Publications by authors named "Richard Iorio"

195 Publications

The 2021 Centers for Medicare and Medicaid Services Fee Schedule's Impact on Adult Reconstruction Surgeon Productivity and Reimbursement.

J Arthroplasty 2021 Jun 11. Epub 2021 Jun 11.

Department of Orthopedic Surgery, NYU Langone Health, New York, NY.

Background: On December 20, 2020, the Centers for Medicare and Medicaid Services (CMS) finalized its proposed rule: CMS-1734-P. This 2021 Final Rule significantly changed Medicare total joint arthroplasty (TJA) reimbursement. The precise impact on surgeon productivity and reimbursement is unknown. In the present study, we sought to model the potential impact of these changes for multiple unique practice configurations.

Methods: A mathematical model was applied to CMS data to determine the impact of CMS-1734-F on multiple, theoretical TJA practice configurations. Variables tested were the annual percentage of revision vs primary arthroplasty cases performed and the annual percentage of operative vs office-based productivity. The model defined baseline annual surgeon productivity as the 2018 Medical Group Management Association hip and knee arthroplasty surgeon median productivity of 10,568 work relative value units (wRVUs).

Results: All modeled simulations demonstrated a year-to-year increase in wRVUs independent of practice configuration. However, simulations that demonstrated less than a 3.35% increase in wRVUs from year-to-year saw a decrease in reimbursement. Those simulations with higher wRVU increases tended to have a higher percentage of revision vs primary arthroplasty cases and/or had annual productivity that was derived to a greater extent from office encounters than surgical cases.

Conclusion: The impact of CMS-1734-F will vary based on 3 factors: (1) the relative contribution of a surgeon's operative TJA practice compared with their office-based practice to their annual wRVUs; (2) the relative percentage of revision TJAs vs the percentage of primary TJAs performed; and (3) the relative percentage of primary TJA compared to non-arthroplasty surgeries as a component of overall operative practice. The decreased reimbursement will be disproportionately felt by arthroplasty surgeons who perform relatively fewer revision TJA procedures and whose office-based productivity makes up a smaller overall percentage of their annual workload.
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http://dx.doi.org/10.1016/j.arth.2021.06.004DOI Listing
June 2021

Investigation of Foot Sensor Insoles for Measuring Functional Outcome After Total Knee Replacement.

Bull Hosp Jt Dis (2013) 2021 Jun;79(2):115-123

Background: To measure functional outcome, patient reported outcome measures (PROMs) are most often used but biomechanical tests can provide valuable supplementary data. The objective of this study was to investigate instrumented insoles for measuring ground-to-foot forces during basic activities.

Methods: Three groups were evaluated: normal controls, preoperative, and postoperative total knees. The Knee Society Scoring System (KSS) Short Form was used, and with foot pressure sensor insoles, a timed-up-and-go (TUG) test and a sit-to-stand (STS) test was used.

Results: Comparing preoperative to postoperative and control groups, there were significant differences in most parameters. There were no significant differences between controls and postoperative knees. Of the 33 correlation coefficients between three PROM parameters and six biomechanical parameters for the three groups, only five coefficients were greater than 0.5.

Conclusions: The biomechanical data was substantially independent of the PROM data and provided additional functional evaluation. The most useful parameters were the left-right force ratios during sit-to stand (STS) and the timed-up-and-go (TUG) time.
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June 2021

Improving Arthroplasty Efficiency and Quality Through Concentrating Service Volume by Complexity: Surviving the Medicare Policy Changes.

J Arthroplasty 2021 Sep 20;36(9):3055-3059. Epub 2021 Apr 20.

Department of Orthopaedic Surgery, Brigham and Women's Health, Boston, MA.

We have an academic medical center (AMC), an associated community-based hospital (CBH) and several ambulatory care centers which are being prepared to provide same day discharge (SDD) total joint arthroplasty (TJA) and unicompartmental knee arthroplasty (UKA). The near-capacity AMC cared for medically and technically complicated TJA patients. The CBH wanted to increase volume, improve margins, and become a center of excellence with an efficient hospital outpatient department and SDD TJA experience.

Methods: We transitioned primary, uncomplicated TJA, UKA, and minimally invasive TJA to the CBH. Revision surgeries, patients with extensive comorbidities, and complex primaries were performed at the AMC. Protocols were developed to facilitate SDD UKA and total hip arthroplasty (THA) as well as rapid recovery protocols for total knee arthroplasty (TKA) at both hospitals. A protocol-based system was put in place to make both hospitals ready for the removal of TKA from the Inpatient-Only list to avoid Quality Improvement Organization and possible resultant Recovery Audit Contractor audits if referred after implementation.

Results: The CBH volume increased 36.7% (+239). AMC volume slightly decreased (-0.46%, -5) resulting in an increase in margin contribution for the system. CBH quality metrics (surgical site infections, length of stay, readmissions, and mortality) were improved. Surgeon satisfaction improved as their volume, efficiency, quality metrics, and finances were enhanced. Although CBH per case revenue was 80.3% and 74.4% of the AMC for THA and TKA, net margins were 3.6% and 18.8% higher for THA and TKA, respectively. Increased efficiency, lower hospital cost, and higher volume at the CBH allowed for an increase in revenue despite lower reimbursement per case.

