Publications by authors named "Atul F Kamath"

189 Publications

Robotic-Arm Assisted versus Manual Total Hip Arthroplasty: Systematic Review and Meta-analysis of Radiographic Accuracy.

Int J Med Robot 2021 Sep 16:e2332. Epub 2021 Sep 16.

Department of Orthopaedic Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.

Background: We systematically reviewed the radiological outcomes of studies comparing robotic-assisted (RA-THA) and manual total hip arthroplasty (mTHA) .

Methods: The PubMed, Embase, and Cochrane databases were queried from 1994-2021 for articles comparing radiographic outcomes between RA-THA and mTHA cohorts. A meta-analysis was conducted whenever sufficient data was present for common outcomes.

Results: Our analysis included 20 articles reporting on 4,140 patients (RA-THA: n=1,228; mTHA: n= 2,912). No differences were demonstrated for acetabular inclination or anteversion. However, RA-THA demonstrated higher rates of cup orientation within the Lewinnek and Callanan safe zones, improved femoral stem alignment, and lower global offset difference (GOD) and limb length discrepancy (all p-values <0.05). Superior femoral canal fill and combined offset were seen among RA-THA patients.

Conclusion: Our review found that the use of RA-THA yields superior radiographic outcomes compared to mTHA counterparts. This information can inform healthcare systems considering investing in and implementing these technologies. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1002/rcs.2332DOI Listing
September 2021

Industry Payments Among Appropriate Use Criteria Voting Panels: An Open Payments Analysis.

J Bone Joint Surg Am 2021 Sep 10. Epub 2021 Sep 10.

Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.

Background: Although multiple studies have consistently demonstrated that orthopaedic surgeons receive greater transfers of value than other specialties, the industry payments of providers who are involved in the formation of practice guidelines have not been thoroughly explored. Therefore, the purpose of our analysis was to evaluate the industry payments of the authors of the Appropriate Use Criteria (AUC) from the American Academy of Orthopaedic Surgeons (AAOS).

Methods: The publicly available AAOS web portal (OrthoGuidelines.org) was queried for all AUCs that had been released between January 1, 2013, and December 31, 2019, regarding the management of musculoskeletal pathologies. A cross-sectional analysis of the Centers for Medicare & Medicaid Services (CMS) Open Payments database was conducted to determine the number and total value of industry payments to AUC voting committee members during the year of voting for the AUC. Industry payments for each orthopaedic surgeon voting member were compared with payments received by orthopaedic surgeons nationwide who received any payment within the same year. The proportion of orthopaedic surgeon voting members who received any industry payment was compared with the proportion of orthopaedic surgeons nationwide who received payments.

Results: Our analysis included a total of 18 different AUCs with 216 voting members, 157 of whom were orthopaedic surgeons. Of the orthopaedic surgeon voting members, 105 (67%) received industry payments, a rate roughly comparable with the national average among orthopaedic surgeons (74%). For 7 of 18 AUCs (39%), the median payment per orthopaedic surgeon voting member was above the median among orthopaedic surgeons receiving payments nationwide that year. Qualitatively, orthopaedic surgeon voting members were more likely to receive payments in the form of royalties, licenses, or speaking fees than orthopaedic surgeons nationwide.

Conclusions: AUC voting members receive payments at frequencies and magnitudes that are roughly comparable with orthopaedic surgeons nationwide. Whether voting panel members receiving payments at these rates is ideal or is in the best interest of patients is a policy decision for the AAOS and society at large. Our study confirms that payments are common and, thus, continued vigilance is justified.
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http://dx.doi.org/10.2106/JBJS.21.00150DOI Listing
September 2021

Comparing early and mid-term outcomes between robotic-arm assisted and manual total hip arthroplasty: a systematic review.

J Robot Surg 2021 Aug 30. Epub 2021 Aug 30.

Department of Orthopaedic Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.

The projected increase in utilization rates of total hip arthroplasty (THA) has created an emphasis on novel technologies that can aid providers in maintaining historically positive outcomes. Widespread utilization of robotic assisted THA (RA-THA) is contingent upon achieving favorable outcomes compared to its traditional manual counterpart (mTHA). Therefore, the purpose of our systematic review was to compare RA-THA and mTHA in terms of the following: (1) functional outcomes and (2) complication rates. The PubMed, Embase, and Cochrane library databases were searched for articles published October 1994 and May 2021 comparing functional outcomes and complication rates between RA-THA and mTHA cohorts. When three or more studies evaluated certain PROMs and complications, a pooled analysis utilizing Mantel-Haenszel (M-H) models was conducted utilizing data from final follow-up. Our final analysis included 18 studies which reported on a total of 2811 patients [RA-THA: n = 1194 (42.48%); mTHA: n = 1617 (57.52%)]. No significant differences were demonstrated for a majority of pooled analyses and when segregating by robotic system. Only WOMAC scores were significantly lower among RA-THA patients (p = 0.0006). For outcomes without sufficient data for a pooled analysis, there were no significant differences reported among included studies. The growing utilization of RA-THA motivates comparisons to its manual counterpart. Collectively, we found comparable functional outcomes and complication profiles between RA-THA and mTHA cohorts. More randomized controlled trials of higher quality and larger sample sizes are necessary to further strengthen these findings.
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http://dx.doi.org/10.1007/s11701-021-01299-0DOI Listing
August 2021

Patient Engagement Approaches in Total Joint Arthroplasty: A Review of Two Decades.

J Patient Exp 2021 19;8:23743735211036525. Epub 2021 Aug 19.

Cleveland Clinic Foundation, Cleveland, OH, USA.

Patient engagement is a comprehensive approach to health care where the physician inspires confidence in the patient to be involved in their own care. Most research studies of patient engagement in total joint arthroplasty (TJA) have come in the past 5 years (2015-2020), with no reviews investigating the different patient engagement methods in TJA. The primary purpose of this review is to examine patient engagement methods in TJA. The search identified 31 studies aimed at patient engagement methods in TJA. Based on our review, the conclusions therein strongly suggest that patient engagement methods in TJA demonstrate benefits throughout care delivery through tools focused on promoting involvement in decision making and accessible care delivery (eg, virtual rehabilitation, remote monitoring). Future work should understand the influence of social determinants on patient involvement in care, and overall cost (or savings) of engagement methods to patients and society.
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http://dx.doi.org/10.1177/23743735211036525DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8381413PMC
August 2021

The accuracy of patient-reported weight prior to total joint arthroplasty and arthroscopy of the lower extremity.

Arch Orthop Trauma Surg 2021 Jul 31. Epub 2021 Jul 31.

Department of Orthopaedic Surgery, Center for Hip Preservation, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA.

Purpose: The accuracy of preoperative patient-reported weight was never evaluated in patients undergoing lower extremity procedures. The purpose of this study was to: (1) compare the disparity between patient-reported and measured weights in patients undergoing lower extremity total joint arthroplasty (LE-TJA) and arthroscopy; and (2) investigate the association between patient-specific factors (patient age, BMI, zip code, and psychiatric comorbidities) and the accuracy of patient-reported weight.

