Stephen Yu

Improvement in Total Joint Replacement Quality Metrics: Year One Versus Year Three of the Bundled Payments for Care Improvement Initiative.

BACKGROUND In January 2013, a large, tertiary, urban academic medical center began participation in the Bundled Payments for Care Improvement (BPCI) initiative for total joint arthroplasty, a program implemented by the Centers for Medicare & Medicaid Services (CMS) in 2011. Medicare Severity-Diagnosis Related Groups (MS-DRGs) 469 and 470 were included. We participated in BPCI Model 2, by which an episode of care includes the inpatient and all post-acute care costs through 90 days following discharge. The goal for this initiative is to improve patient care and quality through a patient-centered approach with increased care coordination supported through payment innovation. METHODS Length of stay (LOS), readmissions, discharge disposition, and cost per episode of care were analyzed for year 3 compared with year 1 of the initiative. Multiple programs were implemented after the first year to improve performance metrics: a surgeon-directed preoperative risk-factor optimization program, enhanced care coordination and home services, a change in venous thromboembolic disease (VTED) prophylaxis to a risk-stratified protocol, infection-prevention measures, a continued emphasis on discharge to home rather than to an inpatient facility, and a quality-dependent gain-sharing program among surgeons. RESULTS There were 721 Medicare primary total joint arthroplasty patients in year 1 and 785 in year 3; their data were compared. The average hospital LOS decreased from 3.58 to 2.96 days. The rate of discharge to an inpatient facility decreased from 44% to 28%. The 30-day all-cause readmission rate decreased from 7% to 5%; the 60-day all-cause readmission rate decreased from 11% to 6%; and the 90-day all-cause readmission rate decreased from 13% to 8%. The average 90-day cost per episode decreased by 20%. CONCLUSIONS Mid-term results from the implementation of Medicare BPCI Model 2 for primary total joint arthroplasty demonstrated decreased LOS, decreased discharges to inpatient facilities, decreased readmissions, and decreased cost of the episode of care in year 3 compared with year 1, resulting in increased value to all stakeholders involved in this initiative and suggesting that continued improvement over initial gains is possible.

Preventing hospital readmissions and limiting the complications associated with total joint arthroplasty

Total joint arthroplasty is a highly successful surgical procedure for patients with painful arthritic joints. The increasing prevalence of the procedure is generating significant expenditures in the American healthcare system. Healthcare payers, specifically the Center for Medicare and Medicaid Services, currently target total joint arthroplasty as an area for healthcare cost-savings initiatives, resulting in increased scrutiny surrounding orthopaedic care, health resource utilization, and hospital readmissions. Identifying the complications associated with total hip and total knee arthroplasty that result in readmissions will be critically important for predictive modeling and for decreasing the number of readmissions following total joint arthroplasty. Additionally, improving perioperative optimization, providing seamless episodic care, and intensifying posthospital coordination of care may result in a decreasing number of unnecessary hospital readmissions. Identified modifiable risk factors that significantly contribute to poor clinical outcome following total joint arthroplasty include morbid obesity; poorly controlled diabetes and nutritional deficiencies; Staphylococcus aureus colonization; tobacco use; venous thromboembolic disease; cardiovascular disease; neurocognitive, psychological, and behavioral problems; and physical deconditioning and fall risk. Both clinical practice and research will be enhanced if there is standardization of defined total joint arthroplasty complications and utilization of stratification schemes to identify high-risk patients. Subsequently, clinical intervention would be warranted to address modifiable risk factors before proceeding with total joint arthroplasty.

Pain Control and Functional Milestones in Total Knee Arthroplasty: Liposomal Bupivacaine versus Femoral Nerve Block.

