Conversion Total Hip Arthroplasty in the Era of Bundled Care Payments: Impacts on Costs of Care

BackgroundConversion hip arthroplasty is defined as a patient who has had prior open or arthroscopic hip surgery with or without retained hardware that is removed and replaced with arthroplasty components. Currently, it is classified under the same diagnosis-related group as primary total hip arthroplasty (THA); however, it frequently requires a higher cost of care.MethodsA retrospective study of 228 conversion THA procedures in an orthopaedic specialty hospital was performed. Propensity score matching was used to compare the study group to a cohort of 510 primary THA patients by age, body mass index, sex, and American Society of Anesthesiologists score. These matched groups were compared based on total costs, implants used, operative times, length of stay (LOS), readmissions, and complications.ResultsConversion THA incurred 25% more mean total costs compared to primary THA (P < .05), longer lengths of surgery (154 versus 122 minutes), and hospital LOS (2.1 versus 1.56 days). A subgroup analysis showed a 57% increased cost for cephalomedullary nail conversion, 34% increased cost for sliding hip screw, 33% for acetabular open reduction and internal fixation conversion, and 10% increased costs in closed reduction and percutaneous pinning conversions (all P < .05). There were 5 intraoperative complications in the conversion group versus none in the primary THA group (P < .01), with no statistically significant difference in readmissions.ConclusionConversion THA is significantly more costly than primary THA and has longer surgical times and greater LOS. Specifically, conversion THA with retained implants had the greatest impact on cost.     

Urinary Self-Catheterization is Not Associated with Increased Risk of Major Complications Following Total Hip and Knee Arthroplasty

BackgroundThe objective of this study is to evaluate urinary self-catheterization as a potential risk factor for postoperative complications following total hip (THA) and knee (TKA) arthroplasty procedures.MethodsSelf-catheterization patients who underwent total joint arthroplasty from 2005 to 2014 were identified in a national insurance database. Rates of death, hospital readmission, emergency room visit, infection, revision, and dislocation for THA or arthrofibrosis for TKA were calculated, as well as cost and length of stay. Self-catheterizing patients were then compared to a 4:1 matched control cohort using a logistic regression analysis to control for confounding factors.ResultsSixty-nine patients underwent THA, and 128 patients who underwent TKA and who actively self-catheterized at the time of surgery were identified. Self-catheterization was not associated with infection, emergency room visits, readmissions, revision surgery, arthrofibrosis, or cost compared to the 4:1 matched control cohort. However, self-catheterization was associated with significantly longer length of stay (difference for THA = 1.91 days, confidence interval = 0.97-2.86, P < .001; difference for TKA = 0.61, odds ratio = 0.16-1.06, P = .01).ConclusionSelf-catheterization does not appear to be associated with increased risk of major complications following total joint arthroplasty with the numbers available in this study. Reassurance can be given regarding concerns for infection and other complications following surgery in this patient population.     

Timing of Readmissions After Elective Total Hip and Knee Arthroplasty: Does a 30-Day All-Cause Rate Capture Surgically Relevant Readmissions?

BackgroundThe 30-day all-cause readmission rate is a widely used metric of hospital performance. However, there is lack of clarity as to whether 30 days is an appropriate time frame following surgical procedures. Our aim is to determine whether a 90-day time window is superior to a 30-day time window in capturing surgically relevant readmissions after total hip arthroplasty (THA) and total knee arthroplasty (TKA).MethodsWe analyzed readmissions following all primary THAs and TKAs recorded in the English National Health Service Hospital Episode Statistics database from 2008 to 2018. We compared temporal patterns of 30- and 90-day readmission rates for the following types of readmission: all-cause, surgical, return to theater, and those related to specific surgical complications.ResultsA total of 1.47 million procedures were recorded. After THA and TKA, over three-quarters of 90-day surgical readmissions took place within the first 30 days (78.5% and 75.7%, respectively). All-cause and surgical readmissions both peaked at day 4 and followed a similar temporal course thereafter. The ratio of surgical to medical readmissions was greater for THA than for TKA, with THA dislocation both being one of the most common surgical complications and clustering early after discharge, with 73.5% of 90-day dislocations occurring within the first 30 days.ConclusionThe 30-day all-cause readmission rate is a good reflection of surgically relevant readmissions that take place in the first 90 days after THA and TKA.     

