Charles M. Davis

Impact of Comorbidities on Hospitalization Costs Following Hip Fracture

BACKGROUND Hip fractures are common in the elderly, and patients with hip fractures frequently have comorbid illnesses. Little is known about the relationship between comorbid illness and hospital costs or length of stay following the treatment of hip fracture in the United States. We hypothesized that specific individual comorbid illnesses and multiple comorbid illnesses would be directly related to the hospitalization costs and the length of stay for older patients following hip fracture. METHODS With use of discharge data from the 2007 Nationwide Inpatient Sample, 32,440 patients who were fifty-five years or older with an isolated, closed hip fracture were identified. Using generalized linear models, we estimated the impact of comorbidities on hospitalization costs and length of stay, controlling for patient, hospital, and procedure characteristics. RESULTS Hypertension, deficiency anemias, and fluid and electrolyte disorders were the most common comorbidities. The patients had a mean of three comorbidities. Only 4.9% of patients presented without comorbidities. The average estimated cost in our reference patient was

Cemented Revision of Failed Uncemented Femoral Components of Total Hip Arthroplasty

13,805. The comorbidity with the largest increased hospitalization cost was weight loss or malnutrition, followed by pulmonary circulation disorders. Most other comorbidities significantly increased the cost of hospitalization. Compared with internal fixation of the hip fracture, hip arthroplasty increased hospitalization costs significantly. CONCLUSIONS Comorbidities significantly affect the cost of hospitalization and length of stay following hip fracture in older Americans, even while controlling for other variables.

Venous thromboembolism: management by American Association of Hip and Knee Surgeons.

Background: The long-term results of revision of failed primary cemented femoral components with use of cement have been reported, but there is little information about the results of revision of failed uncemented femoral components with use of cement. The purpose of the present study was to examine the minimum five-year results for patients in whom a failed uncemented primary femoral component was revised with use of modern cementing techniques. Methods: Forty-eight consecutive hips (forty-seven patients) in which a failed primary uncemented femoral component was revised with use of cement at one institution from 1985 to 1992 were followed prospectively and reviewed retrospectively. The mean age of the patients at the time of revision was sixty-seven years. Only seven revisions were performed with a long-stem femoral component. The postoperative cement mantle was classified, according to the system of Mulroy and Harris, as grade A in four hips, grade B in twenty-five, grade C1 in seven, grade C2 in twelve, and grade D in none. Results: Eleven femoral components were removed or revised because of aseptic loosening (ten) or deep infection (one). An additional four unrevised femoral components had evidence of probable or definite loosening at the time of the final radiographic follow-up. Thus, fourteen (29%) of the forty-eight femoral implants demonstrated aseptic loosening during the study period. Five of the twenty-nine hips in which the postoperative cement mantle was classified as grade A or B had mechanical failure at the time of the final follow-up, compared with nine of the nineteen hips in which the postoperative cement mantle was classified as grade C1 or C2 (p < 0.05). Among the hips with surviving prostheses, 79% had had moderate or severe pain preoperatively whereas 25% had moderate or severe pain at the time of the final follow-up. The six-year rate of survival of the femoral component was 72% with revision for aseptic loosening as the end point and 67% with mechanical failure (revision for aseptic loosening or radiographic loosening) as the end point. Conclusions: While revision of a failed uncemented femoral implant with use of cement provided pain relief and improved function for most patients, the rate of loosening at the time of intermediate-term follow-up was higher than that commonly reported after revision of failed cemented implants with use of cement and also was higher than that commonly reported after revision with use of uncemented extensively porous-coated implants. Bone removal at the time of the initial implantation of the stem and bone loss due to subsequent failure of the uncemented implant often left little intramedullary cancellous bone, which may explain the high rate of loosening observed in the first decade after revision in this series. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Pulse Lavage is Inadequate at Removal of Biofilm from the Surface of Total Knee Arthroplasty Materials

A 2008 survey of American Association of Hip and Knee Surgeons membership explored current venous thromboembolism (VTE) protocols for lower-extremity total joint surgery. Fifty-three percent reported a change in VTE-related practices in the last 5 years. More than 70% reported that their primary hospital now mandates VTE prophylaxis. Although 74% of their primary hospitals recognized the American College of Chest Physicians guidelines, 68% of surgeons felt the American Academy of Orthopaedic Surgeons guidelines were more relevant to their practice. Respondents believe low molecular weight heparin to be the most efficacious but aspirin to be the easiest to use and has the lowest risks of bleeding and wound drainage. Warfarin was the most used in hospital prophylaxis, and 90% of respondents targeted an international normalized ratio of 1.6 to 2.5. Practice patterns continue to evolve, and there remains no consensus on specific treatment protocols or preferences.

