Tranexamic acid (TXA) is an antifibrinolytic agent commonly used to reduce blood loss in total hip arthroplasty (THA). The purpose of our study was to evaluate the efficacy of TXA in primary THA to ...support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine on the use of TXA in primary total joint arthroplasty.
A search was performed using Ovid-MEDLINE, Embase, Cochrane Reviews, Scopus, and Web of Science databases to identify all publications before July 2017 on TXA in primary THA. We completed qualitative and quantitative homogeneity testing of all included studies. Direct and indirect comparisons were analyzed using a network meta-analysis followed by consistency testing of the results.
Two thousand one hundred thirteen publications underwent critical appraisal with 34 publications identified as representing the best available evidence for inclusion in the analysis. Topical, intravenous, and oral TXA formulations provided reduced blood loss and risk of transfusion compared to placebo, but no formulation was clearly superior. Use of repeat doses, higher doses, or variation in timing of administration did not significantly reduce blood loss or risk of transfusion.
Strong evidence supports the use of TXA to reduce blood loss and risk of transfusion after primary THA. No specific routes of administration, dosage, dosing regimen, or time of administration provides clearly superior blood-sparing properties.
Patient satisfaction after total hip (THA) and total knee arthroplasty (TKA) is a core outcome selected by the Outcomes Measurement in Rheumatology. Up to 20% of THA/TKA patients are dissatisfied. ...Improving patient satisfaction is hindered by the lack of a validated measurement tool that can accurately measure change.
The psychometric properties of a proposed satisfaction instrument, consisting of 4 questions rated on a Likert scale, scored 1-100, were tested for validity, reliability, and sensitivity to change using data collected between 2007 and 2011 in an arthroplasty registry.
We demonstrated construct validity by confirming our hypothesis; satisfaction correlated with similar constructs. Satisfaction correlated moderately with pain relief (TKA ρ = 0.61, THA ρ = 0.47) and function (TKA ρ = 0.65, THA ρ = 0.51) at 2 years; there was no correlation with baseline/preoperative pain/function values, as expected. Overall Cronbach’s alpha >0.88 confirmed internal consistency. Test-retest reliability with weighted kappa ranged 0.60-0.75 for TKA and 0.36-0.56 for THA. Hip disability and Osteoarthritis Outcome Score/Knee injury and Osteoarthritis Outcome Scores quality of life improvement (>30 points) corresponds to a mean satisfaction score of 93.2 (standard deviation, 11.5) after THA and 90.4 (standard deviation, 13.8) after TKA, and increasing relief of pain and functional improvement increased the strength of their association with satisfaction. The satisfaction measure has no copyright and is available free of cost and represents minimal responder burden.
Patient satisfaction with THA/TKA can be measured with a validated 4-item questionnaire. This satisfaction measure can be included in a total joint arthroplasty core measurement set for total joint arthroplasty trials.
Background
Demand for total hip arthroplasty (THA) is high and expected to continue to grow during the next decade. Although much of this growth includes working-aged patients, cost-effectiveness ...studies on THA have not fully incorporated the productivity effects from surgery.
Questions/Purposes
We asked: (1) What is the expected effect of THA on patients’ employment and earnings? (2) How does accounting for these effects influence the cost-effectiveness of THA relative to nonsurgical treatment?
Methods
Taking a societal perspective, we used a Markov model to assess the overall cost-effectiveness of THA compared with nonsurgical treatment. We estimated direct medical costs using Medicare claims data and indirect costs (employment status and worker earnings) using regression models and nonparametric simulations. For direct costs, we estimated average spending 1 year before and after surgery. Spending estimates included physician and related services, hospital inpatient and outpatient care, and postacute care. For indirect costs, we estimated the relationship between functional status and productivity, using data from the National Health Interview Survey and regression analysis. Using regression coefficients and patient survey data, we ran a nonparametric simulation to estimate productivity (probability of working multiplied by earnings if working minus the value of missed work days) before and after THA. We used the Australian Orthopaedic Association National Joint Replacement Registry to obtain revision rates because it contained osteoarthritis-specific THA revision rates by age and gender, which were unavailable in other registry reports. Other model assumptions were extracted from a previously published cost-effectiveness analysis that included a comprehensive literature review. We incorporated all parameter estimates into Markov models to assess THA effects on quality-adjusted life years and lifetime costs. We conducted threshold and sensitivity analyses on direct costs, indirect costs, and revision rates to assess the robustness of our Markov model results.
