Septic Revision Total Hip Arthroplasty Is Not Adequately Compensated by Work Relative Value Units

BackgroundPerforming revision total hip arthroplasty (rTHA) for periprosthetic joint infection is complex and may require greater time and resources than aseptic revision cases. Work relative value units (RVUs) assigned may not reflect the difference in actual work required for septic revision hip cases. The purpose of this study is to compare the work effort between aseptic and septic revision hip cohorts, and determine if physicians are appropriately compensated.MethodsData were collected through the National Surgical Quality Improvement Program database for the years 2005 to 2018 to identify all aseptic rTHA cases and septic rTHA cases. Work RVU, operation time, RVU per minute, and dollars per minute were assessed between the aseptic and septic revision hip cohorts. Univariate and multivariate analyses were used for the study.ResultsThe mean operation times for aseptic and septic rTHAs were 146.12 and 173.24 minutes, respectively (P < .001). This resulted in an RVU per minute of 0.257 for the aseptic revision hip cohort compared to 0.212 for the septic cohort (P < .001). Aseptic rTHA cases were valued higher with a dollars per minute of 9.28, whereas septic rTHA cases were 7.65 (P < .001).ConclusionAlthough rTHA for infection is more complex and requires longer mean operative time than aseptic rTHA, physicians are not appropriately reimbursed for this challenging procedure. This inadequate RVU-based reimbursement for septic rTHA may deter physicians from performing these procedures, which could lead to decreased access to care for patients in need of rTHA for infection.     

Hospital and Surgeon Reimbursement Trends for Femoral Neck Fractures Treated With Hip Hemiarthroplasty and Total Hip Arthroplasty

BackgroundThe economic impact of hip fractures on the health care system continues to rise with continued pressure to reduce unnecessary costs while maintaining quality patient care. This study aimed to analyze the trend in hospital charges and payments relative to surgeon charges and payments in a Medicare population for hip hemiarthroplasty and total hip arthroplasty (THA) for femoral neck fracture.MethodsThe 5% Medicare sample database was used to capture hospital and surgeon charges and payments related to 32,340 patients who underwent hemiarthroplasty and 4323 patients who underwent THA for femoral neck fractures between 2005 and 2014. Two values were calculated: (1) charge multiplier (CM, ratio of hospital to surgeon charges), and (2) payment multiplier (PM, ratio of hospital to surgeon payments). Year-to-year variation and regional trends in patient demographics, Charlson Comorbidity Index (CCI), length of stay (LOS), 90-day and 1-year mortality, CM, and PM were evaluated.ResultsHospital charges were significantly higher than surgeon charges and increased substantially for hemiarthroplasty (CM of 13.6 to 19.3, P < .0001) and THA (CM of 9.8 to 14.9, P = .0006). PM followed a similar trend for both hemiarthroplasty (14.9 to 20.2; P = .001) and THA (11.9 to 17.4; P < .0001). LOS decreased significantly for hemiarthroplasty (3.78 to 3.37d; P < .0001) despite increasing CCI (6.36 to 8.39; P = .018), whereas both LOS (3.71 to 3.79 days; P = .421) and CCI (5.34 to 7.08; P = .055) remained unchanged for THA.ConclusionHospital charges and payments relative to surgeon charges and payments have increased substantially for hemiarthroplasty and THA performed for femoral neck fractures.     

The management of osteoporotic acetabular fractures: Current methods and future developments

