Abstract Readmission has been cited as an important quality measure in the Patient Protection and Affordable Care Act. We queried an electronic database for all patients who underwent Total Hip ...Arthroplasty or Total Knee Arthroplasty at our institution from 2006 to 2010 and identified those readmitted within 90 days of surgery, reviewed their demographic and clinical data, and performed a multivariable logistic regression analysis to determine significant risk factors. The overall 90-day readmission rate was 7.8%. The most common readmission diagnoses were related to infection and procedure-related complications. An increased likelihood of readmission was found with coronary artery disease, diabetes, increased LOS, underweight status, obese status, age (over 80 or under 50), and Medicare. Procedure-related complications and wound complications accounted for more readmissions than any single medical complication.
Abstract Two goals of tibial tray placement in TKA are to maximize coverage and establish proper rotation. Our purpose was to utilize MRI information obtained as part of PSI planning to determine the ...impact of tibial tray design on the relationship between coverage and rotation. MR images for 100 consecutive knees were uploaded into PSI software. Preoperative planning software was used to evaluate 3 different tray designs: anatomic, symmetric, and asymmetric. Approximately equally good coverage was achieved with all three trays. However, the anatomic compared to symmetric/asymmetric trays required less malrotation (0.3° vs 3.0/2.4°; P < 0.001), with a higher proportion of cases within 5° of neutral (97% vs 73/77%; P < 0.001). In this study, the anatomic tibia optimized the relationship between coverage and rotation.
Background The US medical malpractice system assumes that the threat of liability should deter negligence, but it is unclear whether malpractice environment affects health care quality. We sought to ...explore the association between state malpractice environment and postoperative complication rates. Study Design This observational study included Medicare fee-for-service beneficiaries undergoing one of the following operations in 2010: colorectal, lung, esophageal, or pancreatic resection, total knee arthroplasty, craniotomy, gastric bypass, abdominal aortic aneurysm repair, coronary artery bypass grafting, or cystectomy. The state-specific malpractice environment was measured by 2010 medical malpractice insurance premiums, state average award size, paid malpractice claims/100 physicians, and a composite malpractice measure. Outcomes of interest included 30-day readmission, mortality, and postoperative complications (eg sepsis, myocardial infarction MI, pneumonia). Using Medicare administrative claims data, associations between malpractice environment and postoperative outcomes were estimated using hierarchical logistic regression models with hospital random-intercepts. Results Measures of malpractice environment did not have significant, consistent associations with postoperative outcomes. No individual tort reform law was consistently associated with improved postoperative outcomes. Higher-risk state malpractice environment, based on the composite measure, was associated with higher likelihood of sepsis (odds ratio OR 1.22, 95% CI 1.07 to 1.39), MI (OR 1.14, 95% CI 1.06 to 1.23), pneumonia (OR 1.09, 95% CI 1.03 to 1.16), acute renal failure (OR 1.15, 95% CI 1.08 to 1.22), deep vein thrombosis/pulmonary embolism (OR 1.22 95% CI 1.13 to 1.32), and gastrointestinal bleed (OR 1.18, 95% CI 1.08 to 1.30). Conclusions Higher risk malpractice environments were not consistently associated with a lower likelihood of surgical postoperative complications, bringing into question the ability of malpractice lawsuits to promote health care quality.
Uncemented femoral implants of various designs have proved to provide stable initial and long-term fixation in patients who undergo total hip arthroplasty. Challenges in primary total hip ...arthroplasty have led to the evolution of short stem designs. These challenges include proximal/metaphyseal and distal/diaphyseal mismatch; facilitation of less-invasive surgical exposures, especially the direct anterior approach; and bone preservation for potential revision surgery.
Abstract If PSI preoperative planning were perfectly precise, a single MRI would give rise to one preoperative plan. Our purpose was to determine whether a single MRI inputted into two different PSI ...software yielded differences in preoperative alignment determination, component sizing, and bone resection within the preoperative plan. This prospective comparative study evaluated 40 preoperative plans generated by two PSI software given identical MRI. Femoral and tibial component sizes differed between software in 37.5% and 30.0% of cases, respectively. The maximum difference in bone resection between software ranged from 2.2 mm to 5.1 mm. Surgeons should be prepared to intraoperatively deviate from PSI selected size by 1 size. It may be necessary to fine tune soft tissue balancing when using a PSI system.
