Bernard A. Pfeifer

Impact of a clinical pathway and implant standardization on total hip arthroplasty: a clinical and economic study of short-term patient outcome.

This study evaluates the impact of a clinical pathway (CP) and a hip implant standardization program (HISP) on the quality and cost of total hip arthroplasty (THA). Two hundred six unilateral THA operations for osteoarthritis were evaluated: 89 operations were performed in 1991 without a CP or HISP (4-year follow-up period); 117 operations were performed in 1993 with a CP and HISP (2-year follow-up period). All patients had good clinical results and excellent outcomes with short-term follow-up evaluation. No differences were seen between groups in terms of patient ratings of outcome and satisfaction or in terms of complication rates in the hospital. Implementation of a CP and HISP did not adversely affect the short-term outcome of THA but did reduce hospital length of stay and hospital cost for THA.

Single-dose irradiation for the prevention of heterotopic ossification after total hip arthroplasty. A comparison of doses of five hundred and fifty and seven hundred centigray.

One hundred and seven hips (ninety-four patients) that had risk factors associated with the development of heterotopic ossification after total hip arthroplasty were treated with a single dose of radiation after the operation in an attempt to prevent the formation of heterotopic bone. A study was conducted to compare the efficacy of a single dose of 550 centigray (nineteen hips) with that of a single dose of 700 centigray (eighty-eight hips). Heterotopic ossification developed in twelve (63 per cent) of the nineteen hips that were treated with 550 centigray; grades 1, 2, and 3, according to the classification of Brooker et al., developed in four hips each. Two of the patients who received 550 centigray were symptomatic. Heterotopic ossification developed in nine (10 per cent) of the eighty-eight hips that were treated with 700 centigray; the lesion was grade 1 in six, grade 2 in one, and grade 3 in two. None of the patients who received 700 centigray were symptomatic. We concluded that single-dose irradiation consisting of 550 centigray is inadequate for the prevention of heterotopic ossification in high-risk patients after total hip arthroplasty. We recommend a dose of 700 centigray as effective prophylaxis for these patients.

Evaluation of autologous shed blood for autotransfusion after orthopaedic surgery

Autologous shed blood for autotransfusion was evaluated at four medical centers in a prospective randomized study. One hundred twenty-eight patients were studied after hip replacement, knee replacement, or spine fusion. The efficacy of autologous shed blood in reducing homologous transfusion was evaluated. The relative risk of transfusion with homologous blood was 0.4 in patients who received shed blood compared with patients who did not receive shed blood. The reinfusion of shed blood reduced the requirement for homologous blood by 60%. Two filter systems were evaluated in reinfusing autologous shed blood. The Pall RC100 filter appeared to be more effective than the Pall 40-mu screen filter in removing fat particles and white blood cells. No significant clinical abnormalities were discovered after autotransfusion with autologous shed blood. Evaluation of clotting studies showed no significant differences between patients who received shed blood and patients who received liquid-preserved red blood cells. These data indicate that unwashed autologous shed blood from orthopaedic wound drainage is a safe and effective substitute for transfusion of autologous predonated blood or homologous liquid-preserved red blood cells.

Cold Compressive Dressing After Total Knee Arthroplasty

The efficacy of a cold compressive dressing after total knee arthroplasty (TKA) was prospectively studied in 105 knees in 76 patients. All components were cemented. All patients were placed in continuous passive motion machines after operation. A cold compressive Cryocuff dressing was applied to 50 knees after operation. An ACE wrap and ice pack were applied to the knees of 55 control patients after operation. Postoperative range of motion was recorded as maximum active flexion at two to four days (interval one), at seven to 14 days (interval two), and four to six weeks (interval three). Swelling was measured at the same time intervals by circumference at the midpatella and circumference at the distal thigh one inch proximal to the superior pole of the patella. Use of postoperative narcotics was calculated for postoperative days zero to three and for postoperative days four to seven. Wound drainage was recorded for all knees. The use of a cold compressive dressing after TKA was not associated with an increase in range of motion at any point after the operation. The Cryocuff dressing did not appreciably reduce swelling around the knee after TKA. No significant difference was found in the amount of postoperative wound drainage between the two groups of patients. In patients undergoing unilateral TKA, no significant difference existed between the narcotic requirements of control patients and patients wearing the cold compressive dressing.

