Ameer Elbuluk

Private Bundles: The Nuances of Contracting and Managing Total Joint Arthroplasty Episodes

In recent years, bundled payment reimbursement models have been used to address the unsustainable rising cost of healthcare. Centers for Medicare and Medicaid Services initiatives, such as Bundled Payment for Care Improvement Program, have already demonstrated their ability to create financial and performance accountability in the public sector. More recently, these value-based models have been introduced among private payers to increase coordination, quality, and efficiency. Bundled payment strategies provide incentives for physicians and healthcare professionals to eliminate unnecessary services and reduce costs. This article discusses our experience at a private institution with transitioning to a bundled payment program, while identifying the challenges and strategies associated with a successful implementation.

Respiratory Synchronized Versus Intermittent Pneumatic Compression in Prevention of Venous Thromboembolism After Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

The objective of this study was to evaluate the efficacy of respiratory synchronized compression devices (RSCDs) versus nonsynchronized intermittent pneumatic compression devices (NSIPCDs) in preventing venous thromboembolism (VTE) after total joint arthroplasty. A systematic literature review was conducted. Data regarding surgical procedure, deep vein thrombosis, pulmonary embolism, mortality, and adverse events were abstracted. Compared with control groups, the risk ratio of deep vein thrombosis development was 0.51 with NSIPCDs and 0.47 with RSCDs. This review demonstrates that RSCDs may be marginally more effective at preventing VTE events than NSIPCDs. Furthermore, the addition of mechanical prophylaxis to any chemoprophylactic regimen increases VTE prevention.

Hospital Consumer Assessment of Healthcare Providers and Systems Scores Do Not Predict Outcomes After Total Hip Arthroplasty

BACKGROUND With the establishment of the Hospital Value-Based Purchasing program, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score has been incorporated into the calculation of the total performance score, which determines redistribution of up to 2% of Medicare payments. This study aims to assess whether the HCAHPS score correlates with validated outcome measures after total hip arthroplasty. METHODS Data from 63 patients who underwent a total hip arthroplasty and completed both an HCAHPS score and patient-reported outcome measures (PROMs) at our institution during the study period from January 1, 2015 to September 2016 were analyzed. The HCAHPS overall hospital rating scores were correlated with the preoperative to postoperative change in validated PROMs, namely EuroQol-EQ-5D Instrument and Hip Disability and Osteoarthritis Outcome Score. RESULTS There was no statistically significant correlation between the HCAHPS overall hospital rating score and PROMs. CONCLUSION This study shows a lack of correlation between established validated PROMs used in orthopedic surgery, and the HCAHPS survey scores, an important determinant of compensation in the pay-for-performance reimbursement models.

3D-MRI versus 3D-CT in the evaluation of osseous anatomy in femoroacetabular impingement using Dixon 3D FLASH sequence

ObjectiveTo determine if hip 3D-MR imaging can be used to accurately demonstrate femoral and acetabular morphology in the evaluation of patients with femoroacetabular impingement.Materials and methodsWe performed a retrospective review at our institution of 17 consecutive patients (19 hips) with suspected femoroacetabular impingement who had both 3D-CT and 3D-MRI performed of the same hip. Two fellowship-trained musculoskeletal radiologists reviewed the imaging for the presence and location of cam deformity, anterior–inferior iliac spine variant, lateral center-edge angle, and neck–shaft angle. Findings on 3D-CT were considered the reference standard. The amount of radiation that was spared following introduction of 3D-MRI was also assessed.ResultsAll 17 patients suspected of FAI had evidence for cam deformity on 3D-CT. There was 100% agreement for diagnosis (19 out of 19) and location (19 out of 19) of cam deformity when comparing 3D-MRI with 3D-CT. There were 3 type I and 16 type II anterior–inferior iliac spine variants on 3D-CT imaging with 89.5% (17 out of 19) agreement for the anterior–inferior iliac spine characterization between 3D-MRI and 3D-CT. There was 64.7% agreement when comparing the neck–shaft angle (11 out of 17) and LCEA (11 out of 17) measurements. The use of 3D-MRI spared each patient an average radiation effective dose of 3.09 mSV for a total reduction of 479 mSV over a 4-year period.Conclusion3D-MR imaging can be used to accurately diagnose and quantify the typical osseous pathological condition in femoroacetabular impingement and has the potential to eliminate the need for 3D-CT imaging and its associated radiation exposure, and the cost for this predominantly young group of patients.

Revision shoulder arthroplasty: Patient-reported outcomes vary according to the etiology of revision

Background The study evaluates patient-reported outcomes in revision shoulder arthroplasty (RevSA) according to etiology. Methods Twenty-three consecutive RevSA (minimum 2-year follow-up) were retrospectively reviewed. Patient-reported outcome (PRO) scores and range of motion were compared by the type of revision procedure and indication. Results EQ5D-QOL, VAS-pain, ASES, and forward elevation improved after RevSA. The infection group had least improvements. Revision to a reverse total shoulder arthroplasty (RTSA) demonstrated the most improvement in VAS-pain, forward elevation, and ASES. Conclusions Revision to RTSA significantly improved PRO scores compared to hemi- or total shoulder arthroplasty. RevSA for infection demonstrated the least improvement in outcomes.