BackgroundAlthough pain management after total knee arthroplasty (TKA) affects rehabilitation, length of stay, and functional outcomes, pain management for patients undergoing TKA has yet to be standardized. Femoral nerve blocks (FNBs) are commonly used as an adjunct; however, these can result in transient quadriceps weakness and have been associated with in-hospital falls. Periarticular infiltration of liposomal bupivacaine has been recently introduced as a long-acting analgesic that can be administered without affecting motor function.Questions/purposes(1) Does periarticular liposomal bupivacaine compared with FNB result in improved pain control as measured by pain scores and narcotic consumption? (2) How do liposomal bupivacaine and FNB compare in terms of gait and stairclimbing milestones and the proportion of patients who experienced a fall in the hospital?MethodsBetween September 2013 and October 2014, a retrospective analysis was conducted involving 24 surgeons who performed a total of 1373 unilateral, primary TKAs. From September 2013 to April 2014, the routine approach to TKA pain management pathway consisted of preoperative administration of oral analgesics, intraoperative anesthesia (preferred spinal or general), an ultrasound-guided FNB, intraoperative analgesic cocktail injection, patient-controlled analgesia, and oral and IV narcotics for pain as needed. A total of 583 patients were included in this study group. Starting May 2014, FNBs were discouraged and there was department-wide adoption of liposomal bupivacaine. Liposomal bupivacaine became routinely used in all patients undergoing TKA with no other changes made to the multimodal analgesia protocol at that time, and 527 patients in this study group were compared with the FNB cohort. Chart review on a total of 1110 patients was conducted by a research assistant who was not participating in patient care. During the inpatient stay, pain scores during 8-hour intervals, narcotic use, and physical therapy milestones were compared.ResultsWith the numbers available, we detected no clinically important difference in pain scores throughout the hospital stay; however, patients treated with liposomal bupivacaine consumed very slightly less narcotics overall (96 ± 62 versus 84 ± 73 eq mg of morphine; [95% confidence interval, 11–13 mg]; p = 0.004) through postoperative Day 2 of inpatient hospitalization. Seventy-seven percent (406 of 527) of patients receiving liposomal bupivacaine achieved their gait milestones of clearing 100 feet of ambulation versus 60% (349 of 583) of patients receiving FNB (p < 0.001) before discharge. Likewise, 94% (497 of 527) of patients receiving liposomal bupivacaine completed stairs compared with 73% (427 of 583) of patients receiving FNB (p < 0.001). Patients who received liposomal bupivacaine were less likely to experience a fall during the hospital stay than were patients treated with FNB (3 of 527 [0.6%] versus 12 of 583 [2%]; p = 0.03).ConclusionsIn the absence of strong data supporting FNB over liposomal bupivacaine, we have modified our TKA pain management protocols by adopting liposomal bupivacaine in lieu of FNBs, facilitating rapid rehabilitation while providing adequate pain control.Level of EvidenceLevel III, therapeutic study.

Shoulder arthroplasty in New York State, 1991 to 2010: changing patterns of utilization

BACKGROUND Shoulder arthroplasty is now used to treat an expanding variety of glenohumeral disorders. METHODS This study assessed the demographic patterns and utilization rates of shoulder hemiarthroplasty (HA) and anatomic or reverse total shoulder arthroplasty (TSA) within New York State (NYS) from 1991 to 2010. Using the New York Statewide Planning and Research Cooperative System database, all shoulder arthroplasty procedures that occurred within NYS during the study period were retrospectively identified and analyzed. RESULTS During the 20-year period, 24,040 shoulder arthroplasty procedures were performed. During the second decade (2001-2010), there was a 393% increase in utilization of TSA with a 98% increase in HA. This disproportionate increase is likely due to the introduction and expanding indications of reverse TSA as an effective procedure in place of HA for the treatment of proximal humerus fractures and rotator cuff arthropathy, as rotator cuff arthropathy as a primary indication for HA was significantly less prevalent in period 2. Also notable was an identifiable disparity in race; whites represented approximately 80% of the shoulder arthroplasty procedures in both decades, whereas African Americans made up <5%. This is significantly different from the general racial demographics of NYS during both periods analyzed. DISCUSSION It is clear that the volume of shoulder arthroplasty procedures performed in NYS is increasing, mirroring the national experience. This trend reflects the expanding indications, the general success of these procedures, the aging demographic of our population, and a greater desire and willingness of patients to consider operative management to maintain or to improve quality of life.

Prostatic Abscess Due to Candida Tropicalis in a Nonacquired Immunodeficiency Syndrome Patient

We report a case of prostatic abscess due to Candida tropicalis in a nonacquired immunodeficiency syndrome patient with diabetes. The diagnosis and management are discussed, and the literature is reviewed.

Risk-Stratified Venous Thromboembolism Prophylaxis After Total Joint Arthroplasty: Aspirin and Sequential Pneumatic Compression Devices vs Aggressive Chemoprophylaxis

BACKGROUND Venous thromboembolism (VTE) is a major concern after total joint arthroplasty (TJA). We evaluated a risk-stratified prophylaxis protocol for patients undergoing TJA. METHODS A total of 2611 TJA patients were retrospectively studied. Patients treated with an aggressive VTE chemoprophylaxis protocol were compared with patients treated with a risk-stratified protocol utilizing aspirin and sequential pneumatic compression devices (SPCDs) for standard-risk patients and targeted anticoagulation for high-risk patients. RESULTS We found equivalence in terms of VTE prevention between the 2 cohorts. There was a decrease in adverse events and readmissions among the risk-stratified cohort, although this did not reach statistical significance. A statistically significant reduction in costs (P < .001) was experienced with the use of aspirin/SPCDs compared with aggressive anticoagulation agents within the risk-stratified cohort. CONCLUSION The use of aspirin/SPCDs in a risk-stratified TJA population is a safe and cost-effective method of VTE prophylaxis.

