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Szymski D, Walter N, Hierl K, Rupp M, Alt V. Direct Hospital Costs per Case of Periprosthetic Hip and Knee Joint Infections in Europe - A Systematic Review. J Arthroplasty 2024:S0883-5403(24)00032-9. [PMID: 38266688 DOI: 10.1016/j.arth.2024.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 12/22/2023] [Accepted: 01/12/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND The rise of periprosthetic joint infections (PJIs) due to aging populations is steadily increasing the number of arthroplasties and treatment costs. This study analyzed the direct health care costs of PJI for total hip arthroplasty and total knee arthroplasty (TKA) in Europe. METHODS The databases PubMed, Scopus, Embase, Cochrane, and Google Scholar were systematically screened for direct costs of PJI in Europe. Publications that defined the joint site and the procedure performed were further analyzed. Mean direct health care costs were calculated for debridement, antibiotics, and implant retention (DAIR), one-stage, and 2-stage revisions for hip and knee PJI, respectively. Costs were adjusted for inflation rates and reported in US-Dollar (USD). RESULTS Of 1,374 eligible publications, 12 manuscripts were included in the final analysis after an abstract and full-text review. Mean direct costs of $32,933 were identified for all types of revision procedures for knee PJI. The mean direct treatment cost including DAIR for TKA after PJI was $19,476. For 2-stage revisions of TKA, the mean total cost was $37,980. For all types of hip PJI procedures, mean direct hospital costs were $28,904. For hip DAIR, one-stage and 2-stage treatment average costs of $7,120, $44,594, and $42,166 were identified, respectively. CONCLUSIONS Periprosthetic joint infections are associated with substantial direct health care costs. As detailed reports on the cost of PJI are scarce and of limited quality, more detailed financial data on the cost of PJI treatment are urgently required.
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Affiliation(s)
- Dominik Szymski
- Department for Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Nike Walter
- Department for Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Katja Hierl
- Department for Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Markus Rupp
- Department for Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Volker Alt
- Department for Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
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De Marziani L, Boffa A, Di Martino A, Andriolo L, Reale D, Bernasconi A, Corbo VR, de Caro F, Delcogliano M, di Laura Frattura G, Di Vico G, Manunta AF, Russo A, Filardo G. The reimbursement system can influence the treatment choice and favor joint replacement versus other less invasive solutions in patients affected by osteoarthritis. J Exp Orthop 2023; 10:146. [PMID: 38135778 PMCID: PMC10746689 DOI: 10.1186/s40634-023-00699-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/16/2023] [Indexed: 12/24/2023] Open
Abstract
PURPOSE The aim of this study was to assess how physicians perceive the role of the reimbursement system and its potential influence in affecting their treatment choice in the management of patients affected by osteoarthritis (OA). METHODS A survey was administered to 283 members of SIAGASCOT (Italian Society of Arthroscopy, Knee, Upper Limb, Sport, Cartilage and Orthopaedic Technologies), a National scientific orthopaedic society. The survey presented multiple choice questions on the access allowed by the current Diagnosis-Related Groups (DRG) system to all necessary options to treat patients affected by OA and on the influence toward prosthetic solutions versus other less invasive options. RESULTS Almost 70% of the participants consider that the current DRG system does not allow access to all necessary options to best treat patients affected by OA. More than half of the participants thought that the current DRG system favors the choice of prosthetic solutions (55%) and that it can contribute to the increase in prosthetic implantation at the expense of less invasive solutions (54%). The sub-analyses based on different age groups, professional roles, and places of work allowed to evaluate the response in each specific category, confirming the findings for all investigated aspects. CONCLUSIONS This survey documented that the majority of physicians consider that the reimbursement system can influence the treatment choice when managing OA patients. The current DRG system was perceived as unbalanced in favor of the choice of the prosthetic solution, which could contribute to the increase in prosthetic implantation at the expense of other less invasive options for OA management.
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Affiliation(s)
- Luca De Marziani
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, Bologna, 1 - 40136, Italy
| | - Angelo Boffa
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, Bologna, 1 - 40136, Italy.
| | - Alessandro Di Martino
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, Bologna, 1 - 40136, Italy
| | - Luca Andriolo
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, Bologna, 1 - 40136, Italy
| | - Davide Reale
- Ortopedia e Traumatologia, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessio Bernasconi
- Orthopaedics and Traumatology Unit, Department of Public Health, University Federico II of Naples Federico II, Naples, Italy
| | | | - Francesca de Caro
- Department of Orthopaedic Surgery, Istituto Di Cura Città Di Pavia, Pavia, Italy
| | - Marco Delcogliano
- Servizio di Ortopedia e Traumatologia dell'Ospedale Regionale di Bellinzona e Valli, Ente Ospedaliero Cantonale, Ticino, Switzerland
| | | | - Giovanni Di Vico
- Department of Orthopaedics and Trauma Surgery, Clinica San Michele, Maddaloni, Italy
| | | | | | - Giuseppe Filardo
- Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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Jud L, Gautschi N, Möller S, Möller K, Giesinger K. Revision total knee arthroplasty results in financial deficits within the Swiss healthcare system. Knee Surg Sports Traumatol Arthrosc 2023; 31:5293-5298. [PMID: 37715052 DOI: 10.1007/s00167-023-07574-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/03/2023] [Indexed: 09/17/2023]
Abstract
PURPOSE Revision total knee arthroplasty (RTKA) results in high costs with inadequately low reimbursement in different healthcare systems. Therefore, a financial analysis was performed comparing costs and reimbursements of primary total knee arthroplasty (PTKA) versus RTKA using financial and total knee arthroplasty-register data from a large tertiary hospital, the Cantonal Hospital of St. Gallen (KSSG), Switzerland. METHODS All PTKA and RTKA performed between January 2012 and September 2019 at the KSSG were included. Financial and TKA-register data for each case were collected, including detailed cost allocation, reimbursement, patients' insurance status, type and indication for surgery and length of hospital stay. RTKA was further subdivided in one-stage and two-stage RTKA. Direct hospital costs were analyzed and compared to reimbursement in both groups. Cost-coverage ratios were calculated. RESULTS 730 PTKA and 106 RTKA were included. The RTKA group contained 66 one-stage and 40 two-stage RTKA. Cost-coverage ratio for PTKA and RTKA showed to be 110.9% and 81.3%, respectively. Cost-coverage ratio was lower for two-stage RTKA than for one-stage RTKA with 74.1% and 92.3%, respectively. CONCLUSION RTKA leads to financial deficits especially for tertiary hospitals within the Swiss healthcare system. Restructuring of the reimbursements for PTKA and RTKA should be considered in favor of RTKA. Otherwise, tertiary hospitals will face a growing financial burden with the constantly increasing annual number of RTKA procedures, predominantly performed in this type of hospitals. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Lukas Jud
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Nora Gautschi
- Institute of Accounting, Control and Auditing, Chair of Controlling / Performance Management, University of St. Gallen, Tigerbergstrasse 9, 9000, St. Gallen, Switzerland
| | - Soeren Möller
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Klaus Möller
- Institute of Accounting, Control and Auditing, Chair of Controlling / Performance Management, University of St. Gallen, Tigerbergstrasse 9, 9000, St. Gallen, Switzerland
| | - Karlmeinrad Giesinger
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland.
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Correlation of Relative Value Units With Surgical Complexity and Physician Workload: A Contemporary Nationwide Analysis of Orthopaedic Procedures. J Am Acad Orthop Surg 2023; 31:413-420. [PMID: 36749881 DOI: 10.5435/jaaos-d-22-00866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/31/2022] [Indexed: 02/09/2023] Open
Abstract
INTRODUCTION Although previous studies have demonstrated inconsistencies between surgeon work and reimbursement, no previous study has calculated expected relative value units (RVUs) based on procedure-specific variables. Our study aimed to evaluate how measures of physician workload and surgical complexity correlate with the work RVUs (wRVUs) assigned to orthopaedic procedures and compare our predicted wRVUs with actual wRVUs. METHODS The National Surgical Quality Improvement Program was used to identify orthopaedic surgeries with the highest procedural volume in 2019. For each Current Procedural Terminology (CPT) code, variables related to surgical complexity and postoperative management were retrieved. A multivariable linear regression was conducted, and R2 values were calculated. RESULTS A total of 229,792 cases from the top 20 CPT codes by frequency in 2019 were identified. Base RVU values ranged from 7.03 mRVUs for arthroscopic meniscectomy to 30.28 mRVUs for revision total hip arthroplasty. A total of 15 (75%) of the projected mRVUs were lower than the actual mRVU of the procedure. For the 5 (25%) procedures with mRVU projections higher than actual values, the largest differences were seen for CPT codes 29,888 (arthroscopic anterior cruciate ligament [ACL] repair; difference: 7.81), 22,630 (posterior arthrodesis of the lumbar interbody; difference: 7.75), and 27,487 (revision total knee arthroplasty; difference: 4.04). CONCLUSION Our analysis demonstrates that current orthopaedic wRVUs do not appropriately compensate for objective measures of overall complexity as it relates to each procedure. Significant undercompensation in projected RVUs was noted for several high-volume orthopaedic procedures including arthroscopic ACL repair and revision total knee arthroplasty.
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Maslaris A, Tsiridis E, Schoeneberg C, Pass B, Spyrou G, Maris A, Matziolis G. Does stem profile have an impact on the failure patterns in revision total knee arthroplasty? Arch Orthop Trauma Surg 2023; 143:1549-1569. [PMID: 36450936 PMCID: PMC9957861 DOI: 10.1007/s00402-022-04683-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 10/23/2022] [Indexed: 12/02/2022]
Abstract
INTRODUCTION Revision total knee arthroplasty (RTKA) has been increasing continuously. The results of RTKA still remain unsatisfactory. Failure patterns and risk factors in RTKA were thoroughly analyzed, with periprosthetic joint infections (PJI) and aseptic loosening remaining at the forefront of re-revision (ReRTKA) causes. While there is evidence that stem profile impacts the revisability of cemented implants, its association with the modes of RTKA failure is unknown. METHODS 50 consecutive ReRTKA performed in a single orthopedic center during 2016-2017 were retrospectively analyzed. The cases were stratified according to age, sex, number of preexisting revisions, fixation technique, stem design and causes of re-revision. All explanted implants with conical vs. cylindrical stem profiles were compared. RESULTS Mean age was 67 ± 11.5, and 54% were females. 72% of the cases had ≥ 3 previous revisions. 88% were full-cemented, 3% hybrid and 9% press-fit stems. 36% of the RTKA had conical, 58% cylindrical and 6% combined stem profiles. 92% of the RTKA components were removed. Removal causes were: PJI (52.2%), aseptic loosening (34.8%), implant malposition (9.8%), painful knee (1.1%) and instability (2.2%). While the overall RTKA failure patterns were equally distributed between conical and cylindrical stems, subgroup analysis of only cemented ReRTKA revealed a higher incidence of aseptic loosening within cylindrical stem profiles (46.7% vs. 25.7%, P = 0.05). CONCLUSION Stem profile may have an impact on the process of aseptic loosening in cemented non-metaphyseal engaging RTKA, with cylindrical designs tending to worse outcomes than conical designs. Large cohort studies could provide more clarity on current observation.
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Affiliation(s)
- Alexander Maslaris
- Department of Orthopedics, Waldkliniken Eisenberg, Jena University Hospital, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany. .,Department of Orthopedics and Trauma Surgery, Alfried-Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131, Essen, Germany.
| | - Eleftherios Tsiridis
- grid.4793.90000000109457005Academic Orthopedic Department, Papageorgiou General Hospital, Aristotle University Medical School, Thessaloniki, GRC Greece
| | - Carsten Schoeneberg
- grid.476313.4Department of Orthopedics and Trauma Surgery, Alfried-Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany
| | - Bastian Pass
- grid.476313.4Department of Orthopedics and Trauma Surgery, Alfried-Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany
| | - Georgios Spyrou
- grid.476313.4Department of Orthopedics and Trauma Surgery, Alfried-Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany
| | - Alexandros Maris
- grid.420468.cDepartment of Orthopedics, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH UK
| | - Georg Matziolis
- grid.275559.90000 0000 8517 6224Department of Orthopedics, Waldkliniken Eisenberg, Jena University Hospital, Klosterlausnitzer Str. 81, 07607 Eisenberg, Germany
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Impact of stem profile on the revisability and the need for osteotomy in well-fixed cemented revision total knee arthroplasty implants. Arch Orthop Trauma Surg 2023; 143:469-479. [PMID: 35930052 PMCID: PMC9886614 DOI: 10.1007/s00402-022-04559-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 07/18/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION While re-revision total knee arthroplasty (ReRTKA) steadily increases, the ease and bone-sparing removal of RTKA implants is gaining more and more in importance. Biomechanical data suggest that cemented conical stems can be removed significantly easier than cylindrical stems. However, no clinical evidence exists supporting this observation. Aim of this study was to compare the revisability and need for osteotomy (OT) between removals of well-fixed cemented conical vs. cylindrical RTKA stems. MATERIALS AND METHODS 55 removals of well-fixed full-cemented RTKA stems (29 knees) performed between 2016 and 2018 were retrospectively analyzed. Main outcome variables were: bone loss, fractures, osteotomy incidence, surgery duration, early postoperative complications (EPC), hemoglobin drop and blood transfusion. SPSS was used for the statistical analysis. RESULTS 44.8% were conical, 48.3% cylindrical, and 6.9% combined stem designs. Causes for re-revision were PJI (75.9%), malposition (17.2%) and persistent pain (6.9%). 10 stem removals (18.2%) required an OT (four femoral, six tibial): eight stems (14.5%) had cylindrical and two (3.6%) conical designs (P = 0.041). Fractures were noted solely in removals without OT (11.1% vs. 0%,). There was a tendency to more bone loss in cylindrical stem revisions (53.8% vs. 32%, P = 0.24). A longer overall surgery time was observed in revisions of cylindrical stems (+ 37 min, P = 0.05). There was higher hemoglobin drop and need for blood transfusion in revisions of cylindrical stems or after OT but without reaching statistical significance. The EPC rates were slightly higher in ReRTKA on cylindrical stems (P = 0.28). CONCLUSION Well-fixed cemented conical stems may be revision friendlier with less demands on OT and shorter overall surgery time than cemented cylindrical stems.
