Outcomes following open acetabular labrum reconstruction: Comparing fresh-frozen tendon with fresh meniscus allograft transplantation

Background

Symptomatic acetabular labral insufficiency in young, active patients is often treated with labral repair or reconstruction using fresh-frozen allografts. However, fresh-frozen tendon allografts do not have tissue or material properties that closely mimic acetabular labral fibrocartilage. Recent studies suggest meniscal allografts may be a better biomechanical, geometric, and material alternative for acetabular labrum reconstruction (ALR).

Hypothesis

Patients undergoing open ALR using fresh meniscus allograft transplants (MAT) will have better outcomes than those using fresh-frozen tendon allografts transplants (TAT) when comparing initial treatment success, diagnostic imaging assessments, and patient-reported pain and function scores.

Study design

Cohort Study.

Methods

With IRB approval, patients undergoing ALR with either TAT or MAT were included when initial (>1-year) outcomes data related to treatment success, pain, and function were available. In addition, a subcohort of patients underwent magnetic resonance imaging at least 6-months after surgery to evaluate allograft healing.

Results

Initial success rate, defined as no need for ALR revision or conversion to total hip arthroplasty (THA), was 88.9% for the entire group (n = 27, TAT = 5, MAT = 22) with 1 (20%) patient in the TAT cohort and 2 patients (9.9%) in the MAT cohort undergoing THA. In the MAT cohort, significant improvements were documented for physical function and pain scores at 1 year and final follow-up (FFU)(mean 26.8 months). Improvements in pain and function were noted at 1-year, but not at FFU (mean 59.6 months) in the TAT group. MRIs completed at least 6 months after labrum reconstruction showed improved allograft integrity and integration in the MAT cohort over the TAT cohort.

Conclusion

For acetabular labrum reconstructions, MAT was associated with a higher initial success rate, superior patient reported outcomes, and subjectively better MRI findings when compared to TAT.

Accelerated versus Standard Rehabilitation after Meniscus Allograft Transplantation in the Knee

Meniscus allograft transplantation (MAT) is a proven treatment option for patients with symptomatic irreparable meniscus deficiency. When patients are adherent to prescribed postoperative restriction and rehabilitation protocols, outcomes after MAT are considered good to excellent. However, nonadherence to standard protocols is common and can be associated with undesirable outcomes and patient dissatisfaction. Based on demonstrated safety for early weight-bearing following MAT in conjunction with significant advances in graft preservation and surgical techniques, our joint preservation center implemented a shift in practice toward accelerated weight-bearing following MAT and designed this study to test the hypothesis that accelerated rehabilitation would be associated with superior adherence, patient-reported outcomes, and patient satisfaction, without diminishing patient safety, when compared with standard rehabilitation. Patients were included for analyses when they had undergone fresh or fresh-frozen MAT using a double bone plug technique for treatment of medial or lateral meniscus deficiency and had at least 1-year treatment outcomes recorded. The results of this study revealed that patients who were prescribed accelerated rehabilitation after MAT were significantly more adherent than patients who were prescribed standard rehabilitation and reported statistically significant and clinically meaningful improvements in knee pain and function for at least 1-year following MAT, whereas those in the standard cohort did not. While not statistically different, treatment failure rate was lower in the accelerated rehabilitation cohort when compared with the standard rehabilitation cohort (11 vs. 29%). Importantly, initial outcomes for revision MAT were associated with short-term success in all the patients who opted for this option in the study population. These data suggest that accelerated weight-bearing after MAT is safe, promotes patient adherence, and is associated with statistically significant and clinically meaningful improvements in patient-reported knee pain and function at early and mid-term follow-up.

Assessment of Outcomes After Multisurface Osteochondral Allograft Transplantations in the Knee

Background

Treatment of multisurface articular cartilage lesions of the knee is a challenging problem.

Hypothesis

Large multisurface cartilage defects in the knee can be successfully managed with transplantation of high chondrocyte viability osteochondral allografts (OCAs) to result in statistically significant improvements in patient-reported outcome measures of pain and function.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients were prospectively enrolled into a registry to follow outcomes after OCA transplantation. The study included patients who received OCA transplantation for multisurface unipolar defects in 1 knee and had minimum 2-year follow-up data, including patient-reported outcome measures, failures, reoperations, and complications. The OCA transplants had been stored using 2 methods: standard preservation (SP) or Missouri Osteochondral Preservation System (MOPS). Preoperative data were compared with outcomes at 1 year and final follow-up, and risk factors for revision surgery or failure (total knee arthroplasty) were analyzed.