Acetabular fractures in the elderly are challenging. Management is complicated by patients' poor physiological status and osteoporotic bone. Analysis of the management of these patients must be separated from the treatment of younger patients.Conservative management continues to have a role in patients who sustain fractures that are non-displaced and are considered stable with weight bearing mobilisation, and in those patients considered too medically frail to undergo surgical intervention.The mainstay of current surgical intervention is open reduction and internal fixation (ORIF) and variations of ORIF and total hip arthroplasty (THA), or fix and replace. Fix and replace is being increasingly favoured in those patients who display poor prognostic factors for long term joint survival after ORIF.Percutaneous fixation has the theoretical benefits of minimally invasive surgery and the potential to make any subsequent THA less complicated. However, it requires specialised fluoroscopic skills and is not suitable for all fracture patterns.There are a number of developments being reported. The use of a reinforcement ring and THA in has been reported in a number of centres, as has the use of trabecular metal acetabular implants. A coned hemi pelvic prosthesis and THA has been described in our centre, with promising early results. The potential for 3D printing to improve preoperative planning and reduce intra-operative time is also being explored.The aim of this review is to provide a summary of the literature supporting current and future treatment methods, tips on reduction techniques and an overview of the treatment algorithm of these patients in our unit.     

Postoperative Delirium in Patients Receiving Hip Bipolar Hemiarthroplasty for Displaced Femoral Neck Fractures: The Risk Factors and Further Clinical Outcomes

BackgroundPostoperative delirium in patients who have hip fractures may lead to poor outcomes. This study aimed to determine perioperative risk factors and clinical outcomes of postoperative delirium in patients undergoing hip bipolar hemiarthroplasty for displaced femoral neck fractures.MethodsAmong 1,353 patients who underwent hemiarthroplasty at our institution during 2013-2021, we identified 78 patients with postoperative delirium diagnosed with the confusion assessment method. The mean delirium duration was 28 hours (range: 15-520). We also included 1:2 sex- and age-matched patients who did not have postoperative delirium after the same surgery as a matching cohort for comparison. Patient comorbidities, perioperative data, delirium occurrence, and outcomes were collected for analyses.ResultsA Charlson Comorbidity Index (CCI) score ≥6 (odds ratio (OR): 2.08, P = .017), nighttime surgery (OR: 3.47, p =<.001), surgical delays (OR: 1.01, P = .012), preoperative anemia (OR: 2.1, P = .012), and blood transfusions (OR: 2.47, P = .01) may increase the risk of postoperative delirium. The presentation of delirium was associated with sepsis (OR: 3.77, P = .04), longer hospital stays (P < .001), higher 1-year mortality (OR: 3.97, P = .002), and overall mortality (OR: 2.1, P = .02).ConclusionPostoperative delirium predicted poor outcomes. Our results emphasized the importance of early identification of patients at risk and optimization of the medical conditions before and after surgery.     

Delayed Total Hip Arthroplasty for Failed Acetabular Fractures: The Influence of Initial Fracture Management on Outcome After Arthroplasty

Background

Total hip arthroplasty (THA) provides a successful salvage option for failed acetabular fractures. The complexity of arthroplasty for a failed acetabular fracture will depend on the fracture pattern and the initial management of the fracture. Our objective was to compare the midterm outcome of THA between patients who presented with failed acetabular fractures following initial surgical or nonsurgical treatment.

Published Operative Times Do Not Reflect Surgeon Effort: A Novel Approach for Calculating Operative Times in Total Hip Arthroplasty to Better Quantify Surgeon Work

BackgroundCurrent estimates of operative time (OT) for total hip arthroplasty (THA) are reported as the mean OT across all procedures. This method does not reflect variability among surgeons and surgical settings and should not be used to infer individual surgeon work. We hypothesized that this method would underestimate the time it takes individual surgeons to perform THA. Therefore, we compared the mean OT for all THA cases (“overall OT”) with the mean OT for individual surgeons (“individual surgeon OT”) and examined which factors were associated with each.MethodsMean OT was calculated for 3972 primary THA cases (“overall OT”) by 41 surgeons from 2015 to 2018 in a single health system. The mean OT for each surgeon was determined (“individual surgeon OT”), averaged across surgeons, and compared with overall OT. Overall OT and individual surgeon OT were assessed for associations with surgeon-related (adult reconstruction fellowship training, THA volume, years’ experience), hospital-related (hospital type, trainee presence), and patient-related (age, body mass index category, American Society of Anesthesiologists physical status classification) factors (alpha = 0.05).ResultsMean individual surgeon OT was significantly longer (106 ± 21 minutes) than overall OT (96 ± 28 minutes) (P = .03), with 73% of individual surgeon OTs being greater than overall OT. Although all surgeon-, hospital-, and patient-related factors were associated with significant differences in overall OT, only hospital type was associated with differences in individual surgeon OT.ConclusionIndividual surgeon OT was longer than overall OT for most surgeons and provides a better estimate of surgeon work.     

