Introduction Total joint arthroplasty (TJA) is projected to be the most common elective surgical procedure in the coming decades, however TJA now accounts for the largest expenditure per procedure ...

IntroductionKnee osteoarthritis is a leading cause of disability around the world. Traditionally, total knee arthroplasty (TKA) is the gold standard treatment; however, unicompartmental knee arthroplasty (UKA) has emerged as a less-invasive alternative to TKA. Patients with UKAs participate earlier with physical therapy (PT), have decreased complications, and faster discharges (1, 2). As UKA has evolved, so has computer navigation and robotic technology. The Robotic Assisted UKA combines the less invasive approach of the UKA with accurate and reproducible alignment offered by a robotic interface (3)(Figure1).A key part of a patient's satisfaction is perioperative pain control. Femoral nerve blocks (FNB) are commonly performed to provide analgesia, though they cause quadriceps weakness which limits PT (4). An alternative is the adductor canal block (ACB) which provides analgesia while limiting quadriceps weakness (4). The adductor canal is an aponeurotic structure in the middle third of the thigh containin...

Background:Complications following hip and knee arthroplasty can occur in any given patient. However, specific risk factors such as increased age, history of coexistent disease, and increased body ...

BACKGROUND:Peri-operative dexamethasone has been shown to effectively reduce post-operative nausea and vomiting and aide in analgesia after total joint arthroplasty (TJA); however, systemic glucocorticoid therapy has many adverse effects. The purpose of this study is to determine the effects of dexamethasone on prosthetic joint infection (PJI) and blood glucose levels in patients undergoing TJA. METHODS:A retrospective chart review of all patients receiving primary TJA from 2011 to 2015 (n = 2317) was conducted. Patients were divided into 2 cohorts: dexamethasone (n = 1426) and no dexamethasone (n = 891); these groups were subdivided into diabetic and non-diabetic patients. The primary outcome was PJI; secondary measures included glucose levels and pre-operative hemoglobin A1c (A1c) values. Statistics were carried out using logistic and regression models. RESULTS:Of the 2317 joints, 1.12% developed PJI; this was not affected by dexamethasone (P = .166). Diabetics were found to have higher rate of infection (P < .001); however, diabetics who received dexamethasone were not found to have a significantly higher infection rate that non-diabetics (P = .646). Blood glucose levels were found to increase post-operatively, and dexamethasone did not increase this change (P = .537). Diabetes (P < .001) and increasing hemoglobin A1c (P < .001) were also associated with increased serum glucose levels; however, this was not influenced by dexamethasone (P = .595). CONCLUSION:Although diabetic patients were found to have a higher infection rate overall, this was not affected by administration of intravenous dexamethasone, nor was the post-operative elevation in serum glucose levels. In this study population, peri-operative intravenous dexamethasone did not increase the rate of PJI and was safe to administer in patients undergoing TJA.

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.

BackgroundHospitalists have assumed an evolving role in the care of postsurgical orthopaedic patients. Literature has provided evidence to suggest improved outcomes in postsurgical hip fracture patients managed by hospitalists in nonteaching hospitals. However, the full impact of a hospitalist co-management model has not been fully investigated with regard to elective joint arthroplasty patients in a multispecialty teaching facility. We hypothesized that a hospitalist co-management model in the setting of a teaching hospital would lead to an increase in unnecessary medical workups for joint arthroplasty patients.MethodsWe retrospectively evaluated 2231 patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA) between May 2010 and January 2014 at one teaching facility, excluding any non-elective trauma patients. The patients were separated into a non-hospitalist (NH) cohort of 1062 patients that did not receive hospitalist co-management postsurgery, and a hospitalist (H) cohort o...

Introduction:Deep infection after total joint arthroplasty is a devastating complication with reported incidence of 1–3% with projection to increase to 6.8% by 2030. The direct costs of revision su...

Extraskeletal osteosarcoma is a rare disease that uncommonly affects the upper extremity. A 46-year-old African American man presented for evaluation of a right middle finger mass. Excisional biopsy demonstrated extraskeletal osteosarcoma of the soft tissues. We performed a transmetacarpal ray resection. Copyright (C) 2018 by the American Society for Surgery of the Hand. All rights reserved.

