Association Between Epidemiological Factors and Nonresponders to Total Joint Replacement Surgery in Primary Osteoarthritis Patients

BackgroundWhile total joint replacement (TJR) is the most effective treatment for end-stage osteoarthritis (OA), one-third of patients do not experience clinically important improvement in pain or function following the surgery. Thus, it is important to identify factors for nonresponders and develop strategies to improve TJR outcomes.MethodsStudy participants were patients who underwent TJR (hip/knee) due to OA and completed the WOMAC before and on average 4 years after surgery. Nonresponders (pain nonresponders, function nonresponders, pain and function nonresponders) were determined using the WOMAC change score from baseline to follow-up under two previously reported criteria. Eighty-eight self-reported factors collected by a general health questionnaire were examined for associations with nonresponders.ResultsA total of 601 patients (30.8% hip and 69.2% knee replacement) were included; 18% of them were found to be either pain or function nonresponders. Nine factors were identified in the univariable analyses to be associated with nonresponders, and 5 of them (clinical depression, multisite musculoskeletal pain [MSMP], younger age, golfer’s elbow, and driving more than 4 hours on average per working day) remained significant in the multivariable analyses in at least one of six categories. Clinical depression, having MSMP, and younger age were the major factors to be independently associated with nonresponders across five categories. In addition, two factors (age at menopause and age at hysterectomy) were significantly associated with female nonresponders.ConclusionOur data suggested potential roles of pain perception, widespread pain sensitization, patient expectations, and early menopause in females in TJR outcomes, warranting further investigation.     

Predictors of Outcome After Primary Total Joint Replacement

Background

Total hip and knee replacements are frequently performed curative treatment options in end-stage arthritis. In this study, we analyzed clinical outcome, complications, and predictors of outcome in modern joint replacement.

髋关节置换术后不稳定的原因分析

目的：研究髋关节置换术后关节不稳定的原因与处理办法，方法：观察44例全髋置换病人手术入路，方式，头与臼的比例，软组织的平衡等与术后不稳定的关系。结果：根据患者术后疼痛，行走，髋关节功能，生活工作能力进行评分。优26例，良11例，可6例，差1例，优良率84．1％，结论：手术入路，方式，头与臼的比例，软组织的平衡等是术后关节不稳定的重要因素，及时，恰当的处理是保证术后关节稳定的重要手段。     

Oncology Patients Are High Cost Outliers in Total Joint Replacement Bundled Payment Systems

BackgroundIn 2016, the Centers for Medicare and Medicaid Services began its first mandatory bundled payment program, the Comprehensive Care for Joint Replacement (CJR) model, which covers a 90-day episode of care. This study determined whether oncology patients enrolled in the CJR bundle incur higher hospital costs than patients with osteoarthritis (OA).MethodsA retrospective review of all patients enrolled in the CJR bundled payments system from April 1, 2016 to June 31, 2018 at a single academic medical center was conducted. To determine whether tumor patients had higher total episode costs, this group was compared to patients diagnosed with OA using a 2-tailed t-test. To adjust for moderators of total hospital costs, we used generalized linear regression with a log-link, including multiple variables abstracted from chart review.ResultsThree hundred fourteen patients met inclusion criteria (12 primary or metastatic tumors, 302 OA). Fifty-eight percent of tumor patients were over the target price vs 16% of OA patients. The mean tumor patient had $40,862 for total internal hospital costs compared to $16,356 in the OA group (P < .001). Length of stay was greater in the tumor group (6.75 vs 2.0 days, P < .001). A greater percentage of tumor patients were discharged to a skilled nursing facility (67% vs 27%, P = .006) with significantly higher skilled nursing facility episode costs ($18,852 vs $7731, P = .04). With adjustment for fracture status, tumor patients were 5.36 times more likely to exceed the CJR target price than OA patients (risk ratio 5.36, confidence interval 3.44-8.35, P < .001) and 50 times more likely to be outliers over the regional threshold than OA patients (risk ratio 50.33, confidence interval 16.33-155.19, P < .001).ConclusionOncology patients enrolled in the CJR bundled payment model incur significantly higher costs and have higher cost variability than patients with OA. We recommend that oncology patients be excluded from the CJR bundle.     

