Background: Obesity is routinely cited as a negative predictive factor for outcomes after total knee arthroplasty (TKA), but the direct mechanism responsible for this relationship has not been described. One possible explanation is a propensity for component malalignment in obese patients that is attributable to difficulty with surgical exposure. Methods: This study evaluated the effect of obesity on TKA component alignment in 251 primary TKAs during a 12-month period at a single center in 2009. Postoperative component alignment was retrospectively measured and compared between patients defined as obese (body mass index [BMI] ≥30 kg/m2) and patients defined as nonobese (BMI <30 kg/m2). Alignment was determined by measuring the coronal tibiofemoral angle, coronal femoral component angle, coronal tibial component angle, sagittal femoral component angle, and sagittal tibial component angle in all of the study patients. Results: Statistical analysis failed to demonstrate a statistically significant relationship between obesity and component alignment in any of the measured parameters. Conclusion: The results of this study support that obesity does not negatively affect TKA component alignment; another factor must be associated with the worse outcomes in obese patients undergoing TKA.

The principle by which a man lives usually determines his character. My father was a complex man with profound integrity. People who did not know him well could easily misinterpret his beliefs and/or his moral qualities. The complexity of his character was defined by his extreme work habit, which

BACKGROUND:Periprosthetic joint infection (PJI) is a significant challenge to the orthopedic surgeon, patient, hospital, and insurance provider. Our study compares the financial information of self-originating and referral 2-stage revision hip and knee surgeries at our tertiary referral center for hip or knee PJI over the last 4 years.METHODS:We performed an in-house retrospective financial review of all patients who underwent 2-stage revision hip or knee arthroplasty for infection between January 2008 and August 2013, comparing self-originating and referral cases.RESULTS:We found an increasing number of referrals over the study period. There was an increased cost of treating hips over knees. All scenarios generated a positive net income; however, referral hip PJIs offered lower reimbursement and net income per case (although not statistically significant), whereas knee PJIs offered higher reimbursement and net income per case (although not statistically significant).CONCLUSION:With referral centers treating increased numbers of infected joints performed elsewhere, we show continued financial incentive in accepting referrals, although with less financial gain than when treating one's own hip PJI and an increased financial gain when treating referral knee PJIs.

Introduction Periprosthetic joint infection (PJI) is a significant challenge to the orthopedic surgeon, patient, hospital, and insurance provider. As the number of total hip and knee replacements has increased, the number of revision procedures has also increased. Revisions for infection require a greater amount of hospital and surgeon resources than noninfectious revisions. Our study compares the financial information for all two-stage revision surgeries performed at our tertiary referral center for hip or knee PJI over the last four years, separating them into two groups: referral versus self-originating cases. Methods We performed a review of all patients who underwent two-stage revision hip or knee arthroplasty for infection between 2008 and 2013 at our facility. We collected detailed financial information for patients and separated them into referral versus self-originating cases, indicating whether index surgery was performed at an outside facility or at our facility, respectively. Only those patients who underwent full two-stage procedure at our facility were included. Results We found an increasing number of referrals over the study period. There was a non-statistical increased cost of treating hips over knees (p=0.24). We found a continued financial incentive, with no statistical difference between referral and self-originating groups, in treating hip (p=0.89) and knee (p=0.84) PJIs (Figure 1). Despite no difference in payer status, there was a non-statistical trend for a much lower reimbursement (p=0.15) in the referral hip group. We found that referral knee PJIs overall reimbursement (p=0.65), and in turn revenue (p=0.55), was non-statistically higher than that of self-originating knee PJIs. There is a significant financial disincentive in treating hip PJI referrals if the antibiotic spacer has already been placed (p=0.036) (Figure 2). We found a non-significant decreased reimbursement for treating referral knee PJIs if the antibiotic spacer has been placed prior to referral (p=0.81). Conclusion To our knowledge, our study is the first to extensively compare the financial implications of treating an institution9s own PJIs of the knee and hip versus treating referred infections. In the modern era of referral centers accepting more of the burden of PJIs, we show there is continued financial incentive to treating one9s own PJIs and referral PJIs, given the antibiotic spacer was not placed at an outside facility.

