Lalit Puri

Use of helical computed tomography for the assessment of acetabular osteolysis after total hip arthroplasty.

Background: Acetabular osteolysis is a major problem affecting long-term survival of total hip prostheses. Since lytic lesions may be asymptomatic until extensive bone loss has occurred, early detection of lytic lesions is important. The purposes of this study were to determine the efficacy and potential role of high-resolution helical (or spiral) computed tomography with metal-artifact minimization in the early detection of osteolysis of the pelvis and to use the method to determine if there was a relationship between the extent of osteolysis and the amount of polyethylene wear. Methods: Forty patients (fifty hips) who had undergone primary cementless total hip arthroplasty between 1988 and 1994 were evaluated as part of an ongoing prospective study. These patients had a history of high-level activity that was believed to place them at increased risk for accelerated polyethylene wear. The most recent follow-up radiographs were compared with the three-month postoperative radiographs. Helical computed tomography scans with metal-artifact minimization were made, and evidence of osteolytic lesions on these scans was compared with that on the radiographs. Two-dimensional wear analysis was performed with use of digitized radiographs, and the results were compared with loss of bone volume as calculated from the computed tomography scans. Results: Acetabular lysis was identified on the radiographs of sixteen hips and on the computed tomography scans of twenty-six hips. Radiographs underestimated the extent of the lysis in thirteen of the sixteen hips. There was no correlation (r = 0.036) between linear wear and the measured volume of bone loss, with the numbers available. On the basis of the amount of lysis seen on the computed tomography scans, one patient underwent a revision procedure. Conclusions: Helical computed tomography with metal-artifact minimization is more sensitive for identifying and quantifying osteolysis after total hip arthroplasty than is plain radiography. Since computed tomography scans show both the extent and the location of lytic lesions, they are useful to guide treatment decisions as well as to assist in planning for surgical intervention, when needed, in patients with suspected osteolysis.

Understanding Readmission After Primary Total Hip and Knee Arthroplasty: Who’s at Risk?

Readmission has been cited as an important quality measure in the Patient Protection and Affordable Care Act. We queried an electronic database for all patients who underwent Total Hip Arthroplasty or Total Knee Arthroplasty at our institution from 2006 to 2010 and identified those readmitted within 90 days of surgery, reviewed their demographic and clinical data, and performed a multivariable logistic regression analysis to determine significant risk factors. The overall 90-day readmission rate was 7.8%. The most common readmission diagnoses were related to infection and procedure-related complications. An increased likelihood of readmission was found with coronary artery disease, diabetes, increased LOS, underweight status, obese status, age (over 80 or under 50), and Medicare. Procedure-related complications and wound complications accounted for more readmissions than any single medical complication.

Maintenance of proximal bone mass with an uncemented femoral stem analysis with dual-energy x-ray absorptiometry

Bone ingrowth into uncemented femoral implants with proximal porous coatings has been designed to avoid proximal stress shielding and preserve femoral strength. Dual-energy x-ray absorptiometry allows repeated quantitative analysis of anteroposterior scans of the proximal femur. By use of dual-energy x-ray absorptiometry and qualitative radiographic changes, 31 total hip arthroplasties with an individually designed, proximally porous-coated prosthesis were evaluated after surgery and at intervals up to 2 years. All implants appeared to achieve successful bone ingrowth and subsequent remodeling. At the most proximal level around the neck osteotomy, the postoperative loss of bone density at 6 months was -14.5%, which persisted at 24 months with -11.6%. At the level of the distal portion of the porous coating in the lower metaphysis, the density change was -8.7%, but bone had remodeled at 24 months with a change in density of only -1.0% compared with the immediate postoperative scan. With a design that results in reliable proximal ingrowth, this study predicts that after an initial decline in bone density, a positive bone remodeling response occurs that could lead to long-term stable fixation of the femoral implant.