非骨水泥型髋关节置换术治疗成人髋臼发育不良

目的探讨非骨水泥型髋关节置换术治疗髋臼发育不良的早期效果。方法回顾性分析2009—2013年我科非骨水泥全髋关节置换术治疗因髋臼发育不良导致的髋骨关节炎患者66例72髋,其中男9例11髋,女57例61髋;年龄46~75岁,平均55岁。按Crowe分型,Ⅰ型27例29髋,Ⅱ型17例18髋,Ⅲ型13例14髋,Ⅳ型9例11髋,均伴有不同程度的跛行、活动受限等症状。采用Harris评分及术前、术后X线片观察评价手术效果。结果术后患者肢体平均延长36 mm。66例患者均获得1~5年随访。除1例不遵守医嘱过度下蹲出现脱位后在全麻下闭合手法复位,所有患者髋臼重建侧植骨均获得愈合,髋关节假体均未出现假体松动。2例自体股骨头植骨区有少量骨吸收,未发现下肢因肢体延长致神经血管损伤症状。术前患者Harris评分(45.05±5.38)分、术前下肢不等长(23.29±19.36)mm、CE角(4±13.92)°改善至(88.62±3.38)°、(3.26±4.06)mm、(29.27±2.68)°,差异均有统计学意义(P0.05)。术后髋关节旋转中心距泪滴水平距离为(27.82±1.25)mm,垂直距离(24.14±2.59)mm。结论全髋关节置换治疗髋臼发育不良手术难度大,术前精心手术评估,真臼处髋臼重建及通过适度软组织松解、转子下截骨等方式的非骨水泥型髋关节置换术治疗成人髋关节发育不良可取得显著的早期疗效。     

A Meta-Analysis of Patellar Replacement in Total Knee Arthroplasty for Patients With Knee Osteoarthritis

Background

This meta-analysis (MA) aims at comparing the clinical outcomes of resurfacing and nonresurfacing the patella in patients undergoing total knee arthroplasty in the treatment of knee osteoarthritis.

体重指数与髋关节骨性关节炎关节置换术的相关性研究

目的 主要探讨体重指数（BMI）是否是导致髋关节骨性关节炎行髋关节置换术的一种危险因素。方法 选取1994年～2004年在本院确诊为髋关节骨性关节炎．并行髋关节置换术的158例,计算他们的人院时的体重指数。与同时期在本院住院的非髋关节骨性关节炎患者为对照,进行1：1病例对照分析。结果 BMI的增加和髋关节置换术有紧密的关联。当BMI≥25．0kg／m。时,男性组的比值比（OR）值为3．30．95％可信区间（CI）为1．61～6．77;女性组OR值为1．61,95％CI为1．01～2．56。结论 肥胖是导致髋关节骨性关节炎最终行髋关节置换术的一个重要危险因素。     

Tranexamic Acid Administration is Associated With a Decreased Odds of Prosthetic Joint Infection Following Primary Total Hip and Primary Total Knee Arthroplasty: A National Database Analysis

BackgroundTranexamic acid (TXA) for the reduction of blood loss in orthopedic surgery is coming into greater adoption. Because TXA administration lowers the incidence of blood transfusion and of hematoma formation, risk factors for infection, we asked whether TXA use might be associated with a lower incidence of periprosthetic joint infection (PJI) following orthopedic surgery.MethodsWe queried the Premier Healthcare database for ICD-9 codes corresponding to elective inpatient primary total hip replacement (THR) or total knee replacement (TKR) from 2012 to 2016, TXA administration on the day of surgery, and PJI during the hospital stay or within 90 days. We performed a multilevel multivariable logistic regression (SAS version 9.4. SAS Institute, Cary, NC) to determine if TXA administration or other covariates were a significant predictor of infection.ResultsAmong 914,990 total joint arthroplasty patients, 46.0% received TXA on the day of surgery. 0.13% developed PJI within 90 days. After adjusting for patient and hospital-related covariates, TXA use was associated with significantly lower odds of PJI within 90 days of surgery (OR 0.49 [0.69, 0.91]).ConclusionAdministration of TXA on the day of surgery in total knee and total hip arthroplasty was associated with a statistically significant decreased odds of PJI in the first 90 days. We therefore conclude that TXA might play an important role in our attempts to decrease PJI after joint arthroplasty. The exact mechanisms and ideal dosage by which TXA can contribute to such a reduction need further study.     