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Murphy M, Killen C, Burnham R, Sarvari F, Wu K, Brown N. Artificial intelligence accurately identifies total hip arthroplasty implants: a tool for revision surgery. Hip Int 2022; 32:766-770. [PMID: 33412939 DOI: 10.1177/1120700020987526] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND A critical part in preoperative planning for revision arthroplasty surgery involves the identification of the failed implant. Using a predictive artificial neural network (ANN) model, the objectives of this study were: (1) to develop a machine-learning algorithm using operative big data to identify an implant from a radiograph; and (2) to compare algorithms that optimise accuracy in a timely fashion. METHODS Using 2116 postoperative anteroposterior (AP) hip radiographs of total hip arthroplasties from 2002 to 2019, 10 artificial neural networks were modeled and trained to classify the radiograph according to the femoral stem implanted. Stem brand and model was confirmed with 1594 operative reports. Model performance was determined by classification accuracy toward a random 706 AP hip radiographs, and again on a consecutive series of 324 radiographs prospectively collected over 2019. RESULTS The Dense-Net 201 architecture outperformed all others with 100.00% accuracy in training data, 95.15% accuracy on validation data, and 91.16% accuracy in the unique prospective series of patients. This outperformed all other models on the validation (p < 0.0001) and novel series (p < 0.0001). The convolutional neural network also displayed the probability (confidence) of the femoral stem classification for any input radiograph. This neural network averaged a runtime of 0.96 (SD 0.02) seconds for an iPhone 6 to calculate from a given radiograph when converted to an application. CONCLUSIONS Neural networks offer a useful adjunct to the surgeon in preoperative identification of the prior implant.
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Affiliation(s)
- Michael Murphy
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Cameron Killen
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Robert Burnham
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Fahad Sarvari
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Karen Wu
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Nicholas Brown
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
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Blom AW, Beswick AD, Burston A, Carroll FE, Garfield K, Gooberman-Hill R, Harris S, Kunutsor SK, Lane A, Lenguerrand E, MacGowan A, Mallon C, Moore AJ, Noble S, Palmer CK, Rolfson O, Strange S, Whitehouse MR. Infection after total joint replacement of the hip and knee: research programme including the INFORM RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2022. [DOI: 10.3310/hdwl9760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background
People with severe osteoarthritis, other joint conditions or injury may have joint replacement to reduce pain and disability. In the UK in 2019, over 200,000 hip and knee replacements were performed. About 1 in 100 replacements becomes infected, and most people with infected replacements require further surgery.
Objectives
To investigate why some patients are predisposed to joint infections and how this affects patients and the NHS, and to evaluate treatments.
Design
Systematic reviews, joint registry analyses, qualitative interviews, a randomised controlled trial, health economic analyses and a discrete choice questionnaire.
Setting
Our studies are relevant to the NHS, to the Swedish health system and internationally.
Participants
People with prosthetic joint infection after hip or knee replacement and surgeons.
Interventions
Revision of hip prosthetic joint infection with a single- or two-stage procedure.
Main outcome measures
Long-term patient-reported outcomes and reinfection. Cost-effectiveness of revision strategies over 18 months from two perspectives: health-care provider and Personal Social Services, and societal.
Data sources
National Joint Registry; literature databases; published cohort studies; interviews with 67 patients and 35 surgeons; a patient discrete choice questionnaire; and the INFORM (INFection ORthopaedic Management) randomised trial.
Review methods
Systematic reviews of studies reporting risk factors, diagnosis, treatment outcomes and cost comparisons. Individual patient data meta-analysis.
Results
In registry analyses, about 0.62% and 0.75% of patients with hip and knee replacement, respectively, had joint infection requiring surgery. Rates were four times greater after aseptic revision. The costs of inpatient and day-case admissions in people with hip prosthetic joint infection were about five times higher than those in people with no infection, an additional cost of > £30,000. People described devastating effects of hip and knee prosthetic joint infection and treatment. In the treatment of hip prosthetic joint infection, a two-stage procedure with or without a cement spacer had a greater negative impact on patient well-being than a single- or two-stage procedure with a custom-made articulating spacer. Surgeons described the significant emotional impact of hip and knee prosthetic joint infection and the importance of a supportive multidisciplinary team. In systematic reviews and registry analyses, the risk factors for hip and knee prosthetic joint infection included male sex, diagnoses other than osteoarthritis, high body mass index, poor physical status, diabetes, dementia and liver disease. Evidence linking health-care setting and surgeon experience with prosthetic joint infection was inconsistent. Uncemented fixation, posterior approach and ceramic bearings were associated with lower infection risk after hip replacement. In our systematic review, synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy for prosthetic joint infection. Systematic reviews and individual patient data meta-analysis showed similar reinfection outcomes in patients with hip or knee prosthetic joint infection treated with single- and two-stage revision. In registry analysis, there was a higher rate of early rerevision after single-stage revision for hip prosthetic joint infection, but, overall, 40% fewer operations are required as part of a single-stage procedure than as part of a two-stage procedure. The treatment of hip or knee prosthetic joint infection with early debridement and implant retention may be effective in > 60% of cases. In the INFORM randomised controlled trial, 140 patients with hip prosthetic joint infection were randomised to single- or two-stage revision. Eighteen months after randomisation, pain, function and stiffness were similar between the randomised groups (p = 0.98), and there were no differences in reinfection rates. Patient outcomes improved earlier in the single-stage than in the two-stage group. Participants randomised to a single-stage procedure had lower costs (mean difference –£10,055, 95% confidence interval –£19,568 to –£542) and higher quality-adjusted life-years (mean difference 0.06, 95% confidence interval –0.07 to 0.18) than those randomised to a two-stage procedure. Single-stage was the more cost-effective option, with an incremental net monetary benefit at a threshold of £20,000 per quality-adjusted life-year of £11,167 (95% confidence interval £638 to £21,696). In a discrete choice questionnaire completed by 57 patients 18 months after surgery to treat hip prosthetic joint infection, the most valued characteristics in decisions about revision were the ability to engage in valued activities and a quick return to normal activity.
Limitations
Some research was specific to people with hip prosthetic joint infection. Study populations in meta-analyses and registry analyses may have been selected for joint replacement and specific treatments. The INFORM trial was not powered to study reinfection and was limited to 18 months’ follow-up. The qualitative study subgroups were small.
Conclusions
We identified risk factors, diagnostic biomarkers, effective treatments and patient preferences for the treatment of hip and knee prosthetic joint infection. The risk factors include male sex, diagnoses other than osteoarthritis, specific comorbidities and surgical factors. Synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy. Infection is devastating for patients and surgeons, both of whom describe the need for support during treatment. Debridement and implant retention is effective, particularly if performed early. For infected hip replacements, single- and two-stage revision appear equally efficacious, but single-stage has better early results, is cost-effective at 18-month follow-up and is increasingly used. Patients prefer treatments that allow full functional return within 3–9 months.
Future work
For people with infection, develop information, counselling, peer support and care pathways. Develop supportive care and information for patients and health-care professionals to enable the early recognition of infections. Compare alternative and new treatment strategies in hip and knee prosthetic joint infection. Assess diagnostic methods and establish NHS diagnostic criteria.
Study registration
The INFORM randomised controlled trial is registered as ISRCTN10956306. All systematic reviews were registered in PROSPERO (as CRD42017069526, CRD42015023485, CRD42018106503, CRD42018114592, CRD42015023704, CRD42017057513, CRD42015016559, CRD42015017327 and CRD42015016664).
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ashley W Blom
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Fran E Carroll
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kirsty Garfield
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shaun Harris
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Setor K Kunutsor
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Athene Lane
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Charlotte Mallon
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew J Moore
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cecily K Palmer
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Ola Rolfson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Simon Strange
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Wang XC, Zhang XM, Cai WL, Li Z, Ma C, Liu YH, He QL, Yan TS, Cao XW. One-stage revision arthroplasty in a patient with ochronotic arthropathy accompanied by joint infection: A case report. World J Clin Cases 2022; 10:9036-9043. [PMID: 36157667 PMCID: PMC9477060 DOI: 10.12998/wjcc.v10.i25.9036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/22/2022] [Accepted: 07/29/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Ochronotic arthropathy (OcA) is a rare disease, which is caused by the accumulation of homogentisic acid in the joint. Patients with OcA have obvious joint pain and the disease progresses rapidly, eventually resulting in disability. Arthroplasty is an efficacious treatment in patients with OcA. However, when OcA patients have joint infection, is joint replacement an option? In the present report, we performed total knee arthroplasty in a patient with OcA and knee infection under the guidance of one-stage revision theory.
CASE SUMMARY A 64-year-old male was referred to our hospital due to severe left knee pain with limited mobility for 2 years. On physical examination, the patient was found to have dark brown pigmentation of the sclera and auricle. Laboratory test results showed elevations in C-reactive protein level (65.79 mg/L) and erythrocyte sedimentation rate (90.00 mm/h). The patient underwent debridement of the left knee joint, during which the cartilage surface of the knee joint was found to be black-brown in color. Bacterial culture of synovial fluid revealed Achromobacter xylosoxidans. We then carried out arthroplasty under the guidance of the theory of one-stage revision. After surgery, the patient's left knee joint pain disappeared and function recovered without joint infection.
CONCLUSION OcA accompanied by joint infection is rare. One-stage revision arthroplasty may be a treatment option for this disease.
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Affiliation(s)
- Xiao-Chao Wang
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong Province, China
| | - Xiao-Min Zhang
- Department of Orthopaedics, Xi’an International Medical Center Hospital, Xi’an 710100, Shaanxi Province, China
| | - Wan-Ling Cai
- Department of Surgery, Baoji Hospital of Traditional Chinese Medicine, Baoji 721000, Shaanxi Province, China
| | - Zhen Li
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong Province, China
| | - Chao Ma
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong Province, China
| | - Yi-Hai Liu
- Department of Orthopaedics, Xi’an International Medical Center Hospital, Xi’an 710100, Shaanxi Province, China
| | - Qi-Lian He
- Department of Orthopaedics, Xi’an International Medical Center Hospital, Xi’an 710100, Shaanxi Province, China
| | - Tian-Sheng Yan
- Department of Orthopaedics, Xi’an International Medical Center Hospital, Xi’an 710100, Shaanxi Province, China
| | - Xue-Wei Cao
- Department of Orthopaedic Surgery, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou 510120, Guangdong Province, China
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Similar outcomes to primary total knee arthroplasty achievable for aseptic revision using the same primary posterior-stabilised prosthesis at a mean follow-up of 49 months. Knee Surg Sports Traumatol Arthrosc 2022; 30:2854-2861. [PMID: 34476561 DOI: 10.1007/s00167-021-06716-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/19/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The aim of the study was to compare clinical and radiological outcomes between primary and aseptic revision TKAs using the same posterior-stabilised (PS) prosthesis. The authors hypothesised similar outcomes between both groups for selected patients. METHODS This retrospective, case-control study assessed 36 patients who underwent aseptic revision TKA compared to a match group of 72 primary TKA. Both groups had the same PS design implant (ANATOMIC®, Amplitude, Valence, France). The International Knee Society (IKS) score, radiological outcomes (postoperative alignment, patellar tilt and radiolucent lines), re-intervention and revision rate were compared between the two groups with a minimum follow-up of 3 years. RESULTS The final study cohort included 29 patients and 63 patients respectively in the revision and primary group, with a mean follow-up of 49.1 months (range 36.1-69). Postoperatively, there was no significant difference in IKS scores between the two groups [169.8 for the revision group and 179.6 for the primary group (p = 0.09)]. No statistical difference was observed for post-operative satisfaction 86.2% versus 92.1% (p = 0.46). Between the two groups, there was no difference in mean radiological assessment, including radiolucent lines (p = 0.7). There was no significant difference for overall implant survivorship 96.5% versus 100% (p = 0.13) at 36 months. CONCLUSION Similar clinical, radiological and survivorship outcomes were found between rTKA and primary TKA groups using the same PS level of constraint in patients undergoing revision surgery for aseptic indications at 3-year follow-up. Use of PS implants in rTKA for the correct indication suggests this to be a safe approach at least in the medium term. LEVEL OF EVIDENCE IV, retrospective case-control study.
