Surgeons Experience Greater Cardiorespiratory Strain and Stress During Total Hip Arthroplasty Than Total Knee Arthroplasty

BackgroundTotal hip arthroplasty (THA) and total knee arthroplasty (TKA) are physically demanding, with a high prevalence of work-related injuries among arthroplasty surgeons. It is unknown whether there are differences in cardiorespiratory output for surgeons while performing THA and TKA. The objective of this study is to characterize whether differences in surgeon physiological response exist while performing primary THA vs TKA.MethodsThis is a prospective cohort study including 3 high-volume, fellowship-trained arthroplasty surgeons who wore a smart garment that recorded cardiorespiratory data on operative days during which they were performing primary conventional TKA and THA. Variables collected included patient body mass index (BMI), operative time (minutes), heart rate, heart rate variability, respiratory rate, minute ventilation, and energy expenditure (calories).ResultsSeventy-six consecutive cases (49 THAs and 27 TKAs) were studied. Patient BMI was similar between the 2 cohorts (P > .05), while operative time was significantly longer in TKAs (60.4 ± 12.0 vs 53.6 ± 11.8; P = .029). During THA, surgeons had a significantly higher heart rate (95.7 ± 9.1 vs 90.2 ± 8.9; P = .012), energy expenditure per minute (4.6 ± 1.23 vs 3.8 ± 1.2; P = .007), and minute ventilation (19.0 ± 3.0 vs 15.5 ± 3.3; P < .001) compared to TKA.ConclusionSurgeons experience significantly higher physiological strain and stress while performing THA. While scheduling THAs and TKAs, surgeons should consider the higher physical demand associated with THAs and ensure adequate personal preparation and sequence of cases.     

Abnormal Coagulation as a Risk Factor for Postoperative Complications After Primary and Revision Total Hip and Total Knee Arthroplasty

BackgroundPatients undergoing total joint arthroplasty (TJA) have an increased likelihood of having an abnormal coagulation profile compared with the general population. Coagulation abnormalities are often screened for before surgery and considered during perioperative planning. This study assesses a preoperative abnormal coagulation profile as a risk factor for postoperative complications after total hip arthroplasty (THA), revision THA (rTHA), total knee arthroplasty (TKA), and revision TKA (rTKA) and then examines specific coagulopathies to determine their influence on complication rates.MethodsPatients who underwent THA, rTHA, TKA, or rTKA from 2011 to 2017 were identified in the American College of Surgeons National Surgical Quality Improvement Program database and then assessed for preoperative abnormal coagulation profiles. Various postoperative complications were analyzed for each cohort, and two separate multivariate regression analyses were used to assess the relationship between abnormal coagulation and postoperative complications.Results403,566 THA, rTHA, TKA, or rTKA cases were identified, and 40,466 (10.0%) of patients were found to have an abnormal coagulation profile. Patients with preoperative coagulation abnormalities had higher likelihoods of postoperative complications after primary TJA than in revision TJA. An international normalized ratio>1.2 was associated with the most types of postoperative complications, followed by a bleeding disorder diagnosis. A partial thromboplastin time>35 seconds was associated with only one type of postoperative complication, while a platelet count <150,000 per μL was associated with postoperative complications only after TKA.ConclusionTJA in patients with abnormal coagulation profiles may result in adverse outcomes. These patients may benefit from preoperative intervention. Prophylactic care needs to be personalized to the specific coagulation abnormalities present.     

The Impact of Epilepsy on Complication Rates After Total Joint Arthroplasty: A Propensity Score–Matched Cohort Study