Conclusion: This strategy will help hospital systems improve net margins while improving patient care despite lower net revenue per TJA episode. These strategies will become increasingly important going forward with the transition of higher numbers of TJA patients to outpatient which will be subjected to further decreases in net revenue per patient.
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http://dx.doi.org/10.1016/j.arth.2021.04.005DOI Listing
September 2021

Patient Engagement Technologies in Orthopaedics: What They Are, What They Offer, and Impact.

J Am Acad Orthop Surg 2021 Jun;29(12):e584-e592

From the Tufts Medical Center (Kavolus and Moverman), Department of Orthopedic Surgery, Boston, MA, the Rush University Medical Center (Karas), Department of Orthopedic Surgery, Chicago, IL, and the Brigham and Women's Hospital/Harvard Medical School (Iorio), Department of Orthopedic Surgery, Boston, MA.

The modern era is an increasingly digital and connected world. Most of the Americans now use a smartphone irrespective of age or income level. As smartphone technologies become ubiquitous, there is tremendous interest and growth in mobile health applications. One segment of these new technologies are the so-called patient engagement platforms. These technologies present a host of features that may improve care. This article provides an introduction to this growing technology sector, offers insight into what they may offer patients and surgeons, and discusses how to evaluate various platforms.
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http://dx.doi.org/10.5435/JAAOS-D-20-00585DOI Listing
June 2021

Low dose aspirin is effective in preventing venous thromboembolism in patients undergoing primary total knee arthroplasty.

J Orthop 2021 Mar-Apr;24:26-28. Epub 2021 Feb 12.

Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA.

Introduction: Venous thromboembolism (VTE) is a known complication after total knee arthroplasty (TKA) with well-established morbidity, mortality, and significant healthcare expenditure. However, no standard form of prophylaxis against VTE currently exists.

Methods: A retrospective review was performed identifying 12,866 TKA cases and post-operative VTE events using either 325 mg aspirin or 81 mg aspirin twice daily (BID).

Results: 133 VTE cases were diagnosed of the 9413 TKA on 325 mg aspirin BID compared to 8 VTE cases out of 3453 TKA on 81 mg aspirin BID (1.41% vs. 0.23%, p < 0.001).

Conclusion: 81 mg aspirin BID significantly improved post-operative VTE rates over 325 mg aspirin BID.
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http://dx.doi.org/10.1016/j.jor.2021.02.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7902281PMC
February 2021

Artificial Intelligence to Identify Arthroplasty Implants From Radiographs of the Hip.

J Arthroplasty 2021 07 16;36(7S):S290-S294.e1. Epub 2020 Nov 16.

Orthopaedic Machine Learning Laboratory, Cleveland Clinic, Cleveland, OH; Department of Orthopaedic Surgery, Brigham & Women's Hospital, Boston, MA.

Background: The surgical management of complications surrounding patients who have undergone hip arthroplasty necessitates accurate identification of the femoral implant manufacturer and model. Failure to do so risks delays in care, increased morbidity, and further economic burden. Because few arthroplasty experts can confidently classify implants using plain radiographs, automated image processing using deep learning for implant identification may offer an opportunity to improve the value of care rendered.

Methods: We trained, validated, and externally tested a deep-learning system to classify total hip arthroplasty and hip resurfacing arthroplasty femoral implants as one of 18 different manufacturer models from 1972 retrospectively collected anterior-posterior (AP) plain radiographs from 4 sites in one quaternary referral health system. From these radiographs, 1559 were used for training, 207 for validation, and 206 for external testing. Performance was evaluated by calculating the area under the receiver-operating characteristic curve, sensitivity, specificity, and accuracy, as compared with a reference standard of implant model from operative reports with implant serial numbers.

Results: The training and validation data sets from 1715 patients and 1766 AP radiographs included 18 different femoral components across four leading implant manufacturers and 10 fellowship-trained arthroplasty surgeons. After 1000 training epochs by the deep-learning system, the system discriminated 18 implant models with an area under the receiver-operating characteristic curve of 0.999, accuracy of 99.6%, sensitivity of 94.3%, and specificity of 99.8% in the external-testing data set of 206 AP radiographs.

Conclusions: A deep-learning system using AP plain radiographs accurately differentiated among 18 hip arthroplasty models from four industry leading manufacturers.
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http://dx.doi.org/10.1016/j.arth.2020.11.015DOI Listing
July 2021

The Utility of Preoperative Labs in Predicting Postoperative Complications Following Primary Total Hip and Knee Arthroplasty.

Bull Hosp Jt Dis (2013) 2020 12;78(4):266-274

Background: Preoperative testing costs billions of dollars despite little evidence supporting its utility. The purpose of this study was to determine the relationship between abnormal preoperative laboratory tests and postoperative complications following total joint arthroplasty.

Methods: The NSQIP database was used to identify 45,936 primary total hip arthroplasty (THA) and 76,041 pri-mary total knee arthroplasty (TKA) cases performed between 2006 and 2013. Complications within 30 days of surgery were collected and multivariable regression modeling was performed incorporating all significant laboratory values as well as demographics and preoperative comorbidities.

