This guideline supersedes a prior one from 2007 on a similar topic. The work group evaluated the available literature concerning various aspects of patient screening, risk factor assessment, and ...prophylactic treatment against venous thromboembolic disease (VTED), as well as the use of postoperative mobilization, neuraxial agents, and vena cava filters. The group recommended further assessment of patients who have had a previous venous thromboembolism but not for other potential risk factors. Patients should be assessed for known bleeding disorders, such as hemophilia, and for the presence of active liver disease. Patients who are not at elevated risk of VTED or for bleeding should receive pharmacologic prophylaxis and mechanical compressive devices for the prevention of VTED. The group did not recommend specific pharmacologic agents and/or mechanical devices. The work group recommends, by consensus opinion, early mobilization for patients following elective hip and knee arthroplasty. The use of neuraxial anesthesia can help limit blood loss but was not found to affect the occurrence of VTED. No clear evidence was established regarding whether inferior vena cava filters can prevent pulmonary embolism in patients who have a contraindication to chemoprophylaxis and/or known VTED.
The prevailing dogma in tissue engineering is cell-centric. One shortcoming of this approach is the failure to provide the implanted cells with a suitable in vivo microenvironment that promotes ...tissue reconstruction. Extracellular matrix (ECM)-based scaffolds provide a three-dimensional microenvironment that can promote constructive and functional tissue remodeling rather than inflammation and scarring even in the absence of any implanted cells. The objective of this study was to determine the ability of an ECM-based scaffold to facilitate functional restoration of the distal gastrocnemius musculotendinous junction in a canine model after complete resection of the tissue. Within 6 months, vascularized, innervated skeletal muscle that was similar to normal muscle tissue had formed at the ECM-scaffold implantation site. This neo-tissue generated 48% of the contractile force of contralateral musculotendinous junction and represents the first report of de novo formation of contractile, vascularized, and innervated skeletal muscle in situ after significant tissue loss.
Under the Merit-based Incentive Payment System (MIPS), the U.S. Centers for Medicare and Medicaid Services (CMS) evaluate clinicians who manage Medicare patients on the basis of cost and quality ...outcomes. CMS contractor Acumen, LLC, convened an expert panel to develop a knee arthroplasty episode-based cost measure (EBCM) for use in the MIPS.
A Clinical Subcommittee of 28 clinician experts affiliated with 27 specialty societies provided guidance in developing the knee arthroplasty EBCM. The Clinical Subcommittee specified all aspects of the EBCM including triggering of the episode, services within the episode, risk adjustment, subgrouping, and exclusions. Services were counted only if the Clinical Subcommittee deemed them under the influence of the clinician assigned to the EBCM (selective service assignment; SSA). We assessed the reliability of the EBCM and compared it with an alternative population-based cost measure constructed without SSA.
We identified 249,301 knee arthroplasty episodes from June 1, 2016, to May 31, 2017, with 10,681 clinicians having at least 10 attributed episodes. The mean episode cost was $19,321 with a standard deviation of $1,816. SSA increased the reliability score from 0.71 to 0.81 relative to an alternative measure that counted all patient costs. SSA also led to reclassification of 41.8% of clinicians into different quintiles of performance.
We found that the use of SSA in the creation of the EBCM substantially reduces random noise (i.e., unrelated medical procedures or costs) and offers a tool for assessing clinicians' costs of management that is focused on care directly related to knee arthroplasty.
The Center for Disease Control and Prevention recently released their 2017 Guideline for the Prevention of Surgical Site Infection. One of their recommendations is the ordering of a single dose of ...preoperative prophylactic antibiotics with no subsequent postoperative dosing; this recommendation includes perioperative antibiotics for patients undergoing total joint arthroplasty. At this time, the American Association of Hip and Knee Surgeons (AAHKS) does not agree with this recommendation vis-a-vis total joint arthroplasty because it contradicts current international standards of care with limited evidence and study. AAHKS still recommends postoperative antibiotics and recommends further research. Both the Board of Counselors and Board of Specialty Societies of the American Academy of Orthopaedic Surgeons have endorsed this AAHKS recommendation through an advisory opinion; the American Academy of Orthopaedic Surgeons Board of Directors adopted that advisory opinion in June 2017. A 2017 Foundation for Arthroplasty Research and Education prospective, randomized study is being undertaken to provide level I evidence for or against single-dose vs 24-hour antibiotic prophylaxis in primary total knee arthroplasty.
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 novel coronavirus, severe acute respiratory coronavirus 2 (SARS-CoV-2), pandemic has delivered a profound and negative impact on the United States. The suspension of elective surgeries including ...arthroplasty will have a lasting effect on all stakeholders including patients, physicians, and healthcare organizations within the US healthcare system. Resumption of elective hip and knee arthroplasty will need to be carefully focused. The purpose of this work is to address potential strategies, concerns, and regulatory barriers in restarting elective hip and knee arthroplasty in the United States.
Coronavirus disease 2019 (COVID-19) pandemic poses an important risk to global health.
This study surveyed 370 international orthopedic surgeons affiliated with the American Association of Hip and ...Knee Surgeons to help identify the global impact of the COVID-19 pandemic on patient care.
A total of 99 surgeons (27% of those surveyed) completed the questionnaire representing 32 different countries. Except for surgeons in Japan, all respondents noted that their practice had been affected to some degree and 70% of the surgeons have canceled elective procedures. More than a third of the surgeons have had to close their practices altogether and the remaining open practices were estimated to be sustainable for 7 weeks on average given their current situation.
The COVID-19 pandemic has resulted in marked changes to the majority of international arthroplasty practices.
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