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. Physicians and physician organizations need to sit at the head of the table to manage future payment bundles and perhaps also act as the convener. We deserve this, as a result of demonstrating high safety and cost savings. For figures, tables, or references, please contact authors directly

Aims. There is concern that aggressive target pricing in the new Bundled Payment for Care Improvement Advanced (BPCI-A) penalizes high-performing groups that had achieved low costs through prior experience in bundled payments. We hypothesize that this methodology incorporates unsustainable downward trends on Target Prices and will lead to groups opting out of BPCI Advanced in favour of a traditional fee for service. Methods. Using the Centers for Medicare and Medicaid Services (CMS) data, we compared the Target Price factors for hospitals and physician groups that participated in both BPCI Classic and BPCI Advanced (legacy groups), with groups that only participated in BPCI Advanced (non-legacy). With rebasing of Target Prices in 2020 and opportunity for participants to drop out, we compared retention rates of hospitals and physician groups enrolled at the onset of BPCI Advanced with current enrolment in 2020. Results. At its peak in July 2015, 342 acute care hospitals and physician groups participated in Lower Extremity Joint Replacement (LEJR) in BPCI Classic. At its peak in March 2019, 534 acute care hospitals and physician groups participated in LEJR in BPCI Advanced. In January 2020, only 14.5% of legacy hospitals and physician groups opted to stay in BPCI Advanced for LEJR. Analysis of Target Price factors by legacy hospitals during both programmes demonstrates that participants in BPCI Classic received larger negative adjustments on the Target Price than non-legacy hospitals. Conclusion. BPCI Advanced provides little opportunity for a reduction in cost to offset a reduced Target Price for efficient providers, as made evident by the 85.5% withdrawal rate for BPCI Advanced. Efficient providers in BPCI Advanced are challenged by the programme’s application of trend and efficiency factors that presumes their cost reduction can continue to decline at the same rate as non-efficient providers. It remains to be seen if reverting back to Medicare fee for service will support the same level of care and quality achieved in historical bundled payment programmes. Cite this article: Bone Joint J 2021;103-B(6 Supple A):119–125

Introduction. Total Knee Arthroplasty (TKA) has been demonstrated to drastically improve a patient's quality of life. The outcomes following TKA are often reported by subjective patient reported outcome measurements (PROMs). However, there are few objective outcome measures following TKA, limiting the amount of information physicians can use to effectively guide a patient's recovery, especially in the first 3 weeks. Newly developed knee sensors have been able to ameliorate this problem by providing the physician with previously unobtainable objective data. Our study aims to evaluate the use of a wearable knee sensor device to measure functional outcomes (range of motion and steps) in real time. Methods. 29 patients who underwent primary, unilateral TKA were recruited for this IRB approved study. Patients were instructed how to use the device and associated mobile phone application preoperatively (Figure 1) and provided knee sensors to wear postoperatively (Figure 2). Patients wore the device for 3 weeks postoperatively to allow for data collection. The device recorded range of motion, number of steps, and percentage of physical therapy exercises completed. Patients were grouped by gender, age (<69 or >=70 years old), and BMI (<30 and >=30 kg/m2) for analysis of functional outcome measurements (maximum flexion, minimum extension, and number of steps). Unpaired two-sample t-tests were used to analyze differences between the groups. Results. Patients were able to tolerate wearing the device without complication and the device collected functional outcome data appropriately as designed. After brief instruction, both patients and physicians were able to monitor patient data via the mobile phone application in real time. The mean maximum flexion and minimum extension did not significantly change from postoperative week 1 to postoperative week 2 and week 3. However, the mean number of steps taken increased from 4,923 steps in postoperative week 1 to 8,163 steps week 2 (p=0.01) and 11,615 steps week 3 (p<0.001) postoperatively. There were no statistically significant differences in maximum flexion, minimum extension, and number of steps between the different gender, age, and BMI groups. Discussion and Conclusion. The knee sensor device used in our study proved to be useful in providing objective functional outcomes following TKA. The device was well tolerated by patients and the mobile phone applications were easy to use for the physicians and the patients. Real time tracking of patients' own range of motion, number of steps, and percentage of exercises completed may motivate them to further their own recovery process. There were wide ranges in the number of steps taken during each postoperative time interval. These results may help identify individuals who are recovering at a faster rate or those who may need more focused physical therapy. Subsequent larger studies can utilize the device to elucidate previously unknown recovery trends among different groups of patients following TKA. In the future, the device's ability to collect real time functional outcome data will allow physicians and other healthcare providers to create individualized physical therapy plans, thereby optimizing the patient's recovery process. For figures, tables, or references, please contact authors directly

