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INTRODUCTION: Although several studies identify risk factors for high-cost patients in an episode of care for total hip (THA) and knee arthroplasty (TKA), few have looked at cost outliers from a facility perspective. The purpose of this study was to use time-driven activity-based costing (TDABC) to identify characteristics of high-cost patients. METHODS: We reviewed a consecutive series of primary THA and TKA patients by 22 different surgeons at two hospitals between 2015 and 2020. Facility costs were calculated using a TDABC algorithm for their entire hospital stay. Patients in the top decile of costs were considered to be high-cost patients. Multivariate regression was done to identify independent patient factors that predicted high costs. RESULTS: Of the 8,647 patients we identified, 60.5% underwent THA and 39.5% underwent TKA. Implant purchase price accounted for 49.5% of total inpatient costs (mean $2,880), followed by intraoperative (15.9%, mean $925) and postoperative personnel costs (16.8%, mean $980). Implant price demonstrated the highest variation between high-cost and low-cost groups (4.4 times). Patient-related factors associated with high costs were female sex (OR = 1.332), Hispanic ethnicity (OR = 1.409), American Society of Anesthesiology score (OR = 1.658), need for transfusion (OR = 2.008), and lower preoperative HOOS/KOOS Jr (OR = 1.009). CONCLUSION: This study identifies several variables for patients at risk to have high facility costs after primary THA and TKA. From the hospital's perspective, efforts to reduce implant purchase prices may translate into substantial cost savings. At the patient level, multidisciplinary initiatives to optimize medical comorbidities, decrease transfusion risk, and control medication expenses in high-risk patients may narrow the existing variation in costs.

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PURPOSE: To improve value in health care delivery, a deeper understanding of the cost drivers in hand surgery is necessary. Time-driven activity-based costing (TDABC) more accurately reflects true resource use compared with traditional accounting methods. This study used TDABC to explore the facility cost of carpal tunnel release and identify preoperative characteristics of high-cost patients. METHODS: Using TDABC, we calculated the facility costs of 516 consecutive patients undergoing open carpal tunnel release at an orthopedic specialty hospital between 2015 and 2021. Patients in the top decile cost were defined as high-cost patients. Multivariable logistic regression was used to determine preoperative characteristics (age, sex, body mass index, race, ethnicity, Elixhauser comorbidity index, American Society of Anesthesiology score, preoperative Disabilities of the Arm, Shoulder and Hand score, Short-Form 12, and anesthesia type) independently associated with high-cost patients. RESULTS: Surgery-related personnel costs were the main driver (38.0%) of total facility costs, followed by preoperative personnel costs (21.3%). There was a 1.8-fold variation in facility cost between patients in the 90th and 10th percentiles ($774.69 vs $431.35), with the widest cost variations belonging to medication costs ($17.67 vs $1.85; variation, 9.6-fold) and other supply costs ($213.56 vs $65.56; variation, 3.3-fold). Using multivariable regression, predictors of high cost were patient age and use of general anesthesia. Total facility costs correlated strongly with the total operating room time and incision to closure time. CONCLUSIONS: Efforts to decrease operating room time may translate into reduced personnel costs and greater cost savings. Multidisciplinary initiatives to control medication expenses for patients at risk of high costs may narrow the existing variation in costs. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analysis II.