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11
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Han SB, Jang KM, Kim JH, Kim SB, Shin KH. Functional outcomes of residual varus alignment versus mechanical alignment in total knee arthroplasty for varus osteoarthritis: A preferred reporting items for systematic reviews and meta-analyses-compliant meta-analysis. J Orthop Surg (Hong Kong) 2022; 30:10225536221115273. [PMID: 35817754 DOI: 10.1177/10225536221115273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND One in five patients with mechanical alignment (MA) after total knee arthroplasty (TKA) was reportedly dissatisfied. As constitutional varus knees are common, restoring the patients' natural residual varus (RV) alignment is as an appealing alternative to neutral MA. This meta-analysis aimed to evaluate the effects of RV alignment on the functional outcomes compared with those of MA in TKA for the knees with varus osteoarthritis. METHODS The MEDLINE/PubMed, Cochrane Library, and EMBASE databases were comprehensively searched for papers comparing the effects of RV alignment and MA on the functional outcomes from the time of inception of the databases to July 2020. Studies comparing the functional outcomes in the knees subjected to TKA with RV alignment (case group) and MA (control group) were included. The Knee Society knee and functional scores (KSKS and KSFS, respectively), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Oxford knee score (OKS), and forgotten joint score (FJS) were compared. RESULTS Seven studies were finally included; all studies showed a low risk of selection bias and provided detailed demographic data. The pooled mean difference in the KSKS (0.06, 95% confidence interval [CI]: -0.14 to 0.27; p = 0.55) and KSFS (0.08, 95% CI: -0.08 to 0.35; p = 0.56) between RV alignment and MA did not significantly differ. The pooled mean differences in the WOMAC (-0.25, 95% CI: -0.57 to 0.07; p = 0.12), OKS (0.06, 95% CI: -0.15 to 0.27; p = 0.56), and FJS (0.41, 95% CI: -0.18 to 1.00; p = 0.18) between the groups were not significant. CONCLUSION The beneficial effects of RV alignment on the functional outcomes are limited compared to those of MA in TKA for varus osteoarthritis to date. Currently, TKA with neutral MA should be considered as the gold standard.
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Affiliation(s)
- Seung-Beom Han
- Department of Orthopaedic Surgery, 37997Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Ki-Mo Jang
- Department of Orthopaedic Surgery, 37997Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Jun-Hyun Kim
- Department of Orthopaedic Surgery, 37997Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Sang-Bum Kim
- Joint Center, Inbone Hospital, Paju-si, South Korea
| | - Kyun-Ho Shin
- Department of Orthopaedic Surgery, Nanoori Hospital (Incheon), Incheon, South Korea
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Hill DL, Pinger C, Noland EL, Morton K, Hunt AMA, Pensler E, Cantu S, Attar PS, Siddiqi A. A novel activated-zinc antiseptic solution effective against MRSA and Pseudomonas aeruginosa: a pig model. J Wound Care 2022; 31:S41-S50. [PMID: 35797249 DOI: 10.12968/jowc.2022.31.sup7.s41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the antimicrobial efficacy of a novel activated zinc solution against meticillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa after one hour, and to evaluate any untoward effect of the solution on local wound tissue at 24 hours after solution exposure in a pig wound model. METHOD A pathogen-free, commercially raised, Yorkshire-cross female pig was acquired 12 days prior to the procedure. Within one week prior to the procedure, a small loopful of test bacteria, Pseudomonas aeruginosa (pig-isolate) and MRSA (ATCC-6538), were streaked and cultured on a non-selective agar. Full-thickness wounds (n=24) were created and evenly divided into three groups: control wounds (exposed to bacteria but untreated, n=8); wounds treated with Compound 1 (n=8), and wounds treated with Compound 2 (n=8). All wounds were dressed and monitored for one hour and 24 hours. RESULTS After one hour, the wounds treated with Compound 1 and Compound 2 had a mean recoverable total bacteria of 2.8 log colony forming units (CFUs) and 3.5 logCFUs, respectively. After one hour, the wounds treated with Compound 1 and Compound 2 had a mean recoverable MRSA of 2.3 logCFUs and 1.6 logCFUs, respectively (p=0.009). After one hour, the wounds treated with Compound 1 and Compound 2 had a mean recoverable Pseudomonas aeruginosa of 0.3 logCFUs and 0.0 logCFUs, respectively (p=0.000). After 24 hours of exposure to Compound 1 and Compound 2, there was no statistically significant increased necrosis (p=0.12, p=0.31, respectively) or neutrophilic infiltrate (Compound 2, p=0.12) when compared with control wounds. CONCLUSION The novel activated-zinc compound used in this study demonstrated a 99.5-99.9% reduction in total bacteria, a 99.9-99.98% reduction in MRSA, and 100% eradication of Pseudomonas aeruginosa one hour after exposure. This novel solution may provide another significant tool to treat and/or prevent wound infections.
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Affiliation(s)
- Derek L Hill
- Michigan State University College of Osteopathic Medicine Hill Orthopedics, US
| | - Cody Pinger
- Institute for Quantitative Health Science and Engineering Michigan State University, US
| | - Erica L Noland
- Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine, Michigan State University, US
| | - Kevin Morton
- Ascension Macomb-Oakland, Michigan State University College of Osteopathic Medicine, US
| | | | | | | | | | - Ahmed Siddiqi
- Cleveland Clinic Foundation, Orthopaedic and Rheumatologic Institute, Cleveland, OH, US
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Patel A, Oladipo VA, Kerzner B, McGlothlin JD, Levine BR. A Retrospective Review of Relative Value Units in Revision Total Knee Arthroplasty: A Dichotomy Between Surgical Complexity and Reimbursement. J Arthroplasty 2022; 37:S44-S49. [PMID: 35304033 DOI: 10.1016/j.arth.2022.02.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/08/2022] [Accepted: 02/09/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Revision total knee arthroplasties (TKA) are costly, time-intensive, and technically demanding procedures. There are concerns regarding the valuation of Current Procedural Terminology (CPT) codes and the assigned relative value units (RVU) as a potential disincentive to perform revision TKAs. This study evaluated the labor and time investment for each component-specific revision and assessed the disparities between procedural value billed and reimbursement. METHODS A retrospective review of 154 primary and revision TKA cases were thoroughly vetted using operative notes and internal billing data. Revision TKAs were stratified by single femoral component, single tibial component, polyethylene liner only, all-component, and spacer placement for prosthetic infection. Operative time, RVUs billed, total charges, deductions, and reimbursements were recorded. Mann-Whitney U tests compared final reimbursement per minute and per RVU between revision and primary TKAs. RESULTS There were 28 primary TKAs, 11 femoral component revisions, 25 tibial component revisions, 25 liner exchanges, 37 all-component revisions, and 28 spacer placements. Revisions involving the tibial component, all-components, and placement of spacers were reimbursed less dollars per minute than primary TKAs (P < .05). Controlling for RVUs, liner exchanges and all-component revisions had fewer dollars per RVU than primary TKAs (P < .05). CONCLUSION As revision complexity increases, physicians face less reimbursement per minute and per RVU. With reductions set by CMS and private insurers, revisions may be financially unfavorable and lead to restrictions and access to care problems. Our data supports the need for reevaluating RVU allocation amongst revision procedures with potential updates to the CPT coding system.
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Affiliation(s)
- Arpan Patel
- Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | - Victoria A Oladipo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Benjamin Kerzner
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | | | - Brett R Levine
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Kreulen RT, Raad M, Musharbash FN, Nayar SK, Best MJ, Puvanesarajah V, Marrache M, Srikumaran U, Wilckens JH. Factors associated with RVU generation in common sports medicine procedures. PHYSICIAN SPORTSMED 2022; 50:233-238. [PMID: 33751911 DOI: 10.1080/00913847.2021.1907258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Relative value units (RVUs) are integral to the U.S. physician compensation system used by the Centers for Medicare & Medicaid Services. The use of 'work RVUs' (herein, wRVUs) is intended to reimburse physicians according to the amount of expertise and effort needed to safely and effectively perform a procedure. Our purpose was to determine: 1) the number of wRVUs/hour generated by common sports medicine surgical procedures; and 2) how patient characteristics, surgical approach, and practice setting are associated with the number of wRVUs/hour. This analysis was performed to infer whether wRVUs are assigned appropriately according to the factors on which they are purported to be based. METHODS We queried the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database for common sports medicine surgical procedures performed in 2018. Data from 19,877 patients (8,258 women) with a mean age of 48 years (range, 18-90) who underwent a surgical sports medicine procedure were analyzed. Work RVUs and operative time were used to calculate work RVUs/hour for each surgical procedure. Univariate and multivariate analyses were used to assess correlations between patient characteristics and wRVUs/hour. RESULTS Knee chondroplasty generated the most mean (± standard deviation) wRVUs/hour at 22 ± 0.5, whereas 'open tenodesis of biceps tendon, long head' generated the least at 9.6 ± 0.25 wRVUs/hour. Factors associated with a greater mean number of wRVUs/hour were younger patient age, female sex, arthroscopic approach, and outpatient setting. Arthroscopic procedures also generated more wRVUs/hour than the same procedures performed through an open approach. wRVUs were not correlated with case complexity or surgical time. CONCLUSION wRVUs/hour in surgical sports medicine procedures vary widely depending on the procedure type, patient characteristics, surgical approach, and practice setting.
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Affiliation(s)
- R Timothy Kreulen
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Farah N Musharbash
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Suresh K Nayar
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Best
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Majd Marrache
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John H Wilckens
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Forootan S, Hajebrahimi S, Janati A, Najafi B, Asghari-Jafarabadi M. Development of a local model for measuring the work of surgeons. Turk J Surg 2021; 37:371-378. [DOI: 10.47717/turkjsurg.2021.5473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/08/2021] [Indexed: 11/23/2022]
Abstract
Objective: The Relative Value Unit (RVU) is the main method of calculating surgeons’ reimbursements and a tool for measuring the work of surgeons. Existing evidence shows that the work Relative Value Unit (wRVU) does not accurately represent surgeon’s work. Therefore, the current study attempted to develop a local model to measure surgeons’ work.
Material and Methods: This study was conducted in two main phases of determining the metrics and model development using quantitative and qualitative approaches from December 2019 to April 2021. Literature review, focused group discussions, and interviews were used to collect data. Con- tent analysis and Exploratory Data Analysis techniques were applied to analyze data.
Results: The findings demonstrated that patient’s conditions (age, severity of disease at referring time, and comorbidities), disease specifications (time, complexity, physical effort, and risk), and provider characteristic (surgeon’s willingness, imposed stress, and surgeon’s skill) were important by 17, 51, and 32%, respectively, in determining surgeons’ work.
Conclusion: Determining a fixed value for each procedure does not accurately estimate the amount of required surgeon’s work for any procedure. Many factors, such as the patient’s condition, surgeon’s characteristics, and disease specification affect surgeons’ work in the operation room. Proper measurement of the surgeon’s work is an important step towards establishing equity in payment in the health system.
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Cooper AM, Connolly K, Penna S, Parvizi J. Evaluation and Management of a Painful Knee After Total Knee Arthroplasty. Orthopedics 2021; 44:341-352. [PMID: 34618636 DOI: 10.3928/01477447-20211001-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pain after total knee arthroplasty (TKA) is not infrequent and may be indicative of a broad spectrum of prosthesis-related, intra-articular, or extra-articular pathologies. To diagnose and treat the underlying cause of a painful TKA, systematic evaluation of the patient is critical to ensure that they are managed appropriately and expeditiously. This evidence-based review presents current concepts regarding the pathophysiology, etiology, and diagnosis of painful TKA and our recommended approach for management. [Orthopedics. 2021;44(6):341-352.].
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Li Z, Sun X, Li W, Zhang M. Tranexamic Acid versus Epsilon-Aminocaproic Acid in Total Knee Arthroplasty: A Meta-Analysis. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:1758066. [PMID: 34777729 PMCID: PMC8580677 DOI: 10.1155/2021/1758066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/20/2021] [Indexed: 11/30/2022]
Abstract
Objective At present, the effect of tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA) on total knee arthroplasty (TKA) remains controversial. Therefore, the aim of this meta-analysis is to compare the differences between the effects of TXA and EACA in TKA. Methods We used electronic databases, including PubMed, Embase, MEDLINE, Ovid, ScienceDirect, Cochran Library, Google Scholar, clinical trial, and Chinese related databases, for literature search to find any effect of TXA and EACA in TKA. The differences between groups were compared by odds ratio (OR), weighted mean difference (WMD), and 95% confidence interval (CI). A total of four studies, including 3 randomized controlled trials (RCT) and 1 cohort study, were involved in this meta-analysis, involving 1836 participants. Among these participants, 816 belonged to the TXA group and 1020 belonged to the EACA group. Results Meta-analysis indicated no difference in surgery time (WMD = 0.01, 95% CI -0.35 to 0.36), total amount of blood loss (WMD = 0.14, 95% CI -0.09 to 0.37), transfusion rate (OR = 0.74, 95% CI 0.20 to 2.78), transfusion units per patient (SMD = -0.15, 95% CI -0.54 to 0.25), complications (OR = 0.75, 95% CI 0.37 to 1.55), and length of stay (SMD = -0.01, 95% CI -0.11 to 0.08). Conclusions Our results suggest that the effect of TXA is not superior to EACA in TKA. However, this conclusion still needs to be further confirmed by multicenter and large-sample clinical trials.
