Cost Analysis and Bundled Care of Hip and Knee Replacement - James Kee, MD; Simon C. Mears, MD, PhD; Paul K. Edwards, MD; and C. Lowry Barnes, MD
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Financial success in a bundled payment system requires knowledge of the costs of care throughout the period of risk. Understanding the significant cost-drivers of total joint arthroplasty (TJA) is crucial in this effort. This article inspects the basics of reimbursement under Medicare’s bundled care programs as well as some common investigative tools used in the literature to measure cost. Additionally, the effects of standardized enhanced recovery clinical pathways on costs are reviewed. Finally, drivers of implant costs and several proven measures for implant cost-reduction are evaluated. This review provides surgeons and hospitals successful measures to reduce the cost of TJA via enhanced recovery pathways and reduced implant pricing. (Journal of Surgical Orthopaedic Advances 28(4):241-249, 2019) Key words: arthroplasty, cost effectiveness, patient education, implant selection
Predictive Accuracy of the ACS-NSQIP Surgical Risk Calculator for Pathologic Humerus Fracture Fixation - Zachary A. Mosher, MD; Eugene W. Brabston III, MD; Michael A. Ewing, MD; Martim C. Pinto, MD; Matthew C. Hess, MD; Nicole K. Behnke, MD; Gerald McGwin, PhD, MS; Brent A. Ponce, MD; and Joshua C. Patt, MD
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Pathologic fractures are associated with poor outcomes. This article investigated the prevalence of underestimation of risk by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator (SRC) in patients with pathologic humerus fractures. Two hundred seven (207) patients were identified and analyzed using the ACS-NSQIP SRC. Predicted and actual outcomes were then compared. Average hospitalization was 6 ± 10 days. Ten patients (5%) had a mild adverse event (AE), and 15 (7%) had a serious AE. The ACS-NSQIP SRC underestimated hospitalizations (p < 0.001), but not serious AE (p = 0.601), mild AE (p = 0.948), cardiac complications (p = 0.817), pneumonia (p = 0.713), surgical site infection (p = 0.692), urinary tract infection (p = 0.286), venous thromboembolism (p = 0.554), acute renal failure (p = 0.191), discharge to acute care facility (p = 0.865), readmission (p = 1.0), reoperation (0.956) or mortality (p = 0.872). Negative outcomes were limited in this cohort, and the SRC demonstrated acceptable accuracy. Future investigation of the calculator in other orthopaedic populations is warranted. (Journal of Surgical Orthopaedic Advances 28(4):250-256, 2019) Key words: pathologic fractures, humerus fractures, musculoskeletal oncology, ACS-NSQIP, ACS-NSQIP Surgical Risk Calculator
Pediatric Patients with Spondylolysis Have High Rates of Vitamin-D Deficiency - Marielle A. Amoli, MD; Jeffrey R. Sawyer, MD; R. Tyler Ellis, MD; James Seymour, DO; David D. Spence, MD; Derek M. Kelly, MD; and William C. Warner, MD
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The objective of this study was to document the 25-hydroxyvitamin D status of patients with a confirmed diagnosis of spondylolysis to determine if these patients have increased rates of vitamin D deficiency. After confirming the diagnosis of spondylolysis, patients were prospectively enrolled in this study. A total of 39 patients (30 male, 9 female) with a mean age of 14.9 years and a mean BMI of 22.9 had vitamin D levels drawn after imaging confirmed the diagnosis of spondylolysis. The mean 25-hydroxyvitamin D level was 26 ng/ml. Only 9 patients (23.1%) were considered to have normal vitamin D levels > 32 ng/ml. An additional 22 patients (56.4%) had insufficient values of 20 to 32 ng/ml, and 8 patients (20.5%) had vitamin D deficiency with values <20 ng/ml. Pediatric patients presenting with spondylolysis, regardless of race or age, have high rates of 25-hydroxyvitamin D deficiency. (Journal of Surgical Orthopaedic Advances 28(4):257-259, 2019) Key words: spondylolysis, vitamin D, deficiency, screening
Rater Variation in Ultrasound Detection of Dorsal Cortex Screw Protrusion in Fixed-Angle Volar Plating of the Distal Radius - Kevin J. Leffers, MD; Joel I. Edionwe, MD; Caroline W. Stegink-Jansen, PhD; Daniel Jupiter, PhD; and Ronald W. Lindsey, MD