BackgroundIt is unclear how epilepsy may affect total joint arthroplasty outcomes. The purpose of this study is to analyze the impact of epilepsy on prosthesis-related complications following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).MethodsA retrospective cohort study was conducted using a national database. Patients who have epilepsy underwent a primary THA (n = 6,981) and TKA (n = 4,987) and were matched 1:4 (THA, n = 27,924; TKA, n = 19,948). Rates of low-energy falls and prosthesis-related complications within 2 years postoperatively were compared for patients who did and did not have epilepsy with multivariable logistic regression.ResultsAfter primary TKA, patients who have epilepsy exhibited significantly higher rates of aseptic revision (4.3% versus 3.5%, odds ratio [OR] 1.21, P = .017) and revision for prosthetic joint infection (1.8% versus 1.3%, OR 1.29, P = .041). THA patients who have epilepsy exhibited significantly higher rates of prosthetic dislocation (3.2% versus 1.9%, OR 1.54, P < .001), periprosthetic fracture (2.2% versus 0.8%, OR 2.39, P < .001), and aseptic loosening (1.7% versus 1.1%, OR 1.40, P = .002). Rates of low-energy falls within 2 years after TKA (14.1% versus 6.4%, OR 2.19, P < .001) and THA (33.6% versus 7.5%, OR 5.95, P < .001) were also significantly higher for patients who have epilepsy.ConclusionEpilepsy was associated with significantly higher rates of falls (P < .001) and prosthesis-related complications after primary THA (P < .05) and TKA (P < .05). Precautions should be implemented in this population during intraoperative and perioperative decision-making to reduce complication risk.Level of EvidenceLevel III.     

Surgeon Reimbursement Unchanged as Hospital Charges and Reimbursements Increase for Total Joint Arthroplasty

BackgroundDespite increasing demands on physicians and hospitals to increase value and reduce unnecessary costs, reimbursement for healthcare services has been under downward pressure for several years. This study aimed to analyze the trend in hospital charges and payments relative to corresponding surgeon charges and payments in a Medicare population for total hip (THA) and knee arthroplasty (TKA).MethodsThe 5% Medicare sample database was used to capture hospital and surgeon charges and payments related to 56,228 patients who underwent primary THA and 117,698 patients who underwent primary TKA between 2005 and 2014. Two values were calculated: (1) the charge multiplier (CM), the ratio of hospital to surgeon charges and (2) the payment multiplier (PM), the ratio of hospital to surgeon payments. Year-to-year variation and regional trends in patient demographics, Charlson Comorbidity Index, length of stay (LOS), CM, and PM were evaluated.ResultsHospital charges were significantly higher than surgeon charges and increased substantially for both THA (CM increased from 8.7 to 11.5, P < .0001) and TKA (CM increased from 7.9 to 11.4, P < .0001). PM followed a similar trend, increasing for both THA and TKA (P < .0001). LOS decreased significantly for both THA and TKA (P < .0001), while Charlson Comorbidity Index remained stable. Both CM (r² = 0.84 THA, 0.90 TKA) and PM (r² = 0.75 THA, 0.84 TKA) were strongly negatively associated with LOS.ConclusionHospital charges and payments relative to surgeon charges and payments have increased substantially for THA and TKA despite stable patient complexity and decreasing LOS.     

What are the Outcomes After Primary Total Hip and Knee Arthroplasty in Patients With Prior Cerebrovascular Accidents?

BackgroundFor patients who have a history of cerebrovascular accident (CVA) with neurological sequelae undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA), we sought to determine mortality rate, implant survivorship, complications, and clinical outcomes.MethodsOur total joint registry identified CVA sequelae patients undergoing primary THA (n = 42 with 25 on affected hip) and TKA (n = 56 with 34 on affected knee). Patients were 1:2 matched based upon age, sex, body mass index, and surgical year to a non-CVA cohort. Mortality and implant survivorship were evaluated via Kaplan-Meier methods. Clinical outcomes were assessed via Harris Hip scores or Knee Society scores . Mean follow-up was 5 years (range, 2-12).ResultsFor CVA sequelae and non-CVA patients, respectively, the 5-year patient survivorship was 69 versus 89% after THA (HR = 2.5; P = .006) and 56 versus 90% after TKA (HR = 2.4, P = .003). No significant difference was noted between groups in implant survivorship free from any reoperation after THA (P > .2) and TKA (P > .6). Postoperative CVA occurred at an equal rate in CVA sequelae and non-CVA patients after TKA (1.8%); none after THA in either group. The magnitude of change in Harris Hip scores (P = .7) and Knee Society scores (P = .7) were similar for CVA sequelae and non-CVA patients.ConclusionComplications, including the risk of postoperative CVA, implant survivorship, and outcome score improvement are similar for CVA sequelae and non-CVA patients. A 2.5-fold increased risk of death at a mean of 5 years after primary THA or TKA exist for CVA sequelae patients.     

