Journal of Arthroplasty最新文献

Background: The delta difference between baseline patient-reported outcome measure scores (PROMS) and postoperative scores is used to measure success following primary total hip arthroplasty (THA). However, statistical improvement is not necessarily equal to clinical benefit. The percentage of the maximal improvement (MOI) is a psychometric tool to determine clinical improvement. This study aimed to determine thresholds for the MOI for the Forgotten Joint Score (FJS), the Harris Hip Score (HHS), and the Visual Analog Scale for Pain (VAS) following THA for osteoarthritis.

Methods: Data were retrospectively reviewed for all patients who underwent primary THA for hip osteoarthritis between October 2014 and July 2020. Patients who answered an anchor question for satisfaction and had baseline and minimum two-year follow-up scores were included. Receiver operating characteristic curve analyses were performed to determine the MOI thresholds with the area under the curve (AUC).

Results: In total, 584 patients were included, 53.1% women and 46.9% men, who had a mean age of 57 years (± 10.4). Improvement was reported for all PROMS (P < 0.0001). The AUC values for MOI for the FJS, HHS, and VAS were 0.788, 0.839, and 0.805, respectively. The MOI for the FJS, the HHS, and the VAS were 54.2, 65, and 67.1%, respectively.

Conclusion: Following primary THA for hip osteoarthritis, percentage thresholds for achieving the MOI for the FJS, the HHS, and the VAS for pain were 54.2, 65, and 67.1%, respectively. No preoperative predictors of achieving the MOI were identified.

Background: As the demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA) continues to grow exponentially, the economic burden on practices and healthcare payers simultaneously increases. Medicare accounts for over 60% of total joint arthroplasty (TJA) cases nationwide, and the reimbursements are worsening despite alternative payment models. Trending the active payers at an institution provides invaluable insight into the financial health of a practice and projects if annual run rates are sustainable.

Methods: Insurance and billing claims were analyzed for all THA and TKA cases between January 1, 2019, and December 31, 2022, from various healthcare payers at a single, high-volume institution. The payers included Medicare, Medicare Advantage, and seven commercial payers. The THA and TKA claims are from institutional facilities across two Northeast states - New Jersey (NJ) and Pennsylvania (PA). Volumes, charges, and payments from each payer were trended over three years (2019 to 2022).

Results: In the years following the COVID-19 pandemic, the number of institutional patients who had Medicare and Medicare Advantage undergoing TJA drastically increased by 29.1 and 37.8%, respectively. As a result, charges spiked by over $20 million for Medicare and nearly $15 million for Medicare Advantage. Despite a higher caseload, the payments received per case decreased by 24.5% for Medicare and 18.7% for Medicare Advantage. Commercial payers grew 20.6% in annual cases, yet payments received per case similarly decreased by 15.0% at the end of 2022.

Conclusions: Rising Medicare and Medicare Advantage TJA volume highlights the increase in costs and resource utilization, while diminishing payments underscore the inadequate reimbursement to hospitals and surgeons. Along with stagnant commercial payments, the trend shows concerns about the financial health of THA and TKA institutions that participate in the care of a large number of Medicare patients.

Background: The purpose of this study was to determine the safety and the clinical outcome of simultaneous, bilateral, and staged bilateral total knee arthroplasty (TKA) performed by a single surgeon at one academic institute.

Methods: We prospectively followed and retrospectively compared the results of 7,155 patients (14,310 knees) who had simultaneous bilateral TKA, 6,671 patients (13,342 knees) who had staggered bilateral TKA, and 4,501 patients (9,002 knees) who had staged bilateral TKA. The mean age of the patients was 67, 65, and 69 years, respectively. The mean follow-up was 15.5, 15.3, and 16.1 years, respectively. The prevalence of mortality and complications were assessed in each group. In addition, patients were assessed clinically and radiographically at each follow-up.

