Brian R. Hallstrom

Prioritizing Perioperative Quality Improvement in Orthopaedic Surgery

BACKGROUND Surgical quality improvement has received increasing attention in recent years, but it is not clear where orthopaedic surgeons should focus their efforts for the greatest impact on perioperative safety and quality. We sought to guide these efforts by prioritizing orthopaedic procedures according to those that generate the greatest number of adverse events. METHODS We used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to identify all patients who had undergone an orthopaedic surgical procedure between 2005 and 2007 (n = 7970). Patients were assigned to forty-four unique procedure groups on the basis of the Current Procedural Terminology (CPT) codes. We first assessed the relative contribution of each procedure group to the overall number of adverse events in the first thirty postoperative days, and we followed that with a description of their relative contribution to an excess length of stay in the hospital. RESULTS Ten procedures accounted for 70% of the adverse events and 65% of the excess hospital days. Hip fracture repair accounted for the greatest share of adverse events, followed by total knee arthroplasty, total hip arthroplasty, revision total hip arthroplasty, knee arthroscopy, laminectomy, lumbar/thoracic arthrodesis, and femoral fracture repair. No other procedure group accounted for >2% of the adverse events. CONCLUSIONS Only a few procedures account for the vast majority of adverse events in the first thirty days following orthopaedic surgery. Concentrating quality-improvement efforts on these procedures may be an effective way for surgeons and other stakeholders to improve perioperative care and reduce costs in orthopaedic surgery. LEVEL OF EVIDENCE Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Trends and predictors of opioid use after total knee and total hip arthroplasty.

Abstract Few studies have assessed postoperative trends in opioid cessation and predictors of persistent opioid use after total knee arthroplasty (TKA) and total hip arthroplasty (THA). Preoperatively, 574 TKA and THA patients completed validated, self-report measures of pain, functioning, and mood and were longitudinally assessed for 6 months after surgery. Among patients who were opioid naive the day of surgery, 8.2% of TKA and 4.3% of THA patients were using opioids at 6 months. In comparison, 53.3% of TKA and 34.7% of THA patients who reported opioid use the day of surgery continued to use opioids at 6 months. Patients taking >60 mg oral morphine equivalents preoperatively had an 80% likelihood of persistent use postoperatively. Day of surgery predictors for 6-month opioid use by opioid-naive patients included greater overall body pain (P = 0.002), greater affected joint pain (knee/hip) (P = 0.034), and greater catastrophizing (P = 0.010). For both opioid-naive and opioid users on the day of surgery, decreases in overall body pain from baseline to 6 months were associated with decreased odds of being on opioids at 6 months (adjusted odds ratio [aOR] = 0.72, P = 0.050; aOR = 0.62, P = 0.001); however, change in affected joint pain (knee/hip) was not predictive of opioid use (aOR = 0.99, P = 0.939; aOR = 1.00, P = 0.963). In conclusion, many patients taking opioids before surgery continue to use opioids after arthroplasty and some opioid-naive patients remained on opioids; however, persistent opioid use was not associated with change in joint pain. Given the growing concerns about chronic opioid use, the reasons for persistent opioid use and perioperative prescribing of opioids deserve further study.

Characteristics of fibromyalgia independently predict poorer long-term analgesic outcomes following total knee and hip arthroplasty

While psychosocial factors have been associated with poorer outcomes after knee and hip arthroplasty, we hypothesized that augmented pain perception, as occurs in conditions such as fibromyalgia, may account for decreased responsiveness to primary knee and hip arthroplasty.