This study compared two popular iPhone-based goniometer applications to the gold standard universal goniometer for the measurement of the hip and knee joints in scenarios mimicking the normal pace of an orthopaedic clinical practice.Three physicians measured hip and knee joint angles 35 times with one of three goniometers: universal 12-inch goniometer, DrGoniometer (iPhone-5 based), and SimpleGoniometer (iPhone-5 based). Data wwere analyzed using Pearson correlation coefficient calculations. Average knee angles measured with the universal goniometer, DrGoniometer, and SimpleGoniometer measured 83.46°, 85.23°, and 80.39°, respectively. The smartphone-based goniometers had moderate agreement with the universal goniometer in the knee (r > .322). Average hip angles measured with the universal goniometer, DrGoniometer, and SimpleGoniometer measured 62.34°, 60.87°, and 59.34°, respectively. The smartphone-based goniometers had moderate agreement with the universal goniometer in the hip (r > .168). Smartphone-based goniometers gave accurate, with weak to moderate correlation, measurements for the knee and hip. (Journal of Surgical Orthopaedic Advances 26(4):223-226, 2017).

Duncan, Scott F.M. MD, MPH, MBA; Waddell, Bradford MD; Meyer, Mark S. MD; Saracevic, Caitlin MA Author Information

Dislocation of the hip is a well-described event that occurs in conjunction with highenergy trauma or postoperatively after total hip arthroplasty. Bigelow first described closed treatment of a dislocated hip in 1870, and in the last decade many reduction techniques have been proposed. In this article, we review all described techniques for the reduction of hip dislocation while focusing on physician safety. Furthermore, we introduce a modified technique for the reduction of posterior hip dislocation that allows the physician to adhere to the back safety principles set for by the Occupational Safety and Health Administration.

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.

Background The Perioperative Surgical Home (PSH) is a multi-disciplinary rapid recovery pathway aimed at transforming surgical care by delivering value and improving outcomes and patient satisfaction. Our institution developed a PSH pathway for total hip arthroplasty (THA) patients in March 2014. The Orthopaedic and Anesthesia Services co-managed the patients throughout the entire surgical process. Weekly meetings were held to discuss medical and social requirements for upcoming patients including disposition planning. All patients received day of surgery physical therapy, and anesthesia post-surgical pain control and medical co-management. We hypothesized that the PSH would provide enhanced care for THA patients. To our knowledge this is the first report on the PSH in a total joint population Methods We prospectively followed 180 THA patients from the PSH group (SH) and compared them to a group matched for age, body mass index (BMI), American society of anesthesiologist score (ASA), and Charleson comorbidity index score (CCI) that were not involved in the PSH (NSH). We used Wilcoxon, Chi square, and multivariate analysis to compare the groups for length of stay (LOS), total direct cost (TDC), complications, readmissions at 30 days, and discharge disposition location. Results No significant difference was found between the two cohorts with respect to age, BMI, ASA, or CCI. The average age, BMI, ASA and CCI were 64, 30, 2.5, and 3.6. The average LOS of the SH cohort was 2.1 days which was significantly lower than the NSH cohort at 3.6 days ( P P =0.006) regardless of age ( P =0.003) and ASA ( P =0.048). No significant difference was found between the two groups with regard to complications ( P =0.346), TDC ( P =0.883), or readmissions at 30 days ( P =0.637). Discussion The implementation of the PSH led to decreased length of stay and allowed more patients to be discharged to home, without an increase in complications or readmissions. We were able to accomplish this in patients with higher ASA and CCI scores which has not been the case in other rapid recovery programs. Effective care pathways require contribution and cooperation by multiple healthcare personnel throughout the phases of patient care. We feel that key factors contributing to the success of the PSH include post-surgical co-management by anesthesia, early physical therapy, and weekly meetings to discuss patients’ individual needs for disposition.

BACKGROUND:C-reactive protein (CRP) has been suggested as an independent risk factor for cardiovascular pathology in the nonsurgical setting. While postoperative CRP and erythrocyte sedimentation rate (ESR) have an established role in aiding the diagnosis of periprosthetic joint infections, some authors suggest a link between preoperative CRP and postoperative complications in patients undergoing total joint arthroplasty.METHODS:We conducted a retrospective cohort study of 351 patients who underwent unilateral primary total knee arthroplasty by a single surgeon during a 28-month period (January 2013 through April 2015). Patient medical records were reviewed for the following complications occurring within 90 days postoperatively: myocardial infarction, arrhythmia, pulmonary embolism, wound infection, acute renal failure, and reoperation.RESULTS:We found no statistically significant link between postoperative complications and preoperative CRP levels (P=0.5005) or ESR levels (P=0.1610).CONCLUSION:The results of this study do not support the routine inclusion of CRP and ESR analysis as part of the preoperative evaluation for elective total knee arthroplasty.