Results: For THA patients, abnormal sodium (p = 0.016, OR = 1.89), white count (p = 0.043, OR = 1.73), and partial thromboplastin time (p = 0.028, OR = 1.43) were significantly associated with complications. For TKA patients, abnormal alkaline phosphatase (p = 0.04, OR = 2.12), creatinine (p = 0.003, OR = 1.56), and INR (p = 0.008, OR = 1.99) were significantly predictive of complications.

Conclusion: Of the 13 laboratory values, only six were significantly associated with complications. These findings may have implications for risk stratification in the inpatient setting.
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December 2020

Weight loss before total joint arthroplasty using a remote dietitian and mobile app: study protocol for a multicenter randomized, controlled trial.

J Orthop Surg Res 2020 Nov 13;15(1):531. Epub 2020 Nov 13.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.

Background: The months prior to elective surgery may present an opportunity for patients to initiate behavior changes that will simultaneously ready them for surgery and improve their overall health status. An upcoming elective total joint arthroplasty (TJA) may serve as motivation for patients with severe obesity (body mass index [BMI]> 40 kg/m) to lose weight, as it may optimize clinical outcomes following TJA and help them become eligible for TJA since some surgeons use a BMI of 40 kg/m as a cut-off for offering surgery in an effort to optimize outcomes.

Methods: The purpose of this multicenter randomized, controlled trial is to assess the feasibility and efficacy of a 12-week remote dietitian (RD) supervised dietary and physical activity weight loss intervention and mobile app for 60 patients with severe obesity prior to undergoing TJA. Intervention participants will receive access to a smartphone app and connect with an RD who will contact these participants weekly or bi-weekly via video calls for up to nine video calls. Together, participants and RDs will set goals for lifestyle modifications, and RDs will check on progress towards achieving these goals using in-app tools such as food logs and text messages between video calls. All patients will be encouraged to lose at least 20 pounds with a goal BMI < 40 kg/m after 12 weeks. Individuals randomized to the control group will receive clinical standard of care, such as nutritionist and/or physical therapy referrals. Outcome and demographic data will be collected from blood serology, chart review, mobile app user data, pre- and postintervention surveys, and phone interviews. The primary outcome measure will be weight change from baseline. Secondary outcome measures will include percentage of patients eligible to undergo TJA, number of sessions completed with dietitians, self-reported global health status (PROMIS Global Health scale), self-reported joint-specific pain and function (Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS)), and serologies such as hemoglobin A1c, total lymphocyte count, albumin, and transferrin. Qualitative responses transcribed from phone interviews about the intervention will also be analyzed.

Discussion: This will be the first study to assess pre-operative weight loss in patients with severe obesity anticipating orthopaedic surgery using an RD and mobile app intervention aimed at helping patients become eligible for TJA.

Trial Registration: Registered on 1 April 2020 at Clincialtrials.gov. Trial number is NCT04330391 .
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http://dx.doi.org/10.1186/s13018-020-02059-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7662734PMC
November 2020

Artificial Intelligence to Identify Arthroplasty Implants From Radiographs of the Knee.

J Arthroplasty 2021 03 17;36(3):935-940. Epub 2020 Oct 17.

Orthopaedic Machine Learning Laboratory, Cleveland Clinic, Cleveland, OH; Department of Orthopaedic Surgery, Brigham & Women''s Hospital, Boston, MA.

Background: Revisions and reoperations for patients who have undergone total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), and distal femoral replacement (DFR) necessitates accurate identification of implant manufacturer and model. Failure risks delays in care, increased morbidity, and further financial burden. Deep learning permits automated image processing to mitigate the challenges behind expeditious, cost-effective preoperative planning. Our aim was to investigate whether a deep-learning algorithm could accurately identify the manufacturer and model of arthroplasty implants about the knee from plain radiographs.

Methods: We trained, validated, and externally tested a deep-learning algorithm to classify knee arthroplasty implants from one of 9 different implant models from retrospectively collected anterior-posterior (AP) plain radiographs from four sites in one quaternary referral health system. The performance was evaluated by calculating the area under the receiver-operating characteristic curve (AUC), sensitivity, specificity, and accuracy when compared with a reference standard of implant model from operative reports.

Results: The training and validation data sets were comprised of 682 radiographs across 424 patients and included a wide range of TKAs from the four leading implant manufacturers. After 1000 training epochs by the deep-learning algorithm, the model discriminated nine implant models with an AUC of 0.99, accuracy 99%, sensitivity of 95%, and specificity of 99% in the external-testing data set of 74 radiographs.

Conclusions: A deep learning algorithm using plain radiographs differentiated between 9 unique knee arthroplasty implants from four manufacturers with near-perfect accuracy. The iterative capability of the algorithm allows for scalable expansion of implant discriminations and represents an opportunity in delivering cost-effective care for revision arthroplasty.
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http://dx.doi.org/10.1016/j.arth.2020.10.021DOI Listing
March 2021

Topical Vancomycin Powder and Dilute Povidone-Iodine Lavage Reduce the Rate of Early Periprosthetic Joint Infection After Primary Total Knee Arthroplasty.

J Arthroplasty 2021 01 31;36(1):286-290.e1. Epub 2020 Jul 31.