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Affiliation(s)
- Zhihui Li
- Department of Trauma Center, Huaihe Hospital of Henan University, Kaifeng 475000, China
| | - Xiaotong Sun
- Department of Trauma Orthopedics, Zaozhuang Municipal Hospital, No. 41 Longtou Road, Zaozhuang City, Shandong Province, China
| | - Weihua Li
- Department of Trauma Center, Huaihe Hospital of Henan University, Kaifeng 475000, China
| | - Minghui Zhang
- Department of Trauma Center, Huaihe Hospital of Henan University, Kaifeng 475000, China
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Scuderi GR. Dealing with the Challenge of Revision Total Knee Arthroplasty. J Knee Surg 2021; 34:1379-1381. [PMID: 34719012 DOI: 10.1055/s-0041-1735161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Dai WL, Lin ZM, Shi ZJ, Wang J. Outcomes following Revision Total Knee Arthroplasty Septic versus Aseptic Failure: A National Propensity-Score-Matched Comparison. J Knee Surg 2021; 34:1227-1236. [PMID: 32131097 DOI: 10.1055/s-0040-1702187] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although periprosthetic joint infection (PJI) has been hypothesized to increase the risk of complications following revision total knee arthroplasty (TKA), strong evidence linking the two is lacking. The aim of this study was to determine whether PJI is an independent risk factor for inpatient perioperative complications, and increased resource use in patients undergoing revision TKA. We relied on the US Nationwide Inpatient Sample (NIS) to identify patients with PJI or non-PJI treated with revision TKA between 2002 and 2014. Overall, 5,316 (16.4%) and 27,033 (83.6%) patients were categorized as PJI and non-PJI, respectively. To adjust for potential baseline differences between the two groups, propensity-score-based matching was performed. This resulted in 5,187 (50%) PJI patients matched to 5,187 (50%) non-PJI patients. The rates of postoperative complications, blood transfusions, prolonged length of stay (pLOS), in-hospital cost, and in-hospital mortality were assessed for both groups. Multivariable logistic regression analyses were performed within the cohort after propensity-score matching. For PJI versus non-PJI, respectively, the following rates were recorded: blood transfusions, 28.3 versus 18.4% (p < 0.0001); postoperative complications, 27.5 versus 19.8% (p < 0.0001); pLOS (>4 d), 61.9 versus 26.9% (p < 0.0001); in-hospital cost (>$39,929), 55.8 versus 44.2% (p < 0.0001); in-hospital mortality, 0.6 versus 0.3% (p = 0.016). In multivariable logistic regression analyses, PJI patients were more likely to receive a blood transfusion (odds ratio [OR]: 1.78; p < 0.0001), to experience postoperative complications (OR: 1.56; p < 0.0001), to have a higher in-hospital cost (OR: 1.65; p < 0.0001), to have a pLOS following surgery following surgery (OR: 4.69; p < 0.0001), and to have a higher in-hospital mortality (OR: 2.14; p = 0.019). After adjustment for potential selection biases, PJI is associated with more adverse perioperative outcomes and resource use than non-PJI patients. This is a Level II (level of evidence), prognostic study.
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Affiliation(s)
- Wen-Li Dai
- Department of Orthopedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Ze-Ming Lin
- Department of Orthopedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Zhan-Jun Shi
- Department of Orthopedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Jian Wang
- Department of Orthopedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
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Okafor C, Hodgkinson B, Nghiem S, Vertullo C, Byrnes J. Cost of septic and aseptic revision total knee arthroplasty: a systematic review. BMC Musculoskelet Disord 2021; 22:706. [PMID: 34407779 PMCID: PMC8371784 DOI: 10.1186/s12891-021-04597-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The increasing incidence of primary total knee arthroplasty (TKA) has led to an increase in both the incidence and the cost burden of revision TKA procedures. This study aimed to review the literature on the cost of revision TKA for septic and aseptic causes and to identify the major cost components contributing to the cost burden. METHODS We searched MEDLINE (OvidSp), Embase, Web of Science, Cochrane Library, EconLit, and Google Scholar to identify relevant studies. Selection, data extraction and assessment of the risk of bias and cost transparency within the studies were conducted by two independent reviewers, after which the cost data were analysed narratively for 1- or 2-stage septic revision without re-revision; 2-stage septic revision with re-revision; and aseptic revision with and without re-revision, respectively. The major cost components identified in the respective studies were also reported. RESULTS The direct medical cost from the healthcare provider perspective for high-income countries for 2-stage septic revision with re-revision ranged from US$66,629 to US$81,938, which can be about 2.5 times the cost of 1- or 2-stage septic revision without re-revision, (range: US$24,027 - US$38,109), which can be about double the cost of aseptic revision without re-revision (range: US$13,910 - US$29,213). The major cost components were the perioperative cost (33%), prosthesis cost (28%), and hospital ward stay cost (22%). CONCLUSIONS Septic TKA revision with re-revision for periprosthetic joint infection (PJI) increases the cost burden of revision TKA by 4 times when compared to aseptic single-stage revision and by 2.5 times when compared to septic TKA revision that does not undergo re-revision. Cost reductions can be achieved by reducing the number of primary TKA that develop PJI, avoidance of re-revisions for PJI, and reduction in the length of stay after revision. TRIAL REGISTRATION PROSPERO; CRD42020171988 .
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Affiliation(s)
- Charles Okafor
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, 170 Kessels Road, Nathan, Queensland, 4111, Australia.
- Menzies Health Institute, Griffith University, Gold Coast, Queensland, Australia.
| | - Brent Hodgkinson
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, 170 Kessels Road, Nathan, Queensland, 4111, Australia
- Menzies Health Institute, Griffith University, Gold Coast, Queensland, Australia
| | - Son Nghiem
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, 170 Kessels Road, Nathan, Queensland, 4111, Australia
- Menzies Health Institute, Griffith University, Gold Coast, Queensland, Australia
| | - Christopher Vertullo
- Menzies Health Institute, Griffith University, Gold Coast, Queensland, Australia
- Knee Research Australia, Gold Coast, Queensland, Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, 170 Kessels Road, Nathan, Queensland, 4111, Australia
- Menzies Health Institute, Griffith University, Gold Coast, Queensland, Australia
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Acuña AJ, Jella TK, Samuel LT, Schwarzkopf R, Fehring TK, Kamath AF. Inflation-Adjusted Medicare Reimbursement for Revision Hip Arthroplasty: Study Showing Significant Decrease from 2002 to 2019. J Bone Joint Surg Am 2021; 103:1212-1219. [PMID: 33764932 DOI: 10.2106/jbjs.20.01643] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Investigations into reimbursement trends for primary and revision arthroplasty procedures have demonstrated a steady decline over the past several years. Revision total hip arthroplasty (rTHA) due to infection (rTHA-I) has been associated with higher resource utilization and complexity, but long-term inflation-adjusted data have yet to be compared between rTHA-I and rTHA due to aseptic complications (rTHA-A). The present study was performed to analyze temporal reimbursement trends regarding rTHA-I procedures compared with those for rTHA-A procedures. METHODS The Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule Look-Up Tool was used to extract Medicare reimbursements associated with 1-stage and 2-stage rTHA-I as well as 1-stage rTHA-A procedures from 2002 to 2019. Current Procedural Terminology (CPT) codes for rTHA were grouped according to the American Academy of Orthopaedic Surgeons coding reference guide. Monetary values were adjusted for inflation using the consumer price index (U.S. Bureau of Labor Statistics; reported as 2019 U.S. dollars) and used to calculate the cumulative and average annual percent changes in reimbursement. RESULTS Following inflation adjustment, the physician fee reimbursement for rTHA-A decreased by a mean [and standard deviation] of 27.26% ± 3.57% (from $2,209.11 in 2002 to $1,603.20 in 2019) for femoral component revision, 27.41% ± 3.57% (from $2,130.55 to $1,542.91) for acetabular component revision, and 27.50% ± 2.56% (from $2,775.53 to $2,007.61) for both-component revision. Similarly, for a 2-stage rTHA-I, the mean reimbursement declined by 18.74% ± 3.87% (from $2,063.36 in 2002 to $1,673.36 in 2019) and 24.45% ± 3.69% (from $2,328.79 to $1,755.45) for the explantation and reimplantation stages, respectively. The total decline in physician fee reimbursement for rTHA-I ($1,020.64 ± $233.72) was significantly greater than that for rTHA-A ($580.72 ± $107.22; p < 0.00001). CONCLUSIONS Our study demonstrated a consistent devaluation of both rTHA-I and rTHA-A procedures from 2002 to 2019, with a larger deficit seen for rTHA-I. A continuation of this trend could create substantial disincentives for physicians to perform such procedures and limit access to care at the population level. LEVEL OF EVIDENCE Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander J Acuña
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Tarun K Jella
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Linsen T Samuel
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ran Schwarzkopf
- Hospital for Joint Diseases, New York University Langone Orthopedic Hospital, New York, NY
| | | | - Atul F Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Okafor CE, Nghiem S, Vertullo C, Byrnes J. Cost of Revision Total Knee Replacement: A Protocol for Systematic Review and Meta-Analysis. PHARMACOECONOMICS - OPEN 2021; 5:331-337. [PMID: 33237525 PMCID: PMC8160044 DOI: 10.1007/s41669-020-00242-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 11/09/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND A major limitation of total knee replacement (TKR), as with other joint replacements, is the risk of revision. Revision TKR is associated with high risk and economic burden to patients, healthcare providers, and societies. It will be worthwhile to assess the economic burden of revision TKR across countries or different study settings. This study aims to review the literature on the cost of revision TKR to assess costs across countries and studies, estimate a pooled cost estimate for homogenous data, and identify major cost components that contribute to the cost burden. METHODS We will conduct a search of the MEDLINE (OvidSp), EMBASE, Web of Science, Cochrane Library, EconLit, and Google Scholar databases to identify relevant studies, and will use an optimally designed search approach to search for relevant studies. EndNote library will be used to manage the searched studies. Selection will be undertaken in two phases-screening and eligibility. Study selection, data extraction, and assessment of the risk of bias will be performed in duplicate, after which the data will be analysed narratively and a meta-analysis performed for homogenous studies, if possible. DISCUSSION This protocol provides a proposed stepwise plan for conducting a systematic review and meta-analysis of the cost of revision TKR. Findings from this systematic review will provide information about the cost across settings and identify the major cost drivers of revision TKR, which will, in turn, stimulate efforts to minimize the cost. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020171988.
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Affiliation(s)
- Charles Ebuka Okafor
- Centre for Applied Health Economics, School of Medicine, Griffith University, 170 Kessels Road, Nathan, QLD, 4111, Australia.
- Menzies Health Institute, Gold Coast, QLD, Australia.
| | - Son Nghiem
- Centre for Applied Health Economics, School of Medicine, Griffith University, 170 Kessels Road, Nathan, QLD, 4111, Australia
- Menzies Health Institute, Gold Coast, QLD, Australia
| | - Christopher Vertullo
- Menzies Health Institute, Gold Coast, QLD, Australia
- Orthopaedic Surgery and Sports Medicine Centre, Gold Coast, QLD, Australia
- Knee Research Australia, Gold Coast, QLD, Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, School of Medicine, Griffith University, 170 Kessels Road, Nathan, QLD, 4111, Australia
- Menzies Health Institute, Gold Coast, QLD, Australia
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23
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Jella TK, Acuña AJ, Samuel LT, Schwarzkopf R, Fehring TK, Kamath AF. Medicare Physician Fee Reimbursement for Revision Total Knee Arthroplasty Has Not Kept Up with Inflation from 2002 to 2019. J Bone Joint Surg Am 2021; 103:778-785. [PMID: 33269896 DOI: 10.2106/jbjs.20.01034] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND As orthopaedic physician fees continue to come under scrutiny by the U.S. Centers for Medicare & Medicaid Services (CMS), there is a continued need to evaluate trends in reimbursement rates across contemporary time intervals. Although substantially lower work relative value units (RVUs) have been previously demonstrated for septic revision total knee arthroplasty (TKA) compared with aseptic revisions, to our knowledge, there has been no corresponding analysis comparing total physician fees. Therefore, the purpose of our study was to analyze temporal trends in Medicare physician fees for septic and aseptic revision TKAs. METHODS Current Procedural Terminology (CPT) codes related to septic 1-stage and 2-stage revision TKAs and aseptic revision TKAs were categorized. From 2002 to 2019, the facility rates of physician fees associated with each CPT code were obtained from the CMS Physician Fee Schedule Look-Up Tool. Monetary data from Medicare Administrative Contractors at 85 locations were used to calculate nationally representative means. All total physician fee values were adjusted for inflation and were translated to 2019 U.S. dollars using Consumer Price Index data from the U.S. Bureau of Labor Statistics. Cumulative annual percentage changes and compound annual growth rates (CAGRs) were computed utilizing adjusted physician fee data. RESULTS After adjusting for inflation, the total mean Medicare reimbursement (and standard deviation) for aseptic revision TKA decreased 24.83% ± 3.65% for 2-component revision and 24.21% ± 3.68% for 1-component revision. The mean septic revision TKA total Medicare reimbursement declined 23.29% ± 3.73% for explantation and 33.47% ± 3.24% for reimplantation. Both the dollar amount (p < 0.0001) and the percentage (p < 0.0001) of the total Medicare reimbursement decline for septic revision TKA were significantly greater than the decline for aseptic revision TKA. CONCLUSIONS Septic revision TKAs have been devalued at a rate greater than their aseptic counterparts over the past 2 decades. Coupled with our findings, the increased resource utilization of septic revision TKAs may result in financial barriers for physicians and subsequently may reduce access to care for patients with periprosthetic joint infections. CLINICAL RELEVANCE The devaluation of revision TKAs may result in reduced patient access to infection management at facilities unable to bear the financial burden of these procedures.
