Publications by authors named "Thorsten M Seyler"

210 Publications

Use of Adjunct Antiseptic Agents in Periprosthetic Joint Infections.

J Am Acad Orthop Surg 2021 Sep 13. Epub 2021 Sep 13.

From the University of Pittsburgh, Pittsburgh, PA (Plate), Wake Forest Baptist Medical Center, Winston Salem, NC (Plate, Zuskov), and Duke University Medical Center, Department of Orthopaedic Surgery, Durham, NC (Seyler).

Periprosthetic joint infection is a leading cause for failure of contemporary total hip arthroplasty and total knee arthroplasty projected to nearly double in the next decade and reach an economic burden of $1.85 billion in the United Sates by 2030. Although multiple treatments for periprosthetic joint infection have been described, a thorough débridement and joint lavage to decrease bacterial bioburden and to remove biofilm remains a critical component of treatment. Various adjunct antiseptic agents such as chlorhexidine, povidone-iodine, hydrogen peroxide, acetic acid, and chlorine compounds are currently in off-label use in this capacity. Each antiseptic agent, however, has a distinct mechanism of action and targets different organisms, and some combinations of agents may lead to tissue toxicity. In this review, currently available adjunct antiseptic washes will be described in detail based on their mechanism of action and the evidence for their use will be reviewed. Furthermore, this review puts forward an evidence-based treatment algorithm based on the specific causative organism.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5435/JAAOS-D-21-00154DOI Listing
September 2021

Revision Total Joint Arthroplasty: Final Stop Tertiary Referral Center.

Orthopedics 2021 Jul-Aug;44(4):e477-e481. Epub 2021 Jul 1.

High complication rates associated with revision total knee arthroplasty (TKA) and total hip arthroplasty (THA) may unequally burden tertiary referral centers, which manage medically complex patients. The authors aimed to quantify TKA and THA referral patterns at a tertiary referral center based on travel distance and patient comorbidities. All patients who underwent primary or revision TKA or THA at the investigating institution from 2012 to 2016 were identified. Travel distance was calculated using each patient's home address and stratified into less than 25 miles, 25 to 74 miles, and 75 miles or more. Age, body mass index, Charlson Comorbidity Index, and postoperative clinical data were identified. Patients were analyzed based on procedure performed and travel distance. A total of 4245 procedures were included for analysis (1754 primary TKAs, 432 revision TKAs, 1503 primary THAs, and 556 revision THAs). Patients living 75 miles or more away had significantly higher odds of undergoing revision arthroplasty compared with patients living within 25 miles (knee: odds ratio [OR], 2.43; hip: OR, 2.61; <.001). Charlson Comorbidity Index did not increase with travel distance. Patients traveling 75 miles or more were more likely to have periprosthetic fracture (OR, 3.91; =.011) and less likely to have dislocation (OR, 0.54; =.026) as the surgical indication for revision. Patients referred to a tertiary center were more likely to necessitate revision total joint arthroplasty but did not differ in comorbidity profile compared with local patients. Periprosthetic fracture, a particularly high-risk surgical indication, was overrepresented among referral patients. These data suggest that factors such as underlying diagnosis, but not preoperative medical comorbidities, may influence referral patterns. [. 2021;44(4):e477-e481.].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3928/01477447-20210618-03DOI Listing
July 2021

Antipsychotic Use Is Associated With Longer In-hospital Lengths of Stay and Higher Rates of Venous Thromboembolism and Costs of Care After Primary Total Knee Arthroplasty.

J Am Acad Orthop Surg 2021 Jul;29(13):e675-e680

From the Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA (Hernandez), Maimonides Medical Center, New York, NY (Vakharia), the Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY (Mont), Orthopaedic Research Institute, Holy Cross Hospital, Ft. Lauderdale, FL (Roche), and the Department of Orthopaedic Surgery, Duke University, Durham, NC (Seyler).

Introduction: Studies have shown that antipsychotic medication use may lead to venous thromboembolisms (VTEs); however, this association has not been demonstrated in patients undergoing primary total knee arthroplasty (TKA). Therefore, the purpose of this study was to investigate whether patients taking antipsychotic medications at the time of their primary TKA have higher rates of in-hospital lengths of stay (LOS), VTEs, and costs of care.

Methods: Patients taking antipsychotic medications were identified and matched to a cohort in a 1:5 ratio by age, sex, and medical comorbidities. Patients who had a history of VTEs or hypercoagulable states before their TKA were excluded. The query resulted in 439,579 patients within the study (n = 73,285) and matching cohorts (n = 366,294). Outcomes analyzed included rates of in-hospital LOS, VTEs, and costs of care. A P value less than 0.01 was considered statistically significant.

Results: We found statistically significant longer in-hospital LOS for patients taking antipsychotic medications (3.27 versus 3.02 days, P < 0.0001). Study patients were also found to have a higher incidence and odds ratio of VTEs (2.37 versus 1.04%; odds ratio: 1.86, 95% confidence interval: 1.75-1.97, P < 0.0001). Ninety-day costs of care were also significantly higher in the study cohort ($17,332.70 versus $15,975.00, P < 0.0001).

Conclusion: After adjusting for confounders, patients taking antipsychotic medication were found to have higher rates of in-hospital LOS, VTEs, and costs of care. The study can be used by orthopaedic surgeons to counsel patients taking these medications concerning the potential complications after their procedure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5435/JAAOS-D-20-00726DOI Listing
July 2021

Antipsychotic Use Is Associated With Longer In-hospital Lengths of Stay and Higher Rates of Venous Thromboembolism and Costs of Care After Primary Total Knee Arthroplasty.

J Am Acad Orthop Surg 2021 Jul;29(13):e675-e680

From the Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA (Hernandez), Maimonides Medical Center, New York, NY (Vakharia), the Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY (Mont), Orthopaedic Research Institute, Holy Cross Hospital, Ft. Lauderdale, FL (Roche), and the Department of Orthopaedic Surgery, Duke University, Durham, NC (Seyler).

Introduction: Studies have shown that antipsychotic medication use may lead to venous thromboembolisms (VTEs); however, this association has not been demonstrated in patients undergoing primary total knee arthroplasty (TKA). Therefore, the purpose of this study was to investigate whether patients taking antipsychotic medications at the time of their primary TKA have higher rates of in-hospital lengths of stay (LOS), VTEs, and costs of care.