Background: The goal of this study was to compare postoperative medical comanagement of total hip arthroplasty and total knee arthroplasty patients using a hospitalist (H) and nonhospitalist (NH) model at a single teaching institution to determine the clinical and economic impact of the hospitalist comanagement.Methods: We retrospectively reviewed the records of 1656 patients who received hospitalist comanagement with 1319 patients who did not. The NH and H cohorts were compared at baseline via chisquare test for the American Society of Anesthesiologists classification, the t test for age, and the Wilcoxon test for the unadjusted Charlson Comorbidity Index score and the age-adjusted Charlson Comorbidity Index score. Chi-square test was used to compare the postoperative length of stay, readmission rate at 30 days after surgery, diagnoses present on admission, new diagnoses during admission, tests ordered postoperatively, total direct cost, and discharge location.Results: The H cohort gained more new diagnoses (P < .001), had more studies ordered (P < .001), had a higher cost of hospitalization (P = .002), and were more likely to be discharged to a skilled nursing facility (P < .001). The H cohort also had a lower length of stay (P < .001), but we believe evolving techniques in both pain control and blood management likely influenced this. There was no significant difference in readmissions.Conclusion: Any potential benefit of a hospitalist comanagement model for this patient population may be outweighed by increased cost. (C) 2016 Elsevier Inc. All rights reserved.

In this issue of Mayo Clinic Proceedings, Sareyyupoglu et al1 of Mayo Clinic describe a series of 18 patients who had aggressive surgical treatment for acute pulmonary embolism (PE). The authors were careful to define the presence of cardiogenic shock and severe right ventricular dysfunction as indications for urgent surgical embolectomy in these critically ill patients. The surgical technique used for acute pulmonary embolectomy is a variation of the modified Trendelenburg procedure used by many surgeons.2-4 Specifically, the operation was conducted through a median sternotomy with aortic and bicaval cannulation and normothermic cardiopulmonary bypass. Incisions into the main pulmonary artery to remove the clot were extended into the distal pulmonary arteries when necessary. The lungs were massaged through bilateral pleurotomies to facilitate clot removal. Inferior vena cava (IVC) filters were placed either preoperatively or within the first 24 hours after surgery to prevent reembolization. Perioperative management included the widely accepted measures of heparin anticoagulation and vena cava filters to prevent progression of deep venous thrombosis and recurrent PE.5-7 Sareyyupoglu et al1 reported a respectable 78% early and 67% long-term survival rate in these severely compromised patients. This aggressive approach to an otherwise lethal problem suggests that acceptable survival is possible in a selected group of patients. Their approach may herald a resurgence of interest in surgical pulmonary embolectomy to treat severe hemodynamic compromise.

"One Sunday morning when both my dad and I were working in our offices, he walked into my office and gave me this manuscript. I read it, said I enjoyed it, and asked where he was going to publish it. He answered, 'Nowhere. I just wrote it for you.' I recently came across it while cleaning out some files. I thought others would like to read it since it was written in the 1960s.'' - John Ochsner, MD

Surgical case volumes in non-university-affiliated cardiothoracic surgery training programs in the US have been extensively studied by the Residency Review Committee (RRC) for thoracic surgery. The RRC has established that these programs offer a broad experience in common cardiothoracic procedures such as myocardial revascularization, valvular surgery, and cardiopulmonary transplantation. However, resident exposure to other important but less common cardiac surgical conditions in these programs remains unanswered. To address this question, an institutional review board-approved retrospective review of the experience of thoracic surgery residents with one of the rarest of surgical conditions, cardiac tumors, was conducted at the Ochsner Clinic Foundation in New Orleans, Louisiana. A survey of existing private, non-university-affiliated US cardiothoracic surgery training programs was conducted to determine the extent of the cardiac tumor experience in these programs. The results were then compared with selected university programs.