathways occurred. Methods. Patients undergoing TKA between 2011 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by BMI < 40 kg/m. 2. and ≥ 40 kg/m. 2. and evaluated by the number of cases per year. The 30-day rates of any complication, wound complications, readmissions, and reoperation were assessed. Trends in these endpoints over the study period were compared between groups using odds ratios (ORs) and multivariate analyses. Results. In total, 314,695 patients underwent TKA and 46,362 (15%) had BMI ≥ 40 kg/m. 2. The prevalence of morbid obesity among TKA patients did not change greatly, ranging between 14% and 16%. Reoperation rate decreased from 1.16% to 0.96% (odds ratio (OR) 0.81 (95% confidence interval (CI) 0.66 to 0.99)) for patients with BMI < 40 kg/m. 2. , as did rates of readmission (4.46% to 2.87%; OR 0.61 (0.55 to 0.69)). Patients with BMI ≥ 40 kg/m. 2. also had fewer readmissions over the study period (4.87% to 3.34%; OR 0.64 (0.49 to 0.83)); however, the rate of reoperation did not change (1.37% to 1.41%; OR 0.99 (0.62 to 1.56)). Significant improvements were not observed for infective complications over time for either group; patients with BMI ≥ 40 kg/m. 2. had increased risk of both deep infection and wound complications compared to non-morbidly obese patients. Rate of any complication decreased for all patients. Conclusion. The proportion of TKAs in morbidly obese patients has not significantly changed over the past decade. Although readmission rates improved for all patients, reductions in reoperation in non-morbidly obese patients were not experienced by the morbidly obese, resulting in a widening of the complication gap between these cohorts. Care improvements have not lowered the differential risk of infective complications in the morbidly obese. Cite this article: Bone Joint J 2021;103-B(6 Supple A):38–44

Introduction. Perioperative optimization efforts have improved outcomes following primary total knee arthroplasty (TKA). However, morbidly obese patients continue to have increased rates of complications. The purpose of this study was to assess if rates of early complications after TKA have similarly improved for both morbidly obese and non-morbidly obese patients. Methods. Elective, primary TKA patients from 2011–2018 were identified in the National Surgical Quality Improvement Program database. Patients were stratified by body mass index (BMI) <40 kg/m. 2. and ≥40 kg/m. 2. Thirty-day rates of infectious complications, readmissions, and reoperation were assessed. Trends in these endpoints over the study period were compared between BMI groups utilizing odds ratios (OR) and multivariate analyses. Results. In total, 314,719 patients underwent TKA and 46,386 (15%) had BMI ≥40 kg/m. 2. From 2011–2018, the reoperation rate significantly improved from 1.2% to 1.0% (OR: 0.6 [0.6–0.7]) for patients with BMI <40 kg/m. 2. , as did rates of readmission (4.5% to 2.9%, OR: 0.8 [0.7–0.99]). Patients with BMI ≥40 kg/m. 2. also had a significant decrease in the rate of readmission over the study period (4.9% to 3.3%, OR: 0.6 [0.5–0.8]); however, the rate of reoperation did not significantly change (1.4% to 1.4%, OR: 1.0 [0.6–1.6]). Significant improvements were not observed for infectious complications over time for either group. However, patients with BMI ≥40 kg/m. 2. consistently had increased risk of both deep infection from 2014–2018 (2014 OR: 2.2 [1.4–3.4], 2018: 2.2 [1.6–3.0]) and wound complications from 2011–2018 (2011 OR: 1.7 [1.2–2.6], 2018 OR: 2.0 [1.7–2.4]) compared to non-morbidly obese patients. Conclusion. Although readmission rates significantly decreased for all patients, improvements in reoperation rates observed in non-morbidly obese patients were not experienced by the morbidly obese – resulting in a widening of the complication gap between these cohorts. Care improvements have not lowered the differential risk of infectious complications compared to non-morbidly obese

We performed a randomised, controlled trial involving 150 patients with a pre-operative level of haemoglobin of 13.0 g/dl or less, to compare the effect of either topical fibrin spray or intravenous tranexamic acid on blood loss after total knee replacement.

A total of 50 patients in the topical fibrin spray group had 10 ml of the reconstituted product applied intra-operatively to the operation site. The 50 patients in the tranexamic acid group received 500 mg of tranexamic acid intravenously five minutes before deflation of the tourniquet and a repeat dose three hours later, and a control group of 50 patients received no pharmacological intervention.

There was a significant reduction in the total calculated blood loss for those in the topical fibrin spray group (p = 0.016) and tranexamic acid group (p = 0.041) compared with the control group, with mean losses of 1190 ml (708 to 2067), 1225 ml (580 to 2027), and 1415 ml (801 to 2319), respectively. The reduction in blood loss in the topical fibrin spray group was not significantly different from that achieved in the tranexamic acid group (p = 0.72).

The aim of this study was to compare the results in patients having a quadriceps sparing total knee replacement (TKR) with those undergoing a standard TKR at a minimum follow-up of two years.

All patients who had a TKR with a high-flex posterior-stabilised prosthesis prior to December 2002 were reviewed retrospectively. There were 57 patients available for follow-up. Those with a quadriceps sparing TKR had less pain peri-operatively with a greater degree of flexion at all the post-operative visits and at the final follow-up, but their operations took longer, with less accurate radiological alignment. There was no difference in the complications and in the Knee Society scores between the two groups at the final follow-up.

Total knee replacement through a quadriceps sparing approach has some peri-operative advantages over the standard incision. At a minimum follow-up of two years the clinical results were similar to those with a standard incision, but the radiological outcomes of the quadriceps sparing group were inferior.