Methods: Patients taking antipsychotic medications were identified and matched to a cohort in a 1:5 ratio by age, sex, and medical comorbidities. Patients who had a history of VTEs or hypercoagulable states before their TKA were excluded. The query resulted in 439,579 patients within the study (n = 73,285) and matching cohorts (n = 366,294). Outcomes analyzed included rates of in-hospital LOS, VTEs, and costs of care. A P value less than 0.01 was considered statistically significant.

Results: We found statistically significant longer in-hospital LOS for patients taking antipsychotic medications (3.27 versus 3.02 days, P < 0.0001). Study patients were also found to have a higher incidence and odds ratio of VTEs (2.37 versus 1.04%; odds ratio: 1.86, 95% confidence interval: 1.75-1.97, P < 0.0001). Ninety-day costs of care were also significantly higher in the study cohort ($17,332.70 versus $15,975.00, P < 0.0001).

Conclusion: After adjusting for confounders, patients taking antipsychotic medication were found to have higher rates of in-hospital LOS, VTEs, and costs of care. The study can be used by orthopaedic surgeons to counsel patients taking these medications concerning the potential complications after their procedure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5435/JAAOS-D-20-00726DOI Listing
July 2021

Do Patients with Paget's Disease Have Worse Outcomes following Primary Total Knee Arthroplasty?

J Knee Surg 2021 May 14. Epub 2021 May 14.

Department of Orthopaedic Surgery, Hospital for Special Surgery, West Palm Beach, Florida.

Well-powered studies evaluating the effects of Paget's disease on patient outcomes following primary total knee arthroplasty (TKA) are limited. The objective of this study was to determine whether Paget's disease patients undergoing primary TKA have higher rates of complications. A query of an administrative database was performed identifying Paget's disease patients undergoing primary TKA as the study cohort. Patients who did not have Paget's disease served as a matching cohort. Study group patients were matched in a 1:5 ratio by age, sex, and comorbidities. The query yielded 34,284 patients in the study ( = 5,714) and matched ( = 28,570) cohorts. Outcomes analyzed included length of stay (LOS), costs of care, 90-day medical and surgical complications, and 2-year implant-related complications. Multivariate logistic regression analyses were used to calculate the odds ratios (ORs) of complications. Paget's disease patients undergoing primary TKA were found to have significantly longer in-hospital LOS (4 vs. 3 days,  < 0.0001). Study group patients incurred significantly higher 90-day episode-of-care costs ($15,124.55 vs. $14,610.01,  < 0.0001). Additionally, Paget's disease patients were found to have higher incidences and odds of medical/surgical (25.93 vs. 13.58%; OR: 1.64,  < 0.0001) and implant-related complications (8.97 vs. 5.02%; OR: 1.71,  < 0.0001). Specifically, Paget's disease patients were more likely to have periprosthetic fractures, mechanical loosening, and revision TKAs ( < 0.0001). This study demonstrated that Paget's disease was associated with longer in-hospital LOS, increased costs, and higher rates of complications. The study can be utilized by physicians to adequately educate patients with Paget's disease concerning potential complications following their primary TKA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0041-1727180DOI Listing
May 2021

Efficacy of common antiseptic solutions against clinically relevant microorganisms in biofilm.

Bone Joint J 2021 May;103-B(5):908-915

Department of Orthopaedics, Duke University Hospital, Durham, North Carolina, USA.

Aims: Periprosthetic joint infections (PJIs) are among the most devastating complications after joint arthroplasty. There is limited evidence on the efficacy of different antiseptic solutions on reducing biofilm burden. The purpose of the present study was to test the efficacy of different antiseptic solutions against clinically relevant microorganisms in biofilm.

Methods: We conducted an in vitro study examining the efficacy of several antiseptic solutions against clinically relevant microorganisms. We tested antiseptic irrigants against nascent (four-hour) and mature (three-day) single-species biofilm created in vitro using a drip-flow reactor model.

Results: With regard to irrigant efficacy against biofilms, Povidone-iodine treatment resulted in greater reductions in nascent MRSA biofilms (logarithmic reduction (LR) = 3.12; p < 0.001) compared to other solutions. Bactisure treatment had the greatest reduction of mature biofilms (LR = 1.94; p = 0.032) and a larger reduction than Vashe or Irrisept for mature biofilms (LR = 2.12; p = 0.025). Pooled data for all biofilms tested resulted in Bactisure and Povidone-iodine with significantly greater reductions compared to Vashe, Prontosan, and Irrisept solutions (p < 0.001).

Conclusion: Treatment failure in PJI is often due to failure to clear the biofilm; antiseptics are often used as an adjunct to biofilm clearance. We tested irrigants against clinically relevant microorganisms in biofilm in vitro and showed significant differences in efficacy among the different solutions. Further clinical outcome data is necessary to determine whether these solutions can impact PJI outcome in vivo. Cite this article:  2021;103-B(5):908-915.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1302/0301-620X.103B5.BJJ-2020-1245.R2DOI Listing
May 2021

Varus-Valgus Constrained Implants in Revision Total Knee Arthroplasty: Mean Clinical Follow-Up of Six Years.

J Arthroplasty 2021 07 15;36(7S):S303-S307. Epub 2020 Dec 15.

Department of Orthopaedic Surgery, Duke University, Durham, NC.

Background: There is scant literature evaluating varus-valgus constrained (VVC) prostheses in contemporary revision total knee arthroplasty (TKA). Therefore, we aimed to evaluate the durability of VVC revision TKA with selective use of cones.

Methods: A retrospective review of 194 revision TKAs with VVC was performed from August 2005 through February 2018 at a single institution. The final cohort consisted of 168 TKAs with a mean follow-up of 6 years. Stems were used in all but 1 TKA, tibial cones in 48%, and femoral cones in 19%. Anderson Orthopaedic Research Institute classification in femurs was 1 in 57, 2A in 33, 2B in 62, 3 in 16, and in tibias, 1 in 42, 2A in 29, 2B in 81, and 3 in 16.