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Affiliation(s)
- Tarun K Jella
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alexander J Acuña
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Linsen T Samuel
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, New York University Langone Health Medical Center, New York, NY
| | | | - Atul F Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Petrie MJ, Harrison TP, Salih S, Gordon A, Hamer AJ, Buckley SC, Kerry RM. Financial analysis of revision knee surgery at a tertiary referral centre as classified according to the Revision Knee Complexity Classification (RKCC). Knee 2021; 29:469-477. [PMID: 33744694 DOI: 10.1016/j.knee.2021.02.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/13/2021] [Accepted: 02/22/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Revision total knee arthroplasty (rTKA) can be complex, with greater costs to the treating hospital than primary TKA. A rTKA regional network has been proposed in England. The aim of this work was to accurately quantify current costs and reimbursement for the rTKA service and to assess whether costs are proportional to case complexity at a tertiary referral centre within the National Health Service (NHS). METHODS A review of all rTKA performed at our institution over two consecutive financial years (2017-2019) was performed. Cases were classified according to the Revision Knee Complexity Classification (RKCC) and by mode of failure; "infected" and "non-infected". Financial data was acquired through Patient-Level Information and Costing System (PLICS). The primary outcome was the financial difference between tariff and cost per episode. Comparisons between groups were analysed using analysis of variance and two-tailed unpaired t-test as appropriate. RESULTS 159 patients underwent 188 rTKA procedures. Length of stay and cost significantly increased between complexity groups (p < 0.0001) and for infected revisions (p < 0.0001). All groups sustained a mean deficit but this significantly increased with revision complexity (from £1,903 to £5,269 per case) and for infected revisions. The total deficit to the Trust for the two-year rTKA service was £667,091. CONCLUSIONS The current level of NHS reimbursement are inadequate for centres that offer rTKA and should be more closely aligned to case complexity. An increase in the most complex rTKA at major revision centres will undoubtedly place an even greater strain on the finances of these units.
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Affiliation(s)
- M J Petrie
- Lower Limb Arthroplasty Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield S5 7AU, United Kingdom.
| | - T P Harrison
- Lower Limb Arthroplasty Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield S5 7AU, United Kingdom
| | - S Salih
- Lower Limb Arthroplasty Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield S5 7AU, United Kingdom
| | - A Gordon
- Lower Limb Arthroplasty Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield S5 7AU, United Kingdom
| | - A J Hamer
- Lower Limb Arthroplasty Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield S5 7AU, United Kingdom
| | - S C Buckley
- Lower Limb Arthroplasty Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield S5 7AU, United Kingdom
| | - R M Kerry
- Lower Limb Arthroplasty Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield S5 7AU, United Kingdom
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25
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Yao JJ, Hevesi M, Visscher SL, Ransom JE, Lewallen DG, Berry DJ, Maradit Kremers H. Direct Inpatient Medical Costs of Operative Treatment of Periprosthetic Hip and Knee Infections Are Twofold Higher Than Those of Aseptic Revisions. J Bone Joint Surg Am 2021; 103:312-318. [PMID: 33252589 PMCID: PMC8327701 DOI: 10.2106/jbjs.20.00550] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periprosthetic joint infections (PJIs) following total hip arthroplasty (THA) and total knee arthroplasty (TKA) are associated with substantial morbidity. A better understanding of the costs of PJI treatment can inform prevention, treatment, and reimbursement strategies. The purpose of the present study was to describe direct inpatient medical costs associated with the treatment of hip and knee PJI. METHODS At a single tertiary care institution, 176 hips and 266 knees that underwent 2-stage revisions for the treatment of PJI from 2009 to 2015 were compared with 1,611 hips and 1,276 knees that underwent revisions for aseptic indications. In addition, 84 hips and 137 knees that underwent irrigation and debridement (I&D) with partial component exchange were compared with 39 hips and 138 knees that underwent partial component exchange for aseptic indications. Line-item details of services billed during hospitalization were retrieved, and standardized direct medical costs were calculated in 2018 inflation-adjusted dollars. RESULTS The mean direct medical cost of 2-stage revision THA performed for the treatment of PJI was significantly higher than that of aseptic revision THA ($58,369 compared with $22,846, p < 0.001). Similarly, the cost of 2-stage revision TKA performed for the treatment of PJI was significantly higher than that of aseptic revision TKA ($56,900 compared with $24,630, p < 0.001). Even when the total costs of aseptic revisions were doubled for a representative comparison with 2-stage procedures, the costs of PJI procedures were 15% to 28% higher than those of the doubled costs of aseptic revisions (p < 0.001). The mean direct medical cost of I&D procedures for PJI was about twofold higher than of partial component exchange for aseptic indications. CONCLUSIONS The direct medical costs of operative treatment of PJI following THA and TKA are twofold higher than the costs of similar aseptic revisions. The high economic burden of PJI warrants efforts to reduce the incidence of PJI. Reimbursement schemes should account for the high costs of treating PJI in order to ensure sustainable patient care. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jie J Yao
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Mario Hevesi
- Departments of Orthopedic Surgery (M.H., D.G.L., D.J.B., and H.M.K.) and Health Sciences Research (S.L.V., J.E.R., and H.M.K.), Mayo Clinic, Rochester, Minnesota
| | - Sue L Visscher
- Departments of Orthopedic Surgery (M.H., D.G.L., D.J.B., and H.M.K.) and Health Sciences Research (S.L.V., J.E.R., and H.M.K.), Mayo Clinic, Rochester, Minnesota
| | - Jeanine E Ransom
- Departments of Orthopedic Surgery (M.H., D.G.L., D.J.B., and H.M.K.) and Health Sciences Research (S.L.V., J.E.R., and H.M.K.), Mayo Clinic, Rochester, Minnesota
| | - David G Lewallen
- Departments of Orthopedic Surgery (M.H., D.G.L., D.J.B., and H.M.K.) and Health Sciences Research (S.L.V., J.E.R., and H.M.K.), Mayo Clinic, Rochester, Minnesota
| | - Daniel J Berry
- Departments of Orthopedic Surgery (M.H., D.G.L., D.J.B., and H.M.K.) and Health Sciences Research (S.L.V., J.E.R., and H.M.K.), Mayo Clinic, Rochester, Minnesota
| | - Hilal Maradit Kremers
- Departments of Orthopedic Surgery (M.H., D.G.L., D.J.B., and H.M.K.) and Health Sciences Research (S.L.V., J.E.R., and H.M.K.), Mayo Clinic, Rochester, Minnesota
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26
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Toner E, Khaled A, Ramesh A, Qureshi MK, Al Suyyagh K, Dunkow P. Financial Impact of Inaccurate Coding Plus Cost-Effectiveness Analysis for Surgically Managed Patients With Periprosthetic Fractures. Cureus 2021; 13:e13060. [PMID: 33680602 PMCID: PMC7929546 DOI: 10.7759/cureus.13060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background An upward trend is seen in a number of periprosthetic fractures. Their management often requires complex surgical intervention, expert skills and expensive equipment. Hospitals get paid according to Healthcare Resource Group (HRG) tariffs. HRG gets generated once diagnoses, Charlson comorbidity (CC) index score, surgical procedures, investigations and length of stay have been coded for. Coding departments consist of non-clinicians. Although auditing systems are in and made of internal and external auditors, we hypothesized that multiple errors can still occur which may result in significant financial losses. Objectives To assess the accuracy of coding for management of periprosthetic fractures. To identify causes for inaccurate coding and assess the financial impact of highly complex trauma in a district general hospital (DGH). Methods Retrospective comparative analysis of case notes for patients with an M966 diagnosis code (periprosthetic fracture) between 1st November 2017 and 1st November 2018. All cases were analysed and data for primary procedure, primary diagnosis, secondary procedures and secondary diagnosis, comorbidities and length of stay were extrapolated and re-coded using the same software in use by the coding team. Costs incurred for each surgically managed patient were calculated using a rough estimate of cost of each procedure. Finally, cost-effectiveness analysis was carried out by comparing our calculated figures to the actual final claim by our institution. Results Twenty-nine patients with the diagnosis of periprosthetic fracture were identified by the coding team using M966 code. A further case was identified by reviewing operating software (Operating Room Management Information System [ORMIS®]). In four cases (13.3 %), the primary diagnosis was coded incorrectly by the coding team. Overall coders accuracy for surgically managed patients (n=21) was 52% (n=11). This resulted in an estimated incurred loss of £25,000. Wrong/omitted site of surgery was found to be the most influential coder error with up to £8000 loss in one case (P<0.05). Cost-effectiveness analysis demonstrated the stark differences in costs for HRG tariffs when used in trauma setting vs non-trauma setting. Open reduction and internal fixation (ORIF) was associated with less financial loss to our trust with closer procedural costs to HRG tariff (average cost of £9200 for ORIF vs £22,030 for a massive endoprosthesis). Conclusions Surgeons should carefully review codes for such complex procedures before or soon after surgery. Wrong/omitted site of surgery is the key cause for losses in our cohort, followed by inadequate recording of comorbidities. Coders can only code for what is documented. Following cost-effectiveness analysis our study highlights the need for HRG tariffs to be revised for such procedures. The cost of ORIF vs massive endoprosthesis should be noted, signifying the implant costs when such specialised revision surgery performed over less expensive ORIF surgery.
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Affiliation(s)
- Ethan Toner
- Trauma and Orthopaedics, Royal Victoria Hospital, Belfast, GBR
| | - Ahmad Khaled
- Trauma and Orthopaedics, Blackpool Victoria Hospital, Blackpool, GBR
| | - Ashwanth Ramesh
- Trauma and Orthopaedics, Lancaster General Hospital, Lancaster, GBR
| | - Mobeen K Qureshi
- Trauma and Orthopaedics, Blackpool Victoria Hospital, Blackpool, GBR
| | | | - Paul Dunkow
- Trauma and Orthopaedics, Blackpool Victoria Hospital, Blackpool, GBR
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27
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The projected volume of primary and revision total knee arthroplasty will place an immense burden on future health care systems over the next 30 years. Knee Surg Sports Traumatol Arthrosc 2021; 29:3287-3298. [PMID: 32671435 PMCID: PMC7362328 DOI: 10.1007/s00167-020-06154-7] [Citation(s) in RCA: 124] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/10/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE Total knee arthroplasty (TKA) rates have increased substantially in the recent decades worldwide, with Germany being one of the leading countries in the prevalence of TKA. The aim of this study was to provide an overview of treatment changes during the last decade and to project the expected burden of primary and revision TKA (rTKA) for the next 30 years. METHODS Comprehensive nationwide data from Germany was used to quantify primary and revision TKA rates as a function of age and gender. Projections were performed with use of a Poisson regression models and a combination of exponential smoothing and autoregressive integrated moving average models on historical procedure rates in relation to official population projections from 2020 to 2050. RESULTS The incidence rate of primary TKAs is projected to increase by around 43% to 299 per 100,000 inhabitants [95% CI 231-368], leading to a projected total number of 225,957 primary TKAs in 2050 (95% CI 178,804-276,442). This increase has been related to a growing number of TKA performed in male patients, with the highest increase modelled in patients between 50 and 65 years of age. At the same time, the annual total number of revision procedures is forecast to increase even more rapidly by almost 90%, accounting for 47,313 (95% CI 15,741-78,885; IR = 62.7 per 100,000, 95% CI 20.8-104.5) procedures by 2050. Those numbers are primarily associated with a rising number of rTKAs secondary to periprosthetic joint infection (PJI). CONCLUSIONS Using this country- specific forecast approach, a rising number of primary TKA and an even more rapidly growing number of rTKA, especially for PJI, has been projected until 2050, which will inevitably provide a huge challenge for the future health care system. As many other industrialized nations will face similar demographic and procedure-specific developments, these forecasts should be alarming for many health care systems worldwide and emphasize the tremendous need for an appropriate financial and human resource management in the future. LEVEL OF EVIDENCE Level III, prognostic study, economic and decision analysis.
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28
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Waterson HB, Baker P. The scale of the problem. Knee 2020; 27:1664-1666. [PMID: 32917492 DOI: 10.1016/j.knee.2020.07.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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29
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Güngör E, Başarır K, Binnet MS. A retrospective comparison of costs for the primary and revision total knee arthroplasty in Turkey. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:541-545. [PMID: 33155567 DOI: 10.5152/j.aott.2020.19114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aimed to compare the cost profiles of patients who underwent a primary or revision total knee arthroplasty (TKA) and to determine the effects of the length of hospital stay, comorbidities, and septic and aseptic revision rates on the treatment costs. METHODS A total of 1,487 patients who underwent primary (n=1,328; 1,131 females, 197 males) or revision TKA (n=159; 137 females, 22 males) between 2010 and 2017 at our institution were retrospectively included in the current study. The patients' demographics (age and gender), the length of hospital stay, comorbidities, and septic and aseptic revision rates were collected from our hospital database. The total costs of revision and primary TKAs were calculated based on the prostheses and surgical equipment used, hospital stay, and other administrative costs in both the Turkish lira (TRY) and US dollar (USD) based on the parity of the 2 currencies from 2010 to 2017. RESULTS The average cost per patient for primary TKAs was 7,985±2,927 TRY (5,265 USD) in 2010 and 7,070±1,775 TRY (1,852 USD) in 2017. The average cost for revision TKAs was 13,647±4,095 TRY (8,999 USD) in 2010 and 22,806±6,155 TRY (5,973 USD) in 2017. In terms of the total costs, significant differences existed over the years, with a significantly higher difference in 2015 compared with that from 2010 to 2013 (p<0.001); however, no difference was determined among the age groups (p=0.675). The difference between the total costs of the septic (n=34; 17,964±13,028 TRY) and aseptic revisions (n=125; 23,377±12,815 TRY) was significant (p=0.001), with a higher cost for patients with septic TKAs but with no significant difference between the total costs for the patients with and without comorbidities (p=0.254). Additionally, the length of hospital stay was 2 times higher in patients with revision TKAs than in those with primary TKAs (12.3 vs 6.2 days). CONCLUSION Revision TKAs cause higher costs than primary TKAs, with a prolonged hospital stay. The septic background seems to be an independent predictive factor for increased costs in revision TKAs.