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BACKGROUND: Optimizing resource utilization after total joint arthroplasty (TJA) has become increasingly vital. The Activity Measure for Post-acute Care (AM-PAC) "6-clicks" scoring system is a validated, physical therapist (PT)-administered metric of patient basic mobility and predicts discharge disposition. This study aimed to determine whether the use of AM-PAC scoring by nurses in the postoperative period could (1) substitute for AM-PAC scoring by therapists and (2) predict 90-day outcomes in TJA patients. METHODS: We retrospectively reviewed all primary TJAs conducted by two surgeons at a single institution from 2019 to 2021. Patients underwent postoperative AM-PAC evaluation by nursing and physical therapy within 24 hours of surgery, and specific timing of nursing and PT scores was determined. Inter-rater reliability between therapy and nursing scores was analyzed. Multiple regression was used to determine the association between AM-PAC scores and readmissions, complications, length of stay, and nonhome discharge. RESULTS: In total, 1,119 patients were included. Agreement testing between therapy and nursing scores was weak for all six AM-PAC components, with a Spearman correlation of 0.437. Nursing scores were typically conducted earlier than therapist scores (204.0 ± 249.9 minutes versus 523.5 ± 449.4 minutes; P < 0.001). Therapy and nursing scores were not notable predictors for 90-day complications or readmissions. However, higher therapy and nursing scores were predictors of less than 2-day hospitalization (odds ratio [OR] 0.63, P < 0.001; OR 0.88, P < 0.001) and fewer nonhome discharges (OR 0.62, P < 0.001; OR 0.84, P < 0.001). CONCLUSION: Although nursing-driven mobility assessments could potentially improve efficiency of patient discharge and control costs, nursing AM-PAC scoring did not serve as an appropriate substitute for PT scoring in patients undergoing primary total hip and knee arthroplasty at our institution.

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Purpose: We assessed the rate of periprosthetic joint infection (PJI) following hand surgery in patients with prosthetic joints, and determined the efficacy of prophylactic antibiotics for preventing PJI in this patient subset. Methods: A systematic review of PubMed (MEDLINE) and Scopus (EMBASE, MEDLINE, COMPENDEX) from 1968 to 2021 was conducted. Primary articles that studied PJIs following hand surgery in patients with prosthetic joints (hip, knee, shoulder, elbow, or ankle) and/or the use of prophylactic antibiotics prior to hand surgery in patients with prosthetic joints were included. Results: A total of 3 studies (439,080 patients) met our inclusion criteria. Of the total study population, 9,070 patients (2.1%) had a prior total joint arthroplasty treated and subsequently underwent soft-tissue hand surgery. A single study reported a 0.2% prevalence of PJI secondary to hand surgery. The remaining 2 studies found no cases of PJI following hand surgery in patients with a history of total joint arthroplasty. On average, 16% (1,214 of 7,374) of patients with prosthetic joints received antibiotics prior to hand surgery. No significant relationships were found between hand surgery, antibiotic prophylaxis, and PJI risks. Conclusions: There is a very low reported incidence of PJI following hand surgery in patients with existing prosthetic joints, with or without the use of prophylactic antibiotics. Therefore, the authors do not recommend the routine use of prophylactic antibiotics in this patient subgroup. The decision to use prophylaxis should be made on a case-by-case basis, accounting for patient-specific comorbidities and risk factors. Further research on hand surgery-associated PJI is warranted. Type of study/level of evidence: Therapeutic III.

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BACKGROUND: The use of preoperative patient-reported outcome measure (PROM) thresholds for patient selection in arthroplasty care has been questioned recently. This study aimed to identify factors affecting achievement of the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) after total knee arthroplasty (TKA) and determine the overlap between the two outcomes. METHODS: We identified 1,239 primary, unilateral TKAs performed at a single institution in 2015-2019. PROMs including the Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and 12-item Short Form Health Survey (SF-12) were collected preoperatively and 1-year postoperatively. The likelihood of attaining PASS as per attainment of MCID was assessed. A multivariable regression was used to identify predictors of MCID and PASS. RESULTS: In total, 71.3% achieved MCID and 75.5% achieved PASS for KOOS-JR. Only 7.7% achieved MCID but not PASS, whereas almost twice this number did not achieve MCID but did achieve PASS (11.9%). Poorer preoperative KOOS-JR (OR 0.925), better SF-12 physical (OR 1.025), and mental (OR 1.027) were associated with MCID attainment. In contrast, better preoperative KOOS-JR (OR 1.030) and SF-12 mental (OR 1.025) were associated with PASS attainment. Age, gender, race, ethnicity, body mass index, Charlson index, American Society of Anesthesiologists classification, and smoking status were not significant predictors. CONCLUSION: Preoperative PROMs were associated with achieving MCID and PASS after TKA, albeit some positively and some negatively. In the era of value-based care, clinicians should not only strive to help patients "feel better" but also ensure that patients "feel good" after surgery. This study does not support the use of PROMs in prioritizing access to care.