Methods: Preoperative self-reported weights were retrospectively compared to measured weights in 400 LE-TJA and 85 control arthroscopy patients. The difference between reported and measured weights was calculated. Additionally, the percent of accurate reporting within 0.5, 1, and 5 kg ranges of the measured weight was calculated. Outcomes were compared between surgical modalities as well as between patient-specific factors.

Results: There was low disparity (p = 0.838) between patient-reported and measured weights among LE-TJA (mean difference 0.18 ± 3.63 kg; p = 0.446) and that of arthroscopy (0.27 ± 4.08 kg; p = 0.129) patients. Additionally, LE-TJA patients were equally likely to report weights accurately within 0.5 kg of the measured weight (74% vs. 71.76%; p = 0.908). LE-TJA and arthroscopy patients had similar reporting accuracy within 1 and 5 kg of the measured weights (p > 0.05).

Conclusion: Preoperative patient-reported weights demonstrated acceptable accuracy in both LE-TJA and lower extremity arthroscopic orthopaedic patient populations making it a potentially reliable parameter of preoperative assessment.
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http://dx.doi.org/10.1007/s00402-021-04095-5DOI Listing
July 2021

Venture Capital Investment in Orthopaedics: Has the Landscape Changed over the Past Two Decades (2000-2019)?

Surg Innov 2021 Jul 9:15533506211031072. Epub 2021 Jul 9.

Department of Orthopaedic Surgery, 2569Cleveland Clinic Foundation, Cleveland, OH, USA.

. Innovations in orthopaedic technologies often require significant funding. Although an increasing trend has been observed for third-party investments in other medical fields, no study has examined the influence of venture capital (VC) funding in orthopaedics. Therefore, this study analyzed trends in VC investments related to the field of orthopaedic surgery, as well as the characteristics of recipients of these investments. . Venture capital investments into orthopaedic-related businesses were reviewed from 2000 to 2019 using Capital IQ, a proprietary intelligence platform documenting financial investments. Metrics categorized were investments by year, investment amount, and subspecialty domain as per the American Academy Orthopaedic Surgeons website. The compound annual growth rate (CAGR) for both quantity and dollar amount of investments was calculated over the study period and the two decade-long periods (2000-2009 and 2010-2019). . Over two decades, 673 VC investments took place, involving a total of US$3.5 billion. Both the number and dollar value of investments were greater in the second decade (440, US$1.9 billion), compared to the first decade (233, US$1.6 billion). Both quantity and dollar amount of VC investments grew over the first decade, with a CAGR 9.53% and 4.97%, respectively. However, investment growth declined in the latter decade. The largest and most frequent investments took place within spine surgery and adult reconstruction. . An initially rising trend in VC investment in orthopaedic-related businesses may have plateaued over the past decade. These findings may have important implications for continued investment into orthopaedic innovations and collaboration between the surgical community and private sector.
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http://dx.doi.org/10.1177/15533506211031072DOI Listing
July 2021

Considerations for Reducing Bias While Addressing Racial/Ethnic Disparities in Academic Surgery.

JAMA Surg 2021 Jun 30. Epub 2021 Jun 30.

Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.

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http://dx.doi.org/10.1001/jamasurg.2021.2325DOI Listing
June 2021

Robotic Arm-Assisted versus Manual Total Knee Arthroplasty: A Propensity Score-Matched Analysis.

J Knee Surg 2021 Jun 29. Epub 2021 Jun 29.

Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio.

The purpose of this study was to compare (1) operative time, (2) in-hospital pain scores, (3) opioid medication use, (4) length of stay (LOS), (5) discharge disposition at 90-day postoperative, (6) range of motion (ROM), (7) number of physical therapy (PT) visits, (8) emergency department (ED) visits, (9) readmissions, (10) reoperations, (11) complications, and (12) 1-year patient-reported outcome measures (PROMs) in propensity matched patient cohorts who underwent robotic arm-assisted (RA) versus manual total knee arthroplasty (TKA). Using a prospectively collected institutional database, patients who underwent RA- and manual TKA were the nearest neighbor propensity score matched 3:1 (255 manual TKA:85 RA-TKA), accounting for various preoperative characteristics. Data were compared using analysis of variance (ANOVA), Kruskal-Wallis, Pearson's Chi-squared, and Fisher's exact tests, when appropriate. Postoperative pain scores, opioid use, ED visits, readmissions, and 1-year PROMs were similar between the cohorts. Manual TKA patients achieved higher maximum flexion ROM (120.3 ± 9.9 versus 117.8 ± 10.2,  = 0.043) with no statistical differences in other ROM parameters. Manual TKA had shorter operative time (105 vs.113 minutes,  < 0.001), and fewer PT visits (median [interquartile range] = 10.0 [8.0-13.0] vs. 11.5 [9.5-15.5] visits,  = 0.014). RA-TKA had shorter LOS (0.48 ± 0.59 vs.1.2 ± 0.59 days,  < 0.001) and higher proportion of home discharges ( < 0.001). RA-TKA and manual TKA had similar postoperative complications and 1-year PROMs. Although RA-TKA patients had longer operative times, they had shorter LOS and higher propensity for home discharge. In an era of value-based care models and the steady shift to outpatient TKA, these trends need to be explored further. Long-term and randomized controlled studies may help determine potential added value of RA-TKA versus manual TKA. This study reflects level of evidence III.
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http://dx.doi.org/10.1055/s-0041-1731323DOI Listing
June 2021

Patient-specific high tibial osteotomy for varus malalignment: 3D-printed plating technique and review of the literature.

Eur J Orthop Surg Traumatol 2021 Jun 20. Epub 2021 Jun 20.

Department of Orthopaedic Surgery, Center for Hip Preservation, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.

Purpose: We report our experience with a 3D patient-specific instrument (PSI) in an opening-wedge tibial osteotomy for the correction of varus malalignment in a patient with prior anterior cruciate ligament reconstruction. Previous studies have not reported the use of 3D PSI in patients with prior knee surgeries.

Methods: A pre-operative CT was used to create a 3D model of the lower extremity using Bodycad Imager. The pre-operative medial proximal tibial angle (MPTA), lateral distal femoral ankle, hip-knee-ankle (HKA), and tibial slope were calculated. The Bodycad Osteotomy software package was used to create a simulated osteotomy and correction. The resulting 3D patient-specific surgical guide and plate were used to conduct the high tibial osteotomy. Radiographic measurements and range of motion were evaluated at 6-week follow-up.

Results: The arthroscopy and open portions of the procedure were performed in 65 min, with only three fluoroscopy shots taken intraoperatively. At 6-week follow-up, the patient had 125° of flexion and minimal pain. The angular correction of the bone was achieved within 1.9° (planned MPTA 91.9° vs. actual 90°); the HKA angle was achieved with an error of 0.7° (planned 2.4° vs. actual 1.7°); and there was no change in the posterior tibial slope (planned 13.5° vs 13.8° actual).