Perioperative Outcomes of Hemiarthroplasty Versus Total Hip Arthroplasty for Geriatric Hip Fracture: The Importance of Studying Matched Populations

BackgroundGeriatric femoral neck fracture is a common injury for which hemiarthroplasty (HA) or total hip arthroplasty (THA) may be considered in select patients. As prior database studies comparing these have not used propensity matching, which is a robust statistical method of controlling for potentially confounding variables, unmatched and matched methodologies are contrasted in the present study.MethodsPatients aged ≥70 years who underwent HA or THA for hip fractures were identified from the 2012-2015 National Surgical Quality Improvement database. Propensity score 1:1 matching was performed. Differences in rates of 30-day postoperative adverse outcomes were compared using multivariate logistic regression for unmatched and matched cohorts.ResultsIn total, 15,558 patients (14,403 HA and 1155 THA) were evaluated. Although multivariate outcomes for the unmatched populations were different for blood transfusion, mortality, minor adverse events, major adverse events, and reoperation, multivariate outcomes for matched populations only differed for blood transfusion (odds ratio 0.6 for HA vs THA, P < .001). Of note, although readmissions were similar for the two groups, patients undergoing THA had a 5.4% greater rate of perioperative readmission due to dislocation.ConclusionGeriatric patients undergoing HA and THA for hip fracture were compared with and without propensity matching. Once matching was performed, the only differences in outcomes between the two groups were a lower transfusion rate among the HA group and a greater readmission rate due to dislocation among the THA group. This suggests that either procedure can be safely considered if found to be advantageous from a longer-term outcome perspective.Level of EvidenceLevel III, retrospective comparative study.     

Improving Value in Total Hip and Knee Arthroplasty: The Role of High Volume Hospitals

Background

Recent healthcare reform efforts have focused on improving the quality of total joint replacement care while reducing overall costs. The purpose of this study is to determine if higher volume centers have lower costs and better outcomes than lower volume hospitals.

The Impact of Spino-Pelvic Alignment on Total Hip Arthroplasty Outcomes: A Critical Analysis of Current Evidence

Background

In this review, we (1) evaluated the effect of adult spine deformity (ASD) and its surgical correction on patients who had a total hip arthroplasty (THA); (2) evaluated the outcomes of THA in patients who have had previous spinal fusion; and (3) we presented an algorithm on how to surgically address patients who simultaneously require THA and ASD correction.

Hemiarthroplasty vs Total Hip Arthroplasty for the Management of Displaced Neck of Femur Fractures: A Systematic Review and Meta-Analysis

BackgroundDisplaced femoral neck fractures (DFNF) are common and can be treated with osteosynthesis, hemiarthroplasty (HA), or total hip arthroplasty (THA). There is no consensus as to which intervention is superior in managing DFNF.MethodsStudies were identified through a systematic search of the MEDLINE database, EMBASE database, and Cochrane Controlled Trials. Included studies were randomized or controlled trials (1966 to August 2018) comparing THA with HA for the management of DFNF. (https://www.crd.york.ac.uk/PROSPERO Identifier: CRD42018110057).ResultsSeventeen studies were included totaling 1364 patients (660 THA and 704 HA). THA was found to be superior to HA in terms of risk of reoperation, Harris Hip Score and Quality of Life (Short Form 36). Overall, the risk of dislocation was greater in THA group than HA in the first 4 years, after which there was no difference. There was no difference between THA and HA in terms of mortality or infection.ConclusionOverall, THA appears to be superior to HA. THA should be the recommended intervention for DFNF in patients with a life expectancy >4 years and in patients younger than 80 years. However, both HA and THA are reasonable interventions in patients older than 80 years and with shorter life expectancy.     