Results

The sample included 25 patients with a mean age of 37.2 years (range, 13-51 years), body mass index of 27.7 (range, 18-38), and follow-up of 45.1 months (median, 49 months; range, 24-68 months). OCAs stored using SP were transplanted into 6 patients, and those stored using MOPS were transplanted into 19 patients. The initial success rate was significantly higher for MOPS OCAs (94.7%) than SP OCAs (33.3%). There were statistically significant improvements in all patient-reported outcomes at 1 year and final follow-up in the MOPS cohort (P < .0001 for all). Revision surgery/failure was significantly associated with patients who were nonadherent to the prescribed postoperative restrictions and rehabilitation protocols (P = .038; odds ratio = 13.5) and with OCAs that had a viable chondrocyte density <70% of the established reference range mean at transplantation (P = .0037; odds ratio = 76).

Conclusion

OCA transplantation for treatment of large multisurface cartilage defects in the knee resulted in a 94.7% initial success rate when grafts with high viable chondrocyte density (≥70%) were used and when patients strictly adhered to prescribed postoperative rehabilitation protocols. Successful outcomes were associated with statistically significant improvements in patient-reported outcome measures of pain and function.

Biologic Joint Restoration: A Translational Research Success Story

Treatment options that result in consistently successful outcomes for young and active patients with joint disorders are needed. This article summarizes two decades of rigorous research using a bedside-to-bench- to-bedside translational approach based on the One Health - One Medicine concept that culminated in successful clinical use of biologic joint restoration options for treatment of knee, hip, ankle, and shoulder problems in this growing patient population.

Financial and Work-flow Benefits of Reducing Avoidable Hospitalizations of Nursing Home Residents

OBJECTIVES

1) Explain the financial benefit of potential revenue recapture (PRR) for non-billable days due to hospitalizations of nursing home (NH) residents using a six-year longitudinal analysis of 11 of 16 NHs participating in the Missouri Quality Initiative (MOQI); and 2) Discuss the work-flow benefits of early detection of changes in health status using qualitative data from all MOQI homes.

DESIGN

A CMS funded demonstration project with full-time advanced practice registered nurses (APRN) and operations support team focused on reducing avoidable hospitalizations for long stay NH residents (2012-2020).

SETTING AND PARTICIPANTS

Setting was a sample of 11 of 16 US NHs participating in the CMS project. The NHs ranged in size between 121 and 321 beds located in urban and rural areas in one midwestern geographic region.

METHODS

Financial and occupancy data were analyzed using descriptive methods. Data are readily available from most NH financial systems and include information about short and long stay residents to calculate non-billable days due to hospitalizations. Average hospital transfer rates per 1000 resident days were used. Qualitative data collected in MOQI informed the work-flow benefits analysis.

RESULTS

There was over $2.6 million in actual revenue recapture due to hospitalization of long stay residents in the 11 participating NHs during five years, 2015-2019, with 2014 as baseline; savings to payers was more than $31 million during those same years. The PRR for both short and long stay residents combined totaled $32.5 million for six years (2014-2019); for each NH this ranged from $590,000 to over $5 million. On average, an additional $500,000 of revenue each year per 200 beds could have been recaptured by further reducing hospitalizations. Workflow improved for nurses and nursing assistants using INTERACT and focusing on early detection of health changes.

CONCLUSIONS

Reducing avoidable hospitalizations reduces costs to payers and increases revenue by substantially recapturing revenue lost each day of hospitalization.

IMPLICATIONS

Focusing nursing staff on early illness recognition and management of condition changes within NHs has benefits for residents as the stress of hospital transfer and resulting functional decline is avoided. Nurses and nursing assistants benefit from workflow improvements by focusing on early illness detection, managing most condition changes within NHs. NHs benefit financially from increased revenue by reducing empty bed days.

Longitudinal Impact of APRNs on Nursing Home Quality Measures in the Missouri Quality Initiative

OBJECTIVES

To measure the impact of advanced practice nurses (APRNs) on quality measures (QM) scores of nursing homes (NHs) in the CMS funded Missouri Quality Initiative (MOQI) that was designed to reduce avoidable hospitalizations of NH residents, improve quality of care, and reduce overall healthcare spending.

DESIGN

A four group comparative analysis of longitudinal data from September 2013 thru December 2019.