Conclusion: Three-dimensional PSI can be successfully used for the accurate and efficient correction of varus malalignment while accommodating pre-existing hardware, with good short-term clinical outcomes.
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http://dx.doi.org/10.1007/s00590-021-03043-8DOI Listing
June 2021

Improved accuracy and reproducibility of a novel CT-free robotic surgical assistant for medial unicompartmental knee arthroplasty compared to conventional instrumentation: a cadaveric study.

Knee Surg Sports Traumatol Arthrosc 2021 Jun 13. Epub 2021 Jun 13.

Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, 44113, USA.

Purpose: Alignment errors in medial unicompartmental knee arthroplasty (UKA) predispose to premature implant loosening and polyethylene wear. The purpose of this study was to determine whether a novel CT-free robotic surgical assistant improves the accuracy and reproducibility of bone resections in UKA compared to conventional manual instrumentation.

Methods: Sixty matched cadaveric limbs received medial UKA with either the ROSA Partial Knee System or conventional instrumentation. Fifteen board-certified orthopaedic surgeons with no prior experience with this robotic application performed the procedures with the same implant system. Bone resection angles in the coronal, sagittal and transverse planes were determined using optical navigation while resection depth was obtained using calliper measurements. Group comparison was performed using Student's t test (mean absolute error), F test (variance) and Fisher's exact test (% within a value), with significance at p < 0.05.

Results: Compared to conventional instrumentation, the accuracy of bone resections with CT-free robotic assistance was significantly improved for all bone resection parameters (p < 0.05), other than distal femoral resection depth, which did not differ significantly. Moreover, the variance was significantly lower (i.e. fewer chances of outliers) for five of seven parameters in the robotic group (p < 0.05). All values in the robotic group had a higher percentage of cases within 2° and 3° of the intraoperative plan. No re-cuts of the proximal tibia were required in the robotic group compared with 40% of cases in the conventional group.

Conclusion: The ROSA Partial Knee System was significantly more accurate, with fewer outliers, compared to conventional instrumentation. The data reported in our current study are comparable to other semiautonomous robotic devices and support the use of this robotic technology for medial UKA.

Level Of Evidence: Cadaveric study, Level V.
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http://dx.doi.org/10.1007/s00167-021-06626-4DOI Listing
June 2021

A Work in Progress: National Opioid Prescription Reductions Across Orthopaedic Subspecialties in a Contemporary Medicare Sample of 5,026,911 Claims.

J Am Acad Orthop Surg Glob Res Rev 2021 05 20;5(5). Epub 2021 May 20.

From the Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH (Acuña, Jella, Dr. Samuel, Cwalina, Dr. Kamath), and the Department of Orthopaedic Surgery, Sutter Health-Burlingame Center, Burlingame, CA (Dr. Kim).

Introduction: As the opioid epidemic continues in the United States, efforts by orthopaedic surgeons to reduce opioid prescriptions remain critical. Although previous studies have demonstrated reductions in prescriptions across surgical specialties, there is limited information regarding contemporary trends in opioid prescriptions across orthopaedic subspecialties. Our analysis sought to estimate the frequency and trends of opioid prescriptions among Medicare Part D enrollees.

Methods: The Medicare Provider Utilization and Payment Data: Part D Prescriber Public Use Files from Centers of Medicare and Medicare from 2014 to 2018 were analyzed. These data were merged with the National Provider Identifier Registry to identify the subspecialty of providers. Prescriber opioid prescription rate, days per claim, and claims per patient were calculated. Temporal trends were tested using linear regression. Poisson regression was used to calculate annual adjusted incidence rate ratios while controlling for year, surgeon sex, average patient comorbidity risk score, and average patient age.

Results: We analyzed 5,026,911 opioid claims prescribed to 2,661,762 beneficiaries. Among all orthopaedic surgeons, the opioid prescription rate per 100 beneficiaries significantly decreased over the study period from 52.99 (95% CI, 52.6 to 53.37) to 44.50 (44.06 to 44.93) (P = 0.002). This decrease was observed for each subspecialty (all P values < 0.05). Similar significant reductions were appreciated across cohorts in the number of claims per beneficiary (all P values < 0.05). The opioid prescription rate among all orthopaedic surgeons and each subspecialty decreased significantly over the study period after controlling for various patient and surgeon characteristics (all P values < 0.05).

Conclusion: Orthopaedic surgeons across subspecialties have reduced their rates of opioid prescriptions over recent years. Although increased prescription-limiting legislation, alternative methods of pain control, and prescriber reeducation regarding the correct quantity of opioids needed for postoperative pain relief, ongoing research, and efforts are needed to translate these reductions into clinically meaningful changes.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-21-00080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8140777PMC
May 2021

Preoperative Albumin, Transferrin, and Total Lymphocyte Count as Risk Markers for Postoperative Complications After Total Joint Arthroplasty: A Systematic Review.

J Am Acad Orthop Surg Glob Res Rev 2020 09;4(9):e19.00057

From the Howard University College of Medicine (Dr. Mbagwu), Washington, DC; the Mount Sinai Hospital (Dr. Mbagwu), New York City, NY; the Department of Orthopaedic Surgery (Dr. Sloan, Dr. Charette, Dr. Kamath, Dr. Nelson), University of Pennsylvania; the Department of Surgery (Dr. Sloan, Dr. Charette, Dr. Nelson), University of Pennsylvania, Philadelphia, PA; the Department of Orthopaedic Surgery (Dr. Neuwirth), Columbia University Medical Center, New York City, NY; the Division of Orthopaedic Surgery (Dr. Baldwin), Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA; the Orthopaedic and Rheumatologic Institute (Dr. Kamath), Cleveland Clinic, Cleveland, OH; the Nth Dimensions, Chicago, IL, (Dr. Mason); the University of Louisville School of Medicine (Dr. Mason), Louisville, KY; and the University of Texas Medical Branch (Dr. Mason), Galveston, TX.

Introduction: The purpose of this systematic review is to identify whether poor nutrition, as defined by the more commonly used markers of low albumin, low transferrin, or low total lymphocyte count (TLC), leads to more postoperative complications. We hypothesized that it may be possible to identify the levels of these laboratory values at which point total joint arthroplasty (TJA) may be ill advised. To this end, we analyzed the available literature regarding links between these three variables on postoperative complications after TJA.

Methods: This systematic review was done in two parts: (1) In the first part, we reviewed the most commonly used malnutrition marker, albumin. (2) In the second part, we reviewed TLC and transferrin. We accessed PubMed, EMBASE, and Cochrane Library using relevant keywords to this study. The biostatistics were visualized using a random-effects forest plot. We compared data from all articles with sufficient data on patients with complications (ie, cases) and patients without complications (ie, noncases) among the two groups, malnourished and normal nutrition, from albumin, transferrin, and TLC data.