Wound Complications in Joint Arthroplasty: Comparing Traditional and Modern Methods of Skin Closure

Various methods of skin closure exist in joint replacement surgery. Although subcuticular skin closure techniques offer an aesthetic advantage over conventional skin stapling, no measurable differences have been reported. Furthermore, newer barbed sutures, such as the V-Loc absorbable suture (Covidien, Mansfield, Massachusetts), theoretically distribute tension evenly through the wound and help decrease knot-related complications. The purpose of this study was to evaluate whether wound complication rates were (1) lower in V-Loc closure cases as theoretically suggested, (2) lower for subcuticular closure vs staples, and (3) significantly different for knee and hip joint reconstruction.A retrospective chart review was conducted of 278 consecutive cases of primary joint reconstruction performed by a single surgeon (L.P.). The study group comprised 106 men and 161 women. Average patient age at surgery was 63 years (range, 18-92 years), and average body mass index of the cohort was 33.7 kg/m(2) (range, 25-51 kg/m(2)). Skin was closed via staple gun or subcuticular stitch (3-0 Biosyn [Covidien] vs V-Loc). Seven (3.9%) wound complications occurred in 181 cases closed with staples. Four (7.8%) wound complications occurred in 51 cases closed via subcuticular Biosyn suture. Six (13.0%) wound complications occurred in 46 cases closed with V-Loc suture. The staple group had a lower rate of complications when compared with the suture group as a whole (P=.033) and when compared specifically with the V-Loc suture group (P=.017).

Complications of Femoral Nerve Blockade in Total Knee Arthroplasty and Strategies to Reduce Patient Risk

Femoral nerve catheters are widely used for analgesia in total knee arthroplasty. Although evidence suggests that catheters improve pain control and may facilitate short-term rehabilitation, few reports exist regarding their complications. This case series explores the experience of femoral nerve catheter use at high-volume orthopedic specialty hospitals. Serious complications including compartment syndrome, periprosthetic fracture, and vascular injury are reported. The authors support femoral nerve catheter use with appropriate precautions taken to reduce risk of patient falls, vascular injury, and wrong-site surgery.

How accurately are we coding readmission diagnoses after total joint arthroplasty

Readmission rates have been cited as an important quality measure in the Affordable Care Act. Accordingly, understanding and accurately tracking the causes for readmission will be increasingly important. We queried an electronic database for all patients who underwent primary THA or TKA at our institution from 2006 through 2010. We identified those readmitted within 90 days of surgery and analyzed 87 random de-identified medical records. We then assigned a clinical diagnosis for each readmission, which was then compared with the coder-derived diagnosis by ICD-9 code. The overall 90-day readmission rate was 7.9%. We identified 22 of 87 patients for whom there was disagreement (25.3%, 95% CI=16.6-35.8%). The most common were procedure-related complications. Coded diagnoses frequently did not correlate with the physician-derived diagnoses. The unverified use of coded readmission diagnoses in calculating quality measures may not be clinically relevant.

Productivity and Cost Implications of Implementing Electronic Medical Records Into an Ambulatory Surgical Subspecialty Clinic

OBJECTIVES Electronic medical records (EMRs) have been proposed as technology through which the quality of healthcare could be improved. We present an analysis of the cost and productivity implications associated with the transition from transcription to an EMR system in an ambulatory setting. METHODS Data were collected from eight consecutive fiscal years from 1998 to 2005. Transcription was used in the first 4-year period, and EMR was implemented and used in the later 4-year period. Productivity was defined as ambulatory revenue and the number of patient encounters. All costs related to transcription and EMR implementation were calculated. All data were adjusted for inflation. RESULTS Within the transcription era, the transcription costs were

A dose-ranging study of 0.5% bupivacaine or ropivacaine on the success and duration of the ultrasound-guided, nerve-stimulator-assisted sciatic nerve block: a double-blind, randomized clinical trial.

395,404, total revenue was

Clopidogrel and neuraxial block: the role of the PFA II and P2Y12 assays.

18,137,945, and patient encounters numbered 52,027. The average transcription cost per encounter was

Single-use instrumentation, cutting blocks, and trials decrease contamination during total knee arthroplasty: a prospective comparison of navigated and nonnavigated cases.

7.60, average revenue per encounter was