Mortality and Complications Following Early Conversion Arthroplasty for Failed Hip Fracture Surgery

BackgroundHip fracture in older patients leads to high morbidity and mortality. Patients who are treated surgically but fail acutely face a more complex operation with conversion total hip arthroplasty (THA). This study investigated mortalities and complications in patients who experienced failure within one year following hip fracture surgery requiring conversion THA.MethodsPatients aged 60 years or more undergoing conversion THA within one year following intertrochanteric or femoral neck fracture were identified and propensity-matched to patients sustaining hip fractures treated surgically but not requiring conversion within the first year. Patients who had two-year follow-up (91 conversions; 247 comparisons) were analyzed for 6-month, 12-month, and 24-month mortalities, 90-day readmissions, surgical complications, and medical complications.ResultsNonunion and screw cutout were the most common indications for conversion THA. Mortalities were similar between groups at 6 months (7.7% conversion versus 6.1% nonconversion, P = .774), 12 months (11% conversion versus 12% nonconversion, P = .999), and 24 months (14% conversion versus 22% nonconversion, P = .163). Survivorships were similar between groups for the entire cohort and by fracture type. Conversion THA had a higher rate of 90-day readmissions (14% versus 3.2%, P = .001), and medical complications (17% versus 6.1%, P = .006). Inpatient and 90-day orthopaedic complications were similar.ConclusionConversion THA for failed hip fracture surgery had comparable mortality rates to hip fracture surgery, with higher rates of perioperative medical complications and readmissions. Conversion THA following hip fracture represents a potential “second hit” that both surgeons and patients should be aware of with initial decision-making.     

Pigmented Villonodular Synovitis of the Hip in Patients Undergoing Total Hip Arthroplasty: A Retrospective Case-Controlled Analysis

BackgroundPigmented villonodular synovitis (PVNS) is a condition affecting larger joints such as the hip and knee. Little is known regarding the impact of PVNS on total hip arthroplasty (THA). Therefore, the aim of this study is to determine if patients with PVNS of the hip undergoing primary THA experience greater (1) in-hospital lengths of stay (LOS); (2) complications; (3) readmission rates; and (4) costs.MethodsPatients undergoing primary THA for PVNS of the hip from the years 2005 to 2014 were identified using a nationwide claims registry. PVNS patients were matched to a control cohort in a 1:5 ratio by age, gender, and various comorbidities. The query yielded 7440 patients with (n = 1240) and without (n = 6200) PVNS of the hip undergoing primary THA. Endpoints analyzed included LOS, complications, readmission rates, and costs. Multivariate logistic regression was used to determine odds ratios (OR) of developing complications. Welch’s t-tests were used to test for significance in LOS and cost between the cohorts. A P-value less than .001 was considered statistically significant.ResultsPVNS patients had approximately 8% longer in-hospital LOS (3.8 vs 3.5 days, P = .0006). PVNS patients had greater odds of (OR 1.60, P < .0001) medical and (OR 1.81, P < .0001) implant-related complications. Furthermore, PVNS patients were found to have higher odds (OR 1.84, P < .0001) of 90-day readmissions. PVNS patients also incurred higher day of surgery ($13,119 vs $11,983, P < .0001) and 90-day costs ($17,169 vs $15,097, P < .0001).ConclusionWithout controlling for global trends in LOS, complications, readmissions, or costs between 2005 and 2014, the findings of the study suggest that PVNS of the hip is associated with worse outcomes and higher costs following primary THA. The study is useful as orthopedic surgeons can use the study to educate patients of the complications which may occur following their hip surgery.     

Total Hip Arthroplasty After Hip Arthroscopy Has Increased Complications and Revision Risk