Results: A meta-analysis of seven large-scale articles detailing the complications of albumin led to an all-cause relative risk increase of 1.93 when operating with hypoalbuminemia. This means that in the studies detailed enough to incorporate in this pooled analysis, operating on elective TJAs with low albumin is associated with a 93% increase in all measured complications. In the largest studies, analysis of transferrin levels for the most common complications revealed a relative risk increase of 2.52 when operating on patients with low transferrin levels. There were not enough subjects to do a biostatistical analysis in articles using TLC as the definition of malnutrition.

Conclusion: The focus is on the trends rather than absolutes. As shown in Table 1, whether the albumin cutoff for albumin was 3.0 g/dL, 3.5 g/dL, or 3.9 g/dL, the trend remains the same. Because low albumin before TJAs tends to increase complications, it is recommended to incorporate albumin levels in preoperative workups. Many patients with hip and knee arthritis undergo months of conservative management (eg, physical therapy and corticosteroid injections) before considering surgery, and it would be wise to optimize their nutritional status in this period to minimize the risk of perioperative complications. The physician should use these data to provide informed consent of the increased risk to patients planning to undergo TJAs with elevated malnutrition markers. Because this research is retrospective in nature, albumin should be studied prospectively in hypoalbuminemic and normoalbuminemic patients and their postoperative outcomes should be measured. Regarding transferrin and TLC, future research should help elucidate their predictive value and determine the value of preoperatively optimizing them and their effect in mitigating postoperative complications.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-19-00057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478613PMC
September 2020

Good Morning, Orthopods: The Growth and Future Implications of Podcasts in Orthopaedic Surgery.

J Bone Joint Surg Am 2021 05;103(9):840-847

Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.

Background: As the landscape of medical education evolves with emerging technologies and the COVID-19 pandemic, e-learning platforms continue to gain popularity. Orthopaedic podcasts, a burgeoning e-learning platform, continue to gain traction; however, there is a paucity of information regarding their coverage of topics and their distribution over time. Therefore, our analysis sought to (1) characterize podcast content related to orthopaedic surgery, and (2) evaluate the changes in the prevalence of orthopaedic podcasts over the past 15 years.

Methods: Three common podcasting platforms (Apple Podcasts, Google Podcasts, and Spotify) were queried using the key terms "orthopaedic," "orthopedic," and "ortho" in order to identify a list of podcasts that are related to orthopaedic surgery. For each unique orthopaedic podcast, the title, the show description, the number of episodes, the date of the first episode, the date of the most recent episode, and episode frequency were collected. Podcasts were then classified based on a predetermined list of podcast domains. The number of existing active (released within the last 3 months) orthopaedic podcasts was then trended on a monthly basis from 2011 to 2020.

Results: Ninety-four unique podcasts met inclusion criteria, 62 of which remained active as of October 25, 2020. The most common podcast domains were "general" (38 [40.4%]) and "clinical knowledge" (20 [21.3%]). Among the assessed podcasts, 90 (95.7%) utilized an exclusively audio format. The majority of podcasts were based in the United States (89.4%), included introductory music (72.3%), and included interviews (63.8%). Most podcast hosts were practicing orthopaedic surgeons (52.1%). Between January 2016 and October 2020, the number of active orthopaedic surgery podcasts grew more than twelvefold (1,240%) at an average rate of roughly 1 new podcast each month (average, 1.0 podcast; standard deviation, 1.8).

Discussion: The past decade has seen sizable growth in the number of readily available podcasts related to orthopaedic surgery. Additional research is required to independently assess the quality of these resources and their implications for remote trainee education.
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http://dx.doi.org/10.2106/JBJS.20.01598DOI Listing
May 2021

How Long Will It Take to Reach Gender Parity in Orthopaedic Surgery in the United States? An Analysis of the National Provider Identifier Registry.

Clin Orthop Relat Res 2021 06;479(6):1179-1189

A. J. Acuña, T. K. Jella, L. T. Samuel, S. H. Jeong, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.

Background: Although previous studies have evaluated how the proportion of women in orthopaedic surgery has changed over time, these analyses have been limited by small sample sizes, have primarily used data on residents, and have not included information on growth across subspecialties and geographic regions.

Question/purpose: We used the National Provider Identifier registry to ask: How have the (1) overall, (2) regional, and (3) subspecialty percentages of women among all currently practicing orthopaedic providers changed over time in the United States?

Methods: The National Provider Identifier Registry of the Centers for Medicare and Medicaid Services (CMS) was queried for all active providers with taxonomy codes pertaining to orthopaedic subspecialties as of April 2020. Women orthopaedic surgeons were identified among all physicians with subspecialty taxonomy codes. As all providers are required to provide a gender when applying for an NPI, all providers with queried taxonomy codes additionally had gender classification. Our final cohort consisted of 31,296 practicing orthopaedic surgeons, of whom 8% (2363 of 31,296) were women. A total of 11,714 (37%) surgeons possessed taxonomy codes corresponding with a specific orthopaedic subspecialty. A univariate linear regression analysis was used to analyze trends in the annual proportions of women who are active orthopaedic surgeons based on NPI enumeration dates. Specifically, annual proportions were defined using cross-sections of the NPI registry on December 31 of each year. Linear regression was similarly used to evaluate changes in the annual proportion of women orthopaedic surgeons across United States Census regions and divisions, as well as orthopaedic subspecialties. The national growth rate was then projected forward to determine the year at which the representation of women orthopaedic surgeons would achieve parity with the proportion of all women physicians (36.3% or 340,018 of 936,254, as determined by the 2019 American Medical Association Physician Masterfile) and the proportion of all women in the United States (50.8% or 166,650,550 of 328,239,523 as determined by 2019 American Community Survey from the United States Census Bureau). Gender parity projections along with corresponding 95% confidence intervals were calculated using the Holt-Winters forecasting algorithm. The proportions of women physicians and women in the United States were assumed to remain fixed at 2019 values of 36.3% and 50.8%, respectively.

Results: There was a national increase in the proportion of women orthopaedic surgeons between 2010 and 2019 (r2 = 0.98; p < 0.001) at a compound annual growth rate of 2%. Specifically, the national proportion of orthopaedic surgeons who were women increased from 6% (1670 of 26,186) to 8% (2350 of 30,647). Assuming constant growth at this rate following 2019, the time to achieve gender parity with the overall medical profession (that is, to achieve 36.3% women in orthopaedic surgery) is projected to be 217 years, or by the year 2236. Likewise, the time to achieve gender parity with the overall US population (which is 50.8% women) is projected to be 326 years, or by the year 2354. During our study period, there were increases in the proportion of women orthopaedic surgeons across US Census regions. The lowest growth was in the West (17%) and the South (19%). Similar growth was demonstrated across census divisions. In each orthopaedic subspecialty, we found increases in the proportion of women surgeons throughout the study period. Adult reconstruction (0%) and spine surgery (1%) had the lowest growth.

Conclusion: We calculate that at the current rate of change, it will take more than 200 years for orthopaedic surgery to achieve gender parity with the overall medical profession. Although some regions and subspecialties have grown at comparably higher rates, collectively, there has been minimal growth across all domains.

