R. Meneghini, A. S. Elston, Antonia F. Chen, M. Kheir, T. Fehring, B. Springer
Background: The direct anterior approach for total hip arthroplasty (THA) is marketed with claims of superiority over other approaches. Femoral exposure can be technically challenging and potentially lead to early failure. We examined whether surgical approach is associated with early THA failure. Methods: A retrospective review of 478 consecutive early revision THAs performed within 5 years after the primary THAs at 3 academic centers from 2011 through 2014 was carried out. Exclusion criteria resulted in a final analysis sample of 342 early-failure THAs. The surgical approach of the primary operation that was revised, the time to the revision, and the etiology of the failure leading to the revision were documented. Results: Analysis of the revisions due to early femoral failure showed them to be more common in patients who had undergone the direct anterior approach (57/112; 50.9%) than in those treated with the direct lateral (39/112; 34.8%) or the posterior (16/112; 14.3%) approach (p = 0.001). In multivariate regression analysis controlling for age, sex, laterality, Dorr bone type, body mass index (BMI) at revision, bilateral procedure (yes/no), and femoral stem type, the direct anterior approach remained a significant predictor of early femoral failure (p = 0.007). The majority of early revisions due to instability were associated with the posterior (19/40; 47.5%) or direct anterior (15/40; 37.5%) approach (p = 0.001 for the comparison with the direct lateral approach [6/40; 15.0%]). Conclusions: Despite claims of earlier recovery and improved outcomes with the direct anterior approach for THA, our findings indicate that that approach may confer a greater risk of early femoral failure and, along with the posterior approach, confer a greater risk of early instability compared with the direct lateral approach. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
{"title":"Direct Anterior Approach: Risk Factor for Early Femoral Failure of Cementless Total Hip Arthroplasty A Multicenter Study","authors":"R. Meneghini, A. S. Elston, Antonia F. Chen, M. Kheir, T. Fehring, B. Springer","doi":"10.2106/JBJS.16.00060","DOIUrl":"https://doi.org/10.2106/JBJS.16.00060","url":null,"abstract":"Background: The direct anterior approach for total hip arthroplasty (THA) is marketed with claims of superiority over other approaches. Femoral exposure can be technically challenging and potentially lead to early failure. We examined whether surgical approach is associated with early THA failure. Methods: A retrospective review of 478 consecutive early revision THAs performed within 5 years after the primary THAs at 3 academic centers from 2011 through 2014 was carried out. Exclusion criteria resulted in a final analysis sample of 342 early-failure THAs. The surgical approach of the primary operation that was revised, the time to the revision, and the etiology of the failure leading to the revision were documented. Results: Analysis of the revisions due to early femoral failure showed them to be more common in patients who had undergone the direct anterior approach (57/112; 50.9%) than in those treated with the direct lateral (39/112; 34.8%) or the posterior (16/112; 14.3%) approach (p = 0.001). In multivariate regression analysis controlling for age, sex, laterality, Dorr bone type, body mass index (BMI) at revision, bilateral procedure (yes/no), and femoral stem type, the direct anterior approach remained a significant predictor of early femoral failure (p = 0.007). The majority of early revisions due to instability were associated with the posterior (19/40; 47.5%) or direct anterior (15/40; 37.5%) approach (p = 0.001 for the comparison with the direct lateral approach [6/40; 15.0%]). Conclusions: Despite claims of earlier recovery and improved outcomes with the direct anterior approach for THA, our findings indicate that that approach may confer a greater risk of early femoral failure and, along with the posterior approach, confer a greater risk of early instability compared with the direct lateral approach. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"38 1","pages":"99–105"},"PeriodicalIF":0.0,"publicationDate":"2017-01-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87202641","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
B. S. Richards, Shawne Faulks, Ozan Razi, Amanda Moualeu, C. Jo
Background: Nonoperative treatment of idiopathic clubfoot is standard. The purpose of this study was to determine if measurements made on standing lateral radiographs of successfully treated clubfeet made at 18 to 24 months of age were predictive of late recurrence. Methods: Inclusion criteria were idiopathic clubfoot with an age at presentation of ⩽3 months, nonoperative treatment resulting in a clinically plantigrade foot at 2 years of age, standing lateral radiograph of the involved foot made at 18 to 24 months of age, and a minimum age of 4 years at the time of follow-up. The radiographs were assessed for the talocalcaneal angle and the tibiocalcaneal angle, with measurements made by 2 trained practitioners. The average values of the 2 raters were used. The interobserver reliability was calculated using intraclass correlation coefficients (ICCs). A total of 211 patients with 312 clubfeet were evaluated. The average age at the time of follow-up was 8.0 years (range, 4.0 to 13.3 years). Results at the time of follow-up were rated as good (maintained plantigrade foot), fair (required limited surgery to maintain, or return to, a plantigrade position), or poor (required posteromedial release). Results: Over time, 75% of the feet had a good result, 19% had a fair result, and 6% had a poor result. With regard to radiographic assessment, the ICCs were 0.97 (talocalcaneal angle) and 0.98 (tibiocalcaneal angle), demonstrating excellent agreement between the raters. The mean talocalcaneal angle differed significantly between the feet with a good clinical outcome and those with a fair outcome (28° versus 24°; p < 0.02), but did not differ significantly between those with a good versus poor outcome (28° versus 26°), or a fair versus poor outcome (24° versus 26°). There were no significant differences in the mean tibiocalcaneal angle among the groups (86°, 90°, and 84°, respectively) (p = 0.17). Conclusions: Most clubfeet that were clinically plantigrade at 2 years of age remained so, while one-fourth subsequently required some surgery for late recurrence, primarily limited procedures. The tibiocalcaneal angle and talocalcaneal angle from standing lateral radiographs made at 18 to 24 months of age were not helpful in predicting future relapse. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