Aims. The COVID-19 pandemic led to a swift adoption of telehealth in orthopaedic surgery. This study aimed to analyze the satisfaction of patients and surgeons with the rapid expansion of telehealth at this time within the division of adult reconstructive surgery at a major urban academic tertiary hospital. Methods. A total of 334 patients underging arthroplasty of the hip or knee who completed a telemedicine visit between 30 March and 30 April 2020 were sent a 14-question survey, scored on a five-point Likert scale. Eight adult reconstructive surgeons who used telemedicine during this time were sent a separate 14-question survey at the end of the study period. Factors influencing patient satisfaction were determined using univariate and multivariate ordinal logistic regression modelling. Results. A total of 68 patients (20.4%) and 100% of the surgeons completed the surveys. Patients were “Satisfied” with their telemedicine visits (4.10/5.00 (SD 0.98)) and 19 (27.9%) would prefer telemedicine to in-person visits in the absence of COVID-19. Multivariate ordinal logistic regression modelling revealed that patients were more likely to be satisfied if their surgeon effectively responded to their questions or concerns (odds ratio (OR) 3.977; 95% confidence interval (CI) 1.260 to 13.190; p = 0.019) and if their visit had a high audiovisual quality (OR 2.46; 95% CI 1.052 to 6.219; p = 0.042). Surgeons were “Satisfied” with their telemedicine experience (3.63/5.00 (SD 0.92)) and were “Fairly Confident” (4.00/5.00 (SD 0.53)) in their diagnostic accuracy despite finding the physical examinations to be only “Slightly Effective” (1.88/5.00 (SD 0.99)). Most adult reconstructive surgeons, seven of eight (87.5%) would continue to use telemedicine in the future. Conclusion. Telemedicine emerged as a valuable tool during the COVID-19 pandemic. Patients undergoing arthroplasty and their surgeons were satisfied with telemedicine and see a role for its use after the pandemic. The audiovisual quality and the responsiveness of physicians to the concerns of patients determine their satisfaction. Future investigations should focus on improving the physical examination of patients through telemedicine and strategies for its widespread implementation. Cite this article: Bone Joint J 2021;103-B(6 Supple A):196–204

Introduction. In November 2017, the Center for Medicare and Medicaid Services (CMS) finalized the 2018 Medicare Outpatient Prospective Payment System rule that removed total knee arthroplasty (TKA) procedures from the Medicare inpatient-only (IPO) list of procedures. This action had significant and unexpected consequences. For several years, CMS has utilized a rule called the “Two-Midnight Rule” to define outpatient status for all procedures not on the IPO list. CMS made TKA subject to the “Two-Midnight Rule” in conjunction with the decision to move TKA off the IPO list. According to the “Two-Midnight Rule,” a hospital admission should be expected to span at least two midnights in order to be covered as an inpatient procedure. If it can be reliably expected that the patient will not require at least two midnights in the hospital, the “Two-Midnight Rule” suggests that the patient is considered an outpatient and is therefore subject to outpatient payment policies. Under prior guidance related to the “Two-Midnight Rule;” however, CMS also states that Medicare may treat some admissions spanning less than two midnights as inpatient procedures if the patient record contains documentation of medical need. The final rule was clear in stating CMS's expectation was that the great majority of TKAs would continue to be provided in an inpatient setting. Methods. We looked at 3 different levels of the IPO rule impact on TKA for Medicare beneficiaries: a national comparison of fee for service (FFS) inpatient and outpatient classification for 2017 vs 2018; a survey of AAHKS surgeons completed in April of 2019; and an in-depth analysis of a large academic medical center experience. An analysis of change in inpatient classification of TKA patients over time, number of Quality Improvement Organization (QIO) audits, compliance solutions of organizations for the new rule and cost implications of those compliance solutions were evaluated. Results. Hospital reimbursement averages $10,122 in an outpatient facility (includes implant, other supplies, ancillary staff, etc.) but does NOT include the physician payment. Average hospital reimbursement in the inpatient setting is $11,760. The difference in reimbursement to hospitals varies widely however due to nuances in the CMS reimbursement formula (90. th. percentile decrease, $6,725 vs 10th percentile $2,048). Physician payments are the same in both settings (avg $1,403). TKA patients not designated for in-patient admissions are not eligible for bundle payment programs thus removing the healthiest, most predictable patients from the program. Patients designated as outpatients are subject to higher out of pocket expenses. Patients may have an annual Medicare Part B Deductible ($185) and a 20% copay as well as prescription and durable medical equipment costs. A survey of AAHKS surgeons demonstrated that 44.74% were doing inpatient designation only, 17.89% were doing outpatient designation only, 25.53 % designated patients as necessary, and 10% were designated by the hospital. This survey showed that 66/374 (17.65%) of AAHKS responders had undergone a QIO audit as a result of issues with the IPO rule. An evaluation of a large academic medical center demonstrated that since January 1, 2018, 470/690 (68.1%) of CMS TKA patients left the institution in less than 2 midnights. During this time period the institution was subjected to 2 QIO audits. All CMS patients had been designated as inpatients prior to May 2019. Conclusions. There are many unintended consequences to the IPO rule application to TKA. Clearly, more study is needed to provide better guidelines to knee replacement surgeons. A well-defined outpatient TKA bundle would allow CMS and TKA surgeons to better serve their patients. For figures, tables, or references, please contact authors directly