Clinical Relevance: Given this meager growth, we believe that substantive changes must be made across all levels of orthopaedic education and leadership to steepen the current curve. These include mandating that all medical school curricula include dedicated exposure to orthopaedic surgery to increase the number of women coming through the orthopaedic pipeline. Additionally, we believe the Accreditation Council for Graduate Medical Education and individual programs should require specific benchmarks for the proportion of orthopaedic faculty and fellowship program directors, as well as for the proportion of incoming trainees, who are women. Furthermore, we believe there should be a national effort led by American Academy of Orthopaedic Surgeons and orthopaedic subspecialty societies to foster the academic development of women in orthopaedic surgery while recruiting more women into leadership positions. Future analyses should evaluate the efficacy of diversity efforts among other surgical specialties that have achieved or made greater strides toward gender parity, as well as how these programs can be implemented into orthopaedic surgery.
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http://dx.doi.org/10.1097/CORR.0000000000001724DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8133193PMC
June 2021

Operative times in primary total hip arthroplasty will remain stable up to the year 2027: prediction models based on 85,808 cases.

Eur J Orthop Surg Traumatol 2021 Mar 30. Epub 2021 Mar 30.

Center for Hip Preservation, Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic, 9500 Euclid Avenue, Mailcode A41, Cleveland, OH, 44195, USA.

Purpose: Recently, the Centers for Medicare and Medicaid have announced the decision to review "potentially misvalued" Current Procedural Terminology codes, including those for primary total hip arthroplasty (THA). While recent studies have suggested that THA operative times have remained stable in recent years, there is an absence of information regarding how operative times are expected to change in the future. Therefore, the purpose of our analysis was to produce 2- and 10-year prediction models developed from contemporary operative time data.

Methods: Utilizing the American College of Surgeons National Surgical Quality Improvement patient database, all primary THA procedures performed between January 1st, 2008 and December 31st, 2017 were identified (n = 85,808 THA patients). Autocorrelation fit significance was determined through Box-Ljung lack of fit tests. Time series stationarity was evaluated using augmented Dickey-Fuller tests. After adjusting non-stationary time series for seasonality-dependent changes, 2-year and 10-year operative times were predicted using Autoregressive integrated moving average forecasting models.

Results: Our models indicate that operative time will continue to remain stable. Specifically, operative time for ASA Class 2 is projected to fall within 1 min of the previously calculated weighted mean. Additionally, ASA Class 3 projections fall within 3 min of this value.

Conclusion: Operative time will remain within 3 min of the most recently reported mean up to the year 2027. Therefore, our findings do not support lowering physician compensation based on this metric. Future analyses should evaluate if operative times adjust over in light of changing patient demographics and alternative reimbursement models.
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http://dx.doi.org/10.1007/s00590-021-02949-7DOI Listing
March 2021

Inflation-Adjusted Medicare Reimbursement for Revision Hip Arthroplasty: Study Showing Significant Decrease from 2002 to 2019.

J Bone Joint Surg Am 2021 Jul;103(13):1212-1219

Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.

Background: Investigations into reimbursement trends for primary and revision arthroplasty procedures have demonstrated a steady decline over the past several years. Revision total hip arthroplasty (rTHA) due to infection (rTHA-I) has been associated with higher resource utilization and complexity, but long-term inflation-adjusted data have yet to be compared between rTHA-I and rTHA due to aseptic complications (rTHA-A). The present study was performed to analyze temporal reimbursement trends regarding rTHA-I procedures compared with those for rTHA-A procedures.

Methods: The Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule Look-Up Tool was used to extract Medicare reimbursements associated with 1-stage and 2-stage rTHA-I as well as 1-stage rTHA-A procedures from 2002 to 2019. Current Procedural Terminology (CPT) codes for rTHA were grouped according to the American Academy of Orthopaedic Surgeons coding reference guide. Monetary values were adjusted for inflation using the consumer price index (U.S. Bureau of Labor Statistics; reported as 2019 U.S. dollars) and used to calculate the cumulative and average annual percent changes in reimbursement.

Results: Following inflation adjustment, the physician fee reimbursement for rTHA-A decreased by a mean [and standard deviation] of 27.26% ± 3.57% (from $2,209.11 in 2002 to $1,603.20 in 2019) for femoral component revision, 27.41% ± 3.57% (from $2,130.55 to $1,542.91) for acetabular component revision, and 27.50% ± 2.56% (from $2,775.53 to $2,007.61) for both-component revision. Similarly, for a 2-stage rTHA-I, the mean reimbursement declined by 18.74% ± 3.87% (from $2,063.36 in 2002 to $1,673.36 in 2019) and 24.45% ± 3.69% (from $2,328.79 to $1,755.45) for the explantation and reimplantation stages, respectively. The total decline in physician fee reimbursement for rTHA-I ($1,020.64 ± $233.72) was significantly greater than that for rTHA-A ($580.72 ± $107.22; p < 0.00001).

Conclusions: Our study demonstrated a consistent devaluation of both rTHA-I and rTHA-A procedures from 2002 to 2019, with a larger deficit seen for rTHA-I. A continuation of this trend could create substantial disincentives for physicians to perform such procedures and limit access to care at the population level.

Level Of Evidence: Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.
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July 2021

No clinically meaningful difference in 1-year patient-reported outcomes among major approaches for primary total hip arthroplasty.

Hip Int 2021 Mar 7:1120700021992013. Epub 2021 Mar 7.

Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA.

Background: Debate continues around the most effective surgical approach for primary total hip arthroplasty (THA). This study's purpose was to compare 1-year patient-reported outcome measures (PROMs) of patients who underwent direct anterior (DA), transgluteal anterolateral (AL)/direct lateral (DL), and posterolateral (PL) approaches.

Methods: A prospective consecutive series of primary THA for osteoarthritis ( = 2,390) were performed at 5 sites within a single institution with standardised care pathways (20 surgeons). Patients were categorised by approach: DA ( = 913; 38%), AL/DL ( = 505; 21%), or PL ( = 972; 41%). Primary outcomes were pain, function, and activity assessed by 1-year postoperative PROMs. Multivariable regression modeling was used to control for differences among the groups. Wald tests were performed to test the significance of select patient factors and simultaneous 95% confidence intervals were constructed.

Results: At 1-year postoperative, PROMs were successfully collected from 1842 (77.1%) patients. Approach was a statistically significant factor for 1-year HOOS pain ( = 0.002). Approach was not a significant factor for 1-year HOOS-PS ( = 0.16) or 1-year UCLA activity ( = 0.382). Pairwise comparisons showed no significant difference in 1-year HOOS pain scores between DA and PL approach (  0.05). AL/DL approach had lower (worse) pain scores than DA or PL approaches with differences in adjusted median score of 3.47 and 2.43, respectively (  0.05).

Conclusions: Patients receiving the AL/DL approach had a small statistical difference in pain scores at 1 year, but no clinically meaningful differences in pain, activity, or function exist at 1-year postoperative.
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March 2021

Metal ion levels with use of modular dual mobility constructs: Can the evidence guide us on clinical use?