{"title":"Nonoperatively Corrected Clubfoot at Age 2 Years: Radiographs Are Not Helpful in Predicting Future Relapse","authors":"B. S. Richards, Shawne Faulks, Ozan Razi, Amanda Moualeu, C. Jo","doi":"10.2106/JBJS.16.00693","DOIUrl":"https://doi.org/10.2106/JBJS.16.00693","url":null,"abstract":"Background: Nonoperative treatment of idiopathic clubfoot is standard. The purpose of this study was to determine if measurements made on standing lateral radiographs of successfully treated clubfeet made at 18 to 24 months of age were predictive of late recurrence. Methods: Inclusion criteria were idiopathic clubfoot with an age at presentation of ⩽3 months, nonoperative treatment resulting in a clinically plantigrade foot at 2 years of age, standing lateral radiograph of the involved foot made at 18 to 24 months of age, and a minimum age of 4 years at the time of follow-up. The radiographs were assessed for the talocalcaneal angle and the tibiocalcaneal angle, with measurements made by 2 trained practitioners. The average values of the 2 raters were used. The interobserver reliability was calculated using intraclass correlation coefficients (ICCs). A total of 211 patients with 312 clubfeet were evaluated. The average age at the time of follow-up was 8.0 years (range, 4.0 to 13.3 years). Results at the time of follow-up were rated as good (maintained plantigrade foot), fair (required limited surgery to maintain, or return to, a plantigrade position), or poor (required posteromedial release). Results: Over time, 75% of the feet had a good result, 19% had a fair result, and 6% had a poor result. With regard to radiographic assessment, the ICCs were 0.97 (talocalcaneal angle) and 0.98 (tibiocalcaneal angle), demonstrating excellent agreement between the raters. The mean talocalcaneal angle differed significantly between the feet with a good clinical outcome and those with a fair outcome (28° versus 24°; p < 0.02), but did not differ significantly between those with a good versus poor outcome (28° versus 26°), or a fair versus poor outcome (24° versus 26°). There were no significant differences in the mean tibiocalcaneal angle among the groups (86°, 90°, and 84°, respectively) (p = 0.17). Conclusions: Most clubfeet that were clinically plantigrade at 2 years of age remained so, while one-fourth subsequently required some surgery for late recurrence, primarily limited procedures. The tibiocalcaneal angle and talocalcaneal angle from standing lateral radiographs made at 18 to 24 months of age were not helpful in predicting future relapse. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"50 1","pages":"155–160"},"PeriodicalIF":0.0,"publicationDate":"2017-01-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82719157","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Kenneth Donohue, K. Little, J. Gaughan, S. Kozin, Brian D Norton, D. Zlotolow
Background: In this study, we investigated the agreement between measurements made on ultrasound and those made on magnetic resonance imaging (MRI) in the assessment of glenohumeral dysplasia resulting from brachial plexus birth palsy. Methods: Thirty-nine patients (14 male and 25 female) with brachial plexus birth palsy were evaluated at 2 tertiary care centers. All patients underwent ultrasonography and MRI for suspected glenohumeral dysplasia. Studies were obtained at an average of 2 months apart (range, 0 to 6 months). The average patient age at the time of the initial imaging study was 20 months (range, 4 to 54 months). Four blinded independent evaluators measured the alpha angle, the posterior humeral head displacement (PHHD), and glenoid version on both the ultrasound and MRI study for each patient. The percentage of the humeral head anterior to the scapular axis (PHHA) was determined on MRI only. Measurements were obtained on OsiriX software (Pixmeo). Intraclass correlation coefficients (ICCs) were used to assess the intrarater and interrater reliability, and Bland-Altman plots were used to compare MRI and ultrasound measurement agreement. Results: We found excellent interrater reliability for measurements of the alpha angle on MRI, glenoid version on MRI, and the alpha angle on ultrasound (ICC: 0.83, 0.75, and 0.78, respectively). The interrater reliability for the PHHD on both MRI and ultrasound was good (ICC: 0.70 and 0.68, respectively), and the interrater reliability for the PHHA on MRI was fair (ICC: 0.57). However, the interrater reliability for glenoid version on ultrasound was poor (ICC: 0.30). Relative to MRI measurements, ultrasound measurements were found to underestimate the alpha angle and glenoid version by an average of 13° ± 23° and 6° ± 17°, respectively, and overestimate the PHHD by an average of 4% ± 20%. Increasing patient age corresponded with a significant increase in the MRI-ultrasound measurement difference for the alpha angle (p < 0.01) and a marginally significant increase in the difference for the PHHD (p < 0.06). Conclusions: Measurements on MRI and ultrasound were reliable, with measured bias. The poor agreement between measurements on MRI and ultrasound calls into question the validity of using ultrasonography as a stand-alone modality in the evaluation of glenohumeral dysplasia. MRI remains the gold standard for fully evaluating the glenohumeral joint. The clinical role of ultrasonography may be that of a screening tool or a way of evaluating joint reduction in real time. Level of Evidence: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.