BackgroundThere has been an increase in hip arthroscopy (HA) over the last decade. After HA, some patients may ultimately require a total hip arthroplasty (THA). However, there is a scarcity of research investigating the outcomes in patients undergoing THA with a history of ipsilateral HA.MethodsThe PearlDiver research program (www.pearldiverinc.com) was queried to capture all patients undergoing THA between 2015 and 2020. Propensity matching was performed to match patients undergoing THA with and without a history of ipsilateral THA. Rates of 30-day medical complications, 1-year surgical complications, and THA revision were compared using multivariate logistic regression. Kaplan-Meier analysis was conducted to estimate survival probabilities of each of the groups with patients undergoing THA .ResultsAfter propensity matching, cohorts of 1940 patients undergoing THA without prior HA and 1940 patients undergoing a THA with prior HA were isolated for analysis. The mean time from HA to THA was 1127 days (standard deviation 858). Patients with a history of ipsilateral HA had an increased risk for dislocation (odds ratio [OR] 1.56, P = .03) and overall decreased implant survival within 4 years of undergoing THA (OR 1.53; P = .05). Furthermore, our data demonstrate the timing of previous HA to be associated with the risk of complications, as illustrated by the increased risk for dislocation (OR 1.75, P = .03), aseptic loosening (OR 2.18, P = .03), and revision surgery at 2 (OR 1.92, P = .02) and 4 years (OR 2.05, P = .01) in patients undergoing THA within 1 year of HA compared twitho patients undergoing THA more than 1 year after HA or with no previous history of HA.ConclusionPatients undergoing THA after HA are at an increased risk for surgical complications, as well as the need for revision surgery.     

Patterns and Costs of 90-Day Readmission for Surgical and Medical Complications Following Total Hip and Knee Arthroplasty

BackgroundUnplanned readmissions following elective total hip (THA) and knee (TKA) arthroplasty as a result of surgical complications likely have different quality improvement targets and cost implications than those for nonsurgical readmissions. We compared payments, timing, and location of unplanned readmissions with Center for Medicare and Medicaid Services (CMS)-defined surgical complications to readmissions without such complications.MethodsWe performed a retrospective analysis on unplanned readmissions within 90 days of discharge following elective primary THA/TKA among Medicare patients discharged between April 2013 and March 2016. We categorized unplanned readmissions into groups with and without CMS-defined complications. We compared the location, timing, and payments for unplanned readmissions between both readmission categories.ResultsAmong THA (N = 23,231) and TKA (N = 43,655) patients with unplanned 90-day readmissions, 27.1% (n = 6307) and 16.4% (n = 7173) had CMS-defined surgical complications, respectively. These readmissions with surgical complications were most commonly at the hospital of index procedure (THA: 84%; TKA: 80%) and within 30 days postdischarge (THA: 73%; TKA: 77%). In comparison, it was significantly less likely for patients without CMS-defined surgical complications to be rehospitalized at the index hospital (THA: 63%; TKA: 63%; P < .001) or within 30 days of discharge (THA: 58%; TKA: 59%; P < .001). Generally, payments associated with 90-day readmissions were higher for THA and TKA patients with CMS-defined complications than without (P < .001 for all).ConclusionReadmissions associated with surgical complications following THA and TKA are more likely to occur at the hospital of index surgery, within 30 days of discharge, and cost more than readmissions without CMS-defined surgical complications, yet they account for only 1 in 5 readmissions.     

Does Surgical Approach Influence the Natural History of the Unstable Total Hip Arthroplasty?

BackgroundDislocation following total hip arthroplasty (THA) is a significant complication that occurs in 0.3%-10% of cases with 13%-42% of patients requiring revision surgery. The literature has primarily focused on the dislocation risk associated with different surgical approaches. However, little is known about the natural history of the dislocated hip and whether surgical approach of the index THA is associated with further instability and revision surgery.MethodsThis is a retrospective, single-center, multi-surgeon consecutive case series of all patients who experienced THA dislocation from 2002 to 2020. Patients were excluded if the initial dislocation was secondary to infection or fracture. The natural history of the cohort as per approach was determined. Outcome measurements of interest were the number of dislocations; the treatment surrounding each dislocation; the necessity and type of revision; and the complications encountered.ResultsOf the 75 patients, 58 (77%) dislocated within 6 months following primary THA. The anterior group had greater odds of dislocation within 2 weeks post-THA compared to the lateral and posterior groups (P = .04). The mean number of dislocations per patient was significantly lower in the anterior (1.5 ± 0.7) compared to the lateral (2.4 ± 1.2) and posterior (2.1 ± 1.0) groups (P = .02). Revision surgery was needed in 30% (6/20) of patients in the anterior, 69% (25/36) of the posterior, and 68% (13/19) of the lateral groups (P = .01).ConclusionThis study illustrates that while primary THA dislocations happen earlier with the anterior approach, they are typically less complicated and have a lower risk of recurrent instability and revision surgery.     

