Background

The Comprehensive Care for Joint Replacement (CJR) model was implemented in April-2016 to standardize cost and improve quality of care for two of the most commonly billed inpatient procedures for Medicare patients, total knee and total hip arthroplasty. The purpose of this study is to compare one institution's predicted savings and losses under the CJR model with actual savings and losses after two years of implementation and discuss new methods to maintain savings.

Aims

We studied the impact of direct anterior (DA) versus non-anterior (NA) surgical approaches on prosthetic joint infection (PJI), and examined the impact of new perioperative protocols on PJI rates following all surgical approaches at a single institution.

Summary

Narcotic administration within the inpatient setting is highly variable any may benefit from the implementation of standardized multi-modal pain management protocols.

Introduction

Complications can be defined as preventable, potentially preventable, or non-preventable. While often discussed, there are virtually no data whether or not the most common causes of revision total hip arthroplasty (THA) are preventable or not. The goal of this study was to identify and report preventable causes of revision THA within 5 years of the index THA.

INTRODUCTION

Most total knees today are CR or PS, with lateral and medial condyles similar in shape. There is excellent durability, but a shortfall in functional outcomes compared with normals, evidenced by abnormal contact points and gait kinematics, and paradoxical sliding. However unicondylar, medial pivot, or bicruciate retaining, are preferred by patients, ascribed to AP stability or retention of anatomic structures (Pritchett; Zuiderbaan). Recently, Guided Motion knees have been shown to more closely reproduce anatomic kinematics (Walker; Willing; Amiri; Lin; Zumbrunn). As a design approach we proposed Design Criteria: reproduce the function of each anatomic stabilizing structure with bearing surfaces on the lateral and medial sides and intercondylar; resected cruciates because this is surgically preferred; avoid a cam-post because of central femur bone removal, soft tissue entrapment, noises, and damage (Pritchett; Nunley). Our hypothesis was that these criteria could produce a Guided Motion design with normal kinematics.

Introduction

Reducing readmissions after total joint arthroplasty (TJA) is challenging. Pre-operative risk stratification and optimization pre surgical care may be helpful in reducing readmission rates after primary TJA. Assessment of the predictive value of individual modifiable risk factors without a tool to properly stratify patients may not be helpful to the surgical community to reduce the risk of readmission. We developed a scoring system: Readmission Risk Assessment Tool (RRAT) as part of a Perioperative Orthopaedic Surgical Home model that allows for risk stratification in patients undergoing elective primary TJA at our institution. We analyzed the relationship between the RRAT score and readmission following primary hip or knee arthroplasty.

INTRODUCTION

The major loss of articular cartilage in medial osteoarthritis occurs in a central band on the distal femur, and in the center of the tibial plateau (Figure). This is consistent with varus deformity due to cartilage loss and meniscal degeneration, together with the sliding regions in walking. Treatment at an early stage such as KL grade 2 or 3, has the advantages of little bone deformity and cruciate preservation, and could be accomplished by resurfacing only the arthritic areas with Early Intervention (EI) components. Such components would need to be geometrically compatible with the surrounding bearing surfaces, to preserve continuity and stability. However because of the relatively small surface area covered, compared with total knees and even unicompartmentals, it is hypothesized that EI components will be an accurate fit on a population of knees with only a small number of sizes, and that accuracy can be maintained without requiring right-left components. We examined this hypothesis using unique design and methodology.

The demand for spinal surgery and its costs have both risen over the past decade. In 2008 the aggregate hospital bill for surgical care of all spinal procedures was reported to be $33.9 billion. One key driver of rising costs is spinal implants. In 2011 our institution implemented a cost containment programme for spinal implants which was designed to reduce the prices of individual spinal implants and to reduce the inter-surgeon variation in implant costs. Between February 2012 and January 2013, our spinal surgeons performed 1493 spinal procedures using implants from eight different vendors. By applying market analysis and implant cost data from the previous year, we established references prices for each individual type of spinal implant, regardless of vendor, who were required to meet these unit prices. We found that despite the complexity of spinal surgery and the initial reluctance of vendors to reduce prices, significant savings were made to the medical centre.

Cite this article: 2015; 97-B:1102–5.

In the large majority of cases of knee osteoarthritis (OA), total knee replacement (TKA) is the selected treatment, due to its proven durability, satisfactory function and familiarity of surgeons. However in recent years there has been an increase in the numbers of uni-compartmental knees used (UKA), due to more favorable follow-up, improved designs and techniques, quicker and better patient recovery, and less hospitalization costs. Designs have been produced for even lesser invasive components than UKA, including simple spacers, with mixed results. Recently, several studies have been carried out on the wear patterns on the femoral and tibial condyles in OA, showing that the main areas of cartilage loss occur on the distal end of the femur, that area engaged in walking activities, and over a large proportion of the tibial plateau. A study we carried out on the bone pieces resected at TKA surgery showed that no less than 22% of the cases could have been done with a device which resurfaced only the medial side. That figure would have been higher if the patients had been treated earlier, before cartilage wear and deformation had progressed. In a more recent study, we showed the progress of the wear of OA by analyzing MRI scans of 50 patients at various stages of OA. The cartilage wear occurred on areas which were initially the thickest on both the femur and the tibia. This was evidently associated with excessive contact stresses, while the menisci, if they had previously been spreading the load over a large area of the cartilage surfaces, were no longer functional. In this paper it is proposed that the treatment modality of OA could be carried out on a sliding scale, based on MRI analysis together with clinical factors including pain and disability. Early Intervention devices, including UKA, could be used much more frequently if the surgical technique was developed to be reliable, simple and reproducible. Specifically there is space for an Early Intervention device (EI) where only the distal end of the femur and the tibial surface are resurfaced. A design has been produced where a pocket is milled into the distal end of the femur to house a plastic runner, and a thin layer is resected from the proximal tibia for a metal plate with a special keel design. The advantages of such a design are ease of exposure, accurate and simple surgery, minimal tibial resection for long term fixation, reduced wear, and ease of restoration of the original joint line. The wear is assessed using a custom-made wear machine, while fixation is evaluated using FEA. It is proposed that such a device would add a valuable option for the treatment of symptomatic early OA where the functional level of the patient can be maintained, and the progress of OA possibly arrested.