Department of Orthopedic Surgery, NYU Langone Health, New York, NY.

Background: Vancomycin powder and dilute povidone-iodine lavage (VIP) was introduced to reduce the incidence of periprosthetic joint infection (PJI) in high-risk total knee arthroplasty (TKA) patients. We hypothesize that VIP can reduce the incidence of early PJI in all primary TKA patients, regardless of preoperative risk.

Methods: An infection database of primary TKAs performed before a VIP protocol was implemented (January 2012-December 2013), during a time when only high-risk TKAs received VIP (January 2014-December 2015), and when all TKAs received VIP (January 2016-September 2019) at an urban, university-affiliated, not-for-profit orthopedic hospital was retrospectively reviewed to identify patients with PJI. Criteria used for diagnosis of PJI were the National Healthcare Safety Network and Musculoskeletal Infection Society guidelines.

Results: VIP reduced early primary TKA PJI incidence in both the high-risk and all-risk cohorts compared with the pre-VIP cohort by 44.6% and 56.4%, respectively (1.01% vs 0.56% vs 0.44%, P = .0088). In addition, after introducing VIP to all-risk TKA patients, compared with high-risk TKA patients, the relative risk of PJI dropped an additional 21.4%, but this finding did not reach statistical significance (0.56% vs 0.44%, P = .4212). There were no demographic differences between the 3 VIP PJI cohorts.

Conclusion: VIP is associated with a reduced early PJI incidence after primary TKA, regardless of preoperative risk. With the literature supporting its safety and cost-effectiveness, VIP is a value-based intervention, but given the nature of this historical cohort study, a multicenter randomized controlled trial is underway to definitively confirm its efficacy.
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http://dx.doi.org/10.1016/j.arth.2020.07.064DOI Listing
January 2021

Low-Dose Aspirin is Safe and Effective for Venous Thromboembolism Prevention in Patients Undergoing Revision Total Knee Arthroplasty: A Retrospective Cohort Study.

J Knee Surg 2020 Sep 8. Epub 2020 Sep 8.

Department of Orthopedic Surgery, NYU Langone Health, New York, New York.

Venous thromboembolism (VTE) events are rare, but serious complications of total joint replacement affect patients and health care systems due to the morbidity, mortality, and associated cost of its complications. There is currently no established universal standard of care for prophylaxis against VTE in patients undergoing revision total knee arthroplasty (rTKA). The aim of this study was to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or sufficient in preventing VTE in patients undergoing rTKAs versus 325-mg ASA BID. In 2017, our institution adopted a new protocol for VTE prophylaxis for arthroplasty patients. Patients initially received 325-mg ASA BID for 1 month and then changed to a lower dose of 81-mg BID. A retrospective review from 2011 to 2019 was conducted identifying 1,438 consecutive rTKA patients and 90-day postoperative outcomes including VTE, gastrointestinal, and wound bleeding complications, acute periprosthetic joint infection, and mortality. In the 74 months prior to protocol implementation, 1,003 rTKAs were performed and nine VTE cases were diagnosed (0.90%). After 26 months of the protocol change, 435 rTKAs were performed with one VTE case identified (0.23%). There was no significant difference in rates or odds in postoperative pulmonary embolism (PE;  = 0.27), DVT ( = 0.35), and total VTE rates ( = 0.16) among patients using either protocol. There were also no differences in bleeding complications ( = 0.15) or infection rate ( = 0.36). No mortalities were observed. In the conclusion, 81-mg ASA BID is noninferior to 325-mg ASA BID in maintaining low rates of VTE and may be safe for use in patients undergoing rTKA.
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http://dx.doi.org/10.1055/s-0040-1716377DOI Listing
September 2020

A Focused Gap Year Program in Orthopaedic Research: An 18-Year Experience.

J Am Acad Orthop Surg 2020 Jul;28(14):e620-e625

From the Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY(Dr. Egol, Ms. Shields, Dr. Jazrawi, Dr. Strauss, Dr. Rokito, and Dr. Zuckerman), the Department of Orthopedic Surgery, University of Miami, Miami, FL (Dr. Errico), and the Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA (Dr. Iorio).

Introduction: Students seek gap years to enhance knowledge and improve chances of professional success. Although many institutions offer research opportunities, no studies have examined outcomes after these experiences. This study evaluates a dedicated year of orthopaedic research on a cohort's ultimate orthopaedic surgery match rate.

Methods: From 2001 to 2018, 129 learners spent a year with our Department of Orthopedic Surgery at a major academic medical center. The students were either completing a gap year after college, during or after medical school, or after an unsuccessful match. Participants were asked to respond to a survey, which included demographics, educational information, and metrics related to the program. For the subcohort of students who ranked orthopaedic surgery, the match rate was compared with the mean for the US orthopaedic surgery match rates from 2006 to 2018 using a chi-square analysis. In addition, a Mann-Whitney U test was used to compare the number of publications before and after the year.

Results: One hundred three students (80%) returned completed questionnaires. Of all learners who applied to and ranked orthopaedic surgery, 91% matched into an orthopaedic surgery residency program. These results compared favorably with the US orthopaedic match from 2006 to 2018 (67.9%; P < 0.001), despite a 4-point lower United States Medical Licensing Examination (USMLE) Step 1 score for the research cohort. Finally, the research cohort had a greater percentage of women (23%) and minorities (40%) than the proportion of woman and minority practicing orthopaedic surgeons.