Prevention of Dislocation After Total Hip Arthroplasty

Background

Prevention of dislocation after primary total hip arthroplasty (THA) begins with patient preoperative assessment and planning.

Dislocation is a Leading Cause of Decreased Survival Rate in Primary Total Hip Arthroplasty Performed by Low-Volume Surgeons: Long-Term Retrospective Cohort Study

BackgroundThis study aimed to evaluate the complications and long-term survival of primary total hip arthroplasty (THA) performed by low-volume (LV) surgeons at a LV hospital. We also determined the relationship between complications and revisions.MethodsThis retrospective cohort study included 220 THAs in 194 patients treated at our institution between 1998 and 2008, who received a minimum of a 10-year follow-up. The median annual THA volume at this hospital was 23 procedures (range, 11-32), and the annual volume per surgeon ranged from 1 to 19. We investigated the 90-day mortality and rates of periprosthetic joint infections, dislocations, and periprosthetic fractures up to the last visit (median follow-up, 11.8 years). Kaplan-Meier survival was calculated with revision as the end point.ResultsPostoperative infections, dislocations, and fractures at any time during the follow-up period were reported for 1 hip (0.5%), 23 hips (9.8%), and 4 hips (1.8%), respectively. One death occurred within the first 90 days postoperatively. Fifteen hips required revision surgery, and the survival rate was 95.5% at 5 years and 94.1% at 10 years. Of 10 hips that required early revision surgery within 5 years after the index surgery, 9 were revisions to address recurrent dislocation.ConclusionThe risk of dislocation was high. A high number of patients who underwent THA by LV surgeons required early revision because of dislocation. To achieve optimal long-term survivorship, LV surgeons should consider measures to reduce the risk of dislocation.     

Total Hip Arthroplasty in Patients Who Have Respiratory Disease Who use Supplemental Home Oxygen

BackgroundThe purpose of this study is to investigate the association between supplemental home oxygen prior to surgery and both medical and surgical complications after primary elective total hip arthroplasty (THA) in patients who have respiratory disease (RD).MethodsThe Mariner database was used to identify patients who have RD who received primary elective THA from 2010 to 2020. The THA patient cohorts consisted of 20,872 patients who had RD prescribed home oxygen and 69,520 patients who had RD without home oxygen. For patients who had a diagnosis of RD and were prescribed supplemental home oxygen (O2) and those who were not, the rates of postoperative medical and surgical complications, hospital readmissions, and emergency room visits were determined. Reimbursements and lengths of stay were also determined. Logistic regression analyses were utilized to compare both cohorts to matched cohorts without RD, as well as to each other directly.ResultsIn comparison to the matched control group, the RD with home oxygen group had a significantly higher rate of pneumonia (odds ratio [OR] 4.27, P < .0001), pulmonary embolism (OR 1.81, P < .0001), periprosthetic joint infection (OR 1.21, P < .0001), and periprosthetic fracture (OR 1.81, P = .001). The RD with home oxygen cohort also had a significantly higher incidence of pneumonia (OR 2.16, P < .0001), periprosthetic joint infection (OR 1.38, P < .0001), and periprosthetic fracture (OR 1.24, P = .009) compared to RD patients who did not have home oxygen.ConclusionSupplemental home oxygen use prior to surgery is associated with a significantly higher risk of postoperative medical and surgical complications after elective THA.     

Dual Mobility and Conventional Bearings Have Comparably Low Dislocation Rates for Anterior-Based Approaches in Total Hip Arthroplasty

BackgroundDual mobility (DM) bearings for total hip arthroplasty (THA) have been proposed to reduce the risk of instability in select patients, especially those undergoing revision surgery. The use of DM bearings has not been studied as extensively for use in primary THA. The purpose of this study is to compare outcomes following primary THA with anterior-based approaches between patients receiving DM bearings vs standard bearing hip implants.MethodsWe retrospectively reviewed a consecutive series of patients undergoing primary THA through an anterior-based approach. A 3:1 propensity score match was performed between the standard and DM bearing patients to control for possible risk factors for instability. Functional outcomes, dislocations, and aseptic revisions were identified for each patient. The effect of DM on postoperative outcomes was determined using univariate statistical analyses.ResultsIn total, 250 DM bearings were compared to 753 standard bearings. We found no difference in dislocation rate between single bearings and DM bearings (0.53% vs 0.4%). There was 1 DM dislocation occurring in a liner with outer diameter of 38 mm. There were no DM dislocations with outer diameter >38 mm. Aseptic revision surgery was more common in DM. This difference was driven by higher incidence of femoral periprosthetic fracture. There were no differences in functional outcomes.ConclusionDislocation rates are comparably low between DM bearings and standard bearings for THA done using an anterior approach to the hip. Further investigation is needed to determine if specific patient populations may benefit from DM implants for primary THA when an anterior approach to the hip is being used.     

