Is Conversion TKA a Primary or Revision? Clinical Course and Complication Risks Approximating Revision TKA Rather Than Primary TKA

Impact of perioperative enhanced recovery after surgery on wound infection in patients undergoing orthopaedic surgery: A meta-analysis

The aim of this study was to evaluate the effects of perioperative application of enhanced recovery after surgery (ERAS) concepts on wound infections and post-operative complications in patients receiving orthopaedic surgery, to provide a theoretical basis for post-operative care. Randomised controlled trials (RCTs) on the application of ERAS to patients receiving orthopaedic surgery, published up to October 2023, were identified in PubMed, Web of Science, Cochrane Library, Embase, Wanfang, China Biomedical Literature Database and China National Knowledge Infrastructure databases. Literature was screened and evaluated by two reviewers based on the inclusion and exclusion criteria, and data were extracted from the final included articles. Data were analysed using RevMan 5.4 software. A total of 20 RCTs were included in the analysis, which included 1875 patients undergoing orthopaedic surgery, of whom 938 and 937 were in the ERAS and control groups, respectively. The analysis revealed that in patients undergoing orthopaedic surgery, implementation of ERAS in the perioperative period was associated with a significantly reduced the rate of wound infections (1.6% vs. 6.19%, risk ratio [RR]: 0.30, 95% confidence interval [CI]: 0.18-0.50, p < 0.001) and complication (5.12% vs. 21.88%, RR: 0.23, 95% CI: 0.17-0.32, p < 0.001) and can effectively shorten the hospital length of stay (standardised mean difference [SMD]: -2.50 days, 95% CI: -3.17 to -1.83 days, p < 0.001) compared with that of conventional care. The available evidence suggests that the implementation of ERAS in the perioperative period of patients undergoing orthopaedic surgery could effectively reduce the rate of wound infections and complications, shorten the hospital length of stay and promote the early recovery of patients.

Cartilage Restoration Prior to Primary Total Knee Arthroplasty

Cartilage restoration procedures are effective for articular defects of the knee. However, studies suggest decreased clinical improvements after total knee arthroplasty (TKA). The purpose of this study was to compare patients who had a prior cartilage restoration undergoing TKA with patients who had TKA without a prior cartilage restoration procedure. We specifically assessed (1) 90-day and 1-year medical/surgical complications; (2) 90-day and 1-year revision rates; and (3) 90-day costs. A search using a national, all-payer database examined matched cohorts of patients who underwent cartilage restoration procedures prior to TKA (n=22,072) and controls who did not (n=220,364) between January 1, 2010, and April 30, 2020. Cartilage restoration procedures included autologous chondrocyte implantation, microfracture, osteochondral autograft transfer system operations, or open and arthroscopic osteochondral allograft transplantation. Outcomes studied included lengths of stay, 30-day readmission rates, 90-day costs, and medical and surgical complications to include 90-day and 1-year prosthetic joint infections, pathologic fractures, dislocations, knee manipulations, and revisions. Comparable rates of 90-day and 1-year medical and surgical complications were found for TKAs after cartilage restoration. Additionally, 90-day and 1-year revision surgery rates were similar. These patients were also found to have 90-day costs almost identical to those of patients who did not have cartilage restoration. This large analysis of patients with cartilage restoration procedures prior to TKA demonstrated that the complication rates may be similar to those of patients who do not have these operations before TKA. These findings provide valuable information to surgeons and patients when deciding to proceed with TKA after cartilage restoration. [Orthopedics. 2023;46(4):250-255.].

Cost Analysis of Conversion Total Knee Arthroplasty: A Multi-Institutional Database Study

BACKGROUND

Total knee arthroplasty (TKA) after prior knee surgery, also known as conversion TKA (convTKA), has been associated with higher complications, resource utilization, time, and effort. The increased surgical complexity of convTKA may not be reflected by the relative value units (RVUs) assigned under the current U.S. coding guidelines. The purpose of this study was to compare the RVUs of primary TKA and convTKA and to calculate the RVU per minute to account for work effort.

METHODS

The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database was analyzed for the years 2005 to 2020. Current Procedural Terminology (CPT) code 27447 alone was used to identify patients who underwent primary TKA, and 27447 plus 20680 were used to identify convTKA. After 1:1 propensity score matching, 1,600 cases were assigned to each cohort. The 2023 Medicare Physician Fee Schedule RVU-to-dollar conversion factor from the U.S. Centers for Medicare & Medicaid Services (CMS) was used to calculate RVU dollar valuations per operative time. Complication rates were compared using a multivariate logistic regression model controlling for baseline characteristics.