Relationship Between Mental Health Disorders and Readmissions Following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

BackgroundThere is limited evidence exploring the relationship between mental health disorders and the readmissions following total joint arthroplasty (TJA). Therefore, we conducted a meta-analysis to evaluate the relationship between mental health disorders and the risk of readmission following TJA.MethodsWe searched PubMed, Cochrane, and Google Scholar from their inception till April 19, 2022. Studies exploring the association of mental health disorders and readmission risk following TJA were selected. The outcomes were divided into 30-day readmission, 90-day readmission, and readmission after 90 days. We also performed subgroup analyses based on the type of arthroplasty: total hip arthroplasty (THA) and total knee arthroplasty (TKA). A total of 12 studies were selected, of which 11 were included in quantitative analysis. A total of 1,345,893 patients were evaluated, of which 73,953 patients suffered from mental health disorders.ResultsThe risk of 30-day readmission (odds ratio = 1.43, 95% CI 1.14-1.80, P = .002, I² = 87%) and 90-day readmission (OR = 1.35, 95% CI 1.22-1.49, P < .00001, I² = 89%) was significantly associated with mental health disorders. On subgroup analyses, 30-day readmission was significantly associated with THA (OR = 1.29, 95% CI 1.04-1.60, P = .02), but not with TKA (OR = 1.44, 95% CI 0.51-4.06, P = .50). Similarly, 90-day readmission was significantly associated with both THA (OR = 1.21, 95% CI 1.14-1.29, P < .00001) and TKA (OR = 1.33, 95% CI 1.17-1.51, P < .0001).ConclusionMental health disorders are significantly associated with increased 30-day and 90-day readmissions. Increasing awareness regarding mental health disorders and readmission in arthroplasty will help in efficient preoperative risk stratification and better postoperative management in these patients.     

Wound Complications Are Affected by Different Skin Closure Methods in Primary Hip and Knee Arthroplasty

BackgroundThere is a lack of consensus on optimal skin closure and dressing strategies to reduce early wound complication rates after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).MethodsAll 13,271 patients at low risk for wound complications undergoing primary, unilateral THA (7,816), and TKA (5,455) for idiopathic osteoarthritis at our institution between August 2016 and July 2021 were identified. Skin closure, dressing type, and postoperative events related to wound complications were recorded during the first 30 postoperative days.ResultsThe need for unscheduled office visits to address wound complications was more frequent after TKA than THA (2.74 versus 1.78%, P < .001), and after direct anterior versus posterior approach THA (2.94 versus 1.39%, P < .001). Patients who developed a wound complication, had a mean of 2.9 additional office visits. Compared to the use of topical adhesives, skin closure with staples had the highest risk of wound complications (odds ratio 1.8 [1.07-3.11], P = .028). Topical adhesives with polyester mesh had higher rates of allergic contact dermatitis than topical adhesives without mesh (1.4 versus 0.5%, P < .0001).ConclusionWound complications after primary THA and TKA were often self-limited but increased burden on the patient, surgeon, and care team. These data, which suggest different rates of certain complications with different skin closure strategies, can inform a surgeon on optimal closure methods in their practice. Adoption of the skin closure technique with the lowest risk of complications in our hospital would conservatively result in a reduction of 95 unscheduled office visits and save a projected $585,678 annually.     

Time Required for Planned and Unplanned Episodes of Care in Septic Two-Stage Revision Hip and Knee Arthroplasty