Conclusion: Students who completed a gap year in research matched into orthopaedics at a higher rate than the national average, despite a lower Step score. Mentors may also target traditionally underrepresented groups to help increase the pool of diverse applicants.
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http://dx.doi.org/10.5435/JAAOS-D-19-00424DOI Listing
July 2020

Economic Impacts of the COVID-19 Crisis: An Orthopaedic Perspective.

J Bone Joint Surg Am 2020 Jun;102(11):937-941

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.2106/JBJS.20.00557DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7219838PMC
June 2020

American Association of Hip and Knee Surgeons Advocacy Efforts in Response to the SARS-CoV-2 Pandemic.

J Arthroplasty 2020 Jul 22;35(7S):S82-S84. Epub 2020 Apr 22.

Department of Orthopaedic Surgery, University of Arkansas, Little Rock, AR.

As soon as it became clear that our economy was going to be paralyzed by the SARS-CoV-2 pandemic, the American Association of Hip and Knee Surgeons leadership acted swiftly to ensure that our members were going to be eligible for the anticipated federal economic stimulus. The cessation of elective surgery, enacted in mid-March and necessary to stop the spread of the SARS-CoV-2 virus, would surely challenge the solvency of many of our members' practices. Although our advocacy efforts discussed further have helped, clearly more relief is needed. Fortunately, our mitigation efforts have led to a "flattening of the curve" and discussions have begun on when, where, and how to safely start elective surgery again.
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http://dx.doi.org/10.1016/j.arth.2020.04.050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7175874PMC
July 2020

Economic Recovery After the COVID-19 Pandemic: Resuming Elective Orthopedic Surgery and Total Joint Arthroplasty.

J Arthroplasty 2020 Jul 18;35(7S):S32-S36. Epub 2020 Apr 18.

Brigham and Women's Hospital, Department of Orthopaedic Surgery, Boston, MA.

Background: The economic effects of the COVID-19 crisis are not like anything the U.S. health care system has ever experienced.

Methods: As we begin to emerge from the peak of the COVID-19 pandemic, we need to plan the sustainable resumption of elective procedures. We must first ensure the safety of our patients and surgical staff. It must be a priority to monitor the availability of supplies for the continued care of patients suffering from COVID-19. As we resume elective orthopedic surgery and total joint arthroplasty, we must begin to reduce expenses by renegotiating vendor contracts, use ambulatory surgery centers and hospital outpatient departments in a safe and effective manner, adhere to strict evidence-based and COVID-19-adjusted practices, and incorporate telemedicine and other technology platforms when feasible for health care systems and orthopedic groups to survive economically.

Results: The return to normalcy will be slow and may be different than what we are accustomed to, but we must work together to plan a transition to a more sustainable health care reality which accommodates a COVID-19 world.

Conclusion: Our goal should be using these lessons to achieve a healthy and successful 2021 fiscal year.
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http://dx.doi.org/10.1016/j.arth.2020.04.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7166028PMC
July 2020

Low-Dose Aspirin Is Safe and Effective for Venous Thromboembolism Prevention in Patients Undergoing Revision Total Hip Arthroplasty: A Retrospective Cohort Study.

J Arthroplasty 2020 08 30;35(8):2182-2187. Epub 2020 Mar 30.

Department of Orthopedic Surgery, NYU Langone Health, New York, NY.

Background: Currently, there is no established universal standard of care for prophylaxis against venous thromboembolism (VTE) in orthopedic patients undergoing revision total hip arthroplasty (rTHA). The aim of this study is to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or effective in preventing VTE in patients undergoing rTHAs vs 325-mg ASA BID.

Methods: In 2017, a large academic medical center adopted a new protocol for VTE prophylaxis in arthroplasty patients at standard risk. Initially, patients received 325-mg ASA BID but switched to 81-mg ASA BID. A retrospective review (2011-2019) was performed to identify 1361 consecutive rTHA patients and their associated 90-day postoperative complications such as VTE, including pulmonary embolism (PE) and/or deep vein thrombosis (DVT), as the primary outcome; and gastrointestinal and wound bleeding, acute periprosthetic joint infection, and mortality as the secondary outcome.

Results: From 2011 to 2017, 973 rTHAs were performed and 13 total VTE cases were diagnosed (1.34%). From 2017 to 2019, 388 rTHAs were performed with 3 total VTE cases identified (0.77%). Chi-squared analyses and logistic regression models showed no differences in rates or odds in postoperative PE (P = .09), DVT (P = .79), PE and DVT (P = .85), and total VTE (P = .38) using either dose. There were also no differences between bleeding complications (P = .14), infection rate (P = .46), and mortality (P = .53).

Conclusion: Using a protocol of 81-mg of ASA BID is noninferior to 325-mg ASA BID and may be safe and effective in maintaining low rates of VTE in patients undergoing rTHA.
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http://dx.doi.org/10.1016/j.arth.2020.03.040DOI Listing
August 2020

Vancomycin Powder and Dilute Povidone-Iodine Lavage for Infection Prophylaxis in High-Risk Total Joint Arthroplasty.