Results: Survival analysis showed that 93% were free of revision for aseptic component loosening, 76% were free of revision for any reason, and 74% were free of reoperation at 6 years. Anderson Orthopaedic Research Institute 3 femur or tibia, age <65 years, and progressive radiographic changes were associated with an increased risk of revision for aseptic loosening (P < .05). Progressive radiographic changes were seen in 19% of femoral and 16% of tibial constructs. The most common reason for re-revision was periprosthetic joint infection (65%).

Conclusion: VVC revision TKA with selective use of cones provided a reasonable outcome as 93% were free of revision for aseptic loosening at 6 years. However, given the rate of patients with progressive radiographic changes and survivorship free of reoperation of 74% at 6 years, long-term follow-up will help assess the durability of these constructs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.12.017DOI Listing
July 2021

Are Patients Taking Benzodiazepines at Increased Risk for Complications Following Primary Total Knee Arthroplasty?

J Arthroplasty 2021 05 5;36(5):1611-1616. Epub 2020 Dec 5.

Department of Orthopaedic Surgery, Duke University, Durham, NC.

Background: Benzodiazepines are commonly taken by patients who are undergoing total knee arthroplasty (TKA), but there is a paucity of studies evaluating any associations. Therefore, we hoped to study if patients taking preoperative benzodiazepines would have increased complications following TKA.

Methods: Using a nationwide database, from 2010 to 2019, we evaluated patients undergoing primary TKA who either did or did not have a preoperative record of benzodiazepine prescription. We performed a multivariable logistic regression analysis, adjusting for multiple variables (age, gender, obesity, and Charlson comorbidity index), to determine the association of preoperative benzodiazepine use and adverse events in a matched cohort. Furthermore, we stratified patients by one vs multiple preoperative benzodiazepine prescription(s). We evaluated 90-day and 2-year rates of revision, resection, femur fracture fixation, manipulation under anesthesia (MUA), and delirium.

Results: Patients filling more than one preoperative benzodiazepine prescription had increased adjusted odds of 90-day (odds ratio [OR] = 1.198, confidence interval [CI] = 1.086-1.320) and 2-year (OR = 1.188, CI = 1.125-1.254) revision; 90-day resection (OR = 1.430, CI = 1.125-1.817); 90-day (OR = 1.639, CI = 1.255-2.141) and 2-year (OR = 1.646, CI = 1.412-1.919) femur fracture fixation; and 2-year delirium (OR = 2.288, CI = 1.564-3.382). Preoperative benzodiazepine users had decreased adjusted odds of 90-day (OR = 0.670, CI = 0.639-0.702) and 2-year (OR = 0.702, CI = 0.671-0.734) MUA.

Conclusion: After controlling for multiple variables, benzodiazepine use was associated with increased rates of revision, resection, femur fracture fixation, and delirium. Furthermore, benzodiazepine use was also associated with a decreased rate of MUA. Orthopaedic professionals can counsel patients taking this group of medications about the associated adverse events. Future studies should assess the use of other muscle relaxants in the prevention of knee stiffness and MUA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.12.004DOI Listing
May 2021

Body Mass Index, American Society of Anesthesiologists Score, and Elixhauser Comorbidity Index Predict Cost and Delay of Care During Total Knee Arthroplasty.

J Arthroplasty 2021 05 15;36(5):1621-1625. Epub 2020 Dec 15.

Department of Orthopedic Surgery, Duke University, Durham, NC.

Background: Body mass index (BMI), American Society of Anesthesiologists (ASA) score, and Elixhauser Comorbidity Index are measures that are utilized to predict perioperative outcomes, though little is known about their comparative predictive effects. We analyzed the effects of these indices on costs, operating room (OR) time, and length of stay (LOS) with the hypothesis that they would have a differential influence on each outcome variable.

Methods: A retrospective review of the institutional database was completed on primary TKA patients from 2015 to 2018. Univariable and multivariable models were constructed to evaluate the strength of BMI, ASA, and Elixhauser comorbidities for predicting changes to total hospital and surgical costs, OR time, and LOS.

Results: In total, 1313 patients were included. ASA score was independently predictive of all outcome variables (OR time, LOS, total hospital and surgical costs). BMI, however, was associated with intraoperative resource utilization through time and cost, but only remained predictive of OR time in an adjusted model. Total Elixhauser comorbidities were independently predictive of LOS and total hospital cost incurred outside of the operative theater, though they were not predictive of intraoperative resource consumption.

Conclusion: Although ASA, BMI, and Elixhauser comorbidities have the potential to impact outcomes and cost, there are important differences in their predictive nature. Although BMI is independently predictive of intraoperative resource utilization, other measures like Elixhauser and ASA score were more indicative of cost outside of the OR and LOS. These data highlight the differing impact of BMI, ASA, and patient comorbidities in impacting cost and time consumption throughout perioperative care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.12.016DOI Listing
May 2021

A New Promising Anti-Infective Agent Inhibits Biofilm Growth by Targeting Simultaneously a Conserved RNA Function That Controls Multiple Genes.

Antibiotics (Basel) 2021 Jan 4;10(1). Epub 2021 Jan 4.

Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA.

Combating single and multi-drug-resistant infections in the form of biofilms is an immediate challenge. The challenge is to discover innovative targets and develop novel chemistries that combat biofilms and drug-resistant organisms, and thwart emergence of future resistant strains. An ideal novel target would control multiple genes, and can be inhibited by a single compound. We previously demonstrated success against biofilms by targeting the tRNA-dependent regulated T-box genes, not present in the human host. Present in Gram-positive bacteria, T-box genes attenuate transcription with a riboswitch-like element that regulates the expression of aminoacyl-tRNA synthetases and amino acid metabolism genes required for cell viability. PKZ18, the parent of a family of compounds selected in silico from 305,000 molecules, inhibits the function of the conserved T-box regulatory element and thus blocks growth of antibiotic-resistant in biofilms. The PKZ18 analog PKZ18-22 was 10-fold more potent than vancomycin in inhibiting growth of in biofilms. In addition, PKZ18-22 has a synergistic effect with existing antibiotics, e.g., gentamicin and rifampin. PKZ18-22 inhibits the T-box regulatory mechanism, halts the transcription of vital genes, and results in cell death. These effects are independent of the growth state, planktonic or biofilm, of the bacteria, and could inhibit emergent strains.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/antibiotics10010041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7824582PMC
January 2021

Cost of Aseptic Revision Total Knee Arthroplasty at a Tertiary Medical Center.