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Affiliation(s)
- Erdal Güngör
- Department of Orthopaedic and Traumatology, Ankara University, İbn-i Sina Hospital, Ankara, Turkey
| | - Kerem Başarır
- Department of Orthopaedic and Traumatology, Ankara University, İbn-i Sina Hospital, Ankara, Turkey
| | - Mehmet Serdar Binnet
- Department of Orthopaedic and Traumatology, Ankara University, İbn-i Sina Hospital, Ankara, Turkey
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30
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Fassihi SC, Gu A, Perim DA, Wei C, Stake S, Thakkar S, Unger AS, Ast MP, Sculco PK. Chronic preoperative corticosteroid use is not associated with surgical site infection following revision total knee arthroplasty. J Orthop 2020; 20:173-176. [PMID: 32025143 PMCID: PMC6997114 DOI: 10.1016/j.jor.2020.01.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 01/25/2020] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION The objective of this study was to determine whether chronic preoperative corticosteroid use is associated with increased infectious complications following revision total knee arthroplasty (rTKA). METHODS A retrospective cohort analysis was conducted using patients from a large national database. Patients were divided into two cohorts based upon chronic steroid usage preoperatively. Infectious complications in the 30-day postoperative period were recorded, and univariate and multivariate analyses were performed. RESULTS A total of 10,973 patients were included in this study. No significant difference was observed in surgical site infection rates between patients with and without preoperative steroid use. In multivariate analysis, preoperative steroid use was independently associated with an increased likelihood of septic shock (OR 6.17; p = 0.015) and prolonged length-of-stay (OR 1.57; p = 0.038). CONCLUSION Chronic preoperative steroid is not a significant risk factor for surgical site infection following rTKA, but it is independently associated with increased risk of septic shock and prolonged hospital length of stay.
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Affiliation(s)
- Safa C. Fassihi
- Department of Orthopedic Surgery, George Washington School of Medicine and Health Sciences, 2300 Eye St NW, Washington DC, 20037, USA
| | - Alex Gu
- Department of Orthopedic Surgery, George Washington School of Medicine and Health Sciences, 2300 Eye St NW, Washington DC, 20037, USA
- Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 E 70th St, New York City, NY, 10021, USA
| | - Dana A. Perim
- Department of Orthopedic Surgery, George Washington School of Medicine and Health Sciences, 2300 Eye St NW, Washington DC, 20037, USA
| | - Chapman Wei
- Department of Orthopedic Surgery, George Washington School of Medicine and Health Sciences, 2300 Eye St NW, Washington DC, 20037, USA
| | - Seth Stake
- Department of Orthopedic Surgery, George Washington School of Medicine and Health Sciences, 2300 Eye St NW, Washington DC, 20037, USA
| | - Savyasachi Thakkar
- Department of Orthopaedic Surgery, MedStar Georgetown Orthopaedic Institute at Washington Hospital Center, 110 Irving St NW, Washington DC, 20010, USA
| | - Anthony S. Unger
- Gildenhorn Institute of Bone and Joint Health, Sibley Memorial Hospital, 5255 Loughboro Road NW, Washington, DC, 20016, USA
| | - Michael P. Ast
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, 535 E 70th St, New York City, NY, 10021, USA
| | - Peter K. Sculco
- Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 E 70th St, New York City, NY, 10021, USA
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Samuel LT, Grits D, Acuña AJ, Piuzzi NS, Higuera-Rueda CA, Kamath AF. Work Relative Value Units Do Not Adequately Support the Burden of Infection Management in Revision Knee Arthroplasty. J Bone Joint Surg Am 2020; 102:230-236. [PMID: 31609889 DOI: 10.2106/jbjs.19.00776] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Revision total knee arthroplasty for infection is challenging. Septic revisions, whether 1-stage or 2-stage, may require more time and effort than comparable aseptic revisions. However, the burden of infection may not be reflected by the relative value units (RVUs) assigned to septic revision compared with aseptic revision. The purposes of this study were to compare the RVUs of aseptic and septic revision total knee arthroplasties and to calculate the RVU per minute for work effort. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was analyzed for the years 2006 to 2017. The Current Procedural Terminology (CPT) code 27487 and the International Classification of Diseases, Ninth Revision (ICD-9) code 996.XX, excluding 996.6X, were used to identify all aseptic revision total knee arthroplasties (n = 12,907). The CPT code 27487 and the ICD-9 code 996.6X were used to determine all 1-stage septic revision total knee arthroplasties (n = 891). The CPT codes 27488 and 11981 were used to identify the first stage of a 2-stage revision (n = 293). The CPT codes 27447 and 11982 were used to identify the second stage of a 2-stage revision (n = 279). After 4:1 propensity score matching, 274 cases were identified per septic cohort (aseptic single-stage: n = 1,096). The RVU-to-dollar conversion factor was provided by the U.S. Centers for Medicare & Medicaid Services (CMS), and RVU dollar valuations were calculated. RESULTS The septic second-stage revision was used as the control group for comparisons. The RVU per minute for the aseptic 2-component revision was 0.215, from a mean operative time of 148.95 minutes. The RVU per minute for the septic, 2-component, 1-stage revision was 0.199, from a mean operative time of 160.6 minutes. For septic, 2-stage revisions, the first-stage RVU per minute was 0.157, from a mean operative time of 138.1 minutes. The second-stage RVU per minute was 0.144, from a mean operative time of 170.0 minutes. Two-component aseptic revision total knee arthroplasty was valued the highest. CONCLUSIONS Despite the increased complexity and worse postoperative outcomes associated with revision total knee arthroplasties for infection, the current physician reimbursement does not account for these challenges. This inadequate compensation may discourage providers from performing these operations and, in turn, make it more difficult for patients with periprosthetic joint infection to receive the necessary treatment. Therefore, the CPT code revaluation may be warranted for these procedures.
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Affiliation(s)
- Linsen T Samuel
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Daniel Grits
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Alexander J Acuña
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Atul F Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Babu S, Al-Obaidi B, Jardine A, Jonas S, Al-Hadithy N, Satish V. A comparative study of 5 different antibiotic prophylaxis regimes in 4500 total knee replacements. J Clin Orthop Trauma 2020; 11:108-112. [PMID: 32001996 PMCID: PMC6985026 DOI: 10.1016/j.jcot.2018.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 12/03/2018] [Accepted: 12/13/2018] [Indexed: 11/24/2022] Open
Abstract
AIM To compare the incidence of surgical site infection with different antibiotic regimes in elective total knee arthroplasty. We hypothesise that a single high dose of Teicoplanin and Gentamicin is as effective as other regimes. METHODS A retrospective study of prospectively collected data on a total of 4500 elective knee replacements over a 9-year period was conducted in a district general hospital. Data were collected on antibiotic regime, patient characteristics, infection (treatment, infective agents, sensitivities) and complications. RESULTS Five different antibiotic regimes that have been used in elective knee arthroplasty were identified in our institution. 40 patients in total were identified who had a deep infection. Rates of deep surgical site infection were not significantly different between the five groups (p = 0.83). CONCLUSION A single pre-operative dose of Teicoplanin and Gentamicin has similar efficacy of prophylaxis to other regimes for patients undergoing primary elective total knee replacements. We recommend the choice of prophylaxis regimen is made locally based on pathogen virulence, drug resistance and cost.
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Affiliation(s)
- Satish Babu
- Frimley Park Hospital, UK,Corresponding author. Frimley Park Hospital, Portsmouth Road, Frimley, GU16 7UJ, UK.
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Jiang N, Wu HT, Lin QR, Hu YJ, Yu B. Health Care Costs of Post-traumatic Osteomyelitis in China: Current Situation and Influencing Factors. J Surg Res 2019; 247:356-363. [PMID: 31679801 DOI: 10.1016/j.jss.2019.10.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 08/04/2019] [Accepted: 10/01/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Currently, very limited information is available regarding the economic burdens of patients with extremity post-traumatic osteomyelitis (OM). This study aimed to investigate direct health care costs and utilization for inpatients with extremity post-traumatic OM and analyze its constituent ratios and influencing factors in Southern China. METHODS We searched in the electronic medical record system for inpatients who had received surgical interventions at our department between 2013 and 2016 for extremity post-traumatic OM. Data of direct health care costs incurred during their hospitalizations were collected in six main categories (service, diagnosis, treatment, materials, pharmaceuticals, and miscellaneous expenses). In addition, data of total medical costs for contemporaneous inpatients with non-post-traumatic OM were also collected as controls. RESULTS A total of 278 post-traumatic OM and 10,420 controls were included. The median cost for the post-traumatic OM inpatients was $10,504 US dollars, 4.8-fold higher than that for those with non-post-traumatic OM ($2189, P < 0.001). The direct cost in the category of materials accounted for the largest proportion (61%), followed by that in pharmaceuticals (12%) and treatment (11%). The median number of hospital admissions for post-traumatic OM patients was 1 time, with a median length-of-stay of 22 d. The most influencing factors for the health care costs of the post-traumatic OM inpatients were use of an external fixator ($16,016 for those who used versus $4956 for those who did not, P < 0.001), external fixator type ($19,563 for ring fixator versus $14,966 for rail fixator, P < 0.001), infection site ($13,755 for tibia, $14,216 for femur and $5673 for calcaneus, P < 0.001), and infection-associated injury type ($12,890 for infection after open fracture versus $8087 for infection after closed fracture, P = 0.001). CONCLUSIONS An unexpectedly large proportion of the direct health care costs for inpatients with extremity post-traumatic OM went to cover an external fixator, with expenses for pharmaceuticals and treatment accounting for only a little more than the tenth of the total health care costs. Use of external fixator, external fixator type, infection site, and infection-associated injury type directly influenced the health care costs.
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Affiliation(s)
- Nan Jiang
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Hang-Tian Wu
- Guangdong Provincial Key Laboratory of Bone & Cartilage Regenerative Medicine, Southern Medical University, Guangzhou, P.R. China
| | - Qing-Rong Lin
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Yan-Jun Hu
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Bin Yu
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China; Guangdong Provincial Key Laboratory of Bone & Cartilage Regenerative Medicine, Southern Medical University, Guangzhou, P.R. China.
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Consensus on Reducing Risk in Total Joint Arthroplasty: Revision Surgery. Tech Orthop 2019. [DOI: 10.1097/bto.0000000000000395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gabor JA, Padilla JA, Feng JE, Anoushiravani AA, Slover J, Schwarzkopf R. A dedicated revision total knee service: a surgeon’s perspective. Bone Joint J 2019; 101-B:675-681. [PMID: 31154839 DOI: 10.1302/0301-620x.101b6.bjj-2018-1504.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Revision total knee arthroplasty (rTKA) accounts for approximately 5% to 10% of all TKAs. Although the complexity of these procedures is well recognized, few investigators have evaluated the cost and value-added with the implementation of a dedicated revision arthroplasty service. The aim of the present study is to compare and contrast surgeon productivity in several differing models of activity. MATERIALS AND METHODS All patients that underwent primary or revision TKA from January 2016 to June 2018 were included as the primary source of data. All rTKA patients were categorized by the number of components revised (e.g. liner exchange, two or more components). Three models were used to assess the potential surgical productivity of a dedicated rTKA service : 1) work relative value unit (RVU) versus mean surgical time; 2) primary TKA with a single operating theatre (OT) versus rTKA with a single OT; and 3) primary TKA with two OTs versus rTKA with a single OT. RESULTS In total, 4570 procedures were performed: 4128 primary TKAs, 51 TKA liner exchanges, and 391 full rTKAs. Surgical time was significantly different between the primary TKA, liner exchange, and rTKA cohorts (100.6, 97.1, and 141.7 minutes, respectively; p < 0.001). Primary TKA yielded a mean of 7.1% more RVU/min per procedure than rTKA. Our one-OT model demonstrated that primary TKA (n = 4) had a 1.9% RVU/day advantage over rTKA (n = 3). If two OTs are used for primary TKA (n = 6), the outcome strongly favours primary TKA by an added 34.6% RVUs/day. CONCLUSION Our results suggest that a dedicated rTKA service would lead to lower surgeon remuneration based on the current RVU paradigm. Revision arthroplasty specialists may need additional or alternative incentives to promote the development of a dedicated revision service. Through such an approach, healthcare organizations could enhance the quality of care provided, but surgeon productivity measures would need to be adjusted to reflect the burden of these cases. Cite this article: Bone Joint J 2019;101-B:675-681.