Increased Synovial Inflammatory Markers in Aseptic Total Hip Arthroplasty Dislocation

BackgroundIn cases of total hip arthroplasty (THA) dislocation, a synovial fluid aspiration is often performed to evaluate for periprosthetic joint infection (PJI). It is currently unclear how aseptic dislocation of a THA influences synovial fluid white blood cell (WBC) count and polymorphonuclear percentage (PMN%). The primary aim of this study is to investigate the influence of THA dislocation on synovial WBC count and PMN%.MethodsTwenty-eight patients who underwent a synovial aspiration of a THA between 2014 and 2019 were identified and enrolled in our case-control study. Patients with an aseptic THA dislocation and synovial hip aspiration were matched against patients without dislocation, patients undergoing hip aspiration before aseptic THA revision surgery, and patients undergoing hip aspiration before septic THA revision surgery.ResultsSynovial WBC count was significantly increased in the dislocation vs aseptic THA revision group (P = .015), as well as between the septic revision group vs dislocation and aseptic THA revision group (both P < .001). The PMN% did not differ significantly between the dislocation and aseptic revision groups (P = .294). Mean C-reactive protein values were 12.4 ± 14.9 mg/dL in THA dislocation, 24.1 ± 37.7 mg/dL in THA without infection compared to 85.7 ± 84.9 mg/dL in THA infection group (P < .001).ConclusionThis study shows that THA dislocation has a significant impact on synovial WBC count in joint aspiration. Our data suggest that in the setting of THA dislocation, synovial WBC and PMN% may not be the best method to evaluate for PJI. Further research should be performed to establish new thresholds for these synovial inflammatory markers in the setting of THA dislocation and PJI.Level of evidenceLevel III; retrospective trial.     

Use of Observation Status Versus Readmission in Elective Total Knee and Hip Arthroplasty Returns to Hospital: A Single-Institution Perspective

BackgroundThe Affordable Care Act’s Readmission Reduction Program (RRP) and ongoing transparency efforts to promote consumer-driven competition place significant institutional focus on improving 30-day readmission rates. It remains unclear whether the reduction in readmission rates subsequent to the RRP occurred due to improved quality and/or partly due to increased use of observation status in conditions that may have been classified as readmissions prior to the RRP. We hypothesize that a significant percentage of our institution’s 30-day readmissions after elective total knee and hip arthroplasty (TKA/THA) overestimate the needs, duration, and complexity of the hospital-based intervention and inaccurately reflect the quality of service provided.MethodsWe performed a retrospective review of prospectively collected quality control data for 30-day returns to hospital after elective TKA/THA at our institution over a 2-year period. After stratification of the readmissions to under 48-hour and over 48-hour length of stay, we calculated the financial implications to our institution if the under 48-hour length of stay admissions were reclassified as an observation by applying discharge-weighted and payment-weighted analyses to the 2017 RRP report. We then calculated the out-of-pocket expenses for the under 48-hour Medicare subpopulation.ResultsWe found that 16.7% of the 30-day readmissions after elective TKA/THA required a length of stay under 48 hours. If the short length of stay TKA/THA readmissions were reclassified as observations, our institution’s 2018 RRP penalty would have been reduced to 39% or $334,512.28. However, this reclassification would result in an increase in out-of-pocket expenses by $540.25 (range $291.56-$1105.08) per patient.ConclusionA subpopulation of 30-day readmissions does not require a level of care consistent with inpatient admission services. Classification of this short length of stay subpopulation as an observation vs an admission per Centers for Medicare and Medicaid Services guidelines would have removed our institution from the TKA/THA-specific RRP penalty. However, this would result in the unintended consequence of shifting costs, particularly self-administered drug costs, to patients.     