Results
Compared with nonsurgical treatments, THA increased average annual productivity of patients by USD 9503 (95% CI, USD 1446–USD 17,812). We found that THA increases average lifetime direct costs by USD 30,365, which were offset by USD 63,314 in lifetime savings from increased productivity. With net societal savings of USD 32,948 per patient, total lifetime societal savings were estimated at almost USD 10 billion from more than 300,000 THAs performed in the United States each year.
Conclusions
Using a Markov model approach, we show that THA produces societal benefits that can offset the costs of THA. When comparing THA with other nonsurgical treatments, policymakers should consider the long-term benefits associated with increased productivity from surgery.
Level of Evidence
Level III, economic and decision analysis.
We quantified surgical site infections (SSIs) after preoperative screening/selective decolonization before elective total joint arthroplasty (TJA) with 2-year follow-up and 2 controls. Concurrent ...controls (n = 2284) were patients of surgeons not participating in screening/decolonization. Preintervention controls (n = 741) were patients of participating surgeons who underwent TJA the previous year. Staphylococcus aureus nasal carriers (321/1285 25%) used intranasal mupirocin and chlorhexidine baths as outpatients. Staphylococcal SSIs occurred in no intervention patients (0/321) and 19 concurrent controls. If all SSIs occurred in carriers and 25% of controls were carriers, staphylococcal SSI rate would have been 3.3% in controls (19/571; P = .001). Overall SSI rate decreased from 2.7% (20/741) in preintervention controls to 1.2% (17/1440) in intervention patients (P = .009). Preoperative screening/selective decolonization was associated with fewer SSIs after elective TJA.
Total knee arthroplasty (TKA) was removed from the Centers for Medicare and Medicaid Services (CMS) Inpatient-Only (IPO) list starting January 1, 2018. Many hospitals responded by instructing ...surgeons to schedule all TKAs as outpatient procedures, and some local Medicare Advantage contractors began to expect outpatient status for all or most TKA cases. This activity and ensuing confusion has caused considerable unintended disruption for surgeons, hospitals, and patients. The purpose of this study was to gauge the impact on providers and patients.
Active members of the American Association of Hip and Knee Surgeons were sent a 9-question survey asking if the surgeon's hospital was treating all patients undergoing TKA as outpatients and if Medicare Advantage administrators and commercial payers were treating all or most the same. Questions also inquired about the impact on surgeon practices and their patients.
Seven hundred thirty members (26%) responded; of which, 59.5% reported that their hospitals have instructed them that all Medicare TKAs should be scheduled as outpatient procedures; 40.5% have been asked to use proscribed documentation to justify that change; 30.4% reported that their patients have incurred added personal cost secondary to their surgical procedure being billed as an outpatient procedure; and 76.1% report that this issue has become an administrative burden.
The CMS clearly stated its expectation in the 2018 Outpatient Prospective Payment System Final Rule that the great majority of Medicare fee-for-service TKA patients would continue to be treated as inpatients. Nonetheless, many hospitals have decided to schedule all TKA cases as outpatients due to the 2-midnight rule despite a moratorium on recovery audits. It is the position of the American Association of Hip and Knee Surgeons that the CMS needs to provide more specific expectations concerning the needed language justifying admission or exempt TKA from the 2-midnight rule to mitigate the unintended confusion demonstrated by hospitals and some payers that has resulted from the removal of TKA from the Inpatient-Only list.