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Affiliation(s)
- J A Gabor
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - J A Padilla
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - J E Feng
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - A A Anoushiravani
- Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York, USA
| | - J Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
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Agarwal S, Kabariti R, Kakar R, Lopez D, Morgan-Jones R. Why are revision knee replacements failing? Knee 2019; 26:774-778. [PMID: 31078394 DOI: 10.1016/j.knee.2019.04.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 02/17/2019] [Accepted: 04/16/2019] [Indexed: 02/02/2023]
Abstract
AIM The number of knee revisions worldwide has been steadily increasing. While being complex and expensive operations, a high percentage of knee revisions fail early. This study was conducted to evaluate the causes of failure of revision knee replacements. PATIENTS AND METHODS This study retrospectively evaluated 95 patients following knee revision surgery and who underwent further knee revision operations. Indications for index revision as well as the reason for re-revision were recorded. Follow-up was from 30 to 97 months (mean 62 months). RESULTS The main cause of failure of revision knee replacements was infection (31 of 95, 32.6%) followed by aseptic loosening (30.5%). Indications for re-revision were instability in 12.6%, persistent stiffness in 10.5%, ongoing pain in 7.3%, extensor mechanism problems in 5.2%, and suspected metal allergy in one. CONCLUSION Infection and loosening continue to be the main reasons for failure of knee revisions. Improving outcomes for infection management and improved fixation methods may help reduce failed knee revisions.
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Kohlhof H, Köhring S, Wirtz DC, Witte H. Force plates may be used for dynamic analyses of endoprostheses explantation procedures. BIOMED ENG-BIOMED TE 2019; 64:243-245. [PMID: 29498932 DOI: 10.1515/bmt-2017-0152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 10/04/2017] [Indexed: 11/15/2022]
Abstract
The number of hip and knee arthroplasty replacement surgeries is increasing steadily. In combination with demographic aging and the number of periprosthetic complications, this development has lead to the phenomenon where the need for revision surgery is rising. The problem is, that, while implantation procedures of hip arthroplasties are more or less standardized, explantation is a non-standardized task for experienced specialists, due to the unpredictability of the adequate loosening method. The surgeon often only gets to decide on which tools and methods may be applied to detach the prosthesis, only after getting access to the operation site. The time taken to detach the prosthesis is hardly predictable and mainly depends on the surgeons' skills. To gain objective data on the mechanics of explantation, new measurement methods are required. One technical base for studies on revision procedures are standard force plates, available in biomechanics laboratories.
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Affiliation(s)
- Hendrik Kohlhof
- Rheinische Friedrich-Wilhelm-Universität Bonn, Orthopädische Universitätsklinik, D-53111 Bonn, Germany
| | - Sebastian Köhring
- Technische Universität Ilmenau, Fachgebiet Biomechatronik, D-98693 Ilmenau, Germany
| | - Dieter Christian Wirtz
- Rheinische Friedrich-Wilhelm-Universität Bonn, Orthopädische Universitätsklinik, D-53111 Bonn, Germany
| | - Hartmut Witte
- Technische Universität Ilmenau, Fachgebiet Biomechatronik, D-98693 Ilmenau, Germany
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Puhto T, Puhto AP, Vielma M, Syrjälä H. Infection triples the cost of a primary joint arthroplasty. Infect Dis (Lond) 2019; 51:348-355. [DOI: 10.1080/23744235.2019.1572219] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Teija Puhto
- Department of Operative Care, Department of Infection Control, Oulu University Hospital, Finland
- Oulu University Hospital, Oulu, Finland
| | - Ari-Pekka Puhto
- Department of Operative Care, Division of Orthopaedic and Trauma Surgery, Oulu University Hospital, Oulu, Finland
| | | | - Hannu Syrjälä
- Department of Operative Care, Department of Infection Control, Oulu University Hospital, Finland
- Oulu University Hospital, Oulu, Finland
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Phillips JRA, Al-Mouazzen L, Morgan-Jones R, Murray JR, Porteous AJ, Toms AD. Revision knee complexity classification-RKCC: a common-sense guide for surgeons to support regional clinical networking in revision knee surgery. Knee Surg Sports Traumatol Arthrosc 2019; 27:1011-1017. [PMID: 30850881 DOI: 10.1007/s00167-019-05462-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 03/04/2019] [Indexed: 01/18/2023]
Abstract
PURPOSE There is considerable variation in practice throughout Europe in both the services provided and in the outcomes of Revision Knee Surgery. In the UK, a recent report published called get it right first time (GIRFT) aims to improve patient outcomes through providing high quality, cost-effective care, and reducing complications. This has led to the development of a classification system that attempts to classify the complexity of revision knee surgery, aiming to encourage and support regional clinical networking. METHODS The revision knee classification system (RKCC) incorporates not only complexity, but also patient factors, the presence of infection, the integrity of the extensor mechanism, and the soft tissues. It then provides guidance for clinical network discussion. Reliability and reproducibility testing have been performed to establish the inter- and intra-observer variabilities using this classification. RESULTS Good correlation between first attempt non-expert and experts, good intra-observer variability of non-expert, and an excellent correlation between second attempt non-expert and experts has been achieved. This supports the use of RKCC by both inexperienced and experienced surgeons. CONCLUSIONS The revision knee complexity classification has been proposed that offers a common-sense approach to recognize the increasing complexity in revision TKR cases. It provides a methodological assessment of revision knee cases and support regional clinical networking and triage of appropriate cases to revision units or specialist centres. LEVEL OF EVIDENCE Expert opinion, Level V.
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Affiliation(s)
- J R A Phillips
- Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Barrack Road, Exeter, UK.
| | - L Al-Mouazzen
- Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol, UK
| | | | - J R Murray
- Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol, UK
| | - A J Porteous
- Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol, UK
| | - A D Toms
- Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Barrack Road, Exeter, UK
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Abstract
BACKGROUND There has been a gradual increase in the revision TKA (RTKA) workload due to expanding indications of total knee arthroplasty (TKA), coupled with improving patient longevity. Western countries are already looking at their data on RTKA to plan for the future heath care needs of these patients. Limited data is available on RTKA from developing countries. Our study attempts to fill this gap in knowledge. MATERIALS AND METHODS We prospectively documented details of all RTKA performed at our centre for a period of six years (2011-16). We recorded the volume, causes and time to failure from index surgery of all RTKA and further recorded microbiological pattern in septic failures. We looked at the proportion of each cause of failure and time from index surgery. RESULTS Of the 5068 TKA procedures performed from January 2011 to December 2016, 201 (4%) were first-time revisions. The predominant cause of revisions was prosthetic infection (61%) followed by aseptic loosening (18%) and instability (7%). In the early, mid term, and late-failure groups, prosthetic infection remained the main cause of failure. In 47% of the septic revisions, the offending organisms could be identified and of those identified most (67%) were Gram-negative. CONCLUSION The volume of first-time RTKA procedures (4%) at our center remained low compared with that of the Western countries. In Western countries, the incidence of late aseptic failures was higher than that of early-septic failures, whereas in our study, revisions were more commonly performed in the early-failure group (48%) and most failures were due to prosthetic infection (61%).
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Affiliation(s)
- Vikas Kulshrestha
- Joint Replacement Centre, Army Hospital Research and Referral, New Delhi, India
| | - Barun Datta
- Joint Replacement Centre, Army Hospital Research and Referral, New Delhi, India,Address for correspondence: Dr. Barun Datta, Joint Replacement Centre, Army Hospital Research and Referral, Delhi Cantt, New Delhi - 110 010, India. E-mail:
| | - Gaurav Mittal
- Joint Replacement Centre, Army Hospital Research and Referral, New Delhi, India
| | - Santhosh Kumar
- Joint Replacement Centre, Army Hospital Research and Referral, New Delhi, India
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Roche M, Law TY, Sultan AA, Umpierrez E, Khlopas A, Rosas S, Kurowicki J, Wang K, Mont MA. Racial Disparities in Revision Total Knee Arthroplasty: Analysis of 125,901 Patients in National US Private Payer Database. J Racial Ethn Health Disparities 2018; 6:101-109. [DOI: 10.1007/s40615-018-0504-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/05/2018] [Accepted: 05/31/2018] [Indexed: 02/04/2023]
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Elbuluk AM, Old AB, Bosco JA, Schwarzkopf R, Iorio R. Strategies for reducing implant costs in the revision total knee arthroplasty episode of care. Arthroplast Today 2017; 3:286-288. [PMID: 29204498 PMCID: PMC5712020 DOI: 10.1016/j.artd.2017.03.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 03/02/2017] [Accepted: 03/10/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Implant price has been identified as a significant contributing factor to high costs associated with revision total knee arthroplasty (rTKA). The goal of this study is to analyze the cost of implants used in rTKAs and to compare this pricing with 2 alternative pricing models. METHODS Using our institutional database, we identified 52 patients from January 1, 2014 to December 31, 2014. Average cost of components for each case was calculated and compared to the total hospital cost for that admission. Costs for an all-component revision were then compared to a proposed "direct to hospital" (DTH) standardized pricing model and a fixed price revision option. Potential savings were calculated from these figures. RESULTS On average, 28% of the total hospital cost was spent on implants for rTKA. The average cost for revision of all components was $13,640 and ranged from $3000 to $28,000. On average, this represented 32.7% of the total hospital cost. Direct to hospital implant pricing could potentially save approximately $7000 per rTKA, and the fixed pricing model could provide a further $1000 reduction per rTKA-potentially saving $8000 per case on implants alone. CONCLUSIONS Alternative implant pricing models could help lower the total cost of rTKA, which would allow hospitals to achieve significant cost containment.
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Affiliation(s)
| | | | | | | | - Richard Iorio
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY, USA
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Redfern RE, Cameron-Ruetz C, O'Drobinak SK, Chen JT, Beer KJ. Closed Incision Negative Pressure Therapy Effects on Postoperative Infection and Surgical Site Complication After Total Hip and Knee Arthroplasty. J Arthroplasty 2017; 32:3333-3339. [PMID: 28705547 DOI: 10.1016/j.arth.2017.06.019] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 05/22/2017] [Accepted: 06/08/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The aim of this study is to determine whether negative pressure wound therapy, used prophylactically in clean surgical incisions, reduces surgical site infection, hematoma, and seroma after total joint replacement. METHODS A single center, open-label study with a prospective cohort of patients undergoing primary total knee arthroplasty or total hip arthroplasty treated with closed incision negative pressure therapy (ciNPT) of clean surgical wounds was conducted. One hundred ninety-six incisions treated with ciNPT in 192 patients were compared with a historical control group of 400 patients treated with traditional gauze dressing. The rates of clinically significant hematoma, seroma, dehiscence, surgical site infection, and complication were compared using univariate analyses and multiple logistic regression. RESULTS The rate of deep infection was unchanged in the ciNPT group compared with control (1.0% vs 1.25%); however, the overall rate of infection (including superficial wound infection) decreased significantly (3.5% vs 1.0%, P = .04). Overall complication rate was lower in the ciNPT group than controls (1.5% vs 5.5%, P = .02). Upon logistic regression, only treatment group was associated with complication; patients treated with ciNPT were about 4 times less likely to experience a surgical site complication compared with control (P = .0277, odds ratio 4.251, 95% confidence interval 1.172-15.414). CONCLUSION ciNPT for total knee arthroplasty and total hip arthroplasty in a comprehensive patient population reduced overall incidence of complication, but did not significantly impact the rate of deep infection. Further research to determine clinical and economic advantages of routine use of ciNPT in total joint arthroplasty is warranted.
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Affiliation(s)
| | | | - Simone K O'Drobinak
- Department of Orthopedic Surgery, Wildwood Orthopedic and Spine Institute, ProMedica Toledo Hospital, Toledo, Ohio
| | - John T Chen
- Department of Mathematics and Statistics, Bowling Green State University, Bowling Green, Ohio
| | - Karl J Beer
- Department of Orthopedic Surgery, Wildwood Orthopedic and Spine Institute, ProMedica Toledo Hospital, Toledo, Ohio
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Haddad FS, Ngu A, Negus JJ. Prosthetic Joint Infections and Cost Analysis? ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 971:93-100. [PMID: 28321829 DOI: 10.1007/5584_2016_155] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Prosthetic joint infection is a devastating complication of arthroplasty surgery that can lead to debilitating morbidity for the patient and significant expense for the healthcare system. With the continual rise of arthroplasty cases worldwide every year, the revision load for infection is becoming a greater financial burden on healthcare budgets. Prevention of infection has to be the key to reducing this burden. For treatment, it is critical for us to collect quality data that can guide future management strategies to minimise healthcare costs and morbidity / mortality for patients. There has been a management shift in many countries to a less expensive 1-stage strategy and in selective cases to the use of debridement, antibiotics and implant retention. These appear very attractive options on many levels, not least cost. However, with a consensus on the definition of joint infection only clarified in 2011, there is still the need for high quality cost analysis data to be collected on how the use of these different methods could impact the healthcare expenditure of countries around the world. With a projected spend on revision for infection at US$1.62 billion in the US alone, this data is vital and urgently needed.
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Affiliation(s)
- F S Haddad
- University College London Hospitals, Euston road, London, NW1 2BU, UK
| | - A Ngu
- University College London Hospitals, Euston road, London, NW1 2BU, UK
| | - J J Negus
- University College London Hospitals, Euston road, London, NW1 2BU, UK.
