Abstract Revision knee data from six joint arthroplasty centers were compiled for 2010 and 2011 to determine mechanism of failure and time to failure. Aseptic loosening was the predominant mechanism ...of failure (31.2%), followed by instability (18.7%), infection (16.2%), polyethylene wear (10.0%), arthrofibrosis (6.9%), and malalignment (6.6%). Mean time to failure was 5.9 years (range 10 days to 31 years). 35.3% of all revisions occurred less than 2 years after the index arthroplasty, 60.2% in the first 5 years. In contrast to previous reports, polyethylene wear is not a leading failure mechanism and rarely presents before 15 years. Implant performance is not a predominant factor of knee failure. Early failure mechanisms are primarily surgeon-dependent.
Purpose of review
Participation in alternative payment models has focused efforts to improve outcomes and patient satisfaction while also lowering cost for elective hip and knee replacement. The ...purpose of this review is to determine if preoperative education classes for elective hip and knee replacement achieve these goals.
Recent findings
Recent literature demonstrates that patients who attend education classes prior to surgery have decreased anxiety, better post-operative pain control, more realistic expectations of surgery, and a better understanding of their surgery. As a result, comprehensive clinical pathways incorporating a preoperative education program for elective hip and knee replacement lead to lower hospital length of stay, higher home discharge, lower readmission, and improved cost.
Summary
In summary, we report convincing evidence that preoperative education classes are an essential element to successful participation in alternative payment models such as the Bundle Payment Care Initiative.
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.
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.
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.
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.
The SARS-CoV-2 (COVID-19) pandemic caused a massive disruption in elective arthroplasty practice in the United States that to date has not been quantified. We sought to determine the impact of ...COVID-19 on arthroplasty volumes in the United States, how this varied across the country, and the resultant financial implications.
We conducted a retrospective analysis of Medicare fee-for-service beneficiaries undergoing primary and revision total knee arthroplasty (TKA) and total hip arthroplasty (THA) from January 1st through March 31st, 2020 with 74,080 TKAs and 54,975 THAs identified. We calculated the percent drop in average daily cases from before and after March 18, 2020. We then examined variation across states in arthroplasty case volumes as it related to reported COVID-19 cases, the impact of COVID-19 on length of stay and percentage of patients discharged home. Finally, we calculated the revenue impact on hospitals and surgeons.
There was a steep decline in TKA and THA volumes in mid-March of 94% and 92%, respectively. There was a significant variation for arthroplasty case volumes across states. We found minimal change in length of stay except for primary THAs with fracture going from 5 + days to 4 days. We saw an increasing trend in discharge to home with the greatest effect in primary THAs with fracture. The total daily hospital Medicare revenue for arthroplasty declined by 87% and surgeon revenue decreased by 85%.
The beginning of the COVID-19 pandemic caused a significant decrease in arthroplasty volumes in the Medicare population with a resultant substantial revenue loss for hospitals and surgeons.
The coronavirus disease 2019 (COVID-19) pandemic impacted the inpatient experience before and after total joint arthroplasty (TJA). This study aimed to examine how these changes affected patient ...satisfaction following TJA as recorded by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) postdischarge surveys and comments at 2 large academic institutions. A retrospective review identified patients who completed HCAHPS surveys following primary and revision TJA at 2 academic institutions: 1 in a predominately rural southern state (Institution A) and 1 in a northeastern metropolitan city (Institution B). Patients were grouped by discharge date: pre-COVID-19 (April 1, 2019, to October 31, 2019) or COVID-19 affected (April 1, 2020, to October 31, 2020). Differences in demographics, survey responses, and comment sentiments and themes were collected and evaluated. The number of HCAHPS surveys completed increased between periods at Institution A but decreased at Institution B (Institution A, 61 vs 103; Institution B, 524 vs 296). Rates of top-box survey responses remained the same across the 2 periods. The number of comments decreased at Institution B (1977 vs 1012) but increased at Institution A (55 vs 88). During the COVID-19-affected period, there was a significant increase in the negative comment rate from Institution B (11.6% vs 14.8%,
=.013) and a significant decrease in the positive comment rate from Institution A (70.9% vs 44.3%,
<.001). There was an increase in negative patient sentiments following TJA during the COVID-19 pandemic as seen in qualitative comments but not quantitative responses. This suggests that certain aspects of the TJA patient experience were impacted by COVID-19.
. 2023;46(2):e105-e110..
Several studies have suggested that spinal anesthesia gives superior outcomes for primary total joint arthroplasty (TJA). However, there is a lack of available data regarding contemporary general ...anesthesia (GA) approaches for revision TJA utilized at high-volume joint arthroplasty centers.
We retrospectively reviewed a series of 850 consecutive revision TJAs (405 revision total hip arthroplasties and 445 revision total knee arthroplasties) performed over 4 years at a single institution that uses a contemporary GA protocol and reported on the lengths of stay, early recovery rates, perioperative complications, and readmissions.