Results: The mortality rate (14 patients, 0.2%) of the patients who underwent simultaneous bilateral TKA was similar to those who underwent staggered bilateral TKA (19 patients, 0.3%) and those who underwent staged bilateral TKA (18 patients, 0.4%) (P > 0.05). The major complication (except death) rate (0.8, 0.5, and 0.4%, respectively) and the minor complication rate (20.7, 19, and 19.6%, respectively) were not significantly different among the three groups (P > 0.05). There was no significant difference in the clinical outcomes, radiographic results, revision rate, or survivorship of TKA implants among the three groups (P > 0.05). Transfusion requirements were different among the three groups (10% in the simultaneous bilateral TKA group, 12% in the staggered bilateral TKA group, and 2% in the staged bilateral TKA group).

Conclusions: We found no significant differences among the simultaneous, staggered, and staged bilateral TKA groups, with regard to the mortality, major complication, minor complication, and revision rates; the survival of TKA implants; and clinical and radiographic results after a mean follow-up of 15.5, 15.3, and 16.1 years, respectively.

Introduction: The Area Deprivation Index (ADI) is a weighted index comprised of 17 census-based markers of material deprivation and poverty. The purpose of this study was to determine whether patients undergoing total hip arthroplasty (THA) in areas of high ADI (greater disadvantage) were associated with differences in 90-day: 1) medical complications; 2) emergency department (ED) utilizations; and 3) readmissions.

Methods: A nationwide database was queried for primary THA patients from 2010 to 2020. The ADI is reported on a scale of 0 to 100, with higher numbers indicating greater disadvantage. Patients undergoing primary THA in regions associated with high ADI (90%+) were compared to those of lower ADI (0 to 89%). A total of 138,670 patients were evenly matched between the two cohorts following 1:1 propensity score matching by age, sex, and Elixhauser Comorbidity Index (ECI). Primary endpoints were 90-day medical complications, ED utilizations, and readmissions. Multivariable logistic regression models calculated the odds ratios (OR) and 95% confidence intervals (95% CI). P-values less than 0.01 were statistically significant.

Results: Patients undergoing THA from high ADI had significantly higher rates and odds of developing any medical complications (13.00 versus 11.91%; OR: 1.09, P < 0.0001), including acute kidney injuries (1.83 versus 1.52%; OR: 1.20, P < 0.0001), myocardial infarctions (0.35 versus 0.24%; OR: 1.45, P = 0.0003), and surgical site infections (0.94 versus 0.76%; OR: 1.23, P = 0.0004). High ADI patients had significantly higher rates and odds of ED visits within 90 days (3.94 versus 3.67%; OR: 1.08, P = 0.008). There was no significant difference in readmissions (5.44 versus 5.69%; OR: 0.95, P = 0.034).

Conclusions: Socioeconomically disadvantaged patients have increased odds of 90-day medical complications and ED utilizations, despite comparable 90-day readmission rates. Measures of neighborhood disadvantage may be valuable metrics to inform healthcare policy and improve post-discharge care.

Background: Periarticular injections (PAIs) have become a critical part of multimodal anesthetic regimens for total knee arthroplasty (TKA). This study assessed the effect of adductor canal blocks (ACBs) alone, PAIs alone, and the combination of both on postoperative pain management in patients undergoing primary TKA.

Methods: Patients who underwent primary TKA were retrospectively identified from February 2022 to February 2023. Patients were stratified based on perioperative local/regional anesthetic regimen (PAI only, PAI with an ACB, and ACB only) and matched in a 1:1:1 ratio. Patients were propensity score-matched based on age, American Society of Anesthesiologists score, body mass index, and preoperative narcotic usage. Patient demographics, narcotic refills, postoperative morphine requirements, pain scores, and readmissions, were compared. After successful matching, there were 40 patients in each cohort.

Results: First postanesthesia care unit visual analog pain scale scores after surgery were not significantly different across all groups (P = 0.082). Pair-wise comparisons of patients receiving either PAI alone or ACB alone showed that patients receiving PAIs had lower narcotic usage at six hours (P = 0.037). A PAI alone also demonstrated a shorter length of stay compared to ACB alone (P = 0.001). Postoperative narcotics refills were similar between ACB only and PAI only (P = 0.056); however, PAI with an ACB had lower postoperative narcotic refills (P = 0.017). The rate of same-day physical therapy clearance was lowest in the ACB-only group (37.5% [15 of 40]) (P = 0.002).