Abstract Proper femoral component rotation is crucial in successful total knee arthroplasty. Rotation using anatomic landmarks has traditionally referenced the transepicondylar axis (TEA), ...Whiteside’s Line (WSL), or posterior condylar axis (PCA). TEA is thought to best approximate the flexion-axis of the knee, however WSL or PCA are common surrogates in the operating room. This study evaluated 560 knees using MRI-based planning software to assess the relationship of WSL and PCA to the TEA and determine if the relationships were influenced by pre-operative coronal deformity. Results showed the WSL–TEA relationship has more variability than PCA–TEA and that the PCA is more internally rotated in females and valgus knees. Axis options and historical assumptions about axis relationships may need to be reassessed as imaging technology advances.
Abstract Readmission rates have been cited as an important quality measure in the Affordable Care Act. Accordingly, understanding and accurately tracking the causes for readmission will be ...increasingly important. We queried an electronic database for all patients who underwent primary THA or TKA at our institution from 2006 through 2010. We identified those readmitted within 90 days of surgery and analyzed 87 random de-identified medical records. We then assigned a clinical diagnosis for each readmission, which was then compared with the coder-derived diagnosis by ICD-9 code. The overall 90-day readmission rate was 7.9%. We identified 22 of 87 patients for whom there was disagreement (25.3%, 95% CI = 16.6–35.8%). The most common were procedure-related complications. Coded diagnoses frequently did not correlate with the physician-derived diagnoses. The unverified use of coded readmission diagnoses in calculating quality measures may not be clinically relevant.
Abstract A prospective comparison of 148 hips in 139 consecutive patients treated with an off-the-shelf uncemented metaphyseal engaging (91–105 mm) stem and 69 hips in 61 patients treated with a ...custom uncemented metaphyseal engaging short stem was conducted to evaluate the mid-term clinical and radiographic results of an off-the-shelf metaphyseal-engaging short stem implant. All implants were radiographically stable with proximal bony in-growth. There was no significant difference in post-operative HHS ( P <. 001) or WOMAC scores ( P < .001) between cohorts. An off-the-shelf short femoral stem designed to fit and fill the metaphysis provides reliable fixation up to eight years with equivalent clinical and radiographic results to a customized implant.
Abstract PSI software adjusts preoperative planning to accommodate differences in implant design. Such adjustments may influence the accuracy of intraoperative jig placement, bone resection, or ...component placement. Our purpose was to determine whether implant design influences PSI accuracy. 96 and 123 PSI TKA were performed by a single surgeon using two different implant systems and identical PSI software. Femoral coronal alignment outliers were greater for Implant 1 (23.9% Implant 1 vs. 13.4% Implant 2; P = 0.050). Tibial coronal alignment outliers were greater for Implant 2 (10.9% Implant 1 vs. 22.7% Implant 2; P = 0.025). There was no difference in overall mechanical axes. Differences in implant design can influence bone resection and component alignment. PSI software rationale must align with surgeons’ intraoperative goals.
Total hip arthroplasty (THA) is a highly successful procedure but limited in many low-resource nations. In response, organizations globally have conducted service trips to provide arthroplasty care ...to underserved populations. Few outcomes data are currently available related to these trips. Our study aims to demonstrate the feasibility of tracking patient-reported outcomes and complications after THA in a low-resource setting and that outcomes are comparable to those in developed countries.
We completed an arthroplasty service trip to Brazil in 2017 where we performed 46 THAs on 38 patients. The mean patient age was 48.8 years. Forty-seven percent were female. Patient-reported outcome scores were collected preoperatively and postoperatively at 2, 6, and 12 weeks and 1 year. A multivariate regression analysis was performed to identify associations between patient factors and 12-week outcomes.
The mean modified Harris Hip Score, Hip Disability and Osteoarthritis Outcome Score, Patient-Reported Outcome Measurement Information System Short Form (PROMIS-SF) Pain Interference, and PROMIS-SF Physical Function all improved significantly compared to baseline at 2, 6, and 12 weeks and 1 year postoperatively. At 1 year, only 29% of patients (11 of 38) were reachable by phone for follow-up.Multivariate regression analysis at 12 weeks found that females had more improvement in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement scores (P = .003) and PROMIS-SF Pain Interference scores (P = .01) than males, and patients with rheumatoid arthritis had more improvement in PROMIS-SF Pain Interference scores (P = .008) compared with all other diagnoses.
Patients in low-resource countries benefitted significantly from THA performed by a visiting surgical team. However, following up patients is difficult in low-resource countries once they leave the hospital.
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