Of the revision arthroplasty patients, 74.4% (632 of 850) were discharged on postoperative day 1 and 68.5% (582 of 850) of subjects were able to participate in physical therapy on the day of surgery. Only 6 patients (0.7%) required an intensive care unit stay postoperatively. The 90-day readmission rate over this time was 11.3% (n = 96), while the reoperation rate was 9.4% (n = 80).
While neuraxial anesthesia is commonly preferred when performing revision TJA, we have demonstrated favorable safety and efficiency metrics utilizing GA in conjunction with contemporary enhanced recovery pathways. Our data support the notion that modern GA techniques can be successfully used in revision TJA.
Multiple papers have purported the superiority of spinal anesthesia used in total joint arthroplasty (TJA). However, there is a paucity of data available for modern general anesthesia (GA) regimens ...used at high-volume joint replacement centers.
We retrospectively reviewed a series of 1527 consecutive primary TJAs (644 total hip arthroplasties and 883 total knee arthroplasties) performed over a 3-year span at a single institution that uses a contemporary GA protocol and report on the length of stay, early recovery rates, perioperative complications, and readmissions.
From the elective TJAs performed using a modern GA protocol, 96.3% (n = 1471) of patients discharged on postoperative day 1, and 97.2% (n = 1482) of subjects were able to participate with physical therapy on the day of surgery. Only 6 patients (0.4%) required an intensive care unit stay postoperatively. The 90-day readmission rate over this time was 2.4% (n = 36), while the reoperation rate was 1.3% (n = 20).
Neuraxial anesthesia for TJA is commonly preferred in high-volume institutions utilizing contemporary enhanced recovery pathways. Our data support the notion that the utilization of modern GA techniques that limit narcotics and certain inhalants can be successfully used in short-stay primary total joint arthroplasty.
IV– Case series.
Abstract Data regarding the posterior slope of the tibia (PTS) are limited and sometimes conflicting. The purpose of this study was to determine the native posterior tibial slope in patients ...undergoing a medial or lateral UKA. A retrospective review was performed on 2395 CT scans in patients indicated for UKA, and the PTS of the osteoarthritic compartment was measured relative to a plane set perpendicular to the sagittal, tibial mechanical axis. The mean preoperative PTS in patients undergoing medial UKA was 6.8° + 3.3°, with 34.3% between 4° and 7°. The mean preoperative PTS in patients undergoing lateral UKA was 8.0° + 3.3°, with 27.5% between 4° and 7°. If attempting to recreate a patient's preoperative tibial slope, a routine target of 5° to 7° will produce a posterior slope less than the patient's native anatomy in 47% of patients undergoing UKA. This is the first, large CT-based review of posterior slope variation of the proximal tibia in patients undergoing UKA.
Flexion Instability After Total Knee Arthroplasty Stambough, Jeffrey B; Edwards, Paul K; Mannen, Erin M ...
Journal of the American Academy of Orthopaedic Surgeons,
2019-Sep-01, Letnik:
27, Številka:
17
Journal Article
Recenzirano
Odprti dostop
Flexion instability after total knee arthroplasty (TKA) is caused by an increased flexion gap compared with extension gap. Patients present with recurrent effusions, subjective instability ...(especially going downstairs), quadriceps weakness, and diffuse periretinacular pain. Manual testing for laxity in flexion is commonly done to confirm a diagnosis, although testing positions and laxity grades are inconsistent. Nonsurgical treatment includes quadriceps strengthening and bracing treatment. The mainstays to surgical management of femoral instability involve increasing the posterior condylar offset, decreasing the tibial slope, raising the joint line in combination with a thicker polyethylene insert, and ensuring appropriate rotation of implants. Patient outcomes after revision TKA for flexion instability show the least amount of improvement when compared with revisions for other TKA failure etiologies. Future work is needed to unify reproducible diagnostic criteria. Advancements in biomechanical analysis with motion detection, isokinetic quadriceps strength testing, and computational modeling are needed to advance the collective understanding of this underappreciated failure mechanism.
In response to the COVID-19 pandemic, hospitals in the United States were recommended to stop performing elective procedures. This stoppage has led to the cancellation of a large number of hip and ...knee arthroplasties. The effect of this on patients’ physical mental and economic health is unknown.
A survey was developed by the AAHKS Research Committee to assess pain, anxiety, physical function, and economic ability of patients to undergo a delayed operation. Six institutions conducted the survey to 360 patients who had to have elective hip and knee arthroplasty cancelled between March and July of 2020.
Patients were most anxious about the uncertainty of when their operation could be rescheduled. Although 85% of patients understood and agreed with the public health measures to curb infections, almost 90% of patients plan to reschedule as soon as possible. Age and geographic region of the patients affected their anxiety. Younger patients were more likely to have financial concerns and concerns about job security. Patients in the Northeast were more concerned about catching COVID-19 during a future hospitalization.
Patients suffering from the pain of hip and knee arthritis continue to struggle with pain from their end-stage disease. They have anxiety about the COVID-19 pandemic. Few patients feel they will be limited financially and 90% want to have surgery as soon as possible. Age and physical location of the patients affect their causes for anxiety around their future surgery.
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