{"title":"Comparison of Ultrasound and MRI for the Diagnosis of Glenohumeral Dysplasia in Brachial Plexus Birth Palsy","authors":"Kenneth Donohue, K. Little, J. Gaughan, S. Kozin, Brian D Norton, D. Zlotolow","doi":"10.2106/JBJS.15.01116","DOIUrl":"https://doi.org/10.2106/JBJS.15.01116","url":null,"abstract":"Background: In this study, we investigated the agreement between measurements made on ultrasound and those made on magnetic resonance imaging (MRI) in the assessment of glenohumeral dysplasia resulting from brachial plexus birth palsy. Methods: Thirty-nine patients (14 male and 25 female) with brachial plexus birth palsy were evaluated at 2 tertiary care centers. All patients underwent ultrasonography and MRI for suspected glenohumeral dysplasia. Studies were obtained at an average of 2 months apart (range, 0 to 6 months). The average patient age at the time of the initial imaging study was 20 months (range, 4 to 54 months). Four blinded independent evaluators measured the alpha angle, the posterior humeral head displacement (PHHD), and glenoid version on both the ultrasound and MRI study for each patient. The percentage of the humeral head anterior to the scapular axis (PHHA) was determined on MRI only. Measurements were obtained on OsiriX software (Pixmeo). Intraclass correlation coefficients (ICCs) were used to assess the intrarater and interrater reliability, and Bland-Altman plots were used to compare MRI and ultrasound measurement agreement. Results: We found excellent interrater reliability for measurements of the alpha angle on MRI, glenoid version on MRI, and the alpha angle on ultrasound (ICC: 0.83, 0.75, and 0.78, respectively). The interrater reliability for the PHHD on both MRI and ultrasound was good (ICC: 0.70 and 0.68, respectively), and the interrater reliability for the PHHA on MRI was fair (ICC: 0.57). However, the interrater reliability for glenoid version on ultrasound was poor (ICC: 0.30). Relative to MRI measurements, ultrasound measurements were found to underestimate the alpha angle and glenoid version by an average of 13° ± 23° and 6° ± 17°, respectively, and overestimate the PHHD by an average of 4% ± 20%. Increasing patient age corresponded with a significant increase in the MRI-ultrasound measurement difference for the alpha angle (p < 0.01) and a marginally significant increase in the difference for the PHHD (p < 0.06). Conclusions: Measurements on MRI and ultrasound were reliable, with measured bias. The poor agreement between measurements on MRI and ultrasound calls into question the validity of using ultrasonography as a stand-alone modality in the evaluation of glenohumeral dysplasia. MRI remains the gold standard for fully evaluating the glenohumeral joint. The clinical role of ultrasonography may be that of a screening tool or a way of evaluating joint reduction in real time. Level of Evidence: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"76 1","pages":"123–132"},"PeriodicalIF":0.0,"publicationDate":"2017-01-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84652222","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Yonatan Schwarcz, Y. Schwarcz, E. Peleg, Leo Joskowicz, R. Wollstein, S. Luria
Background: Our goal was to analyze the movement of acute scaphoid waist fracture fragments and adjacent bones in a common coordinate system. Our hypothesis was that the distal scaphoid fragment flexes and pronates and the proximal fragment extends. Methods: Computed tomography (CT) scans of patients diagnosed with an acute scaphoid waist fracture were evaluated using a 3-dimensional (3D) model. The scans of 57 nondisplaced and 23 displaced fractures were compared with a control group of 27 scans showing no pathological involvement of the wrist. Three anatomical landmarks were labeled on the distal and proximal fragments of the scaphoid, the lunate, and the trapezium. Each set of labels formed a triangle representing the bone or fragment. Four landmarks were labeled on the distal radial articular surface and used to create a common coordinate system. The position of each bone or fragment was calculated in reference to these coordinates. Results: The displaced fracture group showed significant extension, supination, and volar translation of the proximal scaphoid fragment when compared with the other groups. The lunate tended toward a supinated position, which was not statistically significant. The distal scaphoid fragment and the trapezium showed no movement. Conclusions: In acute displaced scaphoid fractures, it is the proximal fragment that displaces and should be reduced. Clinical Relevance: The typical “humpback” deformity is actually a “proximal extension” deformity, the consequence of displacement of the proximal fragment of the scaphoid (with the lunate). Manipulating only the proximal fragment (with the lunate) may be technically easier and more effective than manipulating both fragments.
{"title":"Three-Dimensional Analysis of Acute Scaphoid Fracture Displacement: Proximal Extension Deformity of the Scaphoid","authors":"Yonatan Schwarcz, Y. Schwarcz, E. Peleg, Leo Joskowicz, R. Wollstein, S. Luria","doi":"10.2106/JBJS.16.00021","DOIUrl":"https://doi.org/10.2106/JBJS.16.00021","url":null,"abstract":"Background: Our goal was to analyze the movement of acute scaphoid waist fracture fragments and adjacent bones in a common coordinate system. Our hypothesis was that the distal scaphoid fragment flexes and pronates and the proximal fragment extends. Methods: Computed tomography (CT) scans of patients diagnosed with an acute scaphoid waist fracture were evaluated using a 3-dimensional (3D) model. The scans of 57 nondisplaced and 23 displaced fractures were compared with a control group of 27 scans showing no pathological involvement of the wrist. Three anatomical landmarks were labeled on the distal and proximal fragments of the scaphoid, the lunate, and the trapezium. Each set of labels formed a triangle representing the bone or fragment. Four landmarks were labeled on the distal radial articular surface and used to create a common coordinate system. The position of each bone or fragment was calculated in reference to these coordinates. Results: The displaced fracture group showed significant extension, supination, and volar translation of the proximal scaphoid fragment when compared with the other groups. The lunate tended toward a supinated position, which was not statistically significant. The distal scaphoid fragment and the trapezium showed no movement. Conclusions: In acute displaced scaphoid fractures, it is the proximal fragment that displaces and should be reduced. Clinical Relevance: The typical “humpback” deformity is actually a “proximal extension” deformity, the consequence of displacement of the proximal fragment of the scaphoid (with the lunate). Manipulating only the proximal fragment (with the lunate) may be technically easier and more effective than manipulating both fragments.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"79 1","pages":"141–149"},"PeriodicalIF":0.0,"publicationDate":"2017-01-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79670938","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: The National Institutes of Health (NIH) is the largest supporter of biomedical research in the U.S., yet its contribution to orthopaedic research is poorly understood. In this study, we analyzed the portfolio of NIH funding to departments of orthopaedic surgery at U.S. medical schools. Methods: The NIH RePORT (Research Portfolio Online Reporting Tools) database was queried for NIH grants awarded to departments of orthopaedic surgery in 2014. Funding totals were determined for award mechanisms and NIH institutes. Trends in NIH funding were determined for 2005 to 2014 and compared with total NIH extramural research funding. Funding awarded to orthopaedic surgery departments was compared with that awarded to departments of other surgical specialties in 2014. Characteristics of NIH-funded principal investigators were obtained from department web sites. Results: In 2014, 183 grants were awarded to 132 investigators at 44 departments of orthopaedic surgery. From 2005 to 2014, NIH funding increased 24.3%, to $54,608,264 (p = 0.030), but the rates of increase seen did not differ significantly from those of NIH extramural research funding as a whole (p = 0.141). Most (72.6%) of the NIH funding was awarded through the R01 mechanism, with a median annual award of $343,980 (interquartile range [IQR], $38,372). The majority (51.1%) of the total funds supported basic science research, followed by translational (33.0%), clinical (10.0%), and educational (5.9%) research. NIH-funded orthopaedic principal investigators were predominately scientists whose degree was a PhD (71.1%) and who were male (79.5%). Eleven NIH institutes were represented, with the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) providing the preponderance (74.2%) of the funding. In 2014, orthopaedic surgery ranked below the surgical departments of general surgery, ophthalmology, obstetrics and gynecology, otolaryngology, and urology in terms of NIH funding received. Conclusions: The percentage increase of NIH funding to departments of orthopaedic surgery from 2005 to 2014 was not significantly greater than that of total NIH extramural research funding. Funding levels to orthopaedic surgery departments lag behind funding to departments of other surgical disciplines. Funding levels may not match the academic potential of orthopaedic faculty, and interventions may be needed to increase NIH grant procurement.