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BACKGROUND: While injections within 90 days prior to total knee arthroplasty (TKA) are associated with an increased risk of periprosthetic joint infection (PJI), there is a paucity of literature regarding the impact of cumulative injections on PJI risk. This study was conducted to assess the association between cumulative corticosteroid and hyaluronic acid (HA) injections and PJI risk following TKA. METHODS: This retrospective study using an injection database included patients undergoing TKA with a minimum 1-year follow-up from 2015 to 2020. Patients with injections within 90 days prior to surgery were excluded. The sum of corticosteroid and HA injections within five years prior to TKA was recorded. The primary outcome was PJI within 90 days following TKA. Area under the curve (AUC) values were calculated for a cumulative number of injections. RESULTS: 648 knees with no injections and 672 knees with injections prior to TKA were included, among whom 243 received corticosteroids, 151 received HA, and 278 received both. No significant differences in early PJI rates existed between patients who received injections (0.60%) or not (0.93%) (P = .541). No significant differences existed in early PJI rates between patients injected with corticosteroids (0.82%), HA (0.66%), or both (0.36%) (P = .832). No cutoff number of injections was predictive for PJI. DISCUSSION: A cumulative amount of steroid or HA injections, if given more than 90 days prior to TKA, does not appear to increase the risk of PJI within 90 days postoperatively. Multiple intraarticular corticosteroid injections and HA injections may be safely administered before TKA, without increased risk for early PJI.

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BACKGROUND: The cost-effectiveness of robotic-assisted unicompartmental knee arthroplasty (RA-UKA) remains unclear. Time-driven activity-based costing (TDABC) has been shown to accurately reflect true resource utilization. This study aimed to compare true facility costs between RA-UKA and conventional UKA. METHODS: We identified 265 consecutive UKAs (133 RA, 132 conventional) performed at a specialty hospital in 2016-2020. Itemized facility costs were calculated using TDABC. Separate analyses including and excluding implant costs were performed. Multiple regression was performed to determine the independent effect of robotic assistance on facility costs. RESULTS: Due to longer operative time, RA-UKA patients had higher personnel costs and total facility costs ($2,270 vs $1,854, P < .001). Controlling for demographics and comorbidities, robotic assistance was associated with an increase in personnel costs of $399.25 (95% confidence interval [CI] $343.75-$454.74, P < .001), reduction in supply costs of $55.03 (95% CI $0.56-$109.50, P = .048), and increase in total facility costs of $344.27 (95% CI $265.24-$423.31, P < .001) per case. However, after factoring in implant costs, robotic assistance was associated with a reduction in total facility costs of $235.87 (95% CI $40.88-$430.85, P < .001) per case. CONCLUSION: Using TDABC, overall facility costs were lower in RA-UKA despite a longer operative time. To facilitate wider adoption of this technology, implant manufacturers may negotiate lower implant costs based on volume commitments when robotic assistance is used. These supply cost savings appear to offset a portion of the increased costs. Nonetheless, further research is needed to determine if RA-UKA can improve clinical outcomes and create value in arthroplasty.

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Identification of the causative organism(s) in periprosthetic joint infection (PJI) is a challenging task. The shortcomings of traditional cultures have been emphasized in recent literature, culminating in a clinical entity known as "culture-negative PJI." Amidst the growing burden of biofilm infections that are inherently difficult to culture, the field of clinical microbiology has seen a paradigm shift from culture-based to molecular-based methods. These novel techniques hold much promise in the demystification of culture-negative PJI and revolutionization of the microbiology laboratory. This article outlines the clinical implications of culture-negative PJI, common causes of this diagnostic conundrum, established strategies to improve culture yield, and newer molecular techniques to detect infectious organisms.