Implementation of patient-reported outcome measures in U.S. Total joint replacement registries: rationale, status, and plans

BACKGROUND In the U.S. and abroad, the use of patient-reported outcome measures to evaluate the impact of total joint replacement surgery on patient quality of life is increasingly common. Analyses of patient-reported outcomes have documented substantial pain relief and functional gain among the vast majority of patients managed with total joint replacement. In addition, postoperative patient-reported outcomes are useful to identify persistent pain and suboptimal outcomes in the minority of patients who have them. The leaders of five U.S. total joint replacement registries report the rationale, current status, and vision for the use of patient-reported outcome measures in U.S. total joint replacement registries. METHODS Surgeon leaders of the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement registry, American Joint Replacement Registry, California Joint Replacement Registry, Michigan Arthroplasty Registry Collaborative Quality Initiative, and Virginia Joint Registry report the rationale supporting the adoption of patient-reported outcome measures, factors associated with the selection and successful implementation of patient-reported outcome measures, and barriers to complete and valid data. RESULTS U.S. registries are at varied stages of implementation of preoperative surveys and postoperative total joint replacement outcome measures. Surgeon leaders report unified rationales for adopting patient-reported outcome measures: to capture data on pain relief and functional gain following total joint replacement as well as to identify suboptimal implant performance. Key considerations in the selection of a patient-reported outcome measure include its ability to measure both joint pain and physical function while limiting any burden on patients and surgeons related to its use. Complete patient-reported outcomes data will be associated with varied modes of survey completion, including options for home-based completion, to ensure consistent timing and data capture. CONCLUSIONS The current stage of implementation of patient-reported outcome measures varies widely among U.S. registries. Nonetheless, evidence from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement registry supports the feasibility of successful implementation of patient-reported outcome measures with careful attention to the selection of the outcome measure, mode and timing of postoperative administration, and minimization of any burden on the patient and surgeon.

No Difference in Dislocation Seen in Anterior Vs Posterior Approach Total Hip Arthroplasty

BACKGROUND The direct anterior approach (DAA) for total hip arthroplasty (THA) has rapidly become popular, but there is little consensus regarding the risks and benefits of this approach in comparison with a modern posterior approach (PA). METHODS A total of 2147 patients who underwent DAA THA were propensity score matched with patients undergoing PA THA on the basis of age, gender, body mass index, and American Society of Anesthesia classification using data from a state joint replacement registry. Mean age of the matched cohort was 64.8 years, mean body mass index was 29.1 kg/m(2), and 53% were female. Multilevel logistic regression models using generalized estimating equations to control for grouping at the hospital level were used to identify differences in various outcomes. RESULTS There was no difference in the dislocation rate between patients undergoing DAA (0.84%) and PA (0.79%) THA. Trends indicating a slightly longer length of stay with the PA and a slightly greater risk of fracture, increased blood loss, and hematoma with the DAA are consistent with previous studies. CONCLUSION On the basis of short-term outcome and complication data, neither approach has a compelling advantage over each other, including no difference in the dislocation risk.

The reproducibility of a kinematically-derived axis of the knee versus digitized anatomical landmarks using a knee navigation system.

Component position is critical to longevity of knee arthroplasties. Femoral component rotation is typically referenced from the transepicondylar axis (TEA), the anterior-posterior (AP) axis or the posterior condylar axis. Other studies have shown high variability in locating the TEA while proposing digitization of other landmarks such as the AP axis as a less-variable reference. This study uses a navigation system to compare the reproducibility of computing a kinematically-derived, navigated knee axis (NKA) to digitizing the TEA and AP axis. Twelve knees from unembalmed cadavers were tested. Four arthroplasty surgeons digitized the femoral epicondyles and the AP axis direction as well as flexed and extended the knee repeatedly to allow for NKA determination. The variance of the NKA axis determined under neutral loading conditions was smaller than the variance of the TEA axis when the kinematics were measured in the closed surgical condition (P<0.001). However, varus, valgus, and internal loading of the leg increased the variability of the NKA. Distraction of the leg during knee flexion and extension preserved the low variability of the NKA. In conclusion, a kinematically-derived NKA under neutral or distraction loading is more reproducible than the TEA and AP axis determined by digitization.