Validation of the Spanish Version of the Knee Injury and Osteoarthritis Outcome Score (KOOS) for Elderly Patients With Total Knee Replacement

The purpose of this study was to validate the Knee Injury and Osteoarthritis Outcome Score (KOOS) for elderly patients who undergo total knee replacement (TKR). The validated Spanish versions of the KOOS and Medical Outcomes Study 36‐Item Short‐Form Health Survey (SF‐36) questionnaires were applied to 137 patients (mean age 72.3, SD 7.5 years). Test–retest data were collected with an intermediate period of 1–2 weeks. To evaluate the clinimetric properties of the KOOS, internal consistency (Cronbach's α), reproducibility (intraclass correlation coefficient [ICC]), construct validity (Spearman's correlation), responsiveness (effect sizes [ES], and standardized response mean [SRM]), and floor and ceiling effects (<15%) were assessed. As result, Cronbach's coefficients of the KOOS subscales ranged from 0.78 to 0.93, and ICC from 0.76 to 0.91. Construct validity was supported by the confirmation of the three predefined hypotheses involving expected correlations between KOOS subscale and SF‐36 physical health subscales. Spearman's correlations were strong between KOOS Pain and SF‐36 Bodily Pain (r = 0.81), KOOS Pain and SF‐36 Physical Functioning (r = 0.67), KOOS activities of daily living (ADL) and SF‐36 Bodily Pain (r = 0.69), KOOS ADL and SF‐36 Physical Functioning (r = 0.74), and KOOS Sports/Recreation and SF‐36 Physical Functioning (r = 0.76). Responsiveness at 1 year after TKR was large with the ES ranging from 0.81 to 2.12, and the SRM from 0.70 to 1.91. Floor and ceiling effects were low. In conclusion, the Spanish version of KOOS has successful psychometric characteristics and is a reliable and valid instrument for assessment of patient‐relevant outcomes in elderly patients with advanced OA who undergo TKR. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2157–2162, 2019     

Patient Outcomes Following Total Joint Replacement Surgery: A Comparison of Hospitals and Ambulatory Surgery Centers

BackgroundFor several years, many orthopedic surgeons have been performing total joint replacements in hospital outpatient departments (HOPDs) and more recently in ambulatory surgery centers (ASCs). In a recent shift, the Centers for Medicare and Medicaid Services began reimbursing for total knee replacement surgery in HOPDs. Some observers have expressed concerns over patient safety for the Medicare population particularly if Centers for Medicare and Medicaid Services extends the policy to include total hip replacement surgery and coverage in ASCs.MethodsThis study used a large claims database of non-Medicare patients to examine inpatient and outpatient total knee replacement and total hip replacement surgery performed on a near-elderly population during 2014-2016. We applied propensity score methods to match inpatients with ASC patients and HOPD patients with ASC patients adjusting for risk using the HHS Hierarchical Condition Categories risk adjustment model. We conducted statistical tests comparing clinical outcomes across the 3 settings and examined relative costs.ResultsReadmissions, postsurgical complications, and payments were lower for outpatients than for inpatients. Within outpatient settings, readmissions and postsurgical complications were lower in ASCs than in HOPDs but payments for ASC patients were higher than payments for HOPD patients.ConclusionOur findings support the argument that outpatient total joint replacement is appropriate for select patients treated in both HOPDs and ASCs, although in the commercially insured population, the latter services may come at a cost. Until further study of outpatient total joint replacement in the Medicare population becomes available, how this will extrapolate to the Medicare population is unknown.     

