Joshua C. Rozell

Should All Patients Be Included in Alternative Payment Models for Primary Total Hip Arthroplasty and Total Knee Arthroplasty

BACKGROUND Alternative payment models in total joint replacement incentivize cost effective health care delivery and reward reductions in length of stay (LOS), complications, and readmissions. If not adjusted for patient comorbidities, they may encourage restrictive access to health care. METHODS We prospectively evaluated 802 consecutive primary total hip arthroplasty and total knee arthroplasty patients evaluating comorbidities associated with increased LOS and readmissions. RESULTS During this 9-month period, 115 patients (14.3%) required hospitalization >3 days and 16 (1.99%) were readmitted within 90 days. Univariate analysis demonstrated that preoperative narcotic use, heart failure, stroke, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and liver disease were more likely to require hospitalization >3 days. In multivariate analysis, CKD and COPD were independent risk factors for LOS >3 days. A Charlson comorbidity index >5 points was associated with increased LOS and readmissions. CONCLUSION Patients with CKD, COPD, and Charlson comorbidity index >5 points should not be included in alternative payment model for THA and TKA.

Management of Severe Femoral Bone Loss in Revision Total Hip Arthroplasty

Femoral bone loss is a complex problem in revision total hip arthroplasty. The Paprosky classification is used when determining the degree and location of bone loss. Meticulous operative planning is essential where severe bone loss is a concern. One must correctly identify the bone loss pattern, safely remove the existing components, and proceed with the proper reconstruction technique based on the pattern of bone loss. This article discusses the etiology and classification of bone loss, clinical and radiographic evaluation, components of effective preoperative planning, and clinical results of various treatment options with a focus on more severe bone loss patterns.

Distal Radius Fractures in the Elderly

Distal radius fractures are common in elderly patients, and the incidence continues to increase as the population ages. The goal of treatment is to provide a painless extremity with good function. In surgical decision making, special attention should be given to the patients bone quality and functional activity level. Most of these fractures can be treated nonsurgically, and careful closed reduction should aim for maintenance of anatomic alignment with a focus on protecting fragile soft tissues. Locked plating is typically used for fracture management when surgical fixation is appropriate. Surgical treatment improves alignment, but improvement in radiographic parameters may not lead to better clinical outcomes. Treatment principles, strategies, and clinical outcomes vary for these injuries, with elderly patients warranting special consideration.

Tibial Plateau Fractures in Elderly Patients

Tibial plateau fractures are common in the elderly population following a low-energy mechanism. Initial evaluation includes an assessment of the soft tissues and surrounding ligaments. Most fractures involve articular depression leading to joint incongruity. Treatment of these fractures may be complicated by osteoporosis, osteoarthritis, and medical comorbidities. Optimal reconstruction should restore the mechanical axis, provide a stable construct for mobilization, and reestablish articular congruity. This is accomplished through a variety of internal or external fixation techniques or with acute arthroplasty. Regardless of the treatment modality, particular focus on preservation and maintenance of the soft tissue envelope is paramount.

Recent advances in the treatment of hip fractures in the elderly

The treatment of hip fractures in the elderly represents a major public health priority and a source of ongoing debate among orthopaedic surgeons and anesthesiologists. Most of these injuries are treated with surgery in an expedient fashion. From the surgical perspective, there are certain special considerations in this population including osteoporosis, pre-existing arthritis, age, activity level, and overall health that contribute to the type of surgical fixation performed. Open reduction and internal fixation versus arthroplasty remain the two major categories of treatment. While the indications and treatment algorithms still remain controversial, the overall goal for these patients is early mobilization and prevention of morbidity and mortality. The use of preoperative, regional anesthesia has aided in this effort. The purpose of this review article is to examine the various treatment modalities for hip fractures in the elderly and discuss the most recent evidence in the face of a rapidly aging population.

Biomechanical Comparison of Fully Threaded Solid Cortical Versus Partially Threaded Cannulated Cancellous Screw Fixation for Lisfranc Injuries

There currently exists an array of operative strategies to manage Lisfranc injuries. Modular fixation systems present surgeons with a choice between fully threaded solid cortical (FSC) and partially threaded cannulated cancellous (PCC) bone screws when using a transarticular screw approach. It is currently unknown how screw design influences fixation strength in Lisfranc reconstructions. The purpose of this study was to evaluate the biomechanical differences of FSC and PCC screws using a cadaveric model of a simulated Lisfranc injury and controlled benchtop experiments. Ten matched pairs of cadaveric feet received an acute Lisfranc injury and were repaired with FSC or PCC screws. Diastasis was measured between the medial and intermediate cuneiforms and the first and second metatarsals during simulations of partial weight bearing. Three-point bending and axial pull-out tests were performed to characterize screw mechanics that could not be measured within the cadaveric model. Screw design did not affect cuneiform or metatarsal diastasis. Neither screw loosening nor deformation was observed following cadaveric testing. Bending tests indicated FSC screws had higher ultimate strength, but there was no significant difference in yield load. Partially threaded cannulated cancellous bone screws exhibited superior axial pull-out strength. Fully threaded solid cortical and PCC screws provide equal amounts of fixation strength during partial weight bearing and similar resistance to deformation under bending loads. Partially threaded cannulated cancellous screws may simplify the operative procedure and minimize nonoptimal screw placement. If a clinician so desires, PCC screws may be used in lieu of FSC screws without sacrificing fixation strength. [Orthopedics. 2018; 41(2):e222-e227.].