J Arthroplasty 2021 05 17;36(5):1729-1733. Epub 2020 Dec 17.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC.

Background: Revision total knee arthroplasty (TKA) involves varying levels of case complexity and costs depending on the following: (1) number of components revised, (2) duration of operating room time, and (3) length of hospital stay. However, the cost associated with different types of aseptic TKA revisions, based on number and type of components revised, is not well described. We sought to determine differences in cost associated with different revision types, and to correlate this with average national hospital and surgeon reimbursement based on current Centers for Medicare and Medicaid Services data.

Methods: This is a retrospective review of aseptic revision TKAs performed at a single tertiary referral center from 2015 to 2018. Patient demographic data, operating room time, and direct surgery and total hospital costs obtained from an internal accounting database (Enterprise Performance Systems, Inc) were collected. Patients were stratified by the components revised (polyethylene liner only, tibia only, femur only, or both femur and tibia). We hypothesized that direct surgery and total hospital costs would increase as case complexity increased from poly exchange to single-component revisions and both-component revisions.

Results: In total, 106 patients were included (19 poly exchanges, 10 tibia-only revisions, 13 femur-only revisions, and 64 both-component revisions). Operating room time was significantly lower for poly exchange than all other groups (P < .001). Direct surgery and total hospital costs were significantly lower for poly exchange than all other groups (P < .001), and were significantly lower for tibia-only and femur-only revisions compared to both-component revisions (P < .001). Average national surgeon reimbursement by Medicare decreased as a percentage of direct surgery cost as case complexity increased from poly exchange to tibia-only, femur-only, and both-component revisions. Total hospital cost per average Diagnosis Related Group weight was lowest for single-component revisions and highest for both-component revision.

Conclusion: There are significant differences in cost associated with aseptic TKA revisions based on number and type of components revised. These differences may not be accurately reflected in reimbursement, and often represent a burden to those who treat complex revisions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.11.028DOI Listing
May 2021

Next-generation sequencing not superior to culture in periprosthetic joint infection diagnosis.

Bone Joint J 2021 Jan;103-B(1):26-31

Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA.

Aims: Use of molecular sequencing methods in periprosthetic joint infection (PJI) diagnosis and organism identification have gained popularity. Next-generation sequencing (NGS) is a potentially powerful tool that is now commercially available. The purpose of this study was to compare the diagnostic accuracy of NGS, polymerase chain reaction (PCR), conventional culture, the Musculoskeletal Infection Society (MSIS) criteria, and the recently proposed criteria by Parvizi et al in the diagnosis of PJI.

Methods: In this retrospective study, aspirates or tissue samples were collected in 30 revision and 86 primary arthroplasties for routine diagnostic investigation for PJI and sent to the laboratory for NGS and PCR. Concordance along with statistical differences between diagnostic studies were calculated.

Results: Using the MSIS criteria to diagnose PJI as the reference standard, the sensitivity and specificity of NGS were 60.9% and 89.9%, respectively, while culture resulted in sensitivity of 76.9% and specificity of 95.3%. PCR had a low sensitivity of 18.4%. There was no significant difference based on sample collection method (tissue swab or synovial fluid) (p = 0.760). There were 11 samples that were culture-positive and NGS-negative, of which eight met MSIS criteria for diagnosing infection.

Conclusion: In our series, NGS did not provide superior sensitivity or specificity results compared to culture. PCR has little utility as a standalone test for PJI diagnosis with a sensitivity of only 18.4%. Currently, several laboratory tests for PJI diagnosis should be obtained along with the overall clinical picture to help guide decision-making for PJI treatment. Cite this article: 2021;103-B(1):26-31.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1302/0301-620X.103B1.BJJ-2020-0017.R3DOI Listing
January 2021

Angiotensin Receptor Blockers Were Not Associated With Decreased Arthrofibrosis After Total Knee Arthroplasty.

Orthopedics 2021 Mar-Apr;44(2):e274-e280. Epub 2020 Dec 30.

Stiffness after total knee arthroplasty (TKA) remains a challenging problem. Angiotensin receptor blockers (ARBs) have been associated with decreased muscle fibrosis. The aim of this study was to evaluate whether perioperative use of ARBs was associated with a reduction in arthrofibrosis and manipulation under anesthesia (MUA) in patients undergoing primary TKA at 90 days and 1 year postoperative. In this retrospective study, the authors used a national database to evaluate patients undergoing TKA for primary osteoarthritis from 2007 to 2017. They evaluated patients with filled prescriptions for ARBs within the study time frame and the specific type of ARB and its association with arthrofibrosis and MUA. After adjusting for age, sex, a comorbidity index, and obesity, any ARB or specific ARBs were not associated with a reduction in the rate of arthrofibrosis or MUA after TKA (≥.05). Male sex, age 55 years or older, and obesity were associated with a reduction in the rate of arthrofibrosis and MUA after TKA (≤.05). Studies should be performed to evaluate ARBs to see whether there is a more specific role in preventing joint stiffness in certain patient subpopulations following TKA. [. 2021;44(2):e274-e280.].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3928/01477447-20201216-09DOI Listing
July 2021

A Preoperative Risk Prediction Tool for Discharge to a Skilled Nursing or Rehabilitation Facility After Total Joint Arthroplasty.

J Arthroplasty 2021 04 16;36(4):1212-1219. Epub 2020 Nov 16.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC.

Background: Discharge to rehabilitation or a skilled nursing facility (SNF) after total joint arthroplasty remains a primary driver of cost excess for bundled payments. An accurate preoperative risk prediction tool would help providers and health systems identify and modulate perioperative care for higher risk individuals and serve as a vital tool in preoperative clinic as part of shared decision-making regarding the risks/benefits of surgery.

Methods: A total of 10,155 primary total knee (5,570, 55%) and hip (4,585, 45%) arthroplasties performed between June 2013 and January 2018 at a single institution were reviewed. The predictive ability of 45 variables for discharge location (SNF/rehab vs home) was tested, including preoperative sociodemographic factors, intraoperative metrics, postoperative labs, as well as 30 Elixhauser comorbidities. Parameters surviving selection were included in a multivariable logistic regression model, which was calibrated using 20,000 bootstrapped samples.