Impact of the Economic Downturn on Adult Reconstruction Surgery: A Survey of the American Association of Hip and Knee Surgeons

In acute periprosthetic infection, irrigation and debridement with component retention has a high failure rate in some studies. We hypothesize that pulse lavage irrigation is ineffective at removing biofilm from total knee arthroplasty (TKA) components. Staphylococcus aureus biofilm mass and location was directly visualized on arthroplasty materials with a photon collection camera and laser scanning confocal microscopy. There was a substantial reduction in biofilm signal intensity, but the reduction was less than a ten-fold decrease. This suggests that irrigation needs to be further improved for the removal of biofilm mass below the necessary bioburden level to prevent recurrence of acute infection in total knee arthroplasty.

Body Mass Index More Than 45 kg/m2 as a Cutoff Point Is Associated With Dramatically Increased Postoperative Complications in Total Knee Arthroplasty and Total Hip Arthroplasty

To evaluate the effects of the economic downturn on adult reconstruction surgery in the United States, a survey of the American Association of Hip and Knee Surgeons (AAHKS) membership was conducted. The survey evaluated surgical and patient volume, practice type, hospital relationship, total joint arthroplasty cost control, employee staffing, potential impact of Medicare reimbursement decreases, attitudes toward health care reform options and retirement planning. A surgical volume decrease was reported by 30.4%. An outpatient visit decrease was reported by 29.3%. A mean loss of 29.9% of retirement savings was reported. The planned retirement age increased to 65.3 years from 64.05 years. If Medicare surgeon reimbursement were to decrease up to 20%, 49% to 57% of AAHKS surgeons would be unable to provide care for Medicare patients, resulting in an unmet need of 92,650 to 160,818 total joint arthroplasty procedures among AAHKS surgeons alone. Decreases in funding for surgeons and inadequate support for subspecialty training will likely impact access and quality for Americans seeking adult reconstruction surgery.

Outcomes of Total Hip and Knee Arthroplasty After Cardiac Transplantation

BACKGROUND Higher body mass index (BMI) has been associated with postoperative complications in total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, the association of incremental increases of BMI and its effects on postoperative complications has not been well studied. We hypothesize that there is a BMI cutoff at which there is a significant increase of the risk of postoperative complications. METHODS We studied the American College of Surgeons National Surgical Quality Improvement Program from 2006 to 2013. The final cohort included 77,785 primary TKA and 49,475 primary THA subjects, respectively. Patients were separated into 7 groups based on BMI (18.5-24.9 kg/m(2), 25.0-29.9 kg/m(2), 30.0-34.9 kg/m(2), 35.0-39.9 kg/m(2), 40.0-44.9 kg/m(2), 45.0-49.9 kg/m(2), and >50.0 kg/m(2)). We analyzed data on five 30-day composite complication variables, including any complication, major complication, wound infection, systemic infection, and cardiac and/or pulmonary complication. RESULTS The odds ratio for 4 (any complication, major complication, wound infection, and systemic infection) of 5 composite complications started to increase exponentially once BMI reached 45.0 kg/m(2) or higher in TKA. Similarly, the odds ratio in 3 (any complication, systemic infection, and wound infection) of 5 composite complications showed similar trends in THA patients. These findings were further confirmed with propensity score matching and entropy balancing. CONCLUSIONS Our study suggested that there was a positive correlation between BMI and incidences of 30-day postoperative complications in both TKA and THA. The odds of complications increased dramatically once BMI reached 45.0 kg/m(2).

