Christopher E. Pelt

Patient-specific Total Knee Arthroplasty Required Frequent Surgeon-directed Changes

BackgroundPatient-specific instrumentation potentially improves surgical precision and decreases operative time in total knee arthroplasty (TKA) but there is little supporting data to confirm this presumption.Questions/purposesWe asked whether patient-specific instrumentation would require infrequent intraoperative changes to replicate a single surgeon’s preferences during TKA and whether patient-specific instrumentation guides would fit securely.MethodsWe prospectively evaluated the plan and surgery in 60 patients treated with 66 TKAs performed with patient-specific instrumentation and recorded any changes. A subset of six postoperative radiographic changes to the femoral and tibial components (implant size, coronal and sagittal alignment) was analyzed to determine if surgeon intervention was beneficial. Each guide was evaluated to determine fit. We compared patient demographics and implant sizing in the patient-specific instrumentation group with a control group in which traditional instrumentation was used.ResultsWe recorded 161 intraoperative changes in 66 knee arthroplasties (2.4 changes/knee) performed with patient-specific instrumentation. The predetermined implant size was changed intraoperatively in 77% of femurs and 53% of tibias. We identified a subset of 95 intraoperative changes that could be radiographically evaluated to determine if our changes were an improvement or detriment to reaching goal alignment. Eighty-two of the 95 changes (86%) made by the surgeon were an improvement to the recommended alignment or size of patient-specific instrumentation. The guide did not fit securely on eight femurs (12%) and three tibias (5%). Tourniquet time and blood loss were not improved with patient-specific instrumentation.ConclusionsWe caution surgeons against blind acceptance of patient-specific instrumentation technology without supportive data.Level of EvidenceLevel III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality

IMPORTANCE Transformation of US health care from volume to value requires meaningful quantification of costs and outcomes at the level of individual patients. OBJECTIVE To measure the association of a value-driven outcomes tool that allocates costs of care and quality measures to individual patient encounters with cost reduction and health outcome optimization. DESIGN, SETTING, AND PARTICIPANTS Uncontrolled, pre-post, longitudinal, observational study measuring quality and outcomes relative to cost from 2012 to 2016 at University of Utah Health Care. Clinical improvement projects included total hip and knee joint replacement, hospitalist laboratory utilization, and management of sepsis. EXPOSURES Physicians were given access to a tool with information about outcomes, costs (not charges), and variation and partnered with process improvement experts. MAIN OUTCOMES AND MEASURES Total and component inpatient and outpatient direct costs across departments; cost variability for Medicare severity diagnosis related groups measured as coefficient of variation (CV); and care costs and composite quality indexes. RESULTS From July 1, 2014, to June 30, 2015, there were 1.7 million total patient visits, including 34 000 inpatient discharges. Professional costs accounted for 24.3% of total costs for inpatient episodes (

Postoperative falls after total knee arthroplasty in patients with a femoral nerve catheter: Can we reduce the incidence?

114.4 million of

Center Edge Angle Measurement for Hip Preservation Surgery: Technique and Caveats

470.4 million) and 41.9% of total costs for outpatient visits (

Comparison of Total Knee Arthroplasty With Highly Congruent Anterior-stabilized Bearings versus a Cruciate-retaining Design

231.7 million of

The Prevalence of Radiographic Findings of Structural Hip Deformities in Female Collegiate Athletes

553.1 million). For Medicare severity diagnosis related groups with the highest total direct costs, cost variability was highest for postoperative infection (CV = 1.71) and sepsis (CV = 1.37) and among the lowest for organ transplantation (CV ≤ 0.43). For total joint replacement, a composite quality index was 54% at baseline (n = 233 encounters) and 80% 1 year into the implementation (n = 188 encounters) (absolute change, 26%; 95% CI, 18%-35%; P < .001). Compared with the baseline year, mean direct costs were 7% lower in the implementation year (95% CI, 3%-11%; P < .001) and 11% lower in the postimplementation year (95% CI, 7%-14%; P < .001). The hospitalist laboratory testing mean cost per day was

Patient-Specific Instrumentation in Total Knee Arthroplasty Provides No Improvement in Component Alignment

138 (median [IQR],

Barbed Versus Standard Sutures for Closure in Total Knee Arthroplasty: A Multicenter Prospective Randomized Trial

113 [

Histologic, serologic, and tribologic findings in failed metal-on-metal total hip arthroplasty: AAOS exhibit selection.

79-160]; n = 2034 encounters) at baseline and

Lessons Learned from Selective Soft-Tissue Release for Gap Balancing in Primary Total Knee Arthroplasty: An Analysis of 1216 Consecutive Total Knee Arthroplasties AAOS Exhibit Selection

123 (median [IQR],