Results: A total of 1786 (17.6%) cases were discharged to a SNF/rehab, and a multivariable logistic regression model demonstrated excellent predictive accuracy (area under the receiver operator characteristic curve: 0.824) despite requiring only 9 preoperative variables: age, partner status, the American Society of Anesthesiologists score, body mass index, gender, neurologic disease, electrolyte disorder, paralysis, and pulmonary circulation disorder. Notably, this model was independent of surgery (knee vs hip). Internal validation showed no loss of accuracy (area under the receiver operator characteristic curve: 0.8216, mean squared error: 0.0004) after bias correction for overfitting, and the model was incorporated into a readily available, online prediction tool for easy clinical use.

Conclusion: This convenient, interactive tool for estimating likelihood of discharge to a SNF/rehab achieves excellent accuracy using exclusively preoperative factors. These should form the basis for improved reimbursement legislation adjusting for patient risk, ensuring no disparities in access arise for vulnerable populations.

Level Of Evidence: III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.10.038DOI Listing
April 2021

1.5-Stage Exchange Arthroplasty for Total Knee Arthroplasty Periprosthetic Joint Infections.

J Arthroplasty 2021 03 9;36(3):1114-1119. Epub 2020 Oct 9.

Department of Orthopaedic Surgery, Duke University, Durham, NC.

Background: Periprosthetic joint infection (PJI) in total knee arthroplasty (TKA) is a challenging problem. The purpose of this study was to outline a novel technique to treat TKA PJI. We define 1.5-stage exchange arthroplasty as placing an articulating spacer with the intent to last for a prolonged time.

Methods: A retrospective review was performed from 2007 to 2019 to evaluate patients treated with 1.5-stage exchange arthroplasty for TKA PJI. Inclusion criteria included: articulating knee spacer(s) remaining in situ for 12 months and the patient deferring a second-stage reimplantation because the patient had acceptable function with the spacer (28 knees) or not being a surgical candidate (three knees). Thirty-one knees were included with a mean age of 63 years, mean BMI 34.4 kg/m, 12 were female, with a mean clinical follow-up of 2.7 years. Cobalt-chrome femoral and polyethylene tibial components were used. We evaluated progression to second-stage reimplantation, reinfection, and radiographic outcomes.

Results: At a mean follow-up of 2.7 years, 25 initial spacers were in situ (81%). Five knees retained their spacer(s) for some time (mean 1.5 years) and then underwent a second-stage reimplantation; one of the five had progressive radiolucent lines but no evidence of component migration. Three knees (10%) had PJI reoccurrence. Four had progressive radiolucent lines, but there was no evidence of component migration in any knees.

Conclusions: 1.5-stage exchange arthroplasty may be a reasonable method to treat TKA PJI. At a mean follow-up of 2.7 years, there was an acceptable rate of infection recurrence and implant durability.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.09.048DOI Listing
March 2021

All-Polyethylene Tibia: An Opportunity for Value-Based Care in Bundled Reimbursement Initiatives.

Orthopedics 2021 Jan 3;44(1):e114-e118. Epub 2020 Nov 3.

Surgeons play a critical role in making cost-effective decisions that maintain high-quality patient outcomes, which is the current focus of the Centers for Medicare & Medicaid Services. All-polyethylene tibial (APT) components often cost less during total knee arthroplasty (TKA). The authors sought to determine the relative cost savings of APT, as well as their effect on 90-day quality outcome metrics. This was a retrospective review of primary TKAs performed at a single tertiary referral center participating in the Comprehensive Care for Joint Replacement model, by 2 surgeons, from 2015 to 2017. Patient demographic data and direct hospital costs were collected, and patients were stratified by APTs vs metal-backed components. Univariable and multivariable analyses were performed for all outcome metrics. A total of 188 primary TKAs were included (92 APT, 96 metal-backed). Patients receiving APT components were older (P<.001) and had a lower body mass index (P<.001), but there was no difference in sex or American Society of Anesthesiologists score between groups. Operative time was significantly less (mean, 13 minutes) and direct surgery costs were significantly lower for APTs (P<.001). A multivariable regression model for surgical costs demonstrated significant savings (P<.001), and total hospital cost demonstrated a 6.2% average savings with APT. There was no difference in 90-day emergency department visits or re-admissions. This study demonstrates that the use of an APT is able to significantly affect not only the surgical cost but also the total hospital admission cost while maintaining equivalent 90-day outcome metrics. Strategies like this should be considered in appropriately selected patients as the incidence of TKA continues to expand. [Orthopedics. 2021;44(1):e114-e118.].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3928/01477447-20201009-01DOI Listing
January 2021

Commercially Available Polymerase Chain Reaction Has Minimal Utility in the Diagnosis of Periprosthetic Joint Infection.

Orthopedics 2020 Nov 1;43(6):333-338. Epub 2020 Oct 1.

The use of genetic sequencing modalities in the diagnosis of periprosthetic joint infection (PJI) and the identification of organisms has gained popularity recently. Polymerase chain reaction (PCR) offers timely results for common organisms. The purpose of this study was to compare the accuracy of broad-range PCR, conventional culture, the Musculoskeletal Infection Society (MSIS) criteria, and the recently proposed criteria by Parvizi et al in the diagnosis of PJI. In this retrospective study, aspirate or tissue samples were collected in 104 revision and 86 primary arthroplasties for routine diagnostic workup for PJI and sent to the laboratory for PCR. Concordance along with statistical differences between diagnostic studies were calculated using chi-square test for categorical data. On comparison with the MSIS criteria, concordance was significantly lower for PCR at 64.7% compared with 86.3% for culture (P<.001). There was no significant difference based on diagnosis of prior infection (P=.706) or sample collection method (tissue swab or synovial fluid) (P=.316). Of the 87 patients who met MSIS criteria, only 20 (23.0%) PCR samples had an organism identified. In this series, PCR had little utility as a stand-alone test for the diagnosis of PJI, with a sensitivity of only 23.0% when using MSIS criteria as the gold standard. Polymerase chain reaction also appears to be significantly less accurate than culture in the diagnosis of PJI. Currently, several laboratory tests used for either criteria for PJI diagnosis should be obtained along with the overall clinical picture to help guide decision-making for PJI treatment. [Orthopedics. 2020;43(6):333-338.].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3928/01477447-20200923-01DOI Listing
November 2020

Paget's Disease in Primary Total Hip Arthroplasty Is Associated With Greater In-Hospital Lengths of Stay, Costs, and Complications.