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. Methods. Using CMS data, we compared the target price factors for hospitals that participated in both BPCI classic (2013 –2018) and BPCI Advanced (beginning 10/2018), referred to as “legacy hospitals”, with hospitals that only participated in BPCI Advanced (beginning 10/2018). With the rebasing of BPCI-A target prices in Jan 2020 and the opportunity for participants to drop out of individual episode types or the program all together, we compared the retention of episode types that hospitals initially enrolled at the onset of BPCI-A with the current enrollment in 2020. Locally, we analyzed the BPCI-A target price factors across hospitals for a large orthopaedic practice that participated in BPCI Classic and the impact it had on the financial incentive/disincentive to remain in the lower extremity joint replacement episode type in 2020. Results. At its peak in July 2015, 423 acute care hospitals participated in one or more episode type in BPCI Classic. At its peak in March 2019, 715 acute care hospitals participated in one or more episode types in BPCI-Advanced. 130 (18%) of the hospitals in BPCI Advanced were also legacy participants in BPCI Classic, enrolling in 414 of the same episode types during both programs. In 2020, 251 (61%) of the episode types that hospitals were in enrolled in for both BPCI Classic and BPCI Advanced were dropped, suggesting prior experience in BPCI influences a participant's opportunity for success in BPCI Advanced. Furthermore, an analysis of the target price factors for episode types enrolled in by legacy hospitals during both programs suggests that prior participation in BPCI Classic is correlated with more aggressive target prices. A comparison of target price factors of similar hospitals reveals that legacy BPCI Classic hospitals that participated in lower extremity joint replacement (LEJR) BPCI Advanced received a larger negative adjustment on the target price (0.11 lower on average as a product of the Peer Adjusted Trend factor and ACH Efficiency factor) than non-legacy hospitals that participated in BPCI Advanced. Furthermore, analysis of the hospital targets for a large, high-performing legacy Physician Group Practice in BPCI Classic for LEJR revealed even greater negative adjustment on the target price than non-legacy participants. Comparing participants of similar peer groups on the Peer Adjusted Trend and ACH Efficiency factors suggests that CMS expects costs to decline more for legacy hospitals that have achieved efficiency than hospitals with no prior BP experience and higher baseline spend. Conclusions. BPCI Advanced provides little to no opportunity for a reduction in cost for already efficient TJA providers, as evident by the 55% dropout rate for BPCI-A participants in LEJR between model years 1 and 3. Efficient TJA providers in BPCI Advanced are challenged by the program's utilization of a peer adjusted trend factor and efficiency factor that presumes their costs will decline at the same aggressive rate or more than nonefficient TJA providers. It remains to be seen if reverting to Medicare fee for service will support the same level of care coordination, cost and quality achieved in historical TJA bundled payment programs