BackgroundSeptic revision total hip (rTHA) and knee (rTKA) arthroplasty requires more effort but is reimbursed less than primary procedures per minute of intraoperative time. This study quantified planned and unplanned work performed by the surgical team for septic 2-stage revision surgeries during the entire episode-of-care “reimbursement window” and compared that time to allowable reimbursement amounts.MethodsBetween October 2010 and December 2020 all unilateral septic 2-stage rTHA and rTKA procedures performed by a single surgeon at a single institution were retrospectively reviewed. Time dedicated to planned work was calculated over each episode of care, from surgery scheduling to 90 days postoperatively. Impromptu patient inquiries and treatments after discharge, but within the episode of care, involving the surgeon/surgeon team constituted unplanned work. Planned and unplanned work minutes were summed and divided by the number of patients reviewed to obtain average minutes of work per patient.ResultsSixty-eight hips and 64 knees were included. For 2-stage rTHA and rTKA the average time per patient for planned care was 1728 and 1716 minutes and for unplanned care was 339 and 237 minutes. Compared to the Centers for Medicare and Medicaid Services’ allowable reimbursement times, an additional 799 and 887 minutes of uncompensated time was required to care for 2-stage rTHA and rTKA patients.ConclusionTwo-stage revision procedures are substantially more complex than primary procedures. Financially disincentivizing surgeons to care for these patients reduces access to care when high-quality care is most needed. These findings support increasing the allowable times for 2-stage septic revision cases.     

Does Symptomatic Benign Prostatic Hyperplasia Increase the Risk of Periprosthetic Joint Infection After Primary Total Joint Arthroplasty?

BackgroundPeriprosthetic joint infection (PJI) is among the leading causes of failure in total joint arthroplasty. A recently proposed risk factor for PJI is symptomatic benign prostatic hyperplasia (sBPH). This study aims to determine if sBPH is associated with PJI following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).MethodsUsing the Mariner all-payer claims database, 1745 patients with sBPH undergoing primary THA were propensity-matched with 3490 controls, and 3053 patients with sBPH undergoing primary TKA were propensity-matched with 6106 controls. Additionally, the same 1745 patients with sBPH undergoing THA were compared to 317,360 prematched controls, and the same 3053 patients with sBPH undergoing TKA were compared to 557,730 prematched controls. Univariate analysis was conducted using chi-squared or ANOVA where appropriate.ResultsAt two years postoperatively, patients with sBPH were not at significantly increased risk for PJI following primary THA (1.54% vs 1.43%; P = .745) and TKA (1.99% vs 2.14%; P = .642) relative to postmatch controls. Compared to matched controls, THA patients with sBPH had an increased 90-day incidence of anemia (P < .001), blood transfusion (P < .001), and urinary tract infection (UTI; P < .001). Total knee arthroplasty patients with sBPH had an increased 90-day incidence of anemia (P < .001), blood transfusion (P < .001), cellulitis (P = .023), renal failure (P = .030), heart failure (P = .029), and UTI (P < .001) relative to matched controls.ConclusionIn primary THA and TKA, sBPH does not appear to be an independent risk factor for PJI within two years postoperatively. However, clinicians should be cognizant of the significantly increased risk for postoperative UTI in this patient population.     

Patellar Tracking in Revision Total Knee Arthroplasty: Does Retaining a Patella From a Different Implant System Matter?

BackgroundPatellar maltracking is a potential surgical complication following total knee arthroplasty (TKA) and can result in anterior knee pain, recurrent patellar dislocation, and damage to the medial patellar soft tissue stabilizers. Data remain unclear as to whether the patellar button should be revised during a revision TKA (rTKA) if changing the component implant system. Our study examines whether retaining the original patellar button during an rTKA using a different implant system affects patellar tracking.MethodsA retrospective cohort study of rTKA patients between August 2011 and June 2019 was performed at an urban, tertiary referral center. Patients were divided into 2 cohorts depending on whether their retained patella from their primary TKA was of the same (SIM) or different implant manufacturer (DIM) as the revision system used. Radiographic measurements were performed on preoperative and postoperative knee radiographs and differences were compared between the 2 groups. Baseline demographic data were also collected.ResultsOf the 293 consecutive, aseptic rTKA cases identified, 122 underwent revision in the SIM cohort and 171 in the DIM cohort. There were no demographic differences between the groups. No statistical significance was calculated for differences in preoperative and postoperative patellar tilt or Insall-Salvati ratio between the groups. The DIM group was found to have more lateral patellar translation (?0.01 ± 6.09 vs 2.68 ± 7.61 mm, P = .001). However, when calculating differences in the magnitude of the translation (thereby removing differences due to laterality), no difference was observed (0.06 ± 3.69 vs 0.52 ± 4.95 mm, P = .394).ConclusionNo clinically significant differences in patellar tracking were observed when the original patellar component was retained and a different revision implant system was used. Given the inherent risks of bone loss and fracture with patellar component revision, surgeons performing rTKA may retain the primary patella if it is well fixed and can still expect appropriate patellar tracking regardless of the revision implant system used.Level of EvidenceIII, Retrospective cohort study.     