J Arthroplasty 2021 02 15;36(2):623-629. Epub 2020 Aug 15.

Duke University, Department of Orthopaedic Surgery, Durham, NC.

Background: There are few well-powered studies investigating the association of Paget's disease of bone on patients undergoing primary total hip arthroplasty (THA). This study utilized a nationwide database to determine whether Paget's patients undergoing primary THA are associated with higher rates of (1) lengths of stay (LOS); (2) costs; and (3) complications (medical/surgical and implant-related).

Methods: Using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes, Paget's patients undergoing primary THA were identified and matched to non-Paget's patients in a 1:5 ratio by age, sex, and comorbidities utilizing the PearlDiver database. This resulted in 21,714 patients in Paget's (n = 3619) and non-Paget's (n = 18,095) cohorts. Outcomes assessed included LOS, episode-of-care costs, medical/surgical complications, and implant-related complications. A P value less than .003 was considered statistically significant.

Results: Compared to the matched cohort, Paget's patients undergoing primary THA had significantly longer LOS (P < .0001), higher 90-day total global episode-of-care costs (P < .0001), higher 90-day medical and surgical complications (P < .0001), and higher implant-related complications (P < .0001).

Conclusion: We found that Paget's was associated with higher rates of LOS, costs, and complications. Although there was an association found, the risk appears reasonably low compared to the matched cohort. The study can be utilized by orthopedic professionals to counsel and educate these patients of potential complications which may occur following their procedure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.08.017DOI Listing
February 2021

Patient Risk Profile for Unplanned 90-Day Emergency Department Visits Differs Between Total Hip and Total Knee Arthroplasty.

Orthopedics 2020 Sep;43(5):295-302

Numerous studies have explored 90-day readmissions following total joint arthroplasty; however, there is a paucity of literature concerning 90-day emergency department (ED) visits. The authors aimed to characterize the risk factors for ED presentations and to determine the primary reasons for return, hypothesizing that certain medical comorbidities would account for resource utilization. The institutional database was queried for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients were stratified based on return visits to the ED within 90 days postoperatively. Univariable and multivariable analyses were performed to determine the factors most predictive of ED return for each THA and TKA. A total of 10,479 procedures resulted in 1234 90-day ED visits made by 937 patients. Significant predictors of 90-day ED return after THA included black race, age older than 80 years, congestive heart failure, valvular heart disease, metastatic disease, peripheral vascular disease, alcoholism, drug use, depression, and discharge to a skilled nursing facility. In contrast, only black race, liver insufficiency, cancer, and pulmonary hypertension were predictive of ED return following TKA. The primary risk factors for ED return differ for THA and TKA, and this is not currently reflected in the medical severity diagnosis-related group system. Specifically, black patients with multiple comorbidities are at high risk for unplanned ED visits following THA. This should be considered in patient counseling and outreach programs when attempting to mitigate the postoperative risks and to decrease 90-day resource utilization in this patient population. [Orthopedics. 2020;43(5):295-302.].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3928/01477447-20200818-02DOI Listing
September 2020

A Case Complexity Modifier Is Warranted for Primary Total Knee Arthroplasty.

J Arthroplasty 2021 01 31;36(1):37-41. Epub 2020 Jul 31.

Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC.

Background: The Center for Medicare and Medicaid Services is faced with a challenge of decreasing the cost of care for total knee arthroplasty (TKA) but must make efforts to prevent patient selection bias in the process. Currently, no appropriate modifier codes exist for primary TKA based on case complexity. We sought to determine differences in perioperative parameters for patients with complex primary TKA with the hypothesis that they would require increased cost of care, prolonged care times, and have worse postoperative outcome metrics.

Methods: We performed a single-center retrospective review from 2015 to 2018 of all primary TKAs. Patient demographics, medial proximal tibial angle (mPTA), lateral distal femoral angle (lDFA), flexion contracture, cost of care, and early postoperative outcomes were collected. Complex patients were defined as those requiring stems or augments, and multivariable logistic regression analysis and propensity score matching were performed to evaluate perioperative outcomes.

Results: About 1043 primary TKAs were studied, and 84 patients (8.3%) were deemed complex. For this cohort, surgery duration was greater (P < .001), cost of care higher (P < .001), and patients had a greater likelihood for 90-day hospital return. Deviation of mPTA and lDFA was significantly greater preoperatively before and after propensity score matching. Cut point analysis demonstrated that preoperative mPTA <83 or >91, lDFA <84 or >90, flexion contracture >10, and body mass index >35.7 were associated with complex procedures.

Conclusion: Complex primary TKA may be identifiable preoperatively and those cases associated with prolonged operative time, excess hospital cost of care, and increased 90-day hospital returns. This should be considered in future reimbursement models to prevent patient selection bias, and a complexity modifier is warranted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.07.066DOI Listing
January 2021

The Calpain Gene is Correlated With Metal-on-Metal Hip Replacement Failures.

J Arthroplasty 2021 01 30;36(1):236-241.e3. Epub 2020 Jul 30.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC.

Background: Metal-on-metal (MOM) total hip arthroplasty is associated with unacceptable failure rates secondary to metal ion reactions. Efforts to identify which patients will go on to failure have been limited; recently, there has been a suggestion for a potential genetic basis for the increased risk of revision in MOM hip replacements (MOMHRs). The purpose of this study is to determine whether certain immunologic genotypes are predictive of the need for revision in patients with MOM total hip implants.

Methods: This is a case-control study of all patients undergoing primary MOMHR between September 2002 and January 2012 with a minimum of 5-year follow-up. Our investigational "case" cohort was comprised of patients who underwent revision for MOMHR for a reason other than infection. A single-nucleotide polymorphism (SNP) array analysis was performed to identify a potential genetic basis for failure.