The American Academy of Orthopaedic Surgeons Evidence-Based Clinical Practice Guideline on Surgical Management of Osteoarthritis of the Knee

The outcomes of 18 primary or revision total hip (THA) and knee arthroplasties (TKA) in 9 patients with cardiac transplants were reviewed. Primary total joint arthroplasties were performed for osteonecrosis (5 hips) or osteoarthritis (5 hips, 4 knees). There were no infections in any of these patients. Final Harris Hip Scores were 71.8 for patients with osteonecrosis and 88.6 for osteoarthritis. Eight of 10 hips were pain-free at final follow-up. Two of the 10 primary THAs required late revision at 7 and 10 years after the index arthroplasty. One patient (2 hips and 1 knee) had chronic bilateral lower extremity pain. Total knee arthroplasty range of motion averaged from 7.5° to 118°. Average final Knee Society function score was 79, and objective score was 88. One of 4 patients with primary TKA required a manipulation under anesthesia. No reoperations were required in this group. Overall, patients with heart transplantations on immunosuppression had generally good pain relief after THA and TKA. There were no infections in this small cohort; however, there were many complications.

Ipsilateral femoral neck and shaft fractures: report of two cases using an alternate technique

This article was updated on May 4, 2016, because of a previous error. On page 689, under the “DELAY TKA” heading, the text had previously read “Moderate evidence supports that a 5-month delay to total knee arthroplasty (TKA) does not worsen outcomes.” The text now reads “Moderate evidence supports that an 8-month delay to total knee arthroplasty (TKA) does not worsen outcomes.” An erratum has been published: J Bone Joint Surg Am. 2016 June 15;98(12):e53. The AAOS Evidence-Based Guideline on Surgical Management of Osteoarthritis of the Knee includes both diagnosis and treatment. This clinical practice guideline has been endorsed by the Arthroscopy Association of North America (AANA) and the Society of Military Orthopaedic Surgeons (SOMOS). This brief summary of the AAOS Clinical Practice Guideline contains a list of the recommendations and the rating of strength based on the quality of the supporting evidence. Discussion of how each recommendation was developed and the complete evidence report are contained in the full guideline at http://www.aaos.org/Quality/Clinical\_Practice\_Guidelines/Clinical\_Practice\_Guidelines/. ### BMI AS A RISK FACTOR Strong evidence supports that obese patients have less improvement in outcomes with total knee arthroplasty (TKA). Strength of Recommendation: Strong ★★★★ ### DIABETES AS A RISK FACTOR Moderate evidence supports that patients with diabetes are at higher risk for complications with total knee arthroplasty (TKA). Strength of Recommendation: Moderate ★★★☆ ### CHRONIC PAIN AS A RISK FACTOR Moderate evidence supports that patients with select chronic pain conditions have less improvement in patient reported outcomes with TKA. Strength of Recommendation: Moderate ★★★☆ ### DEPRESSION/ANXIETY AS A RISK FACTOR Limited evidence supports that patients with depression and/or anxiety symptoms have less improvement in patient reported outcomes with total knee arthroplasty (TKA). Strength of Recommendation: Limited ★★☆☆ ### CIRRHOSIS/HEPATITIS C AS A RISK FACTOR Limited evidence supports that patients with cirrhosis …

Prevalence, Timing, Causes, and Outcomes of Hyponatremia in Hospitalized Orthopaedic Surgery Patients

A technique for ipsilateral femoral neck and shaft fracture using the sliding compression hip screw with plate combined with trochanteric antegrade Ender nailing of the femur was applied in two cases. Ender nails can be passed without difficulty past a compression hip screw and the bicortical plating screws. The hip and femur can be fixed internally through a single approach in a single position. Sliding compression hip screw devices can provide excellent preliminary stable femoral neck fixation. Blood supply to the femoral head is not disturbed while the femoral intramedullary fixation is performed. Antegrade Ender nailing avoids the common knee complications associated with other retrograde techniques. Decreased operative time, less blood loss, less technical difficulty, and early mobilization are important factors in the multiple-injured patient. Femoral intramedullary fixation may require open reduction, circlerage to ensure stability, and maintenance of alignment in case of significant comminution to allow early crutch ambulation. This mode of fixation may be advantageous for selected cases.