Safety and Efficacy of Rivaroxaban in Primary Total Hip and Knee Arthroplasty

BackgroundAn optimal venous thromboembolism prophylaxis agent should balance efficacy and safety. While rivaroxaban provides effective venous thromboembolism prophylaxis after total joint arthroplasty, it may be associated with higher rates of bleeding. This study aimed to compare the safety and efficacy of rivaroxaban to aspirin and enoxaparin.MethodsA large national database was queried for patients who underwent elective primary total hip (THA) or total knee arthroplasty (TKA) from January 2015 through December 2020 who received rivaroxaban, aspirin, or enoxaparin. Multivariate analyses were performed to assess the 90-day risk of bleeding and thromboembolic complications. Among TKA patients identified, 86,721 (10.8%) received rivaroxaban, 408,038 (50.8%) received aspirin, and 108,377 (13.5%) received enoxaparin. Among THA patients, 42,469 (9.5%) received rivaroxaban, 242,876 (54.5%) received aspirin, and 59,727 (13.4%) received enoxaparin.ResultsAfter accounting for confounding factors, rivaroxaban was associated with increased risk of transfusion (TKA: adjusted odds ratio [aOR] = 2.58, P < .001; THA: aOR 1.64, P < .001), pulmonary embolism (TKA: aOR = 1.25, P = .007), and deep vein thrombosis (TKA: aOR = 1.13, P = .022) compared to aspirin. Compared to enoxaparin, rivaroxaban was associated with an increased risk of combined bleeding events (TKA: aOR = 1.07, P < .001, THA: aOR = 1.11, P < .001), but decreased risk of combined prothrombotic events (THA: aOR = 0.85, P = .036).ConclusionRivaroxaban chemoprophylaxis following TKA and THA was associated with an increased risk of bleeding and prothrombotic complications compared to aspirin and enoxaparin.     

Life After BPCI: High Quality Total Knee and Hip Arthroplasty Care Can Still Exist Outside of a Bundled Payment Program

BackgroundConcerns regarding target price methodology and financial penalties have led to withdrawal from Medicare bundled payment programs for total hip (THA) and knee arthroplasty (TKA), despite its early successful results. The purpose of this study was to determine whether there was any difference in patient comorbidities and outcomes following our institution’s exit from the Bundled Payments for Care Improvement - Advanced (BPCI-A).MethodsWe reviewed consecutive 2,737 primary TKA and 2,009 primary THA patients following our withdraw from BPCI-A January 1, 2020-March 30, 2021 and compared them to 1,203 TKA and 1,088 THA patients from October 1, 2018-August 2, 2019 enrolled in BPCI-A. We compared patient demographics, comorbidities, discharge disposition, complications, and 90-day readmissions.Multivariate analysis was performed to identify if bundle participation was associated with complications or readmissions.ResultsPost-bundle TKA had shorter length of stay (1.4 vs 1.8 days, P < .001). Both TKA and THA patients were significantly less likely to be discharged to a rehabilitation facility (5.6% vs 19.2%, P < .001 and 6.0% vs 10.0%, P < .001, respectively). Controlling for confounders, post-bundle TKA had lower complications (OR = 0.66, 95% CI 0.45-0.98, P = .037) but no difference in 90-day readmission (OR = 0.80, 95% CI 0.55-1.16, P = .224).ConclusionsSince leaving BPCI-A, we have maintained high quality THA care and improved TKA care with reduced complications and length of stay under a fee-for-service model. Furthermore, we have lowered rehabilitation discharge for both TKA and THA patients. CMS should consider partnering with high performing institutions to develop new models for risk sharing.     