Osteopetrosis is Associated With an Increased Risk for Intraoperative Periprosthetic Fracture in Total Hip Arthroplasty but not in Total Knee Arthroplasty

BackgroundOsteopetrosis is a rare, inherited disorder in which bone remodels to become pathologically dense. There has been a paucity of data evaluating medical and surgical complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) in this patient population. The objective of this study was to evaluate osteopetrosis as a potential risk factor for medical and surgical complications following THA and TKA.MethodsPatients who had a diagnosis of osteopetrosis and underwent THA or TKA from 2010 to 2020 were identified in a national database. A total of 534 THA and 972 TKA patients who had osteopetrosis were identified and compared with matched cohorts of 2,670 and 4,860 patients, respectively. The rates of postoperative medical and surgical complications, hospital readmissions, and emergency room visits were calculated. In addition, reimbursements and lengths of stay were determined. Osteopetrosis patients were then compared to a 5:1 matched cohort without osteopetrosis using logistic regression analyses to control for additional confounding factors.ResultsThe osteopetrosis THA group had a substantially higher incidence of intraoperative periprosthetic fracture compared to the matched cohort (1.12% versus 0.19%, Odds Ratio 5.88, P = .005). Patients who had a history of osteopetrosis were not found to be at a significantly increased risk for other investigated medical or surgical complications compared to matched controls following THA or TKA.ConclusionPatients who had a history of osteopetrosis undergoing elective primary THA are associated with a significantly increased risk for intraoperative periprosthetic fracture. Patients with a history of osteopetrosis undergoing elective primary TKA were not found to be at an increased risk for any of the investigated complications.     

Heart Failure is Associated with Early Medical and Surgery-Related Complications Following Total Hip Arthroplasty: A Propensity-Scored Analysis

IntroductionThere is a paucity of literature that examines how heart failure (HF) impacts surgery-related complications following total hip arthroplasty (THA). We hypothesized that patients who had HF will be at increased risk of early medical- and surgery-related complications following THA.MethodsPatients who had HF and underwent primary THA between 2010 and 2019 were identified using a large national insurance database. Ninety-day incidence of various medical complications, surgery-related complications, and hospital utilizations were evaluated for patients who did and did not have HF, as well as subgroup analyses were performed on patients who were prescribed mortality-benefitting medications for HF 1 year prior to THA. Propensity score matching resulted in 34,000 HF patients who underwent primary THA and 340,000 matching patients.ResultsThe HF cohort was associated with a higher 90-day incidence of pulmonary embolism (PE), deep vein thrombosis (DVT), transfusion, pneumonia, cerebrovascular accident (CVA), myocardial infarction (MI), sepsis, acute post hemorrhagic anemia, acute renal failure (ARF), and urinary tract infection (UTI), as well as 1-year risk of revision THA, periprosthetic joint infection (PJI), aseptic loosening, and dislocation compared to controls. The HF cohort was associated with a higher 90-day incidence of emergency department visits, readmissions, lengths of stay (LOS), and 1-year costs of care. The medication cohort was at decreased risk of PE, DVT, CVA, return to ED, readmission and MI within 90 days of surgery, and 1-year risk of revision THA and aseptic loosening.DiscussionThese findings may help to better risk-stratify patients who have HF and are scheduled to undergo THA, as well as call for additional surveillance of these patients in the immediate and early postoperative period. This study also helps surgeons and internists understand how chronic medications used to treat HF can impact medical- and surgery-related outcomes following THA.     

Early Emergency Department Visits Following Primary Hip and Knee Arthroplasty

BackgroundPostoperative emergency department (ED) utilization remains an understudied aspect of total joint arthroplasty (TJA). The purpose of this study is to characterize 30-day ED visits following TJA.MethodsWe reviewed 4061 primary unilateral total hip and knee arthroplasty cases performed at our hospital from 2013 to 2017. The primary outcome was presentation to our institution’s ED within 30 days of surgery. Chief complaints and their association to the TJA encounter, as well as readmissions and reoperations, were recorded. One-to-three propensity score matched analysis was used to identify index admission variables associated with early ED visits.ResultsThere were 253 recorded ED visits within 30 days of TJA (218 cases, 5.4%). Nearly 60% of ED visits were directly related to the TJA encounter. The remainder were medically related, most commonly for gastrointestinal complaints. The most common TJA-related complaints were surgical limb pain (28%), wound concerns (20%), and swelling (20%). These complaints comprised two-thirds of TJA-related ED visits, though accounted for only 19.4% and 9.5% of readmissions and reoperations observed in this cohort, respectively. Perioperative transfusion, length of stay, primary insurer, and discharge disposition were not associated with an ED visit.ConclusionED visits within 30 days of TJA were common (5.4%). Most visits related to the index procedure were due to surgical limb pain, wound concerns, and swelling. These complaints accounted for a minority of readmissions and reoperations. This study suggests that perioperative strategies addressing common postoperative concerns are warranted to mitigate acute care use after TJA.     