J Orthop 2021 Mar-Apr;24:91-95. Epub 2021 Feb 20.

Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA.

Introduction: Dual mobility (DM) use in total hip arthroplasty (THA) has increased, particularly for prevention and management of instability. However, a modular interface raises concern for metal ion generation. The purpose of this study was to determine the 1) serum cobalt and chromium levels; 2) prevalence of ion levels >1 mcg/L; and 3) effect of femoral head material on ion levels following THA using modular DM bearings.

Methods: We performed a systematic review (MEDLINE, Embase, Cochrane databases) for articles relating to metal ion levels and modular DM (MDM) THA. Eight studies (290 patients) met the inclusion criteria. We recorded post-operative ion levels at a minimum of 12 months, and compared levels with ceramic (n = 125) and metal femoral heads (n = 165). A meta-analysis could not be performed due to poor study quality and heterogeneity.

Results: At average follow-up of 30.4 months, mean cobalt level was 0.71 mcg/L, and mean chromium level was 0.66 mcg/L [22 patients (8%) had elevated ion levels above 1 mcg/L]. When compared to MDM with a ceramic head, metal head use had higher cobalt (1.26 vs. 0.42 mcg/L) and chromium levels (1.23 vs. 0.46 mcg/L). MDM with a metal head was 1.30 times more likely to have elevated ion levels >1 mcg/L. There was no effect of ion levels on outcome scores.

Conclusions: Measurable elevations of serum cobalt and chromium levels are present in patients with well-functioning MDM THAs. The impact and contributions of the additional metal liner interface are still unclear. The use of a ceramic head appears to mitigate ion release, while reducing other mechanisms of metallosis like taper corrosion. Higher quality studies are necessary to understand whether MDM bearings pose long term issues. Until then, the judicious use of MDM articulations is recommended.
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http://dx.doi.org/10.1016/j.jor.2021.02.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910403PMC
February 2021

Contemporary Outpatient Arthroplasty Is Safe Compared with Inpatient Surgery: A Propensity Score-Matched Analysis of 574,375 Procedures.

J Bone Joint Surg Am 2021 04;103(7):593-600

Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio.

Background: Outpatient joint arthroplasty is a potential modality for increased case throughput and is rising in demand. However, we are aware of no study that has compared outcomes between risk-matched outpatient and inpatient procedures within the last 7 years. The aims of this study were to compare matched patient cohorts who underwent outpatient or inpatient joint arthroplasty in terms of 30-day adverse events and readmission rates.

Methods: From the National Surgical Quality Improvement Program database, we identified patients who underwent primary total hip arthroplasty (THA), primary total knee arthroplasty (TKA), and primary unicompartmental knee arthroplasty (UKA) from 2009 to 2018. Using 10 perioperative variables, patients who underwent an outpatient procedure were 1:4 propensity score-matched with patients who underwent an inpatient procedure. The rates of 30-day adverse events and readmission were compared using the McNemar test. The risk factors for adverse events and readmissions were identified using multivariate regression.

Results: Of 574,375 patients identified, 21,506 (3.74%) underwent an outpatient procedure. After propensity score matching, an outpatient joint arthroplasty was associated with a lower rate of adverse events (3.18% compared with 7.45%; p < 0.001). When assessed individually, outpatient TKA (3.15% compared with 8.11%; p < 0.001), THA (4.94% compared with 10.05%; p < 0.001), and UKA (1.78% compared with 3.39%; p < 0.001) were all associated with fewer adverse events overall and there was no difference in the rate of 30-day readmission, when compared with inpatient analogs. Outpatient joint arthroplasty was an independent factor for lower adverse events (odds ratio [OR], 0.407 [95% confidence interval (CI), 0.369 to 0.449]; p < 0.001), with no increase in the risk of readmission (OR, 1.004 [95% CI, 0.878 to 1.148]; p = 0.951).

Conclusions: Contemporary outpatient joint arthroplasty demonstrated lower rates of adverse events with no increased rate of 30-day readmission when compared with risk-matched inpatient counterparts. Although multiple factors should guide the decision for the site of care, outpatient arthroplasty may be a safe alternative to inpatient arthroplasty.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.01307DOI Listing
April 2021

Outcome measures in total hip arthroplasty: have our metrics changed over 15 years?

Arch Orthop Trauma Surg 2021 Feb 11. Epub 2021 Feb 11.

Department of Orthopaedic Surgery, Center for Hip Preservation, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue Mail Code A40, Cleveland, OH, 44195, USA.

Introduction: Consensus has not been reached regarding ideal outcome measures for total hip arthroplasty (THA) clinical evaluation and research. The goal of this review was to analyze the trends in outcome metrics within the THA literature and to discuss the potential impact of instrument heterogeneity on clinical practice.

Materials And Methods: A PubMed search of all manuscripts related to THA from January 2005 to December 2019 was performed. Statistical and linear regression analyses were performed for individual outcome metrics as a proportion of total THA publications over time.

Results: There was a statistically significant increase in studies utilizing outcomes metrics between 2005 and 2019 (15.1-29.5%; P < 0.001; R = 98.1%). Within the joint-specific subcategory, use of the Harris Hip Score (HHS) significantly decreased from 2005 to 2019 (82.8-57.3%; P < 0.001), use of the Hip Disability and Osteoarthritis Outcome Score (HOOS) significantly increased (0-6.7%; P < 0.001), and the modified HHS significantly increased (0-10.5%; P < 0.001). In the quality of life subcategory, EQ-5D demonstrated a significant increase in usage (0-34.8%; P < 0.001), while Short Form-36 significantly decreased (100% vs. 27.3%; P = 0.008).

Conclusions: The utilization of outcome-reporting metrics in THA has continued to increase, resulting in added complexity within the literature. The utilization rates of individual instruments have shifted over the past 15 years. Additional study is required to determine which specific instruments are recommended.
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February 2021

Demographic, Comorbidity, and Episode-of-Care Differences in Primary Total Knee Arthroplasty.

J Bone Joint Surg Am 2021 Feb;103(3):227-234

Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio.

Background: Understanding time trends in age, demographic characteristics, and comorbidities is especially critical to highlight the effects on clinical practice change, outcomes, and the value of total knee arthroplasty (TKA). Therefore, the purpose of this study was to identify trends in the demographic characteristics, comorbidities, and episode-of-care outcomes for patients who underwent TKA from 2008 to 2018.

Methods: The National Surgical Quality Improvement Program (NSQIP) was queried to identify patient demographic characteristics, comorbidities, and episode-of-care outcomes in patients who underwent primary TKA from 2008 to 2018 (n = 350,879). Trends for continuous variables were analyzed using analysis of variance, and categorical variables were analyzed using chi-square tests.