J Arthroplasty 2020 07 2;35(7):1933-1936. Epub 2020 Mar 2.

Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY.

Background: Dilute povidone-iodine lavage has been shown to be safe and effective in decreasing acute periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). Vancomycin powder is reported to be effective in preventing infection in spine surgery. We hypothesize that a "vanco-povidone protocol" (VIP) for TJA patients at high risk for infection is safe and will decrease the rate of PJI.

Methods: High-risk TJA patients (body mass index >40, active smokers, American Society of Anesthesiologists ≥3, immunosuppression/diabetes, methicillin-resistant Staphylococcus aureus colonization, revision surgery) utilizing VIP were compared to a high-risk historical cohort not treated with VIP, at a single institution. VIP consisted of dilute povidone-iodine lavage followed by application of vancomycin powder prior to wound closure. Primary endpoint was PJI within 3 months postoperatively.

Results: The historical, high-risk control cohort consisted of 3251 patients with a PJI incidence of 1.8%. A total of 1413 subjects received the VIP protocol with a PJI incidence of 1.3%. There was a 27.8% risk reduction when compared to the control group of high-risk subjects not treated with the VIP. There were no medical complications secondary to the use of VIP, no increase in vancomycin-resistant enterococcus or vancomycin-resistant Staph aureus, and no cases of acute renal impairment secondary to application of the local vancomycin.

Conclusions: PJI remains a common complication of TJA, especially in high-risk populations. This study indicates that a protocol of dilute povidone-iodine lavage combined with topical vancomycin powder is safe and may reduce PJI incidence in high-risk TJA patients. Due to low, current PJI rates, a multi-institutional randomized controlled trial is necessary to assess interventions that minimize the risk of PJI.

Level Of Evidence: Retrospective Observational Cohort.
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http://dx.doi.org/10.1016/j.arth.2020.02.060DOI Listing
July 2020

Surgical Approaches for Primary Total Hip Arthroplasty from Charnley to Now: The Quest for the Best Approach.

JBJS Rev 2020 01;8(1):e0058

Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY.

» Total hip arthroplasty is one of the most successful surgical interventions of the last century, yet questions remain as to the best surgical approach to use in order to achieve an optimal result. The main approaches to access the hip joint, which will be reviewed in this article, have a long history in the orthopaedic literature. » The evidence behind the advantages and disadvantages of each approach also will be reviewed. In general, it can be said that the anterior approach affords the best early recovery as measured in the first 2 to 4 weeks after surgery. Lateral approaches have the lowest rates of dislocation. The posterior approach has the lowest rates of overall complications, and concerns regarding dislocation have been mitigated with the use of larger-diameter prosthetic femoral heads and advanced soft-tissue repair techniques. » In the end, the selection of approach for total hip arthroplasty should be based on surgeon experience and familiarity with the approach. The pros and cons of each approach seem to equalize by 6 weeks postoperatively. Overall, the reproducibility of the operation is a testament to its continued success.
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http://dx.doi.org/10.2106/JBJS.RVW.19.00058DOI Listing
January 2020

Total Knee Arthroplasty Removal From the Medicare Inpatient-Only List: Implications for Surgeons, Patients, and Hospitals: Introduction.

Authors:
Richard Iorio

J Arthroplasty 2020 06 7;35(6S):S22-S23. Epub 2020 Feb 7.

Brigham and Women's Hospital, Boston, MA.

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http://dx.doi.org/10.1016/j.arth.2020.02.005DOI Listing
June 2020

The Financial Implications of the Removal of Total Knee Arthroplasty From the Medicare Inpatient-Only List.

J Arthroplasty 2020 06 4;35(6S):S33-S36. Epub 2020 Feb 4.

Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR.

Background: Centers for Medicare and Medicaid Services removed total knee arthroplasties (TKAs) from the Inpatient-Only list on January 1, 2018, which meant TKAs could be performed on a hospital outpatient basis. We sought to understand (1) what the financial implications have been for hospitals, (2) to what extent financial incentives have influenced the adoption of outpatient TKAs across hospitals, (3) whether adoption of outpatient TKAs has impacted the success of hospitals with managing post-acute care (PAC) spend, and (4) the financial implications to Medicare of the adoption of outpatient TKAs.

Methods: We used national patient-level Medicare fee-for-service Part A claims data (100% sample) from January 2018 through June 2019 to calculate the inpatient and outpatient TKA payment rate for each hospital, and the distribution in these payments across the country. We then ran case-level regressions to understand the factors associated with adoption of outpatient TKAs, and the drivers of PAC spend. Finally, we quantified the savings to Medicare.

Results: Hospitals on average received $3682 (30%) lower payment from Medicare for outpatient TKA cases, but this varied widely across hospitals. The difference in payment rates across hospitals was not statistically significantly related to their adoption rate of outpatient TKAs. PAC spend was higher for same-day discharges, but lower for cases that stayed at least 1 night. Based on the adoption rate of outpatient TKAs in Q2 2019, Medicare saved $355M on a run rate basis.