Clinical outcome and survivorship analysis of core decompression for early osteonecrosis of the femoral head

Thirty-three hips in 23 patients (followed for 5.3 years) were treated with core decompression for early osteonecrosis of the femoral head (Ficat and Arlet I, IIA, IIB). When the clinical endpoint of severe pain was used for survivorship, 76% of hips survived 1 year, 52% survived 2 years, and 44% survived 5 years. When the radiographic endpoint of progression to stage III disease was used, no progression was found in 72% of hips at 1 year, 61% at 2 years, and 37% at 5 years. When total hip arthroplasty was used as an endpoint, 90% of hips survived 1 year, 70% survived 2 years, and 61% survived 5 years. Lower radiographic stage was associated with a better result. Patients who weighed less than 79.4 kg (175 lb.) (P = .03) or whose bone stock was good (femoral index < 0.56, P < .001) had significantly improved survival. Outcome evaluation documented a 70% overall patient satisfaction rate in patients not undergoing total hip arthroplasty.

Single-dose radiation therapy for prevention of heterotopic ossification after total hip arthroplasty

Single-dose radiation therapy was prospectively evaluated for its efficacy in prevention of heterotopic ossification in patients at high risk after total hip arthroplasty. Thirty-one patients (34 hips) were treated between 1981 and 1988. Risk factors for inclusion in the protocol included prior evidence of heterotopic ossification, ankylosing spondylitis, and diffuse idiopathic skeletal hyperostosis. Patients with hypertrophic osteoarthritis or traumatic arthritis with osteophytes were not included. Operations on 34 hips included 19 primary total and 11 revision total hip arthroplasties and 4 excisions of heterotopic ossification. All patients received radiotherapy to the hip after operation with a single dose of 700 centigray. Radiotherapy is recommended on the first postoperative day. After this single-dose radiation treatment, no patient had clinically significant heterotopic ossification. Recurrent disease developed in two hips (6%), as seen on radiography (grades 2 and 3). This series documents a 100% clinical success rate and a 94% radiographic success rate in preventing heterotopic ossification in patients at high risk after total hip arthroplasty. Single-dose radiotherapy is as effective as other radiation protocols in preventing heterotopic ossification after total hip arthroplasty. It is less expensive and easier to administer than multidose radiotherapy.

Single Price/Case Price Purchasing in Orthopaedic Surgery: Experience at the Lahey Clinic*

Background: Hospital revenues for orthopaedic operations are not keeping pace with inflation or with rising hospital expenses. In an attempt to reduce the hospital cost of orthopaedic operations by reducing the cost of operating-room supplies, we developed a Single Price/Case Price Purchasing Program for implants used in total hip arthroplasty, total knee arthroplasty, and total shoulder arthroplasty as well as for arthroscopic shavers and burrs, interference screws, and bone-suture anchors. Methods: The Lahey Clinic asked orthopaedic vendors to supply all instruments, implants, and disposable items related to these selected products for one single price per unit or case. For example, a single price for total hip arthroplasty implants included instruments, acetabular cups, acetabular liners, acetabular screws, femoral stems, femoral heads, and stem centralizers, if required. The hospital implemented the Single Price/Case Price Purchasing Program with a competitive-bid request for proposal. Surgeons evaluated the responses to the bidding process, and they made final decisions on product selection. Results: The Single Price/Case Price Purchasing Program at the Lahey Clinic was successful in reducing the cost of orthopaedic implants and supplies. In the present article, we could not disclose the specific prices that we agreed to pay our vendors. The specific cost reductions were 32 percent for hip implants with a change of vendor, 23 percent for knee implants without a change of vendor, 25 percent for shoulder implants with a change of vendor, 45 percent for arthroscopic shavers and burrs without a change of vendor, 45 percent for interference screws without a change of vendor, and 23 percent for bone-suture anchors without a change of vendor. Conclusions: The Single Price/Case Price Purchasing Program at the Lahey Clinic allowed the hospital to reduce its cost of orthopaedic operations by lowering the cost of operating-room supplies. This cost reduction is important in a health-care economy in which hospital revenues per unit of service or care are decreasing.