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Son WS, Shon OJ, Lee DC, Park SJ, Yang HS. Efficacy of Open Debridement and Polyethylene Exchange in Strictly Selected Patients with Infection after Total Knee Arthroplasty. Knee Surg Relat Res 2017; 29:172-179. [PMID: 28854762 PMCID: PMC5596396 DOI: 10.5792/ksrr.16.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 12/21/2016] [Accepted: 01/02/2017] [Indexed: 12/14/2022] Open
Abstract
Purpose To assess the efficacy of open debridement and polyethylene exchange (ODPE) combined with proper antibiotic therapy in strictly selected patients with infection after total knee arthroplasty (TKA) and analyze factors associated with treatment failure. Materials and Methods From January 2010 to January 2014, 25 cases that underwent ODPE under the diagnosis of infection within four weeks after TKA or acute hematogenous infection within five days of symptom onset were reviewed in this study. Results Treatment was successful in 22 out of 25 cases (88.0%). Factors associated with failure were accompanying infection (periprosthetic infection in the ipsilateral foot, cervical parotid abscess, and masticator space abscess) and diagnosis of rheumatoid arthritis (RA) before TKA. Resistant bacteria did not entail a risk. On clinical results, the mean postoperative Lysholm score and Korean Knee score were 81.4 and 79.4, respectively, the knee range of motion was 115.4°±12.9°, and duration of hospitalization was 32.3±8.4 days. On radiographic results, 3.47±1.56 mm joint line elevation and a valgus change of 0.61°±2.35° in knee alignment were observed. Conclusions ODPE combined with appropriate antibiotics therapy could be a useful treatment method for infection after TKA if the procedure is performed within a symptom duration of five days or less in the absence of accompanying infection in patients whose indication for TKA was not RA.
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Affiliation(s)
- Whee Sung Son
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Daegu, Korea
| | - Oog-Jin Shon
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Daegu, Korea
| | - Dong-Chul Lee
- Department of Orthopedic Surgery, Bo Gang Hospital, Daegu, Korea
| | - Sang-Jin Park
- Department of Anesthesia, Yeungnam University Medical Center, Daegu, Korea
| | - Han Seok Yang
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Daegu, Korea
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Delanois RE, Mistry JB, Gwam CU, Mohamed NS, Choksi US, Mont MA. Current Epidemiology of Revision Total Knee Arthroplasty in the United States. J Arthroplasty 2017; 32:2663-2668. [PMID: 28456561 DOI: 10.1016/j.arth.2017.03.066] [Citation(s) in RCA: 344] [Impact Index Per Article: 49.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/27/2017] [Accepted: 03/28/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Revision surgery for failed total knee arthroplasty (TKA) continues to pose a substantial burden for the United States healthcare system. The predominant etiology of TKA failure has changed over time and may vary between studies. This report aims to update the current literature on this topic by using a large national database. Specifically, we analyzed: (1) etiologies for revision TKA; (2) frequencies of revision TKA procedures; (3) various demographics including payer type and region; and (4) the length of stay (LOS) and total charges based on type of revision TKA procedure. METHODS The Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) database was used to identify all revision TKA procedures performed between 2009 and 2013. Clinical, economic, and demographic data were collected and analyzed for 337,597 procedures. Patients were stratified according to etiology of failure, age, sex, race, US census region, and primary payor class. The mean LOS and total charges were also calculated. RESULTS Infection was the most common etiology for revision TKA (20.4%), closely followed by mechanical loosening (20.3%). The most common revision TKA procedure performed was all component revision (31.3%). Medicare was the primary payor for the greatest proportion of revisions (57.7%). The South census region performed the most revision TKAs (33.2%). The overall mean LOS was 4.5 days, with arthrotomy for removal of prosthesis without replacement procedures accounting for the longest stays (7.8 days). The mean total charge for revision TKAs was $75,028.07. CONCLUSION Without appropriate measures in place, the burden of revision TKAs may become overwhelming and pose a strain on providers and institutions. Continued insight into the etiology and epidemiology of revision TKAs may be the principle step towards improving outcomes and mitigating the need for future revisions.
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Affiliation(s)
- Ronald E Delanois
- Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Jaydev B Mistry
- Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Chukwuweike U Gwam
- Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Nequesha S Mohamed
- Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Ujval S Choksi
- Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Hassan N, McCarville K, Morinaga K, Mengatto CM, Langfelder P, Hokugo A, Tahara Y, Colwell CS, Nishimura I. Titanium biomaterials with complex surfaces induced aberrant peripheral circadian rhythms in bone marrow mesenchymal stromal cells. PLoS One 2017; 12:e0183359. [PMID: 28817668 PMCID: PMC5560683 DOI: 10.1371/journal.pone.0183359] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 08/02/2017] [Indexed: 01/08/2023] Open
Abstract
Circadian rhythms maintain a high level of homeostasis through internal feed-forward and -backward regulation by core molecules. In this study, we report the highly unusual peripheral circadian rhythm of bone marrow mesenchymal stromal cells (BMSCs) induced by titanium-based biomaterials with complex surface modifications (Ti biomaterial) commonly used for dental and orthopedic implants. When cultured on Ti biomaterials, human BMSCs suppressed circadian PER1 expression patterns, while NPAS2 was uniquely upregulated. The Ti biomaterials, which reduced Per1 expression and upregulated Npas2, were further examined with BMSCs harvested from Per1::luc transgenic rats. Next, we addressed the regulatory relationship between Per1 and Npas2 using BMSCs from Npas2 knockout mice. The Npas2 knockout mutation did not rescue the Ti biomaterial-induced Per1 suppression and did not affect Per2, Per3, Bmal1 and Clock expression, suggesting that the Ti biomaterial-induced Npas2 overexpression was likely an independent phenomenon. Previously, vitamin D deficiency was reported to interfere with Ti biomaterial osseointegration. The present study demonstrated that vitamin D supplementation significantly increased Per1::luc expression in BMSCs, though the presence of Ti biomaterials only moderately affected the suppressed Per1::luc expression. Available in vivo microarray data from femurs exposed to Ti biomaterials in vitamin D-deficient rats were evaluated by weighted gene co-expression network analysis. A large co-expression network containing Npas2, Bmal1, and Vdr was observed to form with the Ti biomaterials, which was disintegrated by vitamin D deficiency. Thus, the aberrant BMSC peripheral circadian rhythm may be essential for the integration of Ti biomaterials into bone.
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Affiliation(s)
- Nathaniel Hassan
- Weintraub Center for Reconstructive Biotechnology, UCLA School of Dentistry, Los Angeles, California, United States of America
- Division of Oral Biology & Medicine, UCLA School of Dentistry, Los Angeles, California, United States of America
| | - Kirstin McCarville
- Weintraub Center for Reconstructive Biotechnology, UCLA School of Dentistry, Los Angeles, California, United States of America
- Division of Oral Biology & Medicine, UCLA School of Dentistry, Los Angeles, California, United States of America
- Division of Advanced Prosthodontics, UCLA School of Dentistry, Los Angeles, California, United States of America
| | - Kenzo Morinaga
- Weintraub Center for Reconstructive Biotechnology, UCLA School of Dentistry, Los Angeles, California, United States of America
- Division of Advanced Prosthodontics, UCLA School of Dentistry, Los Angeles, California, United States of America
- Department of Oral Rehabilitation, Section of Oral Implantology, Fukuoka Dental College, Fukuoka, Japan
| | - Cristiane M. Mengatto
- Weintraub Center for Reconstructive Biotechnology, UCLA School of Dentistry, Los Angeles, California, United States of America
- Department of Conservative Dentistry, School of Dentistry Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Peter Langfelder
- Department of Human Genetics, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Akishige Hokugo
- Weintraub Center for Reconstructive Biotechnology, UCLA School of Dentistry, Los Angeles, California, United States of America
- Division of Plastic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Yu Tahara
- Department of Psychiatry & Biobehavioral Science, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Christopher S. Colwell
- Department of Psychiatry & Biobehavioral Science, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Ichiro Nishimura
- Weintraub Center for Reconstructive Biotechnology, UCLA School of Dentistry, Los Angeles, California, United States of America
- Division of Oral Biology & Medicine, UCLA School of Dentistry, Los Angeles, California, United States of America
- Division of Advanced Prosthodontics, UCLA School of Dentistry, Los Angeles, California, United States of America
- * E-mail:
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48
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Leary JT, Werger MM, Broach WH, Shaw LN, Santoni BG, Bernasek TL, Lyons ST. Complete Eradication of Biofilm From Orthopedic Materials. J Arthroplasty 2017; 32:2513-2518. [PMID: 28434696 DOI: 10.1016/j.arth.2017.03.050] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 03/13/2017] [Accepted: 03/21/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Interest exists in finding alternatives to current management strategies in periprosthetic joint infections, which typically include a 2-stage revision with placement of an antibiotic spacer and delayed placement of a new implant. We studied the efficacy of autoclaving, ultrasonication, and mechanical scrubbing for sterilization and biofilm eradication on infected cobalt-chrome discs. METHODS Strains of Staphylococcus aureus MRSA252 or Staphylococcus epidermidis RP62A were grown on the discs. For each strain, discs were divided into 5 groups (5 discs each) and exposed to several sterilization and biofilm eradication treatments: (1) autoclave, (2) autoclave + sonication, (3) autoclave + saline scrub, (4) autoclave + 4% chlorhexidine (CHC) scrub, and (5) autoclave + sonication + CHC scrub. Sterilization and biofilm eradication were quantified with crystal violet assays and scanning electron microscopy. RESULTS Relative to nontreated controls, autoclaving alone reduced biofilm load by 33.9% and 54.7% for MRSA252 and RP62A strains, respectively. Biofilm removal was maximized with the combined treatment of autoclaving and CHC scrub for MRSA252 (100%) and RP62A (99.5%). The addition of sonication between autoclaving and CHC scrubbing resulted in no statistically significant improvement in biofilm removal. High-resolution scanning electron microscopy revealed no cells or biofilm for this combined treatment. CONCLUSION Using 2 commonly encountered bacterial strains in periprosthetic joint infection, infected cobalt-chrome discs were sterilized and eradicated of residual biofilm with a combination of autoclaving and CHC scrubbing.
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Affiliation(s)
- Jeffrey T Leary
- Adult Reconstruction, Florida Orthopaedic Institute, Tampa, Florida
| | - Matthew M Werger
- Adult Reconstruction, Florida Orthopaedic Institute, Tampa, Florida
| | - William H Broach
- Department of Cell Biology, Microbiology and Molecular Biology, University of South Florida, Tampa, Florida
| | - Lindsey N Shaw
- Department of Cell Biology, Microbiology and Molecular Biology, University of South Florida, Tampa, Florida
| | - Brandon G Santoni
- Department of Research, Foundation for Orthopaedic Research and Education, Tampa, Florida
| | | | - Steven T Lyons
- Adult Reconstruction, Florida Orthopaedic Institute, Tampa, Florida
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Williams RL, Ayre WN, Khan WS, Mehta A, Morgan-Jones R. Acetic Acid as Part of a Debridement Protocol During Revision Total Knee Arthroplasty. J Arthroplasty 2017; 32:953-957. [PMID: 27776909 DOI: 10.1016/j.arth.2016.09.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/25/2016] [Accepted: 09/06/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Thorough debridement is mandatory in revision for infected total knee arthroplasties (TKA). We investigated a novel adjuvant chemical debridement strategy using acetic acid (AA) that seeks to create a hostile environment for microorganisms. We report the first orthopedic in vivo series using an AA soak in infected TKAs. We also investigated the in vitro efficacy of AA against bacteria isolated from these knees. METHODS Twenty-three patients with infected TKA were treated with a standard debridement protocol and chemical debridement with a 20-minute AA soak. In parallel, bacteria from infected TKAs were cultured for in vitro susceptibility testing with AA solutions of different concentrations to understand its potential mechanism of action. RESULTS Intraoperatively, there were no physiological responses during the AA soak or on release of the tourniquet. Postoperatively, there was no increase in analgesic requirements or wound or soft-tissue complications. Clinical follow-up continued for 24 months to monitor recurrent infection. In vitro, zones of inhibition were formed on less than 40% of the organisms, demonstrating that AA was not directly bactericidal against the majority of the isolates. However, when cultured in a bacterial suspension, AA completely inhibited the growth of the isolates at concentrations as low as 0.19% vol/vol. CONCLUSION This study has shown that the use of 3% AA soak, as part of a debridement protocol is safe in patients. While the exact mechanism of action is yet to be determined, AA concentrations as low as 0.19% vol/vol in vitro are sufficient to completely inhibit bacterial growth.
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Affiliation(s)
- Rhodri L Williams
- Cardiff and Vale Orthopaedic Centre, University Hospital Llandough, Cardiff, United Kingdom
| | - Wayne N Ayre
- Cardiff and Vale Orthopaedic Centre, University Hospital Llandough, Cardiff, United Kingdom
| | - Wasim S Khan
- Cardiff and Vale Orthopaedic Centre, University Hospital Llandough, Cardiff, United Kingdom
| | - Amisha Mehta
- Cardiff and Vale Orthopaedic Centre, University Hospital Llandough, Cardiff, United Kingdom
| | - Rhidian Morgan-Jones
- Cardiff and Vale Orthopaedic Centre, University Hospital Llandough, Cardiff, United Kingdom
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[Surgery of sepsis in orthopedics and trauma - A highlight : Current survey by the section for bone and soft tissue infections of the German Society for Orthopedics and Trauma]. Unfallchirurg 2017; 120:262-268. [PMID: 28105482 DOI: 10.1007/s00113-017-0311-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Surgery of sepsis in trauma surgery and orthopedics is attracting increasingly more attention due to the rising presence of multidrug-resistant pathogens and the increasing number of operative interventions. Despite extensive experience over decades neither the symptoms nor the treatment strategies have been evaluated and it has become obvious that a scientific investigation of this complex topic is necessary for optimization of patient care under economically sound conditions. The aim of this article is to give a snapshot from German healthcare institutions for trauma surgery and orthopedics to answer some questions on this topic from the section for bone and soft tissue infections (SeKuWi) of the German Society for Orthopedics and Trauma (DGOU) in cooperation with the German Society for Hospital Hygiene (DGKH).
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