Results: From 2008 to 2018, there was no clinically important difference in age, body mass index (BMI), and percentage of patients with BMI of >40 kg/m2 and no clinically important difference in chronic obstructive pulmonary disease (3.5% in 2008 and 3.2% in 2018), congestive heart failure within 30 days (0.3% in both 2008 and 2018), and acute renal failure (0.1% in 2008 and <0.1% in 2018) among patients undergoing TKA. However, modifiable comorbidities, including smoking status (9.5% in 2008 and 7.7% in 2018; p < 0.001), hypertension (71.0% in 2008 and 63.7% in 2018; p < 0.001), and anemia (16.2% in 2008 and 9.7% in 2018; p < 0.001), functional status, and overall morbidity and mortality probability have improved, with no clinically important difference in the percentage of diabetes (19.0% in 2008 and 18.1% in 2018). The hospital length of stay (mean [and standard deviation], 3.8 ± 2.2 days in 2008 and 2.1 ± 2.0 days in 2018; p < 0.001) and 30-day readmission (4.6% in 2011 and 3.0% in 2018; p < 0.001) decreased, with a significant increase in home discharge (65.6% in 2011 and 87.8% in 2018; p < 0.001).

Conclusions: The overall patient health status improved from 2008 to 2018, with improvement in the modifiable comorbidities of smoking status, malnutrition, hypertension, and anemia; the functional status; and the overall morbidity and mortality probability, with no clinically relevant change in patient age; patient BMI; percentage of patients with BMI of >40 kg/m2; or patients with diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure within 30 days, or acute renal failure. Our findings may be a reflection of a global shift toward value-based care focusing on patient optimization prior to arthroplasty, quality of care, and improved outcomes. The results of our study highlight the potential increase in TKA procedural value, which is paramount for health-care policy changes in today's incentivized, value-based, health-care environment.
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http://dx.doi.org/10.2106/JBJS.20.00597DOI Listing
February 2021

Dual Mobility Reduces Dislocations-Why I Use It in All Revisions.

J Arthroplasty 2021 07 13;36(7S):S63-S69. Epub 2021 Jan 13.

Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA.

Background: Instability remains the most common complication after revision total hip arthroplasty (THA) and presents a unique treatment dilemma for the orthopedic surgeon. Dual mobility (DM) bearing articulations have been used in France since the 1970s, but have only become more widely adopted in the United States over the last decade. The purpose of this symposium was to discuss the role for DM bearings in revision THA.

Methods: We reviewed the existing literature on outcomes after DM bearing articulations in revision THA. We also report several case examples of the use of DM in difficult revision THA cases, including acetabular bone loss, failed constrained liner, and adverse local tissue reaction. Finally, we briefly discuss the limitations associated with the use of DM.

Results: Several large retrospective series demonstrate that DM bearings reduce the incidence of dislocation after revision THA when compared with conventional single bearing THA. Specific complications related to DM bearings including polyethylene wear, loosening, intraprosthetic dislocation, and corrosion remain a concern, but appear to have drastically improved over time with modern implant designs.

Conclusion: Contemporary DM designs have been established as an effective bearing option to reduce instability in revision THA, although concerns do exist. High-quality prospective studies are necessary to further define the role this bearing option has in the coming years.
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http://dx.doi.org/10.1016/j.arth.2021.01.005DOI Listing
July 2021

Spine Fusions, Yoga Instructors, and Hip Fractures: The Role of Dual Mobility in Primary Total Hip Arthroplasty.

J Arthroplasty 2021 07 7;36(7S):S70-S79. Epub 2021 Jan 7.

Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.

Background: Despite the increased use of dual mobility (DM) in primary total hip arthroplasty (THA), debate exists regarding the indications for its use. No specific algorithm exists to guide this decision-making process. Therefore, the purpose of this article is to summarize the currently available literature regarding the use of DM in primary THA and provide evidence-based guidelines based on specific patient populations and risk factors for instability.

Methods: We reviewed the current literature for studies evaluating risk factors for dislocation in primary THA, as well as the clinical use and results of DM in primary THA. Based on the strength of the literature, we discuss the use of DM in specific patient populations. We provide a decision-making algorithm to determine whether a patient may be indicated for DM in primary THA.

Results: Surgeons should consider preoperative patient demographics, risk factors for instability (eg, significant hip-spine issues), type of procedure to be performed (eg, conversion arthroplasty), and indications for surgery (eg, THA for femoral neck fracture). Based on this algorithmic assessment, DM may be warranted in the primary THA setting if a patient's combined risk reaches an established threshold based on the literature.

Conclusion: This evidence-based algorithm may help guide current practice in the use of DM in primary THA. We advocate the continued judicious use of DM in hip arthroplasty. Longer term studies are needed in order to evaluate the durability of DM, as well as any complications related to the DM articulation.
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http://dx.doi.org/10.1016/j.arth.2020.12.057DOI Listing
July 2021

Are We Involving Patients in Shared Decision-Making in Young Adult Hip Surgery? A Systematic Review of Patient Engagement Initiatives in Hip Preservation.

J Patient Exp 2020 Dec 21;7(6):920-924. Epub 2020 Sep 21.

Department of Orthopaedic Surgery, Center for Hip Preservation, Cleveland Clinic Foundation, Cleveland, OH, USA.

There are limited published studies on patient engagement, including shared decision-making, in adolescents and young adults with complex congenital or post-traumatic hip disorders. Despite the limited number of papers, we aim to clearly summarize what is currently available in the literature using a systematic review approach. We hope this serves as a call to action and catalyst for more work in this field. Future research must focus on awareness of what matters most to patients (values), and the development, implementation, and barriers to the use of decision aids and patient engagement optimization specific to hip disease in young adults.
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http://dx.doi.org/10.1177/2374373520956870DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786729PMC
December 2020

Surgical Technique for Anterior Approach for Total Hip Arthroplasty After Bilateral Below-Knee Amputation: A Case Report.

JBJS Case Connect 2020 12 24;10(4):e20.00438. Epub 2020 Dec 24.

Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.

Case: We report a case of a 77-year-old man, with bilateral below-knee amputee, in whom the anterior approach (AA) for a left total hip arthroplasty was used successfully, with 3-year follow-up. This report also summarizes the key studies in the literature on this subject.

Conclusions: The utility of AA surgery performed in the setting of bilateral below-knee amputation has not been previously described. We describe the surgical technique, including considerations and pearls in the amputee population, and particular technical tips related to the use of a fracture table and thin-wire femoral traction for optimum control of the residual limb.
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http://dx.doi.org/10.2106/JBJS.CC.20.00438DOI Listing
December 2020

Cementless Fixation in Primary Total Knee Arthroplasty: Historical Perspective to Contemporary Application.

J Am Acad Orthop Surg 2021 04;29(8):e363-e379

From the Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH (Kamath, Siddiqi, Krebs), and the Department of Orthopedic Surgery, University of Louisville, Louisville, KY (Malkani).