Conclusion: Hospitals have adopted outpatient TKAs independent of the financial impact. Medicare has benefited from lower PAC spend and lower payments to hospitals.
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http://dx.doi.org/10.1016/j.arth.2020.01.074DOI Listing
June 2020

An Examination of the Adoption of Outpatient Total Knee Arthroplasty Since 2018.

J Arthroplasty 2020 06 4;35(6S):S24-S27. Epub 2020 Feb 4.

Avant-garde Health, Boston, MA.

Background: The Centers for Medicare and Medicaid Services removed total knee arthroplasties (TKAs) from the inpatient-only (IPO) list on January 1, 2018, which meant that TKAs could be performed on a hospital outpatient basis. We examined the following: (1) the national rate of adoption of outpatient TKAs over time, (2) how adoption varied across hospitals, and (3) whether adoption of outpatient TKAs has positively or negatively impacted 90-day TKA readmission rates.

Methods: We used national patient-level Medicare Fee-for-Service Part A claims data (100% sample) from January 2017 through June 2019 to look at the quarterly trend in percent of TKAs performed as outpatient, and the distribution in this percentage across hospitals in the country. We ran a case-level regression to understand whether inpatient vs outpatient coding status relates to 90-day readmission rates.

Results: In 2017 prior to the removal of TKAs from the IPO list, 0.2% were performed as outpatient. In the first quarter (Q1 2018) after the rule change, 24.9% were performed as outpatient, and by the second quarter of 2019, 36.4% were performed as outpatient. These rates varied widely across hospitals from 0% (10th and 25th percentiles) to 78% (90th percentile) from January 2018 through March 2019. There was no difference in readmission rates for same-day discharges, but outpatient cases discharged after one or more nights in the hospital had statistically lower readmissions than inpatient cases.

Conclusion: There was a rapid increase in the adoption of hospital outpatient TKAs following their removal from the Medicare IPO, which has resulted in lower readmission rates, and so adoption is likely to continue.
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http://dx.doi.org/10.1016/j.arth.2020.01.073DOI Listing
June 2020

Aseptic Loosening of Porous Metaphyseal Sleeves and Tantalum Cones in Revision Total Knee Arthroplasty: A Systematic Review.

J Knee Surg 2021 Aug 19;34(10):1033-1041. Epub 2020 Feb 19.

Department of Orthopaedic Surgery, New York University Langone Medical Center, New York University Langone Orthopedic Hospital, New York, New York.

Bone loss often complicates revision total knee arthroplasty (TKA). Management of metaphyseal defects varies, with no clearly superior technique. Two commonly utilized options for metaphyseal defect management include porous-coated metaphyseal sleeves and tantalum cones. A systematic review was conducted according to the international Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We combined search terms "Total knee arthroplasty" AND/OR "Sleeve," "Cone" as either keywords or medical subject heading (MeSH) terms in multiple databases according to PRISMA recommendations. All retrieved articles were reviewed and assessed using defined inclusion and exclusion criteria. A total of 27 studies (12 sleeves and 15 cones) of revision TKAs were included. In the 12 studies on sleeve implantation in revision TKAs, 1,617 sleeves were implanted in 1,133 revision TKAs in 1,025 patients. The overall rate of reoperation was 110/1,133 (9.7%) and the total rate of aseptic loosening per sleeve was 13/1,617 (0.8%). In the 15 studies on tantalum cone implantation in revision TKAs, 701 cones were implanted into 620 revision TKAs in 612 patients. The overall rate of reoperation was 116/620 (18.7%), and the overall rate of aseptic loosening per cone was 12/701 (1.7%). Rates of aseptic loosening of the two implants were found to be similar, while the rate of reoperation was nearly double in revision TKAs utilizing tantalum cones. Variability in the selected studies and the likely multifactorial nature of failure do not allow for any definitive conclusions to be made. This review elucidates the necessity for additional literature examining revision TKA implants.
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http://dx.doi.org/10.1055/s-0040-1701434DOI Listing
August 2021

Total Knee Replacement: The Inpatient-Only List and the Two Midnight Rule, Patient Impact, Length of Stay, Compliance Solutions, Audits, and Economic Consequences.

J Arthroplasty 2020 06 15;35(6S):S28-S32. Epub 2020 Jan 15.

Avant-Garde Health, Boston, MA.

Background: In November 2017, CMS finalized the 2018 Medicare Outpatient Prospective Payment System rule that removed TKA from the Medicare inpatient-only (IPO) list. This action had significant and unexpected consequences.

Methods: We looked at 3 levels of the IPO rule impact on TKA for Medicare beneficiaries: a national comparison of FFS inpatient and outpatient classification for 2017 vs 2018; a survey of AAHKS surgeons completed in April 2019; and an in-depth analysis of a large academic medical center experience. An analysis of change in admission classification of patients with TKA over time, number of QIO audits, compliance solutions for the new rule, and cost implications of those compliance solutions were evaluated.