Introduction. A smartphone-based care platform allows a customizable educational and exercise interface with patients, allowing many to recover after surgery without the need for formal physical therapy (PT). Furthermore, advances in wearable technology to monitor physical activity (PA) provides patients and physicians quantifiable metrics of the patient's recovery. The purpose of this study is to determine the feasibility of a smartphone-based exercise educational platform after primary knee arthroplasty as well as identifying factors that may predict the need for formal physical therapy. Methods. This study is part of a multi-institution, prospective study of patients after primary total knee arthroplasty (TKA) and partial knee arthroplasty (PKA) enrolled in a smartphone with smartwatch-based episode of care platform that recorded multimodal PA (steps, kcal, stairs). Postoperatively, all patients initially followed the smartphone-based exercise program. At the surgeon's discretion, patients were prescribed therapy if needed. The outcome of this study was the need for PT outside the app-based exercise program as well as time to return to preoperative step count. Variables assessed were preoperative weekly step counts (steps/day), weekly postoperative activity level (weekly step count compared to preoperative level), compliance with the exercise program (>75% completion) and patient demographic data including gender, age, BMI and narcotic use. One hundred eighty-eight patients were included in analysis: 45 PKA (24%) and 143 TKA (76%). Step count data was available on 135 patients and physical therapy data on 174. Results. Overall educational compliance was 91% and exercise compliance 34%. By 4-weeks postop, 45.6% of patients reached or exceeded their preoperative step count, including 60% of PKA and 41% of TKA (p=0.05). There was no significant difference in reaching step count based on gender (p=0.7), BMI <40kg/m2 (p=0.9) or age <65-years old (p=0.67). Sixty-three percent of patients that were compliant with the exercise program reached the step count compared to 40% of patients that weren't complaint (p=0.01). One hundred thirty-three patients (76.4%) completed the app-based exercise program without the need for PT, which included 81.4% of PKA patients and 75% of TKA patients (p=0.38). Weekly compliance with the exercise program (>75%) was significantly associated with not needing PT (p<0.001). Other factors that were significantly associated with the need for PT were a high physical activity level in postoperative week 1 (p<0.001) and a low physical activity level in postoperative week 2 (p=0.002). Conclusion. A high percentage of patients after primary knee arthroplasty were able to successfully complete the smartphone-based exercise program without the need for PT. Compliance with the exercise program was an important predictor of success. Postoperative activity level may also indicate the need for therapy as patients who were very active in the first postoperative week and then saw a decline in activity in the second week were more likely to be prescribed PT. With this platform, surgeons can monitor a patient's exercise compliance and postoperative activity level allowing many to recover at home, while being able to identify those within the first few weeks who may need structured physical therapy. For figures, tables, or references, please contact authors directly

We are entering a new era with governmental bodies taking an increasingly guiding role, gaining control of registries, demanding direct access with release of open public information for quality comparisons between hospitals. This review is written by physicians and scientists who have worked with the Swedish Knee Arthroplasty Register (SKAR) periodically since it began. It reviews the history of the register and describes the methods used and lessons learned. Cite this article: Bone Joint Res 2014;3:217–22

Aims

The purpose of this study is to determine an individual’s age-specific prevalence of total knee arthroplasty (TKA) after cruciate ligament surgery, and to identify clinical and genetic risk factors associated with undergoing TKA.

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Spinal anaesthesia has seen increased use in contemporary primary total knee arthroplasties (TKAs). However, controversy exists about the benefits of spinal in comparison to general anaesthesia in primary TKAs. This study aimed to investigate the pain control, length of stay (LOS), and complications associated with spinal versus general anaesthesia in primary TKAs from a single, high-volume academic centre.

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Periprosthetic joint infection (PJI) is a challenging complication of any arthroplasty procedure. We reviewed our use of static antibiotic-loaded cement spacers (ABLCSs) for staged management of PJI where segmental bone loss, ligamentous instability, or soft-tissue defects necessitate a static construct. We reviewed factors contributing to their failure and techniques to avoid these complications when using ABLCSs in this context.

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The aim of this study was to evaluate the association between chondral injury and interval from anterior cruciate ligament (ACL) tear to surgical reconstruction (ACLr).

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This study aims to determine difference in annual rate of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis, and to identify risk factors that may be associated with infection.

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The primary aim of this study was to compare the migration of the femoral and tibial components of the cementless rotating platform Attune and Low Contact Stress (LCS) total knee arthroplasty (TKA) designs, two years postoperatively, using radiostereometric analysis (RSA) in order to assess the risk of the development of aseptic loosening. A secondary aim was to compare clinical and patient-reported outcome measures (PROMs) between the designs.

Aims

In cases of severe periprosthetic joint infection (PJI) of the knee, salvage procedures such as knee arthrodesis (KA) or above-knee amputation (AKA) must be considered. As both treatments result in limitations in quality of life (QoL), we aimed to compare outcomes and factors influencing complication rates, mortality, and mobility.

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Total knee arthroplasty (TKA) may provoke ankle symptoms. The aim of this study was to validate the impact of the preoperative mechanical tibiofemoral angle (mTFA), the talar tilt (TT) on ankle symptoms after TKA, and assess changes in the range of motion (ROM) of the subtalar joint, foot posture, and ankle laxity.