The Michigan Experience with Safety and Effectiveness of Tranexamic Acid Use in Hip and Knee Arthroplasty

BACKGROUND The efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion requirements in total hip and knee arthroplasty has been well established in small controlled clinical trials and meta-analyses. The purpose of the current study was to determine the risks and benefits of TXA use in routine orthopaedic surgical practice on the basis of data from a large, statewide arthroplasty registry. METHODS From April 18, 2013, to September 30, 2014, there were 23,236 primary total knee arthroplasty cases and 11,489 primary total hip arthroplasty cases completed and registered in the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI). We evaluated the association between TXA use and hemoglobin drop, transfusion, length of stay (LOS), venous thromboembolism (VTE), readmission, and cardiovascular events by fitting mixed-effects generalized linear and mixed-effects Cox models. We used inverse probability of treatment weighting to enhance causal inference. RESULTS For total hip arthroplasty, TXA use was associated with a smaller drop in hemoglobin (mean difference = -0.65 g/dL; 95% confidence interval [CI] = -0.60 to -0.71 g/dL), decreased odds of blood transfusion (odds ratio [OR] = 0.72; 95% CI = 0.60 to 0.86), and decreased readmissions (OR = 0.77; 95% CI = 0.64 to 0.93) compared with no TXA use. There was no effect on VTE (hazard ratio [HR] = 0.91; 95% CI = 0.62 to 1.33), LOS (incident rate ratio [IRR] = 1.00; 95% CI = 0.97 to 1.03), or cardiovascular events (OR = 0.85; 95% CI = 0.47 to 1.52). For total knee arthroplasty, TXA was associated with a smaller drop in hemoglobin (mean difference = -0.68 g/dL; 95% CI = -0.64 to -0.71 g/dL) and one-fourth the odds of blood transfusion (OR = 0.26; 95% CI = 0.21 to 0.31). There was an association with decreased risk of VTE within 90 days after surgery (HR = 0.56; 95% CI = 0.42 to 0.73), slightly decreased LOS (IRR = 0.93; 95% CI = 0.92 to 0.95), and no association with readmissions (OR = 0.90; 95% CI = 0.79 to 1.04) or cardiovascular events (OR = 1.12; 95% CI = 0.74 to 1.71). CONCLUSIONS In routine orthopaedic surgery practice, TXA use was associated with decreased blood loss and transfusion risk for both total knee and total hip arthroplasty, without evidence of increased risk of complications. TXA use was also associated with reduced risk of readmission among total hip arthroplasty patients and reduced risk of VTE among total knee arthroplasty patients, and did not have an adverse effect on cardiovascular complications in either group. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) as a model for regional registries in the United States

License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php Orthopedic Research and Reviews 2015:7 47–56 Orthopedic Research and Reviews Dovepress

Implications of the Definition of an Episode of Care Used in the Comprehensive Care for Joint Replacement Model.

Importance Under the Comprehensive Care for Joint Replacement (CJR) model, hospitals are held accountable for nearly all Medicare payments that occur during the initial hospitalization until 90 days after hospital discharge (ie, the episode of care). It is not known whether unrelated expenditures resulting from this “broad” definition of an episode of care will affect participating hospitals’ average episode-of-care payments. Objective To compare the CJR program’s broad definition of an episode of care with a clinically narrow definition of an episode of care. Design, Setting, and Participants We identified Medicare claims for 23 251 patients in Michigan who were Medicare beneficiaries and who underwent joint replacement during the period from 2011 through 2013 at hospitals located in metropolitan statistical areas. Using specifications from the CJR model and the clinically narrow Hospital Compare payment measure, we constructed episodes of care and calculated 90-day episode payments. We then compared hospitals’ average 90-day episode payments using the 2 definitions of an episode of care and fit linear regression models to understand whether payment differences were associated with specific hospital characteristics (average Centers for Medicare & Medicaid Services–hierarchical condition categories risk score, rural hospital status, joint replacement volume, percentage of Medicaid discharges, teaching hospital status, number of beds, percentage of joint replacements performed on African American patients, and median income of the hospital’s county). We performed analyses from July 1 through October 1, 2015. Main Outcomes and Measures The correlation and difference between average 90-day episode payments using the broad definition of an episode of care in the CJR model and the clinically narrow Hospital Compare definition of an episode of care. Results We identified 23 251 joint replacements (ie, episodes of care). The 90-day episode payments using the broad definition of the CJR model ranged from

Greater Trochanteric Pain Syndrome Percutaneous Tendon Fenestration Versus Platelet-Rich Plasma Injection for Treatment of Gluteal Tendinosis

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