Implant Standardization for Total Hip Arthroplasty An Implant Selection and a Cost Reduction Program

Total hip arthroplasty (THA) has been targeted by the United States federal government for cost control because of its high cost and rising incidence in the aging population. The hospital cost for THA during the 1980s was controlled by utilization review and a reduction in the volume of services delivered for each THA. The single largest increase in the cost of THA during the 1980s was the cost of hip implants. The Lahey Clinic Hip Implant Standardization Program was developed to provide objective guidelines for hip implant selection. These guidelines are based on the demands a patients is expected to place on his or her hip prosthesis. Because not every patient requires an expensive high-demand hip prosthesis, the standardization program also has the potential to reduce the hospital cost for hip implants without compromising patient care. Patients are assigned to four demand categories based on five objective criteria: age, weight, expected activity, general health, and bone stock. Selection of the prosthesis in each of the four demand categories is intended to match the implants capacity with expected patient demand. The standardization program was retrospectively applied to 103 THAs performed during 1991. Analysis of variance demonstrated that patient variables and demand categories were statistically significant groupings. The cost of hip implants would have been reduced by 25.7% with the Lahey Clinic Hip Implant Standardization Program. A prospective outcome study is required to determine the long-term validity of this standardization program.

Case report: Radiation prevention of heterotopic ossification after bone and joint surgery in sites other than hips

Five patients were given single dose irradiation in an attempt to prevent heterotopic ossification after bone and joint surgery in sites other than hips. All patients were at risk for the development of post-operative heterotopic ossification. Two patients were treated with 6 Gy and three patients were treated with 7 Gy the day after operation. No complications were encountered. Post-operative heterotopic ossification did not develop in patients who received 7 Gy, whereas treatment failed in the two patients who received 6 Gy. Because this is a case report study, no conclusion could be made. Further investigation is needed to assess the efficacy of post-operative single dose irradiation in heterotopic ossification prophylaxis in sites other than hips in high risk patients.

Methylmethacrylate monomer and fat content in shed blood after total joint arthroplasty

Twenty-five patients were prospectively evaluated to quantify levels of methylmethacrylate monomer and fat in systemic blood and in shed blood after total joint arthroplasty. Levels of methylmethacrylate monomer in systemic blood were measured at intervals after insertion of the prosthesis. Levels of methylmethacrylate monomer in shed blood were measured at intervals after insertion of the drain. Levels of fat in systemic blood were measured preoperatively and 30 minutes after insertion of the prosthesis. Levels of fat in shed blood were measured 60 minutes after insertion of the drain. No significant fat or methylmethacrylate monomer was noted in systemic blood. Levels of methylmethacrylate monomer in shed blood were highest five minutes after insertion of the drain. Levels of methylmethacrylate monomer in shed blood collected from the hip were significantly lower than levels in shed blood from the knee. Levels of shed blood from the hip and knee were undetectable six hours after insertion of the drain. Shed blood from the hips and knees contained fat particles of three diameters: fat particles less than 9 microns, 9-40 microns, and greater than 40 microns. The diameter of most of the fat particles in the shed blood was less than 9 microns. Fat particles less than 40 microns in diameter will not be removed by microaggregate screen filters 40 microns in diameter.