Assuntos
Anestesia por Condução , Artroplastia de Quadril , Bloqueio Nervoso , Cirurgiões Ortopédicos , Humanos , Dor , Estados UnidosRESUMO
BACKGROUND: Anterior cruciate ligament (ACL) deficiency is commonly considered a contraindication for unicompartmental knee arthroplasty (UKA). The purpose of this study is to compare the outcomes of UKA after prior ACL reconstruction (rACL cohort) to UKA with an intact native ACL (nACL cohort). METHODS: Forty-five patients from 3 institutions who underwent medial UKA after prior rACL were matched by age, gender, preoperative function scores, and body mass index to 90 patients who underwent UKA with an intact nACL. Primary outcomes were Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Oxford Knee Scores, Knee Society Functional Scores, and Kellgren-Lawrence scores in the unresurfaced, lateral tibiofemoral compartment. Secondary outcomes were postoperative complications and the need for revision to TKA. RESULTS: At a mean of 3.6 years, all PROMs improved significantly with no differences identified between groups. The incidence of revision TKA was similar between cohorts (P = 1.00); however, the mean time to revision for progressive osteoarthritis was 4.0 years in the nACL group and 2.2 years in the rACL group. Twenty percent of rACL patients had a postoperative complication compared to 8% in the nACL group. Despite presenting with a similar degree of lateral arthritis, a greater percentage of patients developed Kellgren-Lawrence scores of ≥3 in the rACL cohort (9%) than in the nACL cohort (0%). CONCLUSION: A previously reconstructed ACL does not appear to compromise the short-term functional outcomes of UKA; however, there is a higher rate of minor complications and progression of lateral compartment arthritis, which should be considered with patients in the shared decision process.
Assuntos
Reconstrução do Ligamento Cruzado Anterior , Artroplastia do Joelho , Osteoartrite do Joelho , Ligamento Cruzado Anterior/cirurgia , Artroplastia do Joelho/efeitos adversos , Humanos , Articulação do Joelho/diagnóstico por imagem , Articulação do Joelho/cirurgia , Osteoartrite do Joelho/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Implementation of rapid recovery protocols and value-based programs in total joint arthroplasty (TJA) has required changes in preoperative management, such as optimization, education, and coordination. This study aimed to quantify the work burden associated with preoperative TJA care. METHODS: Two web-based surveys were distributed to surgeon members of the American Association of Hip and Knee Surgeons. The first questionnaire (265 respondents) consisted of questions related to preoperative patient care in TJA and the associated work burden by orthopedic surgeons and their financially dependent health care providers. The second survey (561 respondents) consisted of questions related to relative change in preoperative patient care work burden since 2013. RESULTS: Greater than 98% of survey respondents reported providing some level of preoperative medical optimization to their patients. The mean amount of reported time spent by the surgeon and/or a qualified health care provider in preoperative activities not included in work captured in current procedural terminology or hospital billing codes was 153 minutes. The mean amount of reported time spent by ancillary clinical staff in preoperative activities was 177 minutes. Most surgeons reported an increase in work burden for total knee (86%) and total hip (87%) arthroplasty since 2013, with a large portion reporting a 20% or greater increase in work (knee 66%, hip 64%). CONCLUSION: To provide quality arthroplasty care with marked reductions in complication rates, lengths of stay, and readmissions, members of the American Association of Hip and Knee Surgeons report a substantial preoperative work burden that is not included in current coding metrics. Policy makers should account for this time in coding models to continue to promote pathway improvements.
Assuntos
Artroplastia de Quadril , Artroplastia do Joelho , Cirurgiões , Humanos , Articulação do Joelho , Inquéritos e Questionários , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Total knee arthroplasty (TKA) was removed from the Centers for Medicare and Medicaid Services (CMS) Inpatient-Only (IPO) list starting January 1, 2018. Many hospitals responded by instructing surgeons to schedule all TKAs as outpatient procedures, and some local Medicare Advantage contractors began to expect outpatient status for all or most TKA cases. This activity and ensuing confusion has caused considerable unintended disruption for surgeons, hospitals, and patients. The purpose of this study was to gauge the impact on providers and patients. METHODS: Active members of the American Association of Hip and Knee Surgeons were sent a 9-question survey asking if the surgeon's hospital was treating all patients undergoing TKA as outpatients and if Medicare Advantage administrators and commercial payers were treating all or most the same. Questions also inquired about the impact on surgeon practices and their patients. RESULTS: Seven hundred thirty members (26%) responded; of which, 59.5% reported that their hospitals have instructed them that all Medicare TKAs should be scheduled as outpatient procedures; 40.5% have been asked to use proscribed documentation to justify that change; 30.4% reported that their patients have incurred added personal cost secondary to their surgical procedure being billed as an outpatient procedure; and 76.1% report that this issue has become an administrative burden. CONCLUSION: The CMS clearly stated its expectation in the 2018 Outpatient Prospective Payment System Final Rule that the great majority of Medicare fee-for-service TKA patients would continue to be treated as inpatients. Nonetheless, many hospitals have decided to schedule all TKA cases as outpatients due to the 2-midnight rule despite a moratorium on recovery audits. It is the position of the American Association of Hip and Knee Surgeons that the CMS needs to provide more specific expectations concerning the needed language justifying admission or exempt TKA from the 2-midnight rule to mitigate the unintended confusion demonstrated by hospitals and some payers that has resulted from the removal of TKA from the Inpatient-Only list.