Conclusions: There was no difference in pain scores immediately after surgery; however, postoperative morphine requirements at 6 hours, same-day physical therapy clearance, and length of stay were better in the PAI group. The use of PAIs may benefit both patients and healthcare systems as an adjunct to perioperative pain control.

Background: Despite the prevalence of total hip arthroplasty (THA) as a treatment for hip-related conditions, there is limited research directly comparing the patient-reported outcome measures between primary and revision total hip arthroplasty (rTHA). This study compared the time to achieve minimal clinically important difference (MCID) between primary and rTHA.

Methods: We conducted a retrospective analysis comparing 6,671 THAs (6,070 primary and 601 all-cause rTHAs) performed between 2016 and 2022. Patient-reported outcomes were evaluated using preoperative and postoperative scores of Patient-Reported Outcomes Measurement Information System (PROMIS) Global Physical, PROMIS Physical Function Short Form 10a (PF-10a), and Hip Injury and Osteoarthritis Outcome Score - Physical Function Short Form (HOOS-PS). The time to achieve MCID was assessed using survival curves with and without interval-censoring, and statistical comparisons were performed using log-rank and weighted log-rank tests.

Results: Comparing the time to achieve MCID without interval-censoring, primary total hip arthroplasty (pTHA) demonstrated significantly faster median times than rTHA for PROMIS Global Physical (3.3 versus 3.9 months, P < 0.001), PROMIS PF-10a (3.6 versus 6.2 months, P < 0.001), and HOOS-PS (3.1 versus 4.0 months, P < 0.001). Similarly, when using interval-censoring, pTHA continued to achieve MCID significantly faster than rTHA for PROMIS Global Physical (0.23 to 0.24 versus 0.50 to 0.51 months, P < 0.001), PROMIS PF-10a (1.43 to 1.44 versus 3.03 to 3.04 months, P < 0.001), and HOOS-PS (0.87 to 0.87 versus 1.20 to 1.21 months, P < 0.001).

Conclusions: Across all patient-reported outcome measures, pTHA achieved MCID significantly faster than rTHA, irrespective of interval-censoring. These findings underscore the importance of setting realistic postoperative recovery expectations during perioperative patient counseling. Future studies should investigate the factors influencing time to achieve MCID and explore how to enhance rTHA techniques and perioperative management for improved patient outcomes.

Level of evidence: III.

Background: Identifying risk factors associated with non-home discharge (NHD) following revision hip and knee total joint arthroplasty (TJA) could reduce the rate of preventable discharge to rehabilitation or skilled nursing facilities. Neighborhood-level deprivation indices are becoming an increasingly important measure of socioeconomic disadvantage as these indices consider multiple social determinants of health. This study aimed to compare the utility of widely used neighborhood social vulnerability indices in predicting NHD following revision TJA patients.

Methods: This study included 1,043 consecutive patients who underwent revision TJA at a single tertiary health system. There were three multivariate logistic regression analyses with the outcome of NHD performed using the area deprivation index (ADI), social deprivation index (SDI), and social vulnerability index while controlling for other demographic variables. Neighborhood-level indices were included in the analysis as continuous variables and categorical quartiles, with the lowest quartile representing the least deprived neighborhoods of the patient cohort. The strength of the association of significant indices was measured.

Results: Patients in the highest ADI and SDI quartiles demonstrated higher odds of NHD compared to the cohort with the lowest quartile (ADI OR [odds ratio] = 1.93, 95% CI [confidence interval] = 1.23 to 3.03, P = 0.005; SDI OR = 1.86, 95% CI = 1.18 to 2.91, P = 0.007). Discharge disposition was more strongly associated with ADI than SDI (0.68 versus 0.26). Age, American Society of Anesthesiologist status, and alcohol use were independent determinants of discharge disposition. No significant association was seen between social vulnerability index and discharge disposition.

Conclusions: Area-level indices can be utilized to identify patients at higher risk of NHD following revision TJA. This study highlights the important differences between these indices' utility when evaluating their effects on clinical outcomes in this patient population. The findings shed light on the potential of integrating these tools into policy development, clinical preoperative programs, and research to better understand and address the health disparities in arthroplasty outcomes.