The Center for Medicare and Medicaid Services (CMS) is faced with a challenge of decreasing the cost of care for total knee arthroplasty (TKA), but must make efforts to prevent patient selection bias in the process. Currently, no appropriate modifier codes exist for primary TKA based on case complexity. We sought to determine differences in perioperative parameters for patients with “complex” primary TKA with the hypothesis that they would require increased cost of care, prolonged care times, and have worse postoperative outcome metrics. We performed a single center retrospective review from 2015 to 2018 of all primary TKA. Patient demographics, medial proximal tibial angle (mPTA), lateral distal femoral angle (lDFA), flexion contracture, cost of care, and early postoperative outcomes were collected. ‘Complex’ patients were defined as those requiring stems or augments, and multivariable logistic regression analysis and propensity score matching were performed to evaluate perioperative outcomes.Introduction
Methods
The Comprehensive Care for Joint Replacement (CJR) model for total hip arthroplasty (THA) involves a target reimbursement set by the Center for Medicare and Medicaid Services (CMS). Many patients exceed these targets, but predicting risk for incurring these excess costs remains challenging, and we hypothesized that select patient characteristics would adequately predict CJR cost overruns. Demographic factors and comorbidities were retrospectively reviewed in 863 primary unilateral CJR THAs performed between 2013 and 2017 at a single institution. A predictive model was built from 31 validated comorbidities and a base set of 5 patient factors (age, gender, BMI, ASA, marital status). A multivariable logistic regression model was refined to include only parameters predictive of exceeding the target reimbursement level. These were then assigned weights relative to the weakest parameter in the model.Introduction
Methods
Hip fractures are a common pathology treated by Orthopaedic surgeons. The Comprehensive Care for Joint Replacement (CJR) model utilizes risk stratification to set target prices for these patients undergoing hemiarthroplasty or total hip arthroplasty (THA). We hypothesized that sub-specialty arthroplasty surgeons would be able to treat patients at a lower cost compared to surgeons of other specialties during cases performed while on call. Patients with hemiarthroplasty or THA for hip fractures were retrospectively collected from June, 2013, to May, 2017, from a single tertiary referral center. Demographic information and outcomes based on length of stay (LOS), net payment, and target payment were collected. Patients were then stratified by surgeon subspecialty (arthroplasty trained vs. other specialty). Univariable and multivariable analysis for payment based on treating surgeon was then performed.Introduction
Methods
Hypoalbuminemia has previously been identified as an independent predictor of postoperative complications following total knee arthroplasty (TKA). Given the morbidity and financial burden associated with TKA complications, significant effort has gone into identifying patients at increased risk for perioperative complications. The American Society of Anesthesiologists (ASA) physical status score has been utilized for risk stratification of surgical patients for many years and is a measure of overall health. However, it is unclear how measures like albumin compare to the prognostic ability of this type of global health measure. This study aims to elucidate the utility of preoperative albumin compared with that of the ASA score in predicting complications following TKA. Patients undergoing TKA between 2005 and 2015 were identified using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were stratified based on preoperative hypoalbuminemia (<3.5 g/dL) and ASA score (≤ 2 vs. > 2). Multivariable regression analysis adjusted for age, sex, BMI, and smoking status was utilized to determine predictive potential of hypoalbuminemia and ASA score on each postoperative complication.Introduction
Methods
Higher re-tear rates after arthroscopic single row rotator cuff repairs have been linked with the inability to restore the native footprint. The objective in our study was to evaluate the biomechanical properties and anatomic footprint restoration after both single and double row repairs. Human cadaveric shoulders (n=22) were tested using a materials testing machine. Cyclic loading was performed on intact, injured (3cm tear), and arthroscopically repaired rotator cuff. Repairs tested: 1) single row A (Lateral Simple, n=6); 2) single row B (Lateral Mattress, n=5); 3) double row A (Medial Mattress/Lateral Simple, n=6); and 4) double row B (Transosseus Simple, n=5). Percentage of footprint restoration was calculated for each repair followed by a load-to-failure protocol. Biomechanical properties were determined from the load-displacement curves. Single and double row repairs restored an average of 40% and 90% of the native footprint (p<
0.05) with small amounts of cyclic creep and permanent elongation. No differences were detected between any of the repairs for the ultimate load (724±344N, 879±247N, 741±339N and 896±229N) and stiffness (100±43N/mm, 106±31N/mm, 89±34N/mm and 100±14N/mm), respectively. Double row repairs have comparable initial strength and increased footprint restoration compared to single row repairs. These similarities can be attributed to the inclusion of surrounding soft tissue structures during testing; however, the increased restoration of the anatomic footprint may lead to increased tendon-to-bone healing with the possibility of improved biomechanical properties and should be examined in the future. The characteristic U-shaped tear confirms clinically observed scenarios which may be caused by overuse after a RC injury has been sustained. The small amount of cyclic creep and permanent deformation in all arthroscopic repairs suggest that initial rehabilitation could be prescribed after surgery without compromising the initial stability of the repair; however, surgeons should carefully select a RC repair based on the state of the surrounding tissue.