Quantifying the Perioperative Work Associated With Total Hip and Knee Arthroplasty: The Burden Has Increased With Contemporary Care Pathways

BackgroundRecently, the Centers for Medicare and Medicaid Services (CMS) has labeled the procedural codes for total hip arthroplasty (THA) and total knee arthroplasty (TKA) as potentially misvalued and has asked the American Medical Association (AMA) and its Relative Value Scale Update Committee (RUC) to review this. To assess the validity of this claim, we aimed to catalog the specific service tasks and duration of time required for each task associated with the perioperative care of the patient who underwent primary THA and TKA.MethodsWe prospectively timed preservice and immediate postservice activities performed outside of the operating room (OR) by 7 arthroplasty surgeons over a four-week period. Specific timing data for preservice activities performed in the OR were obtained retrospectively from our institutional electronic medical record for 500 patients undergoing THA and 500 undergoing TKA. Results were compared with the current approved values reviewed by the RUC in 2013 and converted to work relative value units (wRVUs) based on the intensity coefficients used by the RUC.ResultsThe average total preservice evaluation time was 42.2 minutes. The average time from the patient entering the OR to incision was 40.8 ± 25.4 minute. Immediate postservice tasks took 30.0 minutes. Compared with the 2013 RUC weighted wRVU value of 1.394 for preservice and 0.560 for immediate postservice activities, we found that surgeons actually perform 1.567 wRVUs of preservice and 0.672 of immediate postservice activities.ConclusionPolicymakers should consider these findings when reviewing the time and intensity spent on perioperative care for patients undergoing THA and TKA.     

The Impact of Running,Monofilament Barbed Suture for Subcutaneous Tissue Closure on Infection Rates in Total Hip Arthroplasty: A Retrospective Cohort Analysis

BackgroundRecently, running, monofilament barbed suture has become more popular as an efficient and economical alternative to traditional braided interrupted suture for wound closure following total joint arthroplasty. Its overall association with wound complications following surgery remains unknown at this time. Several studies have investigated its use in total knee arthroplasty (TKA), but there is limited literature surrounding use in total hip arthroplasty (THA). In this retrospective cohort study, our primary objective was to determine whether the use of monofilament barbed suture in THA was associated with reduced rates of postoperative infection when compared to traditional braided suture.MethodsPatients who underwent primary unilateral THA between November 2011 and December 2017 by a single senior surgeon with closure using either monofilament barbed suture (162 patients) or braided interrupted suture (429 patients) were retrospectively reviewed for postoperative wound complications during the first 90 days after surgery. Demographics, comorbidities, and perioperative data were also included to assess for risk factors for infection.ResultsThere was no difference between braided and barbed suture in overall rates of major complication, including periprosthetic joint infection (PJI) (0.47% vs 0.62%, P = .82) or revisions (1.86% vs 1.23%, P = .60). The overall rate of minor, superficial wound complications was also similar between both groups (6.1% vs 3.1%, P = .15). However, when superficial complications were categorized by type (dehiscence vs infection), the use of barbed suture was associated with a decreased rate of superficial wound infection (0% vs 5.4%, P = .003) and an increased rate of wound dehiscence (3.1% vs 0.7%, P = .04).ConclusionThe use of monofilament barbed suture for superficial skin closure in THA leads to similar overall rates of both major and minor wound complications when compared to traditional interrupted braided suture. However, while barbed suture was associated with fewer superficial infections, there was an increased incidence of wound dehiscence. Overall, barbed suture demonstrated a cumulatively equivalent rate of superficial wound complications compared to braided suture. Based on this investigation, barbed suture appears safe to use in THA and may represent an efficient and effective alternative to braided suture for wound closure.Level of EvidenceLevel IV; retrospective cohort study.