Prophylactic Cefuroxime in Total Joint Replacement

Summary Cefuroxime was given during operation to 95 patients undergoing 106 total joint replacements (hip 69: knee 37). Two regimes were used. Either 1 g was given intravenously with induction of anaesthesia and then two intramuscular injections of 1 g 6 and 12 h later, or 1.5 g was given intravenously with induction and two injections of 750 mg each intramuscularly 6 and 12 h later.The concentrations of cefuroxime in bone, capsule and blood were measured in 77 patients. The assays were carried out independently in two laboratories. In most instances concentrations in the bone were above the MICs for likely pathogens, even after allowing for any contaminating blood. Concentrations in synovial capsule were generally higher than in bone.After a follow-up period of 2 years, two patients developed deep infections. The overall infection rates are comparable with the best results reported in the literature using other propyhlactic antibiotics or with ultra-clean air systems.

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Résumé Le Céfuroxime a été administré en peropératoire à 95 sujets qui ont bénéficié de 106 arthroplasties totales (69 hanches et 37 genoux). Deux protocoles ont été utilisés. Dans l'un on a pratiqué une injection intraveineuse d'1 gr au moment de l'induction anesthésique puis 2 injections intra-musculaires d'1 gr 6 h et 12 h plus tard. Dans le second, l'injection IV au moment de l'induction a été de 1,50 gr et les 2 injections IM de 750 mg.Les concentrations de céfuroxime dans l'os, la capsule et le sang ont été mesurées chez 77 opérés. Les dosages ont été effectués indépendamment dans deux laboratoires. La plupart du temps les concentrations osseuses ont été supérieures à la CMI des germes pathogènes éventuels même en tenant compte de la présence de sang à ce niveau. Les concentrations dans la capsule et la synoviale ont été généralement plus élevées que dans l'os.Avec un recul de 2 ans, 2 malades ont présenté une infection profonde. Le pourcentage global d'infection est comparable aux meilleurs résultats publiés concernant l'utilisation d'une antibiothérapie préventive ou de salles hyperstériles.

     

Total Joint Arthroplasty Utilization After Orthopaedic Surgery Referral: Identifying Disparities Along the Care Pathway

BackgroundAlthough racial and ethnic disparities in total joint arthroplasty (TJA) have been thoroughly described, only a few studies have sought to determine exactly where along the care pathway these disparities are perpetuated. The purpose of this study was to investigate disparities in TJA utilization occurring after patients who had diagnosed hip or knee osteoarthritis were referred to a group of orthopaedic providers within an integrated academic institution.MethodsA retrospective, multi-institutional study evaluating patients with diagnosed hip or knee osteoarthritis was conducted between 2015 and 2019. Information pertaining to patient demographics, timing of clinic visits, and subsequent surgical intervention was collected. Utilization rates and time to surgery from the initial clinic visit were calculated by race, and logistic regressions were performed to control for various demographic as well as health related variables.ResultsWhite patients diagnosed with knee osteoarthritis were significantly more likely to receive total knee arthroplasty (TKA) than Black and Hispanic patients, even after adjusting for various demographic variables (Black patients: odds ratio [OR] = 0.63, 95% CI = 0.55-0.72, P = .002; Hispanic patients: OR = 0.69, 95% CI = 0.57-0.83, P = .039). Similar disparities were found among patients diagnosed with hip osteoarthritis who underwent total hip arthroplasty (THA; Black patients: OR = 0.73, 95% CI = 0.60-0.89, P = <.001; Hispanic patients: OR = 0.72, 95% CI = 0.53-0.98, P <.001). There were no differences in time to surgery between races (P > .05 for all).ConclusionIn this study, racial and ethnic disparities in TJA utilization were found to exist even after referral to an orthopaedic surgeon, highlighting a critical point along the care pathway during which inequalities in TJA care can emerge. Similar time to surgery between White, Black, and Hispanic patients suggest that these disparities in TJA utilization may largely be perpetuated before surgical planning while patients are deciding whether to undergo surgery. Further studies are needed to better elucidate which patient and provider-specific factors may be preventing these patients from pursuing surgery during this part of the care pathway.Level of EvidenceLevel IV.     