{"title":"National Institutes of Health Funding to Departments of Orthopaedic Surgery at U.S. Medical Schools","authors":"J. Silvestre, Jaimo Ahn, L. Scott Levin","doi":"10.2106/JBJS.16.00088","DOIUrl":"https://doi.org/10.2106/JBJS.16.00088","url":null,"abstract":"Background: The National Institutes of Health (NIH) is the largest supporter of biomedical research in the U.S., yet its contribution to orthopaedic research is poorly understood. In this study, we analyzed the portfolio of NIH funding to departments of orthopaedic surgery at U.S. medical schools. Methods: The NIH RePORT (Research Portfolio Online Reporting Tools) database was queried for NIH grants awarded to departments of orthopaedic surgery in 2014. Funding totals were determined for award mechanisms and NIH institutes. Trends in NIH funding were determined for 2005 to 2014 and compared with total NIH extramural research funding. Funding awarded to orthopaedic surgery departments was compared with that awarded to departments of other surgical specialties in 2014. Characteristics of NIH-funded principal investigators were obtained from department web sites. Results: In 2014, 183 grants were awarded to 132 investigators at 44 departments of orthopaedic surgery. From 2005 to 2014, NIH funding increased 24.3%, to $54,608,264 (p = 0.030), but the rates of increase seen did not differ significantly from those of NIH extramural research funding as a whole (p = 0.141). Most (72.6%) of the NIH funding was awarded through the R01 mechanism, with a median annual award of $343,980 (interquartile range [IQR], $38,372). The majority (51.1%) of the total funds supported basic science research, followed by translational (33.0%), clinical (10.0%), and educational (5.9%) research. NIH-funded orthopaedic principal investigators were predominately scientists whose degree was a PhD (71.1%) and who were male (79.5%). Eleven NIH institutes were represented, with the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) providing the preponderance (74.2%) of the funding. In 2014, orthopaedic surgery ranked below the surgical departments of general surgery, ophthalmology, obstetrics and gynecology, otolaryngology, and urology in terms of NIH funding received. Conclusions: The percentage increase of NIH funding to departments of orthopaedic surgery from 2005 to 2014 was not significantly greater than that of total NIH extramural research funding. Funding levels to orthopaedic surgery departments lag behind funding to departments of other surgical disciplines. Funding levels may not match the academic potential of orthopaedic faculty, and interventions may be needed to increase NIH grant procurement.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"26 1","pages":"e5"},"PeriodicalIF":0.0,"publicationDate":"2017-01-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91511933","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A. Krych, Patrick J. Reardon, Paul L. Sousa, Ayoosh Pareek, M. Stuart, M. Pagnano
Background: The cases of patients with medial compartment osteoarthritis who were ⩽55 years old and had a proximal tibial osteotomy (PTO) or medial unicompartmental knee arthroplasty (UKA) were compared. Outcomes included postoperative activity level, function, and survivorship free of revision to total knee arthroplasty. Methods: Between 1998 and 2013, data were available for 240 patients between 18 and 55 years old with medial compartment arthritis and varus malalignment who were treated either with PTO (57 patients) or with UKA (183 patients). The mean age was 42.7 years for the 57 patients (41 men and 16 women) in the PTO group versus 49.2 years for the 183 patients (82 men and 101 women) in the UKA group. The Tegner activity level and Lysholm knee scores were evaluated at 3 months and at 1, 2, and 5 years postoperatively as well as at the time of the final follow-up. The end point for survival was defined as revision to total knee arthroplasty. A Wilcoxon rank-sum test was used to evaluate the difference between the groups with respect to the Tegner and Lysholm scores at the respective follow-up intervals. Multivariate regression was used to assess potential confounders. Results: Preoperatively, the PTO and UKA groups had similar Tegner (3.0 ± 1.3 and 2.6 ± 0.09, respectively) and Lysholm scores (69.5 ± 7.3 and 71.6 ± 5.4). Postoperatively, the UKA group had significantly superior mean Tegner scores compared with the PTO group at 3 months (3.82 and 2.02, respectively), at 2 years (4.33 and 3.75), and at the time of the final follow-up (4.48 and 3.08), while the Lysholm scores were higher at 3 months (88.0 and 76.3) and at the final follow-up (90.0 and 80.2) (p < 0.01 for all). Multivariate analysis showed UKA to be an independent predictor of activity level at 3 months, 1 year, and 2 years, as well as at the final follow-up. The survivorship was 77% in the PTO group at an average of 7.2 years and 94% in the UKA group at an average of 5.8 years (p < 0.01). The average time to failure was 98 months (range, 38 to 169 months) in the PTO group and 42 months (range, 2 to 123 months) in the UKA group (p < 0.01). Conclusions: In this comparative cohort study of young patients with isolated unicompartmental arthritis, those treated with UKA reached a higher level of activity early after surgery and it persisted at mid-term follow-up. The UKA group had earlier, but less frequent, revision to total knee arthroplasty. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