Introduction. Although we know that smoking damages health, we do not know impact of smoking on a patient's outcome following primary knee arthroplasty (KA). In the UK, clinical commissioning groups (CCGs) have the authority (& funds) to commission healthcare services for their communities. Over the past decade, an increasing number of CCGs are using smoking as a contraindication for patients with end-stage symptomatic knee arthritis being referred to a specialist for due consideration of KA without any clear evidence of the associated risks & benefits. The overall objective of this study is to compare clinical outcomes after knee arthroplasty surgery in smokers, ex-smokers & non-smokers. Methods. We obtained data from the UK Clinical Research Practice Datalink (CPRD) that contains information on over 11 million patients (7% of the UK population) registered at over 600 general practices. CPRD data was linked to Hospital Episode Statistics, hospital admissions & Patient Reported Outcome Measures (PROMs) data. We collected data on all KAs (n=64,071) performed over a 21-year period (1995 to 2016). Outcomes assessed included: local & systemic complications (at 6-months post-surgery): infections (wound, respiratory, urinary), heart attack, stroke & transient ischaemic attack, venous thromboembolism, hospital readmissions & GP visits (1-year), analgesic use (1-year), surgical revision (up to 20-years), mortality (90-days and 1-year), & 6-month change from pre-operative scores in Oxford Knee Score (OKS). Regression modelling is used to describe the association of smoking on outcomes, adjusting for confounding factors. Results. Smoking was associated with an increased risk of lower respiratory tract infections (LRTI) (4.2% smokers vs. 2.7% non-smokers) (Odds Ratio (OR) 0.76, p-value 0.017). LRTI were similar in ex-smokers & smokers at 3.9%. There was no association with any of the other 6-month complications. Pain medication use over 1-year post surgery was higher in smokers compared to non-smokers: gabapentinoids 7.4% vs. 5.2% (OR 0.74, p< 0.001), opioids 45.9% vs. 35.3% (OR 0.79, p< 0.001), NSAIDs 51.6% vs. 46.1% (OR 0.91, p = 0.044). Mortality was higher in smokers at 1-year compared to non-smokers (hazard ratio (HR) 0.53, p<0.001) & ex-smokers (HR 0.65, p = 0.037), but there was no difference observed at 90-days. There was no association of smoking on revision surgery over 20-years follow up. Smoking was associated with worse postoperative OKS being 3.1 points higher in non-smokers (p<0.001) & 3.0 points higher in ex-smokers (p<0.001). The overall change in OKS before & after surgery was 13.9 points in smokers versus 16.3 points in non-smokers (p<0.001) & 15.7 points in ex-smokers (p<0.001). Over the year following surgery, smokers were more likely to visit their GP, but there was no association with hospital readmission rates. Conclusion. This is the largest study with linked primary care & secondary care data highlighting impact of a preventable patient factor on outcome of a routinely performed planned intervention. Smokers achieved clinical meaningful improvements in patient reported pain & function (OKS) following KA, although their attained post-operative OKS was lower than in non-smokers & ex-smokers. Levels of pain medication use were notably higher in both smokers & ex-smokers. As smokers achieved good clinical outcomes following KA surgery, smoking should not be a barrier to referral for or consideration of KA. However, the study does highlight particular risks a patient is taking if he/she continues to smoke when being considered for elective knee arthroplasty. This study will help the family physicians as well as patients to make an informed decision on whether to go ahead with a planned intervention whilst patient continues to be an active smoker or not. Key Words: Knee Arthroplasty, Smoking, Patient Reported Outcomes, Epidemiology, Complications

Aims

Endoprosthetic reconstruction with a distal femoral arthroplasty (DFA) can be used to treat distal femoral bone loss from oncological and non-oncological causes. This study reports the short-term implant survivorship, complications, and risk factors for patients who underwent DFA for non-neoplastic indications.

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Despite recent literature questioning their use, vancomycin and clindamycin often substitute cefazolin as the preoperative antibiotic prophylaxis in primary total knee arthroplasty (TKA), especially in the setting of documented allergy to penicillin. Topical povidone-iodine lavage and vancomycin powder (VIP) are adjuncts that may further broaden antimicrobial coverage, and have shown some promise in recent investigations. The purpose of this study, therefore, is to compare the risk of acute periprosthetic joint infection (PJI) in primary TKA patients who received cefazolin and VIP to those who received a non-cephalosporin alternative and VIP.

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Hereditary haemochromatosis is a genetic disorder that is caused by several known mutations in the human homeostatic iron regulator protein (HFE) gene. Abnormal accumulation of iron causes a joint disease that resembles osteoarthritis (OA), but appears at a relatively younger age and is accompanied by cirrhosis, diabetes, and injury to other organs. Increased serum transferrin saturation and ferritin levels are known markers of haemochromatosis with high positive predictive values.