Results: Hospital reimbursement averages $10,122 in an outpatient facility but does not include the physician payment. Average hospital reimbursement in the inpatient setting is $11,760. The difference in hospital reimbursement varies widely (90th percentile decrease, $6725 vs 10th percentile $2048). Physician payments are the same in both settings (avg $1403). Patients with TKA not designated for inpatient admissions are not eligible for bundle payment programs. Patients designated as outpatients are subjected 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. An AAHKS survey demonstrated that 45.08% were with inpatient designation only, 17.62% were with outpatient designation only, 25.39% were designated as necessary, and 10.1% were designated by the hospital. This survey showed that 66 of 374 (17.65%) patients had undergone a QIO audit as a result of issues with the IPO rule. An evaluation of an AMC demonstrated that since January 1, 2018, 470 of 690 (68.1%) of CMS patients with TKA left in less than 2 midnights. The institution was subjected to 2 QIO audits.

Conclusions: There are many unintended consequences to the IPO rule application to TKA.
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http://dx.doi.org/10.1016/j.arth.2020.01.007DOI Listing
June 2020

It's a Brave New World: Alternative Payment Models and Value Creation in Total Joint Arthroplasty.

Instr Course Lect 2019 ;68:659-674

Alternative payment models are constantly evolving in an attempt to create value by decreasing cost while improving or maintaining quality. The Bundled Payments for Care Improvement initiative was implemented in 2011, and many institutions have seen early success by using the seven pillars of total joint arthroplasty episode management. Private insurers have seen improvements in care and cost savings by adopting private bundle programs. In each organization, alignment among all stakeholders is paramount to the success of the bundled payment programs. Gainsharing offers a unique opportunity to incentivize physicians to change their care practices in an attempt to reduce costs and improve outcomes. As bundled payments evolve, the cooperation of physicians, health care institutions, payers, and patients will lead to value creation for all stakeholders.
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February 2020

Choices, Compromises, and Controversies in Total Knee Arthroplasty.

Instr Course Lect 2019 ;68:187-216

Although condylar total knee arthroplasty (TKA) has been performed for almost 40 years, many choices, compromises, and controversies remain. In the effort to provide optimal care and beneficial, enduring treatment for an expanding population of patients with debilitating arthritis of the knee and who are using ever-diminishing provider and financial resources, orthopaedic surgeons must carefully examine the available evidence to determine best practices. First, there is debate as to who should be a candidate for TKA. Beyond the established criteria of disease severity, should all patients who can benefit from TKA undergo the procedure, or should surgeons develop exclusion criteria based on complication risk? Current concepts for identifying and managing modifiable risk factors should be considered. Second, there is debate regarding the choice of TKA versus partial knee arthroplasty to manage unicompartmental arthritis. Third, surgeons continue to debate the ideal implant design for primary condylar TKA, whether to proceed with an anatomic approach of preserving one or both cruciate ligaments or a functional approach of resecting and substituting for the cruciate ligaments in various ways.
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February 2020

Technology Applications for Arthroplasty: Moving the Field Forward?

Instr Course Lect 2020 ;69:183-208

Total joint arthroplasty (TJA) is one of the most performed and successful surgeries in the United States for advanced degenerative and inflammatory arthritis with most patients reporting excellent outcomes. However, a large number of patients are still dissatisfied following TJA. To improve outcomes, new technologies such as patient-specific instrumentation and custom implants; smart implant trials; radiologic, computer, and portable accelerometer-based navigation systems; and robotics have been developed. Their overall goals are to avoid the drawbacks of conventional arthroplasty surgery, to simplify the procedures, to improve the accuracy of surgical techniques, to improve outcomes, and to decrease costs. This chapter provides an overview of the current technologies and their applications in TJA.
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February 2020

The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head.

J Arthroplasty 2020 04 27;35(4):933-940. Epub 2019 Nov 27.

Department of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, China.

Background: The Association Research Circulation Osseous (ARCO) presents the 2019 revised staging system of osteonecrosis of the femoral head (ONFH) based on the 1994 ARCO classification.

Methods: In October 2018, ARCO established a task force to revise the staging system of ONFH. The task force involved 29 experts who used a web-based survey for international collaboration. Content validity ratios for each answer were calculated to identify the levels of agreement. For the rating queries, a consensus was defined when more than 70% of the panel members scored a 4 or 5 rating on a 5-point scale.

Results: Response rates were 93.1%-100%, and through the 4-round Delphi study, the 1994 ARCO classification for ONFH was successfully revised. The final consensus resulted in the following 4-staged system: stage I-X-ray is normal, but either magnetic resonance imaging or bone scan is positive; stage II-X-ray is abnormal (subtle signs of osteosclerosis, focal osteoporosis, or cystic change in the femoral head) but without any evidence of subchondral fracture, fracture in the necrotic portion, or flattening of the femoral head; stage III-fracture in the subchondral or necrotic zone as seen on X-ray or computed tomography scans. This stage is further divided into stage IIIA (early, femoral head depression ≤2 mm) and stage IIIB (late, femoral head depression >2 mm); and stage IV-X-ray evidence of osteoarthritis with accompanying joint space narrowing, acetabular changes, and/or joint destruction. This revised staging system does not incorporate the previous subclassification or quantitation parameters, but the panels agreed on the future development of a separate grading system for predicting disease progression.

Conclusion: A staging system has been developed to revise the 1994 ARCO classification for ONFH by an expert panel-based Delphi survey. ARCO approved and recommends this revised system as a universal staging of ONFH.
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http://dx.doi.org/10.1016/j.arth.2019.11.029DOI Listing
April 2020
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