{"title":"Unicompartmental Knee Arthroplasty Provides Higher Activity and Durability Than Valgus-Producing Proximal Tibial Osteotomy at 5 to 7 Years","authors":"A. Krych, Patrick J. Reardon, Paul L. Sousa, Ayoosh Pareek, M. Stuart, M. Pagnano","doi":"10.2106/JBJS.15.01031","DOIUrl":"https://doi.org/10.2106/JBJS.15.01031","url":null,"abstract":"Background: The cases of patients with medial compartment osteoarthritis who were ⩽55 years old and had a proximal tibial osteotomy (PTO) or medial unicompartmental knee arthroplasty (UKA) were compared. Outcomes included postoperative activity level, function, and survivorship free of revision to total knee arthroplasty. Methods: Between 1998 and 2013, data were available for 240 patients between 18 and 55 years old with medial compartment arthritis and varus malalignment who were treated either with PTO (57 patients) or with UKA (183 patients). The mean age was 42.7 years for the 57 patients (41 men and 16 women) in the PTO group versus 49.2 years for the 183 patients (82 men and 101 women) in the UKA group. The Tegner activity level and Lysholm knee scores were evaluated at 3 months and at 1, 2, and 5 years postoperatively as well as at the time of the final follow-up. The end point for survival was defined as revision to total knee arthroplasty. A Wilcoxon rank-sum test was used to evaluate the difference between the groups with respect to the Tegner and Lysholm scores at the respective follow-up intervals. Multivariate regression was used to assess potential confounders. Results: Preoperatively, the PTO and UKA groups had similar Tegner (3.0 ± 1.3 and 2.6 ± 0.09, respectively) and Lysholm scores (69.5 ± 7.3 and 71.6 ± 5.4). Postoperatively, the UKA group had significantly superior mean Tegner scores compared with the PTO group at 3 months (3.82 and 2.02, respectively), at 2 years (4.33 and 3.75), and at the time of the final follow-up (4.48 and 3.08), while the Lysholm scores were higher at 3 months (88.0 and 76.3) and at the final follow-up (90.0 and 80.2) (p < 0.01 for all). Multivariate analysis showed UKA to be an independent predictor of activity level at 3 months, 1 year, and 2 years, as well as at the final follow-up. The survivorship was 77% in the PTO group at an average of 7.2 years and 94% in the UKA group at an average of 5.8 years (p < 0.01). The average time to failure was 98 months (range, 38 to 169 months) in the PTO group and 42 months (range, 2 to 123 months) in the UKA group (p < 0.01). Conclusions: In this comparative cohort study of young patients with isolated unicompartmental arthritis, those treated with UKA reached a higher level of activity early after surgery and it persisted at mid-term follow-up. The UKA group had earlier, but less frequent, revision to total knee arthroplasty. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"295 3","pages":"113–122"},"PeriodicalIF":0.0,"publicationDate":"2017-01-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91429838","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Propionibacterium is commonly recovered from explants or surrounding tissues in revision shoulder arthroplasty. Rather than attempting to differentiate a true infection from a false-positive result on the basis of the number of positive cultures, we characterized the amount of these bacteria in each specimen and shoulder. Methods: The study included 137 revision shoulder arthroplasties from which a minimum of 4 specimens had been submitted for culture and at least 1 was positive for Propionibacterium. Standard microbiology procedures were used to assign a semiquantitative value (0.1, 1, 2, 3, or 4), called the Specimen Propi Value, to the amount of growth in each specimen. The sum of the Specimen Propi Values for each shoulder was defined as the Shoulder Propi Score, which was then divided by the total number of specimens to calculate the Average Shoulder Propi Score. Results: The number and percentage of positive specimen-specific cultures (of material obtained from the stem explant, head explant, glenoid explant, humeral membrane, collar membrane, other soft tissue, fluid, or other) per shoulder ranged from 1 to 6 and 14% to 100%. A high percentage of specimens (mean, 43%; median, 50%) from the culture-positive shoulders showed no growth. Only 32.6% of the fluid cultures were positive in comparison with 66.5% of the soft-tissue cultures and 55.6% of the cultures of explant specimens. The average Specimen Propi Value (and standard deviation) for fluid specimens (0.35 ± 0.89) was significantly lower than those for the soft-tissue (0.92 ± 1.50) and explant (0.66 ± 0.90) specimens (p < 0.001). The Shoulder Propi Score was significantly higher in men (3.56 ± 3.74) than in women (1.22 ± 3.11) (p < 0.001). Similarly, men had a significantly higher Average Shoulder Propi Score (0.53 ± 0.51) than women (0.19 ± 0.43) (p < 0.001). Conclusions: This investigation suggests that Propionibacterium is unevenly distributed within culture-positive revised shoulders. As a result, the specimen number and source (explant, soft tissue, or fluid) have major influences on the culture results for a revised shoulder arthroplasty. We found no evidence that suggested useful threshold values for defining a true infection. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