SETTING

NHs in the interventions of both Phases 1 (2012-2016) and 2 (2016-2020) of MOQI (n=16) in the St. Louis area; matched comparations in the same counties as MOQI NHs (n=27); selected Phase 2 payment intervention NHs in Missouri (n=24); NHs in the remainder of the state (n=406).

PARTICIPANTS

NHs in Missouri Intervention: Phase 1 of The Missouri Quality Initiative (MOQI), a Centers for Medicare and Medicaid (CMS) Innovations Center funded research initiative, was a multifaceted intervention in NHs in the Midwest, which embedded full-time APRNs in participating NHs to reduce hospitalizations and improve care of NH residents. Phase 2 extended the MOQI intervention in the original intervention NHs and added a CMS designed Payment Intervention; Phase 2 added a second group of NHs to receive the Payment. Intervention Only.

MEASUREMENTS

Eight QMs selected by CMS for the Initiative were falls, pressure ulcers, urinary tract infections, indwelling catheters, restraint use, activities of daily living, weight loss, and antipsychotic medication use. For each of the monthly QMs (2013 thru 2019) an unobserved components model (UCM) was fitted for comparison of groups.

RESULTS

The analysis of QMs reveals that that the MOQI Intervention + Payment group (group with the embedded APRNs) out-performed all comparison groups: matched comparison with neither intervention, Payment Intervention only, and remainder of the state.

CONCLUSION

These results confirm the QM analyses of Phase 1, that MOQI NHs with full-time APRNs are effective to improve quality of care.

Results of the Missouri Quality Initiative in Sustaining Changes in Nursing Home Care: Six-Year Trends of Reducing Hospitalizations of Nursing Home Residents

OBJECTIVES

The purpose of this article is to present six-year findings of the Missouri Quality Initiative (MOQI) to reduce unnecessary hospitalizations for long-stay nursing home residents.

DESIGN

A CMS funded demonstration project analyzed over 6-years using a single group design.

SETTING AND PARTICIPANTS

The setting was 16 Midwestern US nursing homes ranging in size between 121 and 321 beds located in urban and rural areas in one geographic region. The sample of eligible residents averaged from 1819 in 2014 to 1068 in 2019.

MEASURES

Resident data were analyzed using descriptive methods of aggregate facilities' hospital transfer rates per 1000 resident days and changes per year of average hospital transfer rates. Individual facility transfer rates were grouped by level of performance (best, mixed, and low). Leadership turnover and engagement were also described.

INTERVENTION

Full-time advanced practice registered nurses (APRN) and an operations support team focused on reducing unnecessary hospitalizations for long-stay nursing home residents.

RESULTS

Total transfers for 2014-2019 was 6913 and the average transfer rate per 1000 resident days declined from 2.48 in 2014 to a low of 1.89 in 2018 and slightly increased to 1.99 in 2019. Eleven nursing homes achieved sustained improvement, five did not. Differences in leadership turnover and engagement were noted by level of performance; however, three outlier facilities were identified.

CONCLUSIONS/IMPLICATIONS

The MOQI intervention achieved improved outcomes over six-years in the majority of nursing homes in the project. The embedded APRN's daily focus on project goals supported by a multi-disciplinary operations team facilitated success. Facility leadership stability and engagement in the project likely contributed to outcomes. Full-time presence of APRNs coupled with an operations' support team improved nursing homes outcomes, however Medicare currently restricts APRNs hired by nursing homes from billing Medicare for direct care services. This unnecessary restriction of practice discourages nursing homes from hiring APRNs and should be abolished.

Venous cannulation and topical ethyl chloride in patients receiving nitrous oxide

The purpose of this study was to evaluate the effect of ethyl chloride spray on the anxiety and pain associated with placing an intravenous catheter in patients sedated with nitrous oxide. Eighty-eight patients scheduled for dental surgery with a combination of intravenous and nitrous oxide sedation were randomly assigned to have ethyl chloride spray or a placebo, water spray, applied before cannulation of a vein. Anxiety and pain were reported using a 10.0-cm visual analog scale before nitrous oxide administration, after nitrous oxide sedation, following application of the spray, and following venous cannulation. The first 2 assessments measured overall levels of patient anxiety and pain and confirmed that nitrous oxide sedation reduced anxiety without changing already low levels of pain. The second 2 assessments of anxiety and pain measured the reaction toward the spray and cannulation. The application of ethyl chloride spray produced significantly more anxiety and pain than did the placebo. The results of this study demonstrate that ethyl chloride spray does not significantly reduce the anxiety and pain associated with venous cannulation in patients sedated with nitrous oxide.