Results: Thirty-two patients (15 case and 17 control) were included in our analysis. All patients in the revision group had a chief complain of pain; revision patients were more likely to have a posterior approach (P = .01) and larger head size (P = .04) than nonrevision patients. No patient or implant characteristics were independently associated with revision in a multivariate analysis. Patients with SNP kgp9316441 were identified as having an increased odds of revision for MOM failure (P < .001).

Conclusion: This study identified an SNP, kgp9316441, encoding proteins associated with inflammation and macrophage activation. This SNP was associated with significantly increased odds of revision for MOMHR. Future studies are warranted to validate this gene target both in vitro and in vivo.

Level Of Evidence: III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.07.054DOI Listing
January 2021

Arthroplasty Surgeons Do Not Improve Acute Outcomes for Patients With Hip Fracture Relative to Other Subspecialists.

Orthopedics 2020 Sep 7;43(5):e442-e446. Epub 2020 Jul 7.

As bundled reimbursement models continue to evolve, there is a continued effort to increase the value of care for patients undergoing arthroplasty. The authors sought to evaluate the effect of surgeon specialization (arthroplasty vs non-arthroplasty) on acute outcomes for patients with hip fracture who underwent total hip arthroplasty (THA), in an effort to determine whether the value of care can be improved by surgeons specializing in these procedures. They performed a multicenter retrospective cohort study of patients who had hip fracture and were treated with THA between June 2013 and February 2018 at 2 academic institutions that were involved in bundled reimbursement initiatives. Patients were stratified based on the subspecialty training of the operative surgeon (fellowship-trained adult reconstruction vs other orthopedic sub-specialty), and 90-day readmissions, length of stay, and discharge disposition were compared between groups. A total of 291 patients were included in the final cohort, with 120 (41.2%) undergoing surgery performed by a fellowship-trained adult reconstruction surgeon. No significant difference was found in age, sex, race, or American Society of Anesthesiologists score between the 2 groups. In addition, no significant difference was found in length of stay, discharge to a facility, or 90-day readmissions on univariable or multivariable analysis when adjusted for age, sex, body mass index, and American Society of Anesthesiologists score. This study showed that the acute outcomes used to assess the value of care for patients undergoing THA were not significantly different when the surgery was performed by an adult reconstruction specialist compared with other orthopedic surgeons at 2 high-volume academic centers with perioperative care pathways. Alternative modalities to significantly improve acute postoperative outcomes in a bundled reimbursement model must be investigated. [Orthopedics. 2020;43(5):e442-e446.].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3928/01477447-20200619-11DOI Listing
September 2020

Total Knee Arthroplasty in Patients with Dementia.

J Knee Surg 2020 May 27. Epub 2020 May 27.

Department of Orthopaedic Surgery, Duke University, Durham, North Carolina.

There are few studies evaluating total knee arthroplasty (TKA) in patients with dementia. The purpose of this study was to evaluate the rate of revision, complication, emergency department (ED) visitation, and discharge disposition in patients with dementia undergoing primary TKA. In this retrospective study, we evaluated patients from 2007 to 2017 using a national database. Ninety-day complications in patients with dementia undergoing TKA were increased risk of ED visitation and skilled nursing facility (SNF) disposition (  ≤  0.05). Two-year complications in patients with dementia undergoing TKA were increased risk of ED visitation and SNF disposition (  ≤  0.05). Patients with dementia undergoing TKA are at an increased risk of resource utilization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0040-1712086DOI Listing
May 2020

Same-day Bilateral Total Knee Arthroplasty Did Not Increase 90-day Hospital Returns.

J Orthop Surg (Hong Kong) 2020 Jan-Apr;28(2):2309499020918170

Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC, USA.

Purpose: Bilateral total knee arthroplasty (TKA) can be performed in patients with bilateral knee arthritis. Outside of nationwide database studies, which have limitations, few studies have compared outcomes for same-day versus staged TKA. We sought to compare patient outcomes at a single tertiary referral center.

Methods: The institutional database was queried from March 2014 to December 2017 for primary TKA. Patients undergoing bilateral procedures were stratified by same-day versus staged; length of stay (LOS), disposition, 90-day emergency department (ED) visits, and 90-day readmissions were examined through univariable and multivariable analyses.

Results: A total of 676 patients were evaluated (113 same-day and 563 staged bilateral TKA patients) with mean age 66.0 (8.5) at first surgery and 292.1 (241.6) days between staged procedures. Same-day bilateral TKA patients were younger ( < 0.001), had lower body mass index (BMI) ( = 0.010), and had lower American Society of Anesthesiologists (ASA) scores ( = 0.030). They were more likely to have a prolonged LOS ( < 0.001) and be discharged to skilled nursing facility or rehab facility ( < 0.001). Total LOS for separate hospitalizations in staged procedures was greater than LOS for same-day bilateral TKAs ( < 0.001). There was no difference in 90-day ED visits ( = 0.623) or readmission ( = 0.286). In a multivariable model controlling for age, BMI, and ASA score, same-day bilateral TKA was not significantly associated with ED visits or readmissions.

Conclusions: Patients undergoing same-day bilateral TKAs were more likely to be discharged to post-acute care facilities, however they did not have increased 90-day readmissions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2309499020918170DOI Listing
March 2021

Total Hip Arthroplasty in Patients With Dementia.

J Arthroplasty 2020 06 4;35(6):1667-1670.e2. Epub 2020 Feb 4.

Department of Orthopaedic Surgery, Duke University, Durham, NC.

Background: There are few studies evaluating total hip arthroplasty (THA) in patients with dementia. The purpose of this study is to evaluate the rate of revision, complication, emergency department (ED) visitation, and discharge disposition in patients with dementia undergoing THA.

Methods: In this retrospective study, we evaluated patients from 2007 to 2017 using a national database. We evaluated complications in patients with a diagnosis of dementia undergoing primary THA for osteoarthritis.

Results: In patients with dementia undergoing THA, the 90-day complications were increased risk of revision, delirium, ED visitation, and skilled nursing facility disposition (P < .05). In patients with dementia undergoing THA, the 2-year complications were increased risk of delirium, ED visitation, and skilled nursing facility disposition (P < .05).

Conclusion: Patients with dementia undergoing THA are at an increased risk of complications and 90-day resource utilization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.01.070DOI Listing
June 2020

Impact of Patent Foramen Ovale on Total Knee Arthroplasty Cerebrovascular Accident Perioperative Management.