{"title":"Characterizing the Propionibacterium Load in Revision Shoulder Arthroplasty: A Study of 137 Culture-Positive Cases","authors":"Zahab S. Ahsan, J. Somerson, Frederick A Matsen","doi":"10.2106/JBJS.16.00422","DOIUrl":"https://doi.org/10.2106/JBJS.16.00422","url":null,"abstract":"Background: Propionibacterium is commonly recovered from explants or surrounding tissues in revision shoulder arthroplasty. Rather than attempting to differentiate a true infection from a false-positive result on the basis of the number of positive cultures, we characterized the amount of these bacteria in each specimen and shoulder. Methods: The study included 137 revision shoulder arthroplasties from which a minimum of 4 specimens had been submitted for culture and at least 1 was positive for Propionibacterium. Standard microbiology procedures were used to assign a semiquantitative value (0.1, 1, 2, 3, or 4), called the Specimen Propi Value, to the amount of growth in each specimen. The sum of the Specimen Propi Values for each shoulder was defined as the Shoulder Propi Score, which was then divided by the total number of specimens to calculate the Average Shoulder Propi Score. Results: The number and percentage of positive specimen-specific cultures (of material obtained from the stem explant, head explant, glenoid explant, humeral membrane, collar membrane, other soft tissue, fluid, or other) per shoulder ranged from 1 to 6 and 14% to 100%. A high percentage of specimens (mean, 43%; median, 50%) from the culture-positive shoulders showed no growth. Only 32.6% of the fluid cultures were positive in comparison with 66.5% of the soft-tissue cultures and 55.6% of the cultures of explant specimens. The average Specimen Propi Value (and standard deviation) for fluid specimens (0.35 ± 0.89) was significantly lower than those for the soft-tissue (0.92 ± 1.50) and explant (0.66 ± 0.90) specimens (p < 0.001). The Shoulder Propi Score was significantly higher in men (3.56 ± 3.74) than in women (1.22 ± 3.11) (p < 0.001). Similarly, men had a significantly higher Average Shoulder Propi Score (0.53 ± 0.51) than women (0.19 ± 0.43) (p < 0.001). Conclusions: This investigation suggests that Propionibacterium is unevenly distributed within culture-positive revised shoulders. As a result, the specimen number and source (explant, soft tissue, or fluid) have major influences on the culture results for a revised shoulder arthroplasty. We found no evidence that suggested useful threshold values for defining a true infection. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"31 1","pages":"150–154"},"PeriodicalIF":0.0,"publicationDate":"2017-01-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76036680","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
J. Kellam, D. Archibald, J. W. Barber, E. P. Christian, Richard J. D’Ascoli, R. Haynes, S. Hecht, S. Hurwitz, A. McLaren, T. Peabody, S. Southworth, R. Strauss, V. Wadey
Background: With the changing delivery of orthopaedic surgical care, there is a need to define the knowledge and competencies that are expected of an orthopaedist providing general and/or acute orthopaedic care. This article provides a proposal for the knowledge and competencies needed for an orthopaedist to practice general and/or acute care orthopaedic surgery. Methods: Using the modified Delphi method, the General Orthopaedic Competency Task Force consisting of stakeholders associated with general orthopaedic practice has proposed the core knowledge and competencies that should be maintained by orthopaedists who practice emergency and general orthopaedic surgery. Results: For relevancy to clinical practice, 2 basic sets of competencies were established. The assessment competencies pertain to the general knowledge needed to evaluate, investigate, and determine an overall management plan. The management competencies are generally procedural in nature and are divided into 2 groups. For the Management 1 group, the orthopaedist should be competent to provide definitive care including assessment, investigation, initial or emergency care, operative or nonoperative care, and follow-up. For the Management 2 group, the orthopaedist should be competent to assess, investigate, and commence timely non-emergency or emergency care and then either transfer the patient to the appropriate subspecialist’s care or provide definitive care based on the urgency of care, exceptional practice circumstance, or individual’s higher training. This may include some higher-level procedures usually performed by a subspecialist, but are consistent with one’s practice based on experience, practice environment, and/or specialty interest. Conclusions: These competencies are the first step in defining the practice of general orthopaedic surgery including acute orthopaedic care. Further validation and discussion among educators, general orthopaedic surgeons, and subspecialists will ensure that these are relevant to clinical practice. Clinical Relevance: These competencies provide many stakeholders, including orthopaedic educators and orthopaedists, with what may be the minimum knowledge and competencies necessary to deliver acute and general orthopaedic care. This document is the first step in defining a practice-based standard for training programs and certification groups.