Providers of total hip and knee replacements are being judged regarding quality/cost by payers using competition-based performance measures with poor medical and no socioeconomic risk adjustment. ...Providers might assume that other providers shed risk and the perception of added risk can influence practice. A poll was collected to examine such perceptions.
In 2019 a poll was sent to the 2800 surgeon members of the American Association of Hip and Knee Surgeons using Survey Monkey while protecting respondent anonymity/confidentiality. The questions asked whether the perception of poorly risk-adjusted medical comorbidities and socioeconomic risk factors influence surgeons to selectively offer surgery.
There were 474 surgeon responses. Prior to elective total hip arthroplasty/total knee arthroplasty, 95% address modifiable risk factors; 52% require a body mass index <40, 64% smoking cessation, 96% an adequate hemoglobin A1C; 82% check nutrition; and 63% expect control of alcohol 2. Due to lack of socioeconomic risk adjustment, 83% reported feeling pressure to avoid/restrict access to patients with limited social support, specifically the following: Medicaid/underinsured, 81%; African Americans, 29%; Hispanics/ethnicities, 27%; and low socioeconomic status, 73%. Of the respondents, 93% predicted increased access to care with more appropriate risk adjustment.
Competition-based quality/cost performance measures influence surgeons to focus on medical risk factors in offering lower extremity arthroplasty. The lack of socioeconomic risk adjustment leads to perceptions of added risk from such factors as well. This leads to marginal loss of access for patients within certain medical and socioeconomic classes, contributing to existing healthcare disparities. This represents an unintended consequence of competition-based performance measures.
The chemotactic properties of a biologic scaffold composed of extracellular matrix (ECM) and subjected to in vivo degradation and remodeling were evaluated in a mouse model of Achilles tendon ...reconstruction. Following a segmental resection of the Achilles tendon in both C57BL/6 and MRL/MpJ mice, the defect was repaired with either an ECM scaffold composed of urinary bladder matrix (UBM) or resected autologous tendon. The surgically repaired and the contralateral tendons were harvested at 3, 7, and 14 days following surgery from each animal. Chemotaxis of multipotential progenitor cells toward the harvested tissue was quantified using a fluorescent-based cell migration assay. Results showed greater migration of progenitor cells toward tendons repaired with UBM-ECM scaffold compared to both the tendons repaired with autologous tissue and the normal contralateral tendon in both the MRL/MpJ and C57BL/6 mice. The magnitude and temporal pattern of the chemotactic response differed between the two mouse strains.
Tranexamic acid (TXA) is effective in reducing blood loss in total joint arthroplasty (TJA), but concerns still remain regarding the drug's safety. The purpose of this direct meta-analysis was to ...evaluate and establish a basis for the safety recommendations of the combined clinical practice guidelines on the use of TXA in primary TJA.
A search was completed for studies published before July 2017 on TXA in primary TJA. We performed qualitative and quantitative homogeneity testing and a direct comparison meta-analysis. We used the American Society of Anesthesiologists (ASA) score of 3 or greater as a proxy for patients at higher risk for complications in general and performed a meta-regression analysis to investigate the influence of comorbidity burden on the risk of arterial thromboembolic event and venous thromboembolic event (VTE).
Topical, intravenous, and oral TXA were not associated with an increased risk of VTE after TJA. In addition, meta-regression demonstrated that TXA use in patients with an ASA status of 3 or greater was not associated with an increased risk of VTE after total knee arthroplasty.
Although most studies included in our analysis excluded patients with a history of prior thromboembolic events, our findings support the lack of evidence of harm from TXA administration in patients undergoing TJA. Moderate evidence supports the safety of TXA in patients undergoing total knee arthroplasty with an ASA score of 3 or greater. The benefits of using TXA appear to outweigh the potential risks of thromboembolic events even in patients with a higher comorbidity.
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