Salvage of failed internal fixation of intertrochanteric hip fractures: clinical and functional outcomes of total hip arthroplasty versus hemiarthroplasty

Background Failed internal fixation of intertrochanteric (IT) hip fractures presents a significant challenge in the elderly, osteoporotic population. Conversion total hip arthroplasty (cTHA) and hemiarthroplasty (cHA) are both accepted salvage operations for failed IT fracture fixation, though limited clinical data exist regarding the optimal treatment between these procedures. Methods A systematic review of 3 databases (PubMed, Cochrane, and Embase) was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were English-language studies that compared clinical or functional outcomes after failed fixation of IT fractures with total hip arthroplasty and hemiarthroplasty in adult subjects (>18 years of age). Data regarding research design, surgical technique, and clinical or functional outcomes were obtained and analyzed from eligible studies using a Mantel-Haenszel random-effects analysis model. Results Six studies with 188 patients (100, total hip arthroplasty; 88, hemiarthroplasty) met inclusion and exclusion criteria. There was no significant difference between cTHA and cHA for postoperative dislocation, reoperation, infection, intraoperative fractures, postoperative fractures, or stem subsidence. The mean change in Harris Hip Scores was significantly higher (P < .001) in the cTHA group (47.5 ± 4.9) than that in the cHA (38.9 ± 7.2) group at minimum 14-month follow-up. Conclusions Despite potential advantages of cTHA or cHA for failed IT fractures, there were no differences in complications between either of the salvage procedures. Our analysis found a slight advantage in functional outcomes (Harris Hip Score) for cTHA at a minimum 14-month follow-up. Our study suggests that cTHA and cHA are both effective salvage procedures. Additional prospective studies are warranted to further delineate outcomes after salvage arthroplasty performed for failed IT fracture fixation.

The Surgical Hip and Femur Fracture Treatment Model: Medicare’s Next Orthopaedic Bundle

The Centers for Medicare & Medicaid Services (CMS) has created alternative, innovative payment models to address the rising health-care costs in the United States.Bundled-payment programs are intended to improve care delivery by shifting financial risk to providers, which requires optimizing resource utilization and providing more-coordinated, higher-quality care.CMS has recently announced a proposed payment model for episodes of care surrounding surgical hip/femur fracture treatment (SHFFT) excluding lower-extremity joint replacement.The provisions and implications of the proposed SHFFT bundle are complex and will require substantial investments of time, cost, and effort for selected hospitals and providers.

A Comprehensive Review of Stem-Cell Therapy

>> Regenerative orthopaedics has been used as a biological alternative to conventional therapy and surgical intervention for treating musculoskeletal conditions associated with limited therapeutic options.>> Orthopaedic investigators have shown promising early clinical results by developing cell-based approaches to regenerate injured cartilage, tendon, ligaments, and bone.>> Despite continued research, issues regarding harvesting, delivery of treatment, cost, indications, and optimal timing of intervention must be considered.>> Multidisciplinary networks of investigators are essential to achieve the full clinical and therapeutic potential of mesenchymal stem cells in orthopaedics.>> Although mesenchymal stem cells offer great promise for the treatment of degenerative diseases and orthopaedic conditions, there is still a dearth of properly conducted controlled clinical studies.

The effect of wound dressings on infection following total joint arthroplasty

Background The use of perioperative surgical wound dressings is an important factor in the mitigation of infection following total joint arthroplasty (TJA). Few studies have been published comparing wound dressings and infection rates after TJA. Methods MEDLINE, PubMed, and EMBASE were searched for studies published between 2006 and 2016 reporting infection rates in patients using various wound dressings after undergoing TJA. All studies comparing Hydrofibre dressings to Standard dressings or Absorbent dressings were included in this meta-analysis. Studies looking at TJA secondary to trauma were excluded. Two individuals independently extracted data, and study results were divided based on type of treatment. The primary outcome was to compare the infection rate of Hydrofibre dressings to that of both Standard Dressings and Absorbent dressings. Results Of a total of 3721 participants, 1483 were treated with Standard dressings (non-impregnated gauze), 1911 with Hydrofibre dressings, and 327 with Absorbent dressings. The risk ratio for infection comparing Standard with Hydrofibre was 4.16 (95% confidence interval, 1.71-10.16) as compared to 2.60 (95% confidence interval, 0.66-10.27) when comparing Absorbent with Hydrofibre dressings. Conclusions Our analysis suggests that Hydrofibre dressings may be significantly better than Standard and Absorbent dressings with respect to reducing infection. However, given the observed heterogeneity and small number of studies included, more comparative studies are needed to definitively recommend superiority among dressings following TJA. Level of Evidence Level 1.

Variance in predicted cup size by 2-dimensional vs 3-dimensional computerized tomography–based templating in primary total hip arthroplasty

Background Preoperative total hip arthroplasty templating can be performed with radiographs using acetate prints, digital viewing software, or with computed tomography (CT) images. Our hypothesis is that 3D templating is more precise and accurate with cup size prediction as compared to 2D templating with acetate prints and digital templating software. Methods Data collected from 45 patients undergoing robotic-assisted total hip arthroplasty compared cup sizes templated on acetate prints and OrthoView software to MAKOplasty software that uses CT scan. Kappa analysis determined strength of agreement between each templating modality and the final size used. t tests compared mean cup-size variance from the final size for each templating technique. Interclass correlation coefficient (ICC) determined reliability of digital and acetate planning by comparing predictions of the operating surgeon and a blinded adult reconstructive fellow. Results The Kappa values for CT-guided, digital, and acetate templating with the final size was 0.974, 0.233, and 0.262, respectively. Both digital and acetate templating significantly overpredicted cup size, compared to CT-guided methods (P < .001). There was no significant difference between digital and acetate templating (P = .117). Interclass correlation coefficient value for digital and acetate templating was 0.928 and 0.931, respectively. Conclusions CT-guided planning more accurately predicts hip implant cup size when compared to the significant overpredictions of digital and acetate templating. CT-guided templating may also lead to better outcomes due to bone stock preservation from a smaller and more accurate cup size predicted than that of digital and acetate predictions.