Revision Total Knee Arthroplasty in Young Patients: Higher Early Reoperation and Rerevision

BackgroundRevision total knee arthroplasty (rTKA) rates are increasing in younger patients. Few studies have assessed outcomes of initial aseptic rTKA performed for younger patients compared with traditional-aged patients.MethodsA detailed medical record review was performed to identify patient demographics, medical comorbidities, surgical rTKA indications, timing from index TKA to rTKA, subsequent reoperation rates, component rerevision rates, and salvage procedures for 147 young patients (158 knees) aged 55 years and younger and for a traditional older cohort of 276 patients (300 knees) between 60 and 75 years. Univariate analysis was performed to assess differences in these primary variables, and a log-rank test was used to estimate 5-year implant survival based on either reoperation or component revision and salvage procedures.ResultsYounger TKA patients were more likely to undergo initial aseptic rTKA within 2 years of their primary TKA (52.5% vs 29.0%, P < .001) and were more likely to undergo early reoperation (17.7% vs 9.7%, P = .02) or component rerevision (11.4% vs 6.0%, P < .05) after rTKA. Infection and extensor mechanism complications were more commonly noted in younger patients. Estimated 5-year survival was also lower for both reoperation (59.4% vs 65.7%, P = .02) and component rerevision or salvage (65.8% vs 80.1%, P = .02).ConclusionEarly reoperation and component re-rTKA were performed nearly twice as often in younger rTKA than traditional-aged TKA patients. Care should be given to reduce perioperative infection and extensor mechanism failures after rTKA in younger patients.     

Effects of the Obesity Epidemic on Total Hip and Knee Arthroplasty Demographics

BackgroundHigher body mass index (BMI) is a well-known risk factor for the development of hip and knee osteoarthritis and predicts total hip arthroplasty (THA) and total knee arthroplasty (TKA) at an earlier age. The purpose of this study is to document the nationwide trends in age and obesity in primary THA and TKA throughout the obesity epidemic.MethodsA retrospective analysis of the National Inpatient Sample database was conducted on patients undergoing primary THA and TKA for primary OA between 2002 and 2017. Analysis of variance and chi-square tests were performed to examine changes in age and obesity percentage over time, respectively. Pearson correlations were used to assess the relationship between patient age, BMI, and year of surgery.ResultsA total of 688,371 THA and 1,556,651 TKA were identified over the sixteen-year period. Between 2002 and 2017, the proportion of obese patients increased for both THA (7.0% to 22.7%, P < .001) and TKA (10.7% to 30.4%, P < .001). Mean age significantly decreased for both THA (66.7 to 65.9 years, P < .001) and TKA (67.6 to 66.8 years; P < .001). Over time, BMI significantly increased (THA: r = 0.221 vs. TKA: r = 0.272) and patient age decreased (THA: r = -0.031 vs. TKA: r = -0.137) for both procedures (P < .001 for all).ConclusionTHA and TKA patients have become younger and increasingly more obese throughout the obesity epidemic, as obesity rates have tripled over this time period. The current investigation is the first to demonstrate significant trends in both age and obesity in the THA and TKA populations on a national level.Level of EvidenceIII.     

Dual Mobility Cups in Revision Total Hip Arthroplasty: Efficient Strategy to Decrease Dislocation Risk

BackgroundRevision total hip arthroplasty (rTHA) is a challenging surgery with a higher rate of complications than primary arthroplasty, particularly instability and aseptic loosening. The purpose of this study is to compare dual mobility cup (DMC) and standard mobility cup (SMC) in all rTHAs performed at our institution over a decade with a 1 year minimum follow-up.MethodsTwo hundred ninety-five rTHAs (acetabular only and bipolar revisions) between 2006 and 2016 were retrospectively reviewed. These were divided into those with a DMC (184 revisions) or SMC (111 revisions). Dislocation and complications requiring re-revision were reported.ResultsThe rTHA mean age was 69 years ± 13.9 (19-92) and the mean follow-up was 2.3 years. Dislocation risk was statistically lower (P = .01) with a DMC (3.8%; 7/184) than with an SMC (13.5%; 15/111). DMC required re-rTHA in 24/184 (13%) for any reason compared to SMC in 19/111 (17.1%) (P = .34). There was no significant difference in early aseptic loosening (P = .28) between the 2 groups. For young patients (≤55 years), results were similar with a lower dislocation rate in the DMC group (P = .24) and no increased risk of early aseptic loosening (P = .49).ConclusionThis study demonstrates that for all rTHA indications DMC compared to SMC has a significantly decreased risk of postoperative dislocation without risk of early aseptic loosening at medium term follow-up. The use of DMC in rTHA is an important consideration particularly with the predicted increased incidence of both primary and revision THA globally.     