RESULTS

The mean operative time for TKA was 97.8 minutes, with a corresponding RVU per minute of 0.25, while the mean operative time for convTKA was 124.3 minutes, with an RVU per minute of 0.19 (p < 0.0001). Using the conversion factor of $33.06 per RVU, this equated to $8.11 per minute for TKA versus $6.39 per minute for convTKA. ConvTKA was associated with higher overall complication (10.9% versus 6.5%, p < 0.0001), blood transfusion (6.6% versus 3.7%, p < 0.01), reoperation (2.3% versus 0.94%, p < 0.0001), and readmission (3.7% versus 1.8%, p < 0.001) rates.

CONCLUSIONS

The current billing guidelines lead to lower compensation for convTKA despite its increased complexity. The longer operative time, higher complication rate, and increased resource utilization may incentivize providers to avoid performing this operation. CPT code revaluation is warranted to reflect the time and effort associated with this procedure.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Conversion Total Knee Arthroplasty after Failed Osteochondral Allograft Reconstruction: Similar Functional Performance with Lower Patient Satisfaction

BACKGROUND

This study presents surgical techniques used in conversion total knee arthroplasty (cTKA) following early failure of large osteochondral allograft joint replacement and compares postoperative patient reported outcomes measures (PROMs) and satisfaction scores with a contemporary primary total knee arthroplasty (pTKA) cohort.

METHODS

We retrospectively evaluated 25 consecutive cTKA patients (26 procedures) to define utilized surgical techniques, radiographic disease severity, preoperative and postoperative PROMs (visual analog scale (VAS) pain, knee injury and osteoarthritis outcome score for joint replacement (KOOS-JR), University of California Los Angeles (UCLA) Activity), expected improvement and postoperative satisfaction (5-point Likert), and reoperations in comparison with an age and body mass index (BMI) propensity matched cohort of 50 pTKA performed for osteoarthritis (52 procedures).

RESULTS

Revision components were used in 12 cTKA cases (46.1%), with 4 cases requiring augmentation (15.4%), and 3 cases utilizing varus-valgus constraint (11.5%). While no significant differences were noted in expectation level or in other PROMs, mean patient reported satisfaction was lower in the conversion group (4.4 +/- 1.1 vs 4.8 +/- 0.5 points, P=0.02). High cTKA satisfaction was associated with higher postoperative KOOS-JR (84.4 vs 64.2 points, P=0.01) and trend towards higher UCLA activity (6.9 vs 5.7 points, P=0.08). Four patients in each group underwent manipulation (15.3 vs 7.6%, P=0.42), and one primary TKA patient was treated for early postoperative infection (0 vs 1.9%, P=1.0).

CONCLUSION

Conversion TKA following failed biological replacement was associated with similar postoperative improvement as in pTKA. Lower patient reported cTKA satisfaction was associated with lower postoperative KOOS-JR scores.

Is Conversion Total Knee Arthroplasty a Distinct Surgical Procedure? A Comparison to Primary and Revision Total Knee Arthroplasty

Conversion total knee arthroplasty (TKA) is suggested to incur similar complication rates to revision arthroplasties. However, current billing codes do not allow for the differentiation between this operation and primary TKAs. Therefore, the purpose of this study was to compare outcomes of these two surgeries, as well as revision TKAs. Specifically, we analyzed (1) medical complications, (2) surgical complications, and (3) revision rates at 90 days and 1 year. We queried a national, all-payer database to identify patients who underwent TKA without prior implants (n = 1,358,767), required conversion TKA (n = 15,378), and who underwent revision TKA (n = 33,966) between January 1, 2010, and April 30, 2020. Conversion TKA patients (prior implant removal) were identified using the Current Procedural Terminology (CPT) codes. Outcomes studied included 30-day readmission rates and 90-day, as well as 1-year, medical and surgical complications. Conversion TKAs had greater 30-day readmission rates and incidences of most of the complications studied when compared with primary TKAs. The majority of outcomes when comparing between primary, conversion, and revision TKAs were significantly different (p < 0.01). In contrast, conversion TKA complications were similar to revision TKA. Conversion TKAs have higher postoperative complications than primary TKAs and share more similarities with revision TKAs. Thus, the lack of billing codes differentiating conversion and primary TKAs creates a challenge for orthopaedic surgeons.