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This study evaluates rater accuracy and variation for the purpose of using intraoperative ultrasound (US) imaging to detect dorsal screw protrusion during fixed-angle volar plating of distal radius fractures. Stabilizing volar plates and screws with varying lengths of dorsal protrusion were applied to 10 cadaver wrist pairs. After a brief training session, seven surgeons without prior ultrasound experience assessed screw protrusion on two separate occasions using a diagnostic ultrasound machine. Screw protrusions were visually confirmed after data collection was completed. Statistical analyses included percent agreement and Cohen’s kappa for accuracy and intra- and inter-rater reliability, sensitivity, specificity, and positive and negative predictive values. Only two out of seven raters met acceptable levels of accuracy and consistency. Our findings inform us that accuracy and consistency of ultrasound-guided detection of dorsal screw protrusion are negatively impacted by rater variation. Further investigations are needed to improve rater effectiveness. (Journal of Surgical Orthopaedic Advances 28(4):260-267, 2019) Key words: distal radius fractures, ultrasound imaging, screw protrusion, volar plating, diagnostic testing, measurement
The Saline Load Test is Effective at Diagnosing Traumatic Arthrotomies of the Shoulder - Daniel Gittings, MD; Jonathan Dattilo, MD; George Fryhofer, MD; Anthony Martin, MD; Michael Hast, MD; and Samir Mehta, MD
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The purpose of this study is to evaluate the fluid volume required for a saline load test to detect intra-articular involvement of the glenohumeral joint after penetrating trauma. A human cadaver study was conducted with 22 thawed, fresh-frozen forequarter amputations. A standard posterior shoulder portal was made with an 11-blade scalpel. A 19-gauge needle was inserted into the anterior portal site, and intra-articular position of both the blade and needle was confirmed with fluoroscopy. The blade was removed and normal saline was injected through the needle until extravasation of fluid was observed through the posterior portal. Injection volume required for extravasation was recorded. A logarithmic distribution of the volumes was then calculated in order to obtain estimated sensitivity ranges. Using a logarithmic distribution, 90%, 95% and 99% of simulated glenohumeral arthrotomies could be detected using injections of: 62 ml [41–96], 81 ml [50–133] and 136 ml [72–252], respectively. (Journal of Surgical Orthopaedic Advances 28(4):268-271, 2019) Key words: traumatic arthrotomy, shoulder, glenohumeral joint, saline load
Smoking as a Risk Factor for Readmission in Arthroscopic Surgery: A Propensity Matched Analysis - Daniel J. Johnson, MD; Joshua P. Castle, BS; Matthew J. Hartwell, MD; Hayden Baker, BA; Ryan S. Selley, MD; Richard W. Nicolay, MD; and Vehniah K. Tjong, MD
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The objective of this study was to perform a propensity matched analysis exploring smoking as a risk factor for readmission following hip, knee and shoulder arthroscopy. Patients undergoing knee, shoulder or hip arthroscopy between 2006-2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Patient’s smoking was analyzed for its effect on 30-day readmission using multivariate regression adjusting for demographics and comorbidities. A propensity matched analysis control identified 19,732 non-smokers to serve as the control group. The readmission rate for the non-smoking cohort was 0.9% and 1.3% in the smoking group (p = 0.01). In a multivariate analysis adjusting for baseline characteristics and medical comorbidities, smoking status was associated with increased risk readmission (Odds Ratio: 1.37 [95% Confidence Interval: 1.133–1.657] p = 0.0012). This study suggests that smoking increases chances of readmission in all arthroscopic surgery. (Journal of Surgical Orthopaedic Advances 28(4):272-276, 2019) Key words: arthroscopy, smoking, readmission
Incidence of Periprosthetic Femur Fractures Utilizing the Posterior Approach with a Single Wedge Tapered Stem - Peter Formby, MD; Cierra S. Hong, BA; Sean Ryan, MD; Samuel Wellman, MD; Michael Bolognesi, MD
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We sought to determine early periprosthetic femur fracture rate and stem-related failures in primary total hip arthroplasty (THA) performed through a posterior approach with a cementless wedge stem. We reviewed 818 primary THAs in 713 patients with a single wedge tapered titanium component. We used multivariate logistic regression to determine predisposing factors to stem failure. The mean radiographic follow up was 1.6 years. Overall there were eight perioperative femur fractures (0.98%). There were two intraoperative fractures (0.24%), six postoperative fractures (0.73%) and one case of stem subsidence (0.1%). There was a 0.49% rate of operative fractures occurring within 90 days of surgery. There were five stem revisions due to loosening or fracture (0.61%). When excluding infection, the ultimate stem retention rate at latest follow up was 99.3%. Multivariate logistic regression did not find age, sex, body mass index or American Society of Anesthesiologists (ASA) score significantly associated with periprosthetic fracture. (Journal of Surgical Orthopaedic Advances 28(4):277-280, 2019) Key words: periprosthetic femur fracture, posterior approach, wedge stem, taperloc, pressfit stem, femur fractures