The Impact of COVID-19 on Total Joint Arthroplasty Fellowship Training

BackgroundCOVID-19 created unprecedented challenges in surgical training especially in specialties with high elective case volume. We hypothesized that case volume during total joint arthroplasty fellowship training would decrease by 25% given widespread economic shutdowns encountered during the fourth quarter of the 2019-2020 academic year.MethodsCase logs from the Accreditation Council for Graduate Medical Education were obtained for accredited total joint arthroplasty fellowships (2017-2018 to 2020-2021). Case volumes were extracted and summarized as means ± SD. Student’s t tests were used for inter-year comparisons.ResultsOne hundred and eighty three arthroplasty fellows from 24 accredited fellowships were included. There was a 14% year-over-year decrease in total case volume during the 2019-2020 academic year (390 ± 108 vs 453 ± 128, P < .001). Case volume rebounded during the 2020-2021 academic year to 465 ± 93 (19% increase, P < .001). Case categories with the most significant percentage declines in 2019-2020 were primary total knee arthroplasty (TKA, ?23%), revision total hip arthroplasty (THA, ?19%), revision TKA (rTKA, ?11%), and primary THA (?10%).ConclusionThere was a 14% overall decrease in arthroplasty case volume during the 2019-2020 academic year, which correlated with the widespread economic shutdowns during the COVID-19 pandemic. Certain elective case categories like primary TKA experienced the greatest negative impact. Results from this study may inform prospective trainees and faculty during future national emergencies.     

The opportunity cost of arthroplasty training in orthopaedic surgery

IntroductionTraining the next generation of surgeons is a crucial role fulfilled by consultant orthopaedic surgeons. However we are increasingly constrained by limited time and resources. We sought to compare operative time and length of stay (LOS) for total hip and total knee arthroplasties (THA, TKA) performed by a consultant orthopaedic surgeon with those performed by supervised trainees.Materials and methodsA prospective database of arthroplasty procedures performed from 2015 to 2018 was collated. Primary surgeon grade was recorded. Patient demographics, ASA grade, LOS and operative time were recorded. For THA both cemented and uncemented arthroplasties were used. SPSS version 23 was used for statistical analysis.Results394 arthroplasty procedures were carried out during the study period. Trainee surgeons performed a high proportion of both THA (53.2%, n = 123) and TKA (44.8%, n = 73) surgeries. Trainees performed 57% of cemented THA procedures. LOS did not differ between consultant and trainee surgeons for THA (5.9 ± 4.8 days) or TKA (5.6 ± 4.1 days). Age had a significant effect on LOS (p < 0.001). For THA the mean operative time for trainees was 90.3 ± 19.23 min, 18.2 min longer than the consultant group. For TKA the mean operative time was 89.06 ± 18.87 min for trainees, 24.4 min longer than the consultant group.DiscussionAt our institution trainee surgeons can be expected to take between 18 and 24 min longer to perform arthroplasty procedures. This should be factored into resource planning, as the training of orthopaedic surgeons is crucial to sustaining and improving health service provision.     