Orthopedics 2020 May 20;43(3):e151-e158. Epub 2020 Feb 20.

Venous thromboembolism and ischemic stroke are major complications following total knee arthroplasty (TKA) and potentially are associated with a patent foramen ovale (PFO). Although this association has been shown in other surgical disciplines, it has not been demonstrated in patients undergoing TKA. This study was undertaken to determine whether patients with a PFO would have a significantly increased risk of cerebrovascular accident (CVA) following TKA. The Humana national database was used to identify TKA patients who were stratified by the presence of a PFO from 2007 to 2016. Ninety-day follow-up was used for the primary outcome of CVA. Potential confounding comorbidities also were investigated, including age, sex, anticoagulation, insurance type, arrhythmia, valvular disease, peripheral vascular disease, chronic kidney disease, and diabetes mellitus. Of 153,245 TKAs, a total of 2272 patients had strokes; 479 of these patients had a PFO. On multivariable analysis, PFO remained an independent predictor of CVA postoperatively (odds ratio, 3.824; 95% confidence interval, 2.614-5.406; P<.0001). Other significant comorbidities associated with CVA included arrhythmia, chronic kidney disease, diabetes mellitus, peripheral vascular disease, and coronary valve disease. Importantly, low-molecular weight heparin or factor Xa inhibitor administration postoperatively had a negative correlation with stroke (odds ratio, 0.762; 95% confidence interval, 0.663-0.871; P=.0001 and odds ratio, 0.749; 95% confidence interval, 0.628-0.885; P=.0009, respectively). The findings of the multivariable analysis indicate PFO is associated with early postoperative CVA within 90 days following TKA. If known preoperatively, appropriate referral should be made to a cardiologist for PFO management and anticoagulation to reduce the overall risk of stroke. [Orthopedics. 2020;43(3):e151-e158.].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3928/01477447-20200213-06DOI Listing
May 2020

Total Hip Arthroplasty for Femoral Neck Fracture: The Economic Implications of Orthopedic Subspecialty Training.

J Arthroplasty 2020 06 29;35(6S):S101-S106. Epub 2020 Jan 29.

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

Background: Hip fractures have significant economic implications as a result of their associated direct and indirect medical costs. Under alternative payment models, it has become increasingly important for institutions to find avenues by which costs could be reduced while maintaining outcomes in these cases.

Methods: A multi-institutional retrospective analysis of Medicare patients who underwent total hip arthroplasty (THA) for femoral neck fracture was conducted to assess the impact of fellowship training in adult reconstruction (AR) on the total costs of the 90-day episode of care. Patients were divided into 2 cohorts according to fellowship training status of the operating surgeon: (1) AR-trained and (2) other fellowship training (non-AR). The primary outcome was the total cost of the 90-day episode of care converted to a percentage of the bundled payment target price.

Results: A total of 291 patients who underwent THA for the treatment of a femoral neck fracture were included. The average total cost percentage of the 90-day episode of care was significantly lower for the AR cohort 70.9% (±36.6%) than the non-AR cohort 82.6% (±36.1%) (P < .01). After controlling for baseline demographics in the multivariable logistic regression, the care episodes in which the operating surgeons were AR fellowship-trained were still found to be significantly lower, at a rate of 0.87 times the costs of the non-AR surgeons (95% confidence interval 0.78-0.97, P = .011). In addition, the non-AR cohort exceeded the bundle target price more frequently than the AR cohort, 49 (28.7%) vs 16 (13.3%) (P = .02).

Conclusion: In an era of bundled payments, ascertaining factors that may increase the value of care while decreasing the cost is paramount for institutions and policymakers alike. The results presented in this study suggest that in the femoral neck fracture population, surgeons trained in AR achieve lower total costs for the THA episode of care. Furthermore, non-AR fellowship-trained surgeons exceeded the bundled payment target more frequently than the AR surgeons.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.01.047DOI Listing
June 2020

Use and Cost of Reverse Shoulder Arthroplasty Versus Hemiarthroplasty for Acute Proximal Humerus Fractures.

Orthopedics 2020 Mar 13;43(2):119-125. Epub 2020 Jan 13.

Although reverse total shoulder arthroplasty (RTSA) may outperform hemiarthroplasty (HSA) for acute proximal humerus fractures (PHF), both the RTSA implant and the procedure are more expensive. The goal of this study was to compare the use and longitudinal cost of care for RTSA vs HSA for the treatment of PHF. Patients were selected from a private payer database with a surgical date between 2010 and 2015. The International Classification of Diseases, 9th Revision, Clinical Modification(ICD-9-CM), codes were used to identify patients who underwent RTSA and HSA for PHF. The 1-year cost follow-up was guaranteed. During the study period, a total of 1038 patients underwent RTSA and 1046 patients underwent HSA for the treatment of PHF. A total of 601 patients who underwent RTSA and 431 patients who underwent HSA with at least 1 year of follow-up were matched by age and sex. The average Charlson Comorbidity Index for the RTSA and HSA groups was 4, indicating similar health status. From 2010 to 2015, the use of RTSA increased linearly (R=0.986), whereas the use of HSA decreased linearly (R=0.796). The average index admission cost was higher for RTSA than for HSA ($15,263 vs $14,356, respectively; mean difference [MD], $907; 95% confidence interval [CI], $58-$1760; P=.04). At 1 year postoperatively, however, no statistically significant difference was noted in cost (P=.535). The 1-year physical and occupational therapy cost per patient was higher after HSA than after RTSA (MD, $723; CI, $718-$728; P<.001), but no difference was noted in discharge disposition or 1-year revision or readmission rates. The results of this study suggest that despite the higher initial cost of RTSA, the total cost of care in the year after RTSA and HSA is similar. Therefore, RTSA should be considered in the appropriate clinical setting. [Orthopedics. 2020;43(2):119-125.].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3928/01477447-20200107-06DOI Listing
March 2020

Response to Letter to the Editor on "The Role of Malnutrition in Ninety-Day Outcomes After Total Joint Arthroplasty".

J Arthroplasty 2020 03 22;35(3):901-902. Epub 2019 Nov 22.

Duke Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2019.11.022DOI Listing
March 2020
-->