In Hospital Outcomes of Total Hip Arthroplasty in the Medicaid Population - Brian E. Schwartz, MD; Neal R. Shah, MD; Colin Woon, MD; Vincent Moretti, MD; Awais K. Hussain, MD, Amit Parekh, MD; Benjamin Goldberg, MD; Feroz Osmani, MD; Mark H. Gonzalez, MD, PhD
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Total hip arthroplasty (THA) is one of the most common orthopaedic procedures. This study’s purpose was to evaluate national trends, patient demographics and hospital outcomes for Medicaid patients who underwent a primary THA. The National Hospital Discharge Survey (NHDS) database was queried for patients undergoing THA from 2001–2010. Patients were stratified into two groups based on insurance. We found from 2001–2005, Medicaid accounted for 2.38% of all THA performed, increasing insignificantly to 2.61% between 2006–2010. The Medicaid group was younger (50.3 vs. 65.6 years, p < 0.01). Length of stay was longer for the Medicaid group (4.6 vs. 4.0 days, p < 0.01). Medicaid patients were more likely to be discharged home (53.7% vs. 47.2%, p < 0.01) and less likely to be discharged to rehabilitation facilities (24.4% vs. 29.0%, p < 0.05). In conclusion, we discovered that the rate of Medicaid insurance in patients undergoing primary THA was stable through 2010, prior to the Affordable Care Act. We found Medicaid THA patients had longer length of stay, despite being a mean 15 years younger than the non-Medicaid cohort. Medicaid insurance status should be factored into risk adjustment models to avoid creating additional disincentive to treat the Medicaid population. (Journal of Surgical Orthopaedic Advances 28(4):281-284, 2019) Key words: total hip arthroplasty, Medicaid, insurance, NHDS, outcomes, morbidity, mortality, length
New NCAA Bat Standard, BBCOR, is Associated with an Increased Incidence of Hamate Fractures - Ryan Nathe, MD; Tyler Nathe, MD; Trevor J. Shelton, MD, MS; and Robert M. Szabo, MD, MPH
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Our institution saw four hamate fractures in the 2011 baseball season, the first season following implementation of new batting standards in collegiate baseball. The purpose of this paper was to identify whether the incidence of hamate fractures increased with the introduction of the new batting standard. Surveys sent to Division 1 collegiate baseball athletic trainers reported the number, mechanism, treatment and return to play of hamate fractures from 2008–2010 (old batting standards) and for the 2011 season. This study shows that there was more than a 200% increased risk of hamate fracture with implementation of the 2011 collegiate baseball batting standards. The most common injury mechanism was batting with the down hand (79%). We suggest that a national injury database be considered for collegiate athletics so that injury rates, risk factors and results of interventions could be studied to improve the health of our nations’ athletes. (Journal of Surgical Orthopaedic Advances 28(4):285-289, 2019) Key words: hamate fracture, bat standard, NCAA, baseball
The Quality and Accuracy of Online Resources for Total and Reverse Shoulder Replacement - Emily J. Monroe, MD; Ryan S. Selley, MD; Mufaddal M. Gombera, MD; Rueben Nair, MD; Alexander Martusiewicz, MD; Robert A. Christian, MD; Guido Marra, MD; and Matthew D. Saltzman, MD
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Recent literature suggests that many online patient resources are poor in quality and lack important clinical information. The purpose of this study was to investigate the value of online resources available to patients considering shoulder arthroplasty. A total of 84 websites were discovered with the terms ‘‘total shoulder replacement’’ (TSR) and ‘‘reverse shoulder replacement’’ (RSR), they were reviewed and graded for quality and accuracy. Overall quality scores were low for TSR and RSR websites, 22.8/45 (95% confidence interval (CI): 19.9–25.6) and 24.2/45 (95% CI: 21.6–26.9), respectively. The authorship of a website significantly influenced the quality for both TSR (p = 0.013) and RSR (p = 0.048). When comparing search rank to quality scores, websites that appeared earlier demonstrated significantly higher quality scores, TSR (p = 0.017) and RSR (p = 0.018). Overall, most websites were accurate but provided incomplete information. Websites authored by professional societies have higher quality scores than websites authored by medical providers or commercial entities. (Journal of Surgical Orthopaedic Advances 28(4):290-294, 2019) Key words: total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (rTSA), online resources, quality, accuracy, patient information