Impact of COVID-19 Protocols on Primary and Revision Total Hip Arthroplasty

BackgroundSurgical site infection (SSI) after total hip arthroplasty (THA) is associated with increased morbidity, mortality, and healthcare expenditures. Our institution intensified hygiene standards during the COVID-19 pandemic; hospital staff exercised greater hand hygiene, glove use, and mask compliance. We examined the effect of these factors on SSI rates for primary THA (pTHA) and revision THA (rTHA).MethodsA retrospective review was performed identifying THA from January 2019 to June 2021 at a single institution. Baseline characteristics and outcomes were compared before (January 2019 to February 2020) and during (May 2020 to June 2021) the COVID-19 pandemic and during the first (May 2020 to November 2020) and second (December 2020 to June 2021) periods of the pandemic. Cohorts were compared using the Chi-squared test and independent samples t-test.ResultsA total of 2,682 pTHA (prepandemic: 1,549 [57.8%]; pandemic: 1,133 [42.2%]) and 402 rTHA (prepandemic: 216 [53.7%]; Pandemic: 186 [46.2%]) were included. For primary and revision cases, superficial and deep SSI rates were similar before and during COVID-19. During COVID-19, the incidence of all (?0.43%, P = .029) and deep (?0.36%, P = .049) SSIs decreased between the first and second periods for rTHA. pTHA patients had longer operative times (P < .001) and shorter length of stay (P = .006) during COVID-19. Revision cases had longer operative times (P = .004) and length of stay (P = .046). Both pTHA and rTHA were discharged to skilled nursing facilities less frequently during COVID-19.ConclusionDuring COVID-19, operative times were longer in both pTHA and rTHA and patients were less likely to be discharged to a skilled nursing facility. Although intensified hygienic standards may lower SSI rates, infection rates did not significantly differ after our hospital implemented personal protective guidelines and a mask mandate.     

Trends in Revenue,Cost, and Contribution Margin for Total Joint Arthroplasty 2011-2021

BackgroundRegulatory change has created a growing demand to decrease the hospital costs associated with primary total joint arthroplasty (TJA). Concurrently, the removal of lower extremity TJA from the in-patient only list has affected hospital reimbursement. The purpose of this study is to investigate trends in hospital revenue versus costs in primary TJA.MethodsWe retrospectively reviewed all patients who underwent primary TJA from June 2011 to May 2021 at our institution. Patient demographics, revenue, total cost, direct cost, and contribution margin were collected. Changes over time as a percentage of 2011 numbers were analyzed. Linear regression analysis was used to determine overall trend significance and develop projection models.ResultsTotal knee arthroplasty (TKA) insured by government-managed/Medicaid (GMM) plans showed a significant upward trend (P = .013) in total costs. Direct costs of TKA across all insurance providers (P = .001 and P < .001) and total hip arthroplasty (THA) for Medicare (P = .009) and GMM (P = .001) plans demonstrated significant upward trends. Despite this, 2011-2021 modeling found no significant change in contribution margin for TKA and THA covered under all insurance plans. However, models based on 2018-2021 financial data demonstrated a significant downward trend in contribution margin across Medicare (P < .001) and GMM (P < .001) insurers for both TKA and THA.ConclusionPhysician-led innovation in cost-saving strategies has maintained contribution margin over the past decade. However, the increase in direct costs seen over the past few years could lead to negative contribution margins over time, if further efficiency and cost-saving measures are not developed.Level III EvidenceRetrospective Cohort Study.     

Preoperative Depression Is Associated With Increased Risk Following Revision Total Joint Arthroplasty

BackgroundThe incidence of revision total hip (rTHA) and knee (rTKA) arthroplasty continues to increase. Preoperative depression is known to influence outcomes following primary arthroplasty. Despite this, it remains unknown whether the same relationship exists for patients undergoing revision procedures. The purpose of this study, therefore, is to investigate this relationship.MethodsThis is a retrospective cohort study. Patients undergoing rTHA and rTKA were identified from the Truven MarketScan database. Patients with a diagnosis of prosthetic joint infection were excluded. Two cohorts were created: those with preoperative depression and those without. We included patients who were enrolled in the database for 1 year preoperatively and postoperatively. Demographic and complication data were collected, and statistical analysis was then performed comparing complications between cohorts.ResultsA total of 10,017 patients undergoing rTHA and 13,973 patients undergoing rTKA were included in this study. Of these, 1305 (13.1%) and 2012 (14.4%) had depression, respectively. Multivariate analysis found that, after rTHA, preoperative depression was associated with extended length of stay, nonhome discharge, 90-day readmission, 90-day emergency department visit, prosthetic joint infection, revision surgery, and increased costs (P < .001). Similarly, following rTKA, depression was associated with extended length of stay, nonhome discharge, 90-day readmission, 90-day emergency department visit, revision surgery, and increased costs (P < .001).ConclusionDepression before revision total joint arthroplasty is common and is associated with increased risk of complication and increased healthcare resource utilization following both rTHA and rTKA. Further research will be needed to delineate to what degree this represents a modifiable risk factor.