Cemented total knee arthroplasty (TKA) has been considered the benchmark, with excellent clinical outcomes and low rates of aseptic loosening at the long-term follow-up. However, alterations of the bone/cement interface leading to aseptic loosening, particularly in younger and obese patients, along with increased life expectancy have led to a renewed interest in noncemented TKA fixation. Certain early noncemented designs exhibited higher rates of subsidence and component failure. Improvements in designs, materials, and surgical technique offer promise for improved results with contemporary noncemented TKA applications. In an increasing cost-conscious healthcare environment, implant cost is important to consider because press-fit prostheses are generally more expensive. However, this cost may be offset by shorter surgical times, cement costs, and the potential for osseous integration. Technological advances have improved the manufacturing of porous metals, with reported excellent midterm survivorship. Future prospective, randomized trials, and registry data are needed to delineate differences between cemented and noncemented fixation, survivorship, and patient-reported outcomes, especially in young, functionally active, and/or obese populations.
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http://dx.doi.org/10.5435/JAAOS-D-20-00569DOI Listing
April 2021

Direct Anterior Approach for Revision Total Hip Arthroplasty: Anatomy and Surgical Technique.

J Am Acad Orthop Surg 2021 Mar;29(5):e217-e231

From the Department of Orthopedics, Cleveland Clinic Foundation, Cleveland, OH (Kamath and Siddiqi), the Hinsdale Orthopaedics, Hinsdale, IL (Alden), and the Norton Orthopedic Institute, Louisville, KY (Yerasimides).

There has been increased interest and literature on the efficacy of direct anterior approach (DAA) for total hip arthroplasty (THA). Developments in surgical technique and instrumentation, along with exposure earlier in orthopaedic residency training, may augment the adoption of this approach among practicing orthopaedic surgeons. With the increasing number of primary THA performed through the DAA, understanding the indications and techniques associated with revision THA via the DAA has proved increasingly important. Patient positioning, understanding surgical anatomy and extensile maneuvers, and applying key reconstructive methods are essential for obtaining adequate exposure and fixation. Acetabular exposure can be facilitated through capsular and soft-tissue release, along with extensile approaches to the pelvis and acetabulum. Extensile distal extension can be performed for safe access to the femur, including extended femoral osteotomies. The purpose of this review is to describe indications, surgical anatomy, intraoperative tips, clinical outcomes, and complications after DAA for revision THA.
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http://dx.doi.org/10.5435/JAAOS-D-20-00334DOI Listing
March 2021

Medicare Physician Fee Reimbursement for Revision Total Knee Arthroplasty Has Not Kept Up with Inflation from 2002 to 2019.

J Bone Joint Surg Am 2021 May;103(9):778-785

Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.

Background: As orthopaedic physician fees continue to come under scrutiny by the U.S. Centers for Medicare & Medicaid Services (CMS), there is a continued need to evaluate trends in reimbursement rates across contemporary time intervals. Although substantially lower work relative value units (RVUs) have been previously demonstrated for septic revision total knee arthroplasty (TKA) compared with aseptic revisions, to our knowledge, there has been no corresponding analysis comparing total physician fees. Therefore, the purpose of our study was to analyze temporal trends in Medicare physician fees for septic and aseptic revision TKAs.

Methods: Current Procedural Terminology (CPT) codes related to septic 1-stage and 2-stage revision TKAs and aseptic revision TKAs were categorized. From 2002 to 2019, the facility rates of physician fees associated with each CPT code were obtained from the CMS Physician Fee Schedule Look-Up Tool. Monetary data from Medicare Administrative Contractors at 85 locations were used to calculate nationally representative means. All total physician fee values were adjusted for inflation and were translated to 2019 U.S. dollars using Consumer Price Index data from the U.S. Bureau of Labor Statistics. Cumulative annual percentage changes and compound annual growth rates (CAGRs) were computed utilizing adjusted physician fee data.

Results: After adjusting for inflation, the total mean Medicare reimbursement (and standard deviation) for aseptic revision TKA decreased 24.83% ± 3.65% for 2-component revision and 24.21% ± 3.68% for 1-component revision. The mean septic revision TKA total Medicare reimbursement declined 23.29% ± 3.73% for explantation and 33.47% ± 3.24% for reimplantation. Both the dollar amount (p < 0.0001) and the percentage (p < 0.0001) of the total Medicare reimbursement decline for septic revision TKA were significantly greater than the decline for aseptic revision TKA.

Conclusions: Septic revision TKAs have been devalued at a rate greater than their aseptic counterparts over the past 2 decades. Coupled with our findings, the increased resource utilization of septic revision TKAs may result in financial barriers for physicians and subsequently may reduce access to care for patients with periprosthetic joint infections.

Clinical Relevance: The devaluation of revision TKAs may result in reduced patient access to infection management at facilities unable to bear the financial burden of these procedures.
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http://dx.doi.org/10.2106/JBJS.20.01034DOI Listing
May 2021

The international normalised ratio predicts perioperative complications in revision total hip arthroplasty.

Hip Int 2020 Dec 3:1120700020973972. Epub 2020 Dec 3.

Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.

Background: Standard preoperative protocols in total joint arthroplasty utilise the international normalised ratio (INR) to determine patient coagulation profiles. However, the relevance of preoperative INR values in joint arthroplasty remains controversial. Therefore, we examined (1) the relationship between preoperative INR values and various outcome measures, including, but not limited to: surgical site complications, medical complications, bleeding, number of readmissions, and mortality. Additionally, we sought to determine (2) specific INR values associated with these complications and (3) cutoff INR levels which correlated with specific outcomes. We additionally applied these analyses to (4) examine the relationship between INR and length-of-stay (LOS).

Methods: The American College of Surgeons National Surgical Quality Improvement Program database (ACS-NSQIP) was queried for rTHA procedures performed between 2006 and 2017. INR ranges were used to stratify cohorts: ⩽1.0, 1.0-⩽1.25, 1.25-⩽1.5, >1.5. INR values were determined using receiver operating characteristics (ROC) curves for each outcome of interest. Optimal cutoff INR values for each outcome were then obtained using univariate/multivariate models. 2012 patients who underwent rTHA met inclusion criteria.

Results: Patients with progressively higher INR values had a significantly different risk of mortality within 30 days ( = 0.005), bleeding requiring transfusion ( 0.001), sepsis ( = 0.002), stroke ( 0.001), failure to wean from ventilator within 48 hours ( = 0.001), readmission ( = 0.01), and hospital length of stay ( < 0.001). Similar results were obtained when utilising optimal INR cutoff values. When correcting for other factors, the following poor outcomes were significantly associated with the respective INR cutoff values (Estimate, 95% CI, value): LOS >4 days (1.67, 1.34-2.08, < 0.001), bleeding requiring transfusion (1.65, 1.30-2.09, < 0.001), sepsis (2.15, 1.11-4.17, = 0.022), and any infection (1.82, 1.01-3.29, = 0.044).

Conclusions: Our analysis illustrates a direct relationship between specific preoperative INR levels and poor outcomes following rTHA, including increased LOS, transfusion requirements and infection. Therefore, current INR guideline targets may need to be re-examined when optimising patients for revision arthroplasty.
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December 2020
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