Two-stage revision for infected shoulder arthroplasty

BACKGROUND Periprosthetic shoulder infections (PSIs) are challenging to treat and often result in significant patient morbidity. Without a standardized treatment protocol, PSIs are often managed similarly to periprosthetic hip and knee infections. Because 2-stage revision is the gold standard for treating periprosthetic hip and knee infections, we performed a case series and literature review to determine its effectiveness in PSIs. METHODS We identified 19 patients (14 men) from our institution who were treated with a 2-stage revision after presenting with a PSI. Mean patient age was 63 ± 9 years, and average body mass index was 30.8 ± 5.8. The average time from the index arthroplasty to treatment was 40 months, 8 of 13 positive cultures were Propionibacterium acnes, and 9 of 19 patients had multiple shoulder operations before presenting with infection. Minimum follow-up for all patients was 2 years. RESULTS After a mean follow-up of 63 months (range, 25-184 months), 15 of 19 patients in our study were successfully treated for PSI. Average postoperative American Shoulder and Elbow Surgeons (ASES) Shoulder Assessment score was 69 (range, 32-98) and average postoperative forward elevation was significantly increased from 58° to 119° (P < .001). The incidence of recurrent infection was 26%. The rate of noninfection complications was 16%, for a total complication rate of 42%. CONCLUSION In patients with PSIs, especially those with intractable, chronic infections, a 2-stage revision represents a viable treatment option for eradicating infection and restoring function. However, it is important to recognize the risk of recurrent infection and postoperative complications in this challenging patient population.

Definitive Treatment of Infected Shoulder Arthroplasty With a Cement Spacer

Infection in the setting of shoulder arthroplasty can result in significant pain, loss of function, and the need for additional surgery. As the use of shoulder arthroplasty increases, the medical and economic burdens of periprosthetic joint infection increase as well. The ideal management of infected shoulder prostheses has not been established. This report describes 9 patients from a single institution who had an infected shoulder arthroplasty that was definitively managed with a cement spacer. All patients had a minimum of 2 years of follow-up. Of the 9 patients in this study, 6 were men. Mean age was 73±9 years. Of the study patients, 1 had diabetes, 2 presented with Parkinsons disease, and 5 had a history of tobacco use. Average body mass index was 27.9±7 kg/m(2). After mean follow-up of 4 years, none of the patients had clinical or radiographic evidence of infection. Functional outcomes, as measured by American Shoulder and Elbow Surgeons scores, were good or fair in 89% of patients, and the average American Shoulder and Elbow Surgeons score was 57. A review of recent literature suggested that the current findings were similar to those in studies reporting 1- or 2-stage revision procedures. Although cement spacers are typically used as part of a 2-stage revision procedure, the current findings suggest that cement spacers can be used effectively to eradicate infection and allow for acceptable functional recovery and range of motion in patients who have severe medical comorbidities and cannot tolerate additional surgery. [Orthopedics. 2016; 39(5):e924-e930.].

Long Term Treatment Results for Deep Infections of Total Knee Arthroplasty

This study aims to identify the long-term outcomes of total knee arthroplasty (TKA) treated for deep infection. 3270 consecutive primary and 175 revision TKAs were followed prospectively. There were 39 deep infections (1.16%): 29 primary (0.9%) and 10 revision (5.7%) cases. Two-stage resection and re-implantation procedure was performed in 13 primary cases with 10/13 (77%) successfully resolved. Early (<1 month) Irrigation and Debridement (I&D) was performed in 16 primary cases with 100% success. Late (>4 months) I&D was performed in 6 cases with 5/6 (83.3%) successful. Infection following revision TKA resulted in poor outcomes with both two-stage (2/4 successful) and I&D (2/6 successful). Deep infection after primary TKA can be successfully resolved with I&D and appropriate antibiotic treatment in the early postoperative course.

Conversion to Reverse Total Shoulder Arthroplasty with and without Humeral Stem Retention: The Role of a Convertible-platform Stem

Background: Revision shoulder arthroplasty is a technically challenging procedure. It is associated with increased blood loss and operative time, and it frequently necessitates revision implants, augments, and bone-grafting. Shoulder arthroplasty systems with a convertible-platform humeral stem have been developed to reduce the complexity of revision procedures by eliminating the need for humeral component explantation when converting from anatomic shoulder arthroplasty (hemiarthroplasty or total shoulder arthroplasty) to reverse total shoulder arthroplasty (rTSA). Methods: A multicenter, retrospective analysis involving 102 consecutive shoulders (102 patients) that underwent revision of an anatomic shoulder arthroplasty to an rTSA was conducted. During the revision, 73 of the shoulders needed exchange of the humeral stem (the exchange group) and 29 had retention of a convertible-platform humeral component (the retention group). Patient demographics, operative time, blood management, range of motion, complications, and patient-reported outcomes were compared between the 2 groups. Results: Patients with retention had significantly shorter operative time (mean and standard deviation, 130 ± 48 versus 195 ± 58 minutes; p < 0.001) and lower estimated blood loss (292 ± 118 versus 492 ± 334 mL; p = 0.034). The rate of intraoperative complications was lower in the retention group (0% versus 15%; p = 0.027). Patients with retention had slightly better postoperative range of motion (active external rotation, 26° ± 23° versus 11° ± 23° [p = 0.006]; active forward elevation, 112° ± 37° versus 96° ± 33° [p = 0.055]). Conclusions: Shoulder arthroplasty systems that utilize a convertible-platform humeral stem offer an advantage for rTSA conversion in that a well-fixed, well-positioned humeral stem can be retained. There were significantly fewer complications as well as significantly decreased blood loss and operative time when a convertible-platform stem was utilized (p < 0.050). Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.