Disparities in Elective and Nonelective Total Hip Arthroplasty

BackgroundPrior studies have shown disparities in utilization of primary and revision total hip arthroplasty (THA). However, little is known about patient population differences associated with elective and nonelective surgery. Therefore, the aim of this study was to explore factors that influence primary utilization and revision risk of THA based on surgery indication.MethodsData were obtained from 7,543 patients who had a primary THA from 2014 to 2020 in a database, which consists of multiple health partner systems in Louisiana and Texas. Of these patients, 602 patients (8%) underwent nonelective THA. THA was classified as “elective” or “nonelective” if the patient had a diagnosis of hip osteoarthritis or femoral neck fracture, respectively.ResultsAfter multivariable logistic regression, nonelective THA was associated with alcohol dependence, lower body mass index (BMI), women, and increased age and number of comorbid conditions. No racial or ethnic differences were observed for the utilization of primary THA. Of the 262 patients who underwent revision surgery, patients who underwent THA for nonelective etiologies had an increased odds of revision within 3 years of primary THA (odds ratio (OR) = 1.66, 95% Confidence Interval (CI) = 1.06-2.58, P-value = .025). After multivariable logistic regression, patients who had tobacco usage (adjusted odds ratio (aOR) = 1.36, 95% CI = 1.04-1.78, P-value = .024), alcohol dependence (aOR = 2.46, 95% CI = 1.45-4.15, P-value = .001), and public insurance (OR = 2.08, 95% CI = 1.18-3.70, P-value = .026) had an increased risk of reoperation.ConclusionDemographic and social factors impact the utilization of elective and nonelective primary THA and subsequent revision surgery. Orthopaedic surgeons should focus on preoperative counseling for tobacco and alcohol cessation as these are modifiable risk factors to directly decrease reoperation risk.     

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.     

Compensated Cirrhosis Is Associated With Increased Risk of Complications Following Total Hip Arthroplasty in a Large Medicare Database

BackgroundThe aim of this study is to evaluate medical and surgical complications of liver cirrhosis patients following total hip arthroplasty (THA), with attention to different etiologies of cirrhosis and their financial burden following THA.MethodsIn total, 18,321 cirrhotics and 722,757 non-cirrhotics who underwent primary elective THA between 2006 and 2013 were identified from a retrospective database review. This cohort was further subdivided into 2 major etiologies of cirrhosis (viral and alcoholic cirrhosis) and other cirrhotic etiology. Cirrhotics were compared to non-cirrhotics for hospital length of stay, 90-day mean total charges and reimbursement, hospital readmission, and major medical and arthroplasty-specific complications.ResultsCirrhosis was associated with increased rates of major medical complications (4.3% vs 2.4%; odds ratio [OR] 1.20, P < .001), minor medical complications, transfusion (3.4% vs 2.1%; OR 1.16, P = .001), encephalopathy, disseminated intravascular coagulation, and readmission (13.5% vs 8.6%; OR 1.18, P < .001) within 90 days. Cirrhosis was associated with increased rates of revision, periprosthetic joint infection, hardware failure, and dislocation within 1 year postoperatively (3.1% vs 1.6%; OR 1.37, P < .001). Cirrhosis independently increased hospital length of stay by 0.14 days (P < .001), and it independently increased 90-day charges and reimbursements by $13,791 (P < .001) and $1707 (P < .001), respectively. Viral and alcoholic cirrhotics had higher rates of 90-day and 1-year complications compared to controls—other causes only had higher rates of 90-day medical complications, encephalopathy, readmission, and 1-year revision, hardware failure, and dislocation compared to controls.ConclusionCirrhosis, especially viral and alcoholic etiologies, is associated with higher risk of early postoperative complications and healthcare utilization following elective THA.