人工全髋置换治疗成人髋臼发育不良合并骨关节炎

目的探讨人工全髋关节置换术治疗成人髋臼发育不良的方法。方法 2002年5月至2009年1月,对17例21髋成人髋臼发育不良患者,应用人工全髋关节置换术予以治疗。其中男4例,女13例,年龄40~72岁。双髋4例,单髋13例。髋关节脱位按C row e分期,Ⅰ期4髋,Ⅱ期9髋,Ⅲ期7髋,Ⅳ期1髋。结果本组均获随访,随访时间6个月~6年,平均3.2年。采用H arris髋关节评分法进行评分,平均83.4分。结论人工全髋置换是治疗成人髋臼发育不良型骨关节炎的有效方法,但手术较常规置换复杂,宜严格手术适应证。     

Demand Matching Total Joint Replacement Patients Results in Reduction of Post-Discharge Costs

BackgroundThe shift from fee-for-service to value-based care has focused payers and providers on resource utilization. One important component of value-based care is to reduce the use of post-discharge (PD) services in a clinically appropriate manner following total joint arthroplasty (TJA). Demand matching in healthcare is the process of tailoring appropriate medical care to a patient with respect to that patient’s specific medical needs and social determinants. Outcomes following the implementation of a demand-matching algorithm for coordinating PD services after TJA were analyzed in this study.MethodsPayment data from all Medicare patients undergoing primary unilateral TJA between July 2014 and December 2018 from a single orthopedic practice were included. These payments were separated into acute and PD care. The initial acute and PD costs were compared to costs at the end of the 4-year study period using multiple linear regression and chi-square.ResultsA total of 9,638 patients (4,212 total hip arthroplasties and 5,430 total knee arthroplasties) were included. Acute costs of TJA were stable averaging $13,712.00. PD costs fell steadily from a baseline average of $7,319.00 in July 2014 to $4,678.00 in December 2018 (P < .001), representing a 36.1% decline. Discharge to home increased steadily from 45.8% to 79.9% during the same interval (P < .001.)ConclusionOur results demonstrate a statistically significant reduction in PD costs over a 4-year period using a demand-matching strategy to align with the Centers for Medicare and Medicaid Services mandate for value-based care. Based on these data, we conclude that thoughtful preoperative assessment of patient factors such as social determinants and medical comorbidities could allow for cost reduction through better utilization of PD services.     

Total Joint Arthroplasty and Preoperative Low Back Pain

Lower extremity osteoarthritis with concomitant low-back pain (LBP) may obscure a clinician’s ability to properly evaluate the status of hip or knee osteoarthritis and subsequent total joint arthroplasty (TJA) candidacy. A prospective cohort study was conducted to determine prevalence and severity of preoperative LBP among TJA patients, and the effect of TJA on alleviating LBP. Preoperative moderate to worst imaginable LBP pain on the Oswestry Disability Index (ODI) was significantly higher among hips compared to knees (28.8% vs. 16.1%, P < 0.0001). Compared to knees, hips also saw significant ODI improvement from preoperative to one-year postoperative. TJA candidates with considerable preoperative LBP should be counselled that TJA outcome may be impaired by the coexistence of spine disease, and that residual spine pain may continue following otherwise successful TJA.     

人工全髋关节置换对血液流变学影响的研究

目的探讨人工全髋关节置换术对血液流变学的影响。方法2005年10月至2006年10月，32例因股骨颈骨折行人工全髋关节置换术患者，于手术前1d、手术后1、4、7、14d清晨空腹抽血5mL，用LG—R-80A型血粘度仪检测血流变学各项指标，采用t检验、单因素方差分析手术前后各指标改变。结果血流变学术后明显改变，主要表现在：全血粘度、血浆粘度术后1、4d与术前1d比较无明显变化（P〉0．05），但逐渐升高，术后7d达高峰，差异显著（P〈0．05），术后14d接近术前水平；术后1、4、7d全血还原粘度较术前显著增高（P〈0．05）。术后1d较术前红细胞变形指数明显降低（P〈0．05），刚性指数明显升高（P〈0．05），并于术后4d接近术前水平；红细胞聚集指数、纤维蛋白原术后1、4、7天明显升高（P〈0．05），术后14天接近术前水平。结论人工全髋关节置换术后血液呈高粘滞状态，1周达高峰，两周逐渐恢复。术后早期红细胞流变性显著降低，可能是术后下肢深静脉血栓形成的重要原因之一。