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.

This study's purpose was to assess the impact of a preoperative risk stratification program on joint arthroplasty outcomes at a single institution. We hypothesized that by using a standardized preoperative risk stratification center we would see better outcomes and decreased costs. The triage cohort (T) included 1498 patients assessed at a standardized risk stratification center, and the non-triage cohort (NT) included 1100 patients who did not utilize the center. The T cohort had significantly higher ASA classification (P<0.0001) and ACCI scores (P=0.028). We found no significant difference in complication rates. The T cohort showed a significant decrease in LOS (P<0.0001) and an increase in average reimbursement (P=0.009). A standardized preoperative risk stratification center can contribute to decreased LOS, increased reimbursement and help prevent complications.

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.

Efficacy of antibiotic cement (ALBC) in primary knee arthroplasty (pTKA) has been debated. The study's purpose was to examine efficacy of ALBC versus plain cement (PBC) in preventing infection in high-risk patients undergoing pTKA. 3292 consecutive pTKAs were divided into three cohorts: (1) patients receiving only PBC, (2) patients receiving only ALBC, and (3) only high-risk patients receiving ALBC. Cohorts' infections were compared. The 30-day infection rates for cohorts 1, 2, 3 were 0.29%, 0.20%, and 0.13% respectively. 6-month rates were 0.39%, 0.54% and 0.38%. 1-year rates were 0.78%, 0.61%, and 0.64%. Differences in infection rates at all time intervals were not statistically significant. The study supports that even judicious risk-stratified usage of ALBC may not confer added benefit in decreasing infection at one year.

Topical vancomycin powder (VP) has shown efficacy and safety in decreasing post-operative spine infections. VP use in arthroplasty has not been established. Concerns remain for third-body wear with the addition of crystalline substrate at the implant interface. The study's purpose was to compare wear behavior of CoCr on UHMWPE to identical wear couples with VP. A six-station wear simulator was utilized and cyclic articulations were run for 10 million cycles (Mc). UHMWPE wear was measured using photography, stereomicroscopy, and gravimetric measurement. There were no differences in wear mark length (P=0.43), width (P=0.49), or gravimetric wear at 10 Mc (P=0.98). VP and control groups lost 0.32 and 0.33mg, respectively. VP may have a role in PJI prevention. A well-designed clinical study is needed.

Background: Complications following hip and knee arthroplasty can occur in any given patient. However, specific risk factors such as increased age, history of coexistent disease, and increased body mass index have been found to increase the risk of complications after such procedures. Complications often require prolonged hospital admission periods and added hospital resources which ultimately results in increased costs per hospital stay. However, if patients are pre-operatively risk stratified, and followed post-operatively for specific high risk medical issues, many complications may be avoided. By using a hospital standardised peri-operative risk stratification process, the cost per hospital stay for hip and knee arthroplasty may decrease. Hypothesis: Overall hospital costs related to joint arthroplasty will be decreased by using a multi-disciplinary peri-operative risk stratification programme. Methods/Materials: We reviewed 2,640 joint arthroplasty cases performed at one hospital from January 2008 until August 2012 consisting of primary and revision hip and knee arthroplasties. This group was separated into a non-triage group (N) and a triage group (T). The non-triage group (N) consisted of 1,142 cases that were performed prior to the formation of a multi-disciplinary peri-operative risk stratification programme for joint arthroplasty at the hospital. The triage group (T) consisted of 1,498 cases that were performed after the formation of a multi-disciplinary peri-operative risk stratification programme. These two groups were first compared with regards to ASA score and Charleston co-morbidity scale pre-operatively. Post-operatively the two groups were compared with regards to length of stay, major and minor complication rates up to 30 and 90 days, and cost per hospital stay. Results: The preliminary results have shown a statistically significant difference in length of stay between the two groups (p Conclusion: After the establishment of a multi-disciplinary, peri-operative, risk stratification programme at our hospital, the average length of stay per knee and hip arthroplasty was significantly decreased per patient. The average complications rate per patient did not change significantly. These findings took place even though the ASA score of the population undergoing knee and hip arthroplasty increased significantly after the multi-disciplinary, peri-operative, risk stratification programme was established. Level of evidence: Level III Retrospective Cohort