Assuntos
Procedimentos Cirúrgicos Ambulatórios , Artroplastia do Joelho , Centers for Medicare and Medicaid Services, U.S./normas , Cirurgiões Ortopédicos/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado , Hospitais , Humanos , Pacientes Internados , Medicaid , Medicare , Pacientes Ambulatoriais , Estados UnidosRESUMO
BACKGROUND: The introduction of the Musculoskeletal Infection Society (MSIS) criteria for periprosthetic joint infection (PJI) in 2011 resulted in improvements in diagnostic confidence and research collaboration. The emergence of new diagnostic tests and the lessons we have learned from the past 7 years using the MSIS definition, prompted us to develop an evidence-based and validated updated version of the criteria. METHODS: This multi-institutional study of patients undergoing revision total joint arthroplasty was conducted at 3 academic centers. For the development of the new diagnostic criteria, PJI and aseptic patient cohorts were stringently defined: PJI cases were defined using only major criteria from the MSIS definition (n = 684) and aseptic cases underwent one-stage revision for a noninfective indication and did not fail within 2 years (n = 820). Serum C-reactive protein (CRP), D-dimer, erythrocyte sedimentation rate were investigated, as well as synovial white blood cell count, polymorphonuclear percentage, leukocyte esterase, alpha-defensin, and synovial CRP. Intraoperative findings included frozen section, presence of purulence, and isolation of a pathogen by culture. A stepwise approach using random forest analysis and multivariate regression was used to generate relative weights for each diagnostic marker. Preoperative and intraoperative definitions were created based on beta coefficients. The new definition was then validated on an external cohort of 222 patients with PJI who subsequently failed with reinfection and 200 aseptic patients. The performance of the new criteria was compared to the established MSIS and the prior International Consensus Meeting definitions. RESULTS: Two positive cultures or the presence of a sinus tract were considered as major criteria and diagnostic of PJI. The calculated weights of an elevated serum CRP (>1 mg/dL), D-dimer (>860 ng/mL), and erythrocyte sedimentation rate (>30 mm/h) were 2, 2, and 1 points, respectively. Furthermore, elevated synovial fluid white blood cell count (>3000 cells/µL), alpha-defensin (signal-to-cutoff ratio >1), leukocyte esterase (++), polymorphonuclear percentage (>80%), and synovial CRP (>6.9 mg/L) received 3, 3, 3, 2, and 1 points, respectively. Patients with an aggregate score of greater than or equal to 6 were considered infected, while a score between 2 and 5 required the inclusion of intraoperative findings for confirming or refuting the diagnosis. Intraoperative findings of positive histology, purulence, and single positive culture were assigned 3, 3, and 2 points, respectively. Combined with the preoperative score, a total of greater than or equal to 6 was considered infected, a score between 4 and 5 was inconclusive, and a score of 3 or less was not infected. The new criteria demonstrated a higher sensitivity of 97.7% compared to the MSIS (79.3%) and International Consensus Meeting definition (86.9%), with a similar specificity of 99.5%. CONCLUSION: This study offers an evidence-based definition for diagnosing hip and knee PJI, which has shown excellent performance on formal external validation.
Assuntos
Artrite Infecciosa/diagnóstico , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Infecções Relacionadas à Prótese/diagnóstico , Reoperação/estatística & dados numéricos , Líquido Sinovial/química , Idoso , Área Sob a Curva , Artrite Infecciosa/etiologia , Sedimentação Sanguínea , Proteína C-Reativa/análise , Hidrolases de Éster Carboxílico , Testes Diagnósticos de Rotina , Medicina Baseada em Evidências , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Secções Congeladas , Humanos , Inflamação/cirurgia , Articulação do Joelho/cirurgia , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/etiologia , Sensibilidade e Especificidade , Adulto JovemRESUMO
BACKGROUND: In patients with adverse local tissue reaction (ALTR) secondary to a failed metal-on-metal (MoM) bearing or corrosion at the head-neck junction in a metal-on-polyethylene bearing, ruling in or out periprosthetic joint infection (PJI) can be challenging. Alpha-defensin has emerged as an accurate test for PJI. The purpose of this multicenter, retrospective study was to evaluate the accuracy of the alpha-defensin synovial fluid test in detecting PJI in patients with ALTR. METHODS: We reviewed medical records of 26 patients from 3 centers with ALTR that had an alpha-defensin test performed. Patients were assessed for PJI using the Musculoskeletal Infection Society criteria. Thirteen of these subjects had MoM total hip arthroplasty, 9 had ALTR secondary to head-neck corrosion, and 4 had MoM hip resurfacing. RESULTS: Only 1 of the 26 patients met Musculoskeletal Infection Society criteria for infection. However, 9 hips were alpha-defensin positive, including 1 true positive and 8 that were falsely positive (31%). All 8 of the false positives were also Synovasure positive, although 5 of 8 had an accompanying warning stating the results may be falsely positive due to a low synovial C-reactive protein value. CONCLUSION: Similar to synovial fluid white blood cell count, alpha-defensin testing is prone to false-positive results in the setting of ALTR. Therefore, we recommend an aggressive approach to ruling out PJI including routine aspiration of all hips with ALTR before revision surgery to integrate the synovial fluid blood cell count, differential, cultures and adjunctive tests like alpha-defensin to allow for accurate diagnosis preoperatively.