{"title":"The Core Competencies for General Orthopaedic Surgeons","authors":"J. Kellam, D. Archibald, J. W. Barber, E. P. Christian, Richard J. D’Ascoli, R. Haynes, S. Hecht, S. Hurwitz, A. McLaren, T. Peabody, S. Southworth, R. Strauss, V. Wadey","doi":"10.2106/JBJS.16.00761","DOIUrl":"https://doi.org/10.2106/JBJS.16.00761","url":null,"abstract":"Background: With the changing delivery of orthopaedic surgical care, there is a need to define the knowledge and competencies that are expected of an orthopaedist providing general and/or acute orthopaedic care. This article provides a proposal for the knowledge and competencies needed for an orthopaedist to practice general and/or acute care orthopaedic surgery. Methods: Using the modified Delphi method, the General Orthopaedic Competency Task Force consisting of stakeholders associated with general orthopaedic practice has proposed the core knowledge and competencies that should be maintained by orthopaedists who practice emergency and general orthopaedic surgery. Results: For relevancy to clinical practice, 2 basic sets of competencies were established. The assessment competencies pertain to the general knowledge needed to evaluate, investigate, and determine an overall management plan. The management competencies are generally procedural in nature and are divided into 2 groups. For the Management 1 group, the orthopaedist should be competent to provide definitive care including assessment, investigation, initial or emergency care, operative or nonoperative care, and follow-up. For the Management 2 group, the orthopaedist should be competent to assess, investigate, and commence timely non-emergency or emergency care and then either transfer the patient to the appropriate subspecialist’s care or provide definitive care based on the urgency of care, exceptional practice circumstance, or individual’s higher training. This may include some higher-level procedures usually performed by a subspecialist, but are consistent with one’s practice based on experience, practice environment, and/or specialty interest. Conclusions: These competencies are the first step in defining the practice of general orthopaedic surgery including acute orthopaedic care. Further validation and discussion among educators, general orthopaedic surgeons, and subspecialists will ensure that these are relevant to clinical practice. Clinical Relevance: These competencies provide many stakeholders, including orthopaedic educators and orthopaedists, with what may be the minimum knowledge and competencies necessary to deliver acute and general orthopaedic care. This document is the first step in defining a practice-based standard for training programs and certification groups.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"100 1","pages":"175–181"},"PeriodicalIF":0.0,"publicationDate":"2017-01-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76121895","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
J. Parvizi, Ronald C. Huang, C. Restrepo, Antonia F Chen, M. Austin, W. Hozack, J. Lonner
Background: Aspirin is a safe and effective prophylaxis for the prevention of venous thromboembolism following total joint arthroplasty. The optimal dose of aspirin prophylaxis is unknown. Our hypothesis was that lower-dose aspirin is as effective as higher-dose aspirin for the prevention of venous thromboembolism and is associated with fewer gastrointestinal side effects. Methods: In a prospective, crossover study, we analyzed 4,651 primary total joint arthroplasty cases performed from July 2013 to June 2015. For 4 weeks, 3,192 patients received enteric-coated 325-mg aspirin twice daily (the 325-mg aspirin group) and 1,459 patients received 81-mg aspirin twice daily (the 81-mg aspirin group). There were no significant differences (p > 0.05) in sex, body mass index, or Charlson Comorbidity Index between the two patient populations. Recorded complications occurring within 90 days postoperatively included symptomatic venous thromboembolism (deep venous thrombosis and pulmonary embolism), gastrointestinal complications, acute periprosthetic joint infection, and death. Results: The incidence of venous thromboembolism of 0.1% (95% confidence interval [CI], 0% to 0.3%) in the 81-mg aspirin group (1 with deep venous thrombosis and 1 with pulmonary embolism) was not significantly different (p = 0.345) from 0.3% (95% CI, 0.1% to 0.6%) in the 325-mg aspirin group (7 with deep venous thrombosis and 5 with pulmonary embolism). The incidence of gastrointestinal bleeding or ulceration of 0.3% (95% CI, 0% to 0.5%) in the 81-mg aspirin group was slightly, but not significantly (p = 0.66), lower than the 0.4% (95% CI, 0.2% to 0.6%) in the 325-mg aspirin group. The incidence of acute periprosthetic joint infection was 0.2% (95% CI, 0% to 0.4%) in the 81-mg aspirin group compared with 0.5% (95% CI, 0.2% to 0.7%) in the 325-mg aspirin group (p = 0.28). The 90-day mortality rate was similar in both groups at 0.1% (95% CI, 0% to 0.2%) in the 81-mg aspirin group and 0.1% (95% CI, 0% to 0.2%) in the 325-mg aspirin group (p = 0.78). Conclusions: Our study demonstrates that low-dose aspirin is not inferior to high-dose aspirin for venous thromboembolism prophylaxis following total joint arthroplasty. This is not unexpected, as the available literature demonstrates that low-dose aspirin is as effective as higher-dose aspirin in the prevention of acute coronary syndrome and cerebrovascular events. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
{"title":"Low-Dose Aspirin Is Effective Chemoprophylaxis Against Clinically Important Venous Thromboembolism Following Total Joint Arthroplasty: A Preliminary Analysis","authors":"J. Parvizi, Ronald C. Huang, C. Restrepo, Antonia F Chen, M. Austin, W. Hozack, J. Lonner","doi":"10.2106/JBJS.16.00147","DOIUrl":"https://doi.org/10.2106/JBJS.16.00147","url":null,"abstract":"Background: Aspirin is a safe and effective prophylaxis for the prevention of venous thromboembolism following total joint arthroplasty. The optimal dose of aspirin prophylaxis is unknown. Our hypothesis was that lower-dose aspirin is as effective as higher-dose aspirin for the prevention of venous thromboembolism and is associated with fewer gastrointestinal side effects. Methods: In a prospective, crossover study, we analyzed 4,651 primary total joint arthroplasty cases performed from July 2013 to June 2015. For 4 weeks, 3,192 patients received enteric-coated 325-mg aspirin twice daily (the 325-mg aspirin group) and 1,459 patients received 81-mg aspirin twice daily (the 81-mg aspirin group). There were no significant differences (p > 0.05) in sex, body mass index, or Charlson Comorbidity Index between the two patient populations. Recorded complications occurring within 90 days postoperatively included symptomatic venous thromboembolism (deep venous thrombosis and pulmonary embolism), gastrointestinal complications, acute periprosthetic joint infection, and death. Results: The incidence of venous thromboembolism of 0.1% (95% confidence interval [CI], 0% to 0.3%) in the 81-mg aspirin group (1 with deep venous thrombosis and 1 with pulmonary embolism) was not significantly different (p = 0.345) from 0.3% (95% CI, 0.1% to 0.6%) in the 325-mg aspirin group (7 with deep venous thrombosis and 5 with pulmonary embolism). The incidence of gastrointestinal bleeding or ulceration of 0.3% (95% CI, 0% to 0.5%) in the 81-mg aspirin group was slightly, but not significantly (p = 0.66), lower than the 0.4% (95% CI, 0.2% to 0.6%) in the 325-mg aspirin group. The incidence of acute periprosthetic joint infection was 0.2% (95% CI, 0% to 0.4%) in the 81-mg aspirin group compared with 0.5% (95% CI, 0.2% to 0.7%) in the 325-mg aspirin group (p = 0.28). The 90-day mortality rate was similar in both groups at 0.1% (95% CI, 0% to 0.2%) in the 81-mg aspirin group and 0.1% (95% CI, 0% to 0.2%) in the 325-mg aspirin group (p = 0.78). Conclusions: Our study demonstrates that low-dose aspirin is not inferior to high-dose aspirin for venous thromboembolism prophylaxis following total joint arthroplasty. This is not unexpected, as the available literature demonstrates that low-dose aspirin is as effective as higher-dose aspirin in the prevention of acute coronary syndrome and cerebrovascular events. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"20 1","pages":"91–98"},"PeriodicalIF":0.0,"publicationDate":"2017-01-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86166213","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
D. Fry, M. Pine, S. Nedza, David G. Locke, Agnes M. Reband, Gregory Pine
Background: Comparative measurement of hospital outcomes can define opportunities for care improvement and will assume great importance as alternative payment models for inpatient total joint replacement surgical procedures are introduced. The purpose of this study was to develop risk-adjusted models for Medicare inpatient and post-discharge adverse outcomes in elective lower-extremity total joint replacement and to apply these models for hospital comparison. Methods: Hospitals with ≥50 qualifying cases of elective total hip replacement and total knee replacement from the Medicare Limited Data Set database of 2010 to 2012 were studied. Logistic risk models were designed for adverse outcomes of inpatient mortality, prolonged length-of-stay outliers in the index hospitalization, 90-day post-discharge deaths without readmission, and 90-day readmissions after excluding non-related readmissions. For each hospital, models were used to predict total adverse outcomes, the number of standard deviations from the mean (z-scores) for hospital performance, and risk-adjusted adverse outcomes for each hospital. Results: A total of 253,978 patients who underwent total hip replacement and 672,515 patients who underwent total knee replacement were studied. The observed overall adverse outcome rates were 12.0% for total hip replacement and 11.6% for total knee replacement. The z-scores for 1,483 hospitals performing total hip replacements varied from −5.09 better than predicted to +5.62 poorer than predicted; 98 hospitals were ≥2 standard deviations better than predicted and 142 hospitals were ≥2 standard deviations poorer than predicted. The risk-adjusted adverse outcome rate for these hospitals was 6.6% for the best-decile hospitals and 19.8% for the poorest-decile hospitals. The z-scores for the 2,349 hospitals performing total knee replacements varied from −5.85 better than predicted to +11.75 poorer than predicted; 223 hospitals were ≥2 standard deviations better than predicted and 319 hospitals were ≥2 standard deviations poorer than predicted. The risk-adjusted adverse outcome rate for these hospitals was 6.4% for the best-decile hospitals and 19.3% for the poorest-decile hospitals. Conclusions: Risk-adjusted outcomes demonstrate wide variability and illustrate the need for improvement among poorer-performing hospitals for bundled payments of joint replacement surgical procedures. Clinical Relevance: Adverse outcomes are known to occur in the experience of all clinicians and hospitals. The risk-adjusted benchmarking of hospital performance permits the identification of adverse events that are potentially preventable.
{"title":"Risk-Adjusted Hospital Outcomes in Medicare Total Joint Replacement Surgical Procedures","authors":"D. Fry, M. Pine, S. Nedza, David G. Locke, Agnes M. Reband, Gregory Pine","doi":"10.2106/JBJS.15.01455","DOIUrl":"https://doi.org/10.2106/JBJS.15.01455","url":null,"abstract":"Background: Comparative measurement of hospital outcomes can define opportunities for care improvement and will assume great importance as alternative payment models for inpatient total joint replacement surgical procedures are introduced. The purpose of this study was to develop risk-adjusted models for Medicare inpatient and post-discharge adverse outcomes in elective lower-extremity total joint replacement and to apply these models for hospital comparison. Methods: Hospitals with ≥50 qualifying cases of elective total hip replacement and total knee replacement from the Medicare Limited Data Set database of 2010 to 2012 were studied. Logistic risk models were designed for adverse outcomes of inpatient mortality, prolonged length-of-stay outliers in the index hospitalization, 90-day post-discharge deaths without readmission, and 90-day readmissions after excluding non-related readmissions. For each hospital, models were used to predict total adverse outcomes, the number of standard deviations from the mean (z-scores) for hospital performance, and risk-adjusted adverse outcomes for each hospital. Results: A total of 253,978 patients who underwent total hip replacement and 672,515 patients who underwent total knee replacement were studied. The observed overall adverse outcome rates were 12.0% for total hip replacement and 11.6% for total knee replacement. The z-scores for 1,483 hospitals performing total hip replacements varied from −5.09 better than predicted to +5.62 poorer than predicted; 98 hospitals were ≥2 standard deviations better than predicted and 142 hospitals were ≥2 standard deviations poorer than predicted. The risk-adjusted adverse outcome rate for these hospitals was 6.6% for the best-decile hospitals and 19.8% for the poorest-decile hospitals. The z-scores for the 2,349 hospitals performing total knee replacements varied from −5.85 better than predicted to +11.75 poorer than predicted; 223 hospitals were ≥2 standard deviations better than predicted and 319 hospitals were ≥2 standard deviations poorer than predicted. The risk-adjusted adverse outcome rate for these hospitals was 6.4% for the best-decile hospitals and 19.3% for the poorest-decile hospitals. Conclusions: Risk-adjusted outcomes demonstrate wide variability and illustrate the need for improvement among poorer-performing hospitals for bundled payments of joint replacement surgical procedures. Clinical Relevance: Adverse outcomes are known to occur in the experience of all clinicians and hospitals. The risk-adjusted benchmarking of hospital performance permits the identification of adverse events that are potentially preventable.","PeriodicalId":22579,"journal":{"name":"The Journal of Bone and Joint Surgery","volume":"36 1","pages":"10–18"},"PeriodicalIF":0.0,"publicationDate":"2017-01-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78972846","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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