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BACKGROUND: Poor surgical ergonomics and physiological stress have been shown to impair surgical performance and cause injuries. The prevalence of musculoskeletal pain among arthroplasty surgeons is inordinately high. This study compared surgeon stress and strain during robotic-assisted total knee arthroplasty (rTKA) and conventional TKA (cTKA). METHODS: Continuous cardiorespiratory and ergonomic data of a single surgeon were measured during 40 consecutive unilateral TKAs (20 rTKAs, 20 cTKAs) using a smart garment and wearable sensors. Heart rate (HR), HR variability, respiratory rate, minute ventilation, and calorie expenditure were used as surrogate measures for physiological stress. Intraoperative ergonomics were assessed by measuring cervical and lumbar flexion, extension and rotation, and shoulder abduction/adduction. RESULTS: Mean operative time was longer for rTKA (48.2 ± 9 vs 31.8 ± 7 min, P < .001). Calories expended per minute was lower for rTKA (2.53 vs 3.50, P < .001). Total calorie expenditure in rTKA cases 11-20 was significantly lower than the first 10 (107.1 ± 27 vs 137.6 ± 24, P = .015), and lower than cTKA (112.3 ± 37). Mean HR was lower for rTKA (81.5 ± 4 vs 90.1 ± 5, P < .001). Minute ventilation was also lower for rTKA (14.9 ± 1 vs 17.0 ± 1.0 L/min, P < .001). Mean lumbar flexion as well as the percentage of time spent in a demanding flexion position >20° were significantly lower during rTKA (P < .001). CONCLUSION: rTKA resulted in less surgeon physiologic stress, energy expenditure per minute, and postural strain compared to cTKA. Robotic assistance may help to increase surgical efficiency and reduce physician workload, but further studies are needed to determine whether these benefits will reduce musculoskeletal pain and injury among surgeons.

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BACKGROUND: Payer coverage policies have recently begun requiring physical therapy (PT) prior to total hip arthroplasty and total knee arthroplasty (TKA). It remains controversial if such a mandate is appropriate for patients with end-stage, symptomatic osteoarthritis. The purpose of this study is to assess if such patients are amenable to delaying surgery for a trial of PT. METHODS: All patients scheduled for elective primary total hip arthroplasty and TKA in a 3-month period by 1 of 7 surgeons at a single institution were contacted and asked to participate in a survey. Participation in PT within the prior 6 months was noted. Patients were asked if they would be willing to delay surgery for a PT trial as a nonsurgical option to improve their symptoms. The primary reason for their answer was also recorded. RESULTS: In total, 200 patients were successfully contacted and agreed to participate. The mean age was 66 years, 47% were male, the mean body mass index was 31 kg/m2, and 66% were scheduled for TKA. In total, 157 patients (79%) stated they had not done PT in the preceding 6 months, and 185 patients (93%) stated they would not want to delay surgery for mandatory PT. The most common reasons for refusing PT were "surgery is inevitable" (44%) and "unlikely to improve pain" (29%). CONCLUSION: Patients with end-stage hip and knee osteoarthritis who are otherwise candidates for surgery appear overwhelmingly opposed to mandatory preoperative PT, mostly due to a lack of perceived efficacy in providing long-term symptom relief compared to total joint arhtroplasty.

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BACKGROUND: Although studies have compared the claims costs of simultaneous and staged bilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA), whether a simultaneous procedure is cost-effective to the facility remains unknown. This study aimed to compare facility costs and perioperative outcomes of simultaneous vs staged bilateral THA and TKA. METHODS: We reviewed a consecutive series of 560 bilateral THA (170 staged and 220 simultaneous) and 777 bilateral TKA (163 staged and 451 simultaneous). Itemized facility costs were calculated using time-driven activity-based costing. Ninety-day outcomes were compared. Margin was standardized to unadjusted Medicare Diagnosis Related Group payments (simultaneous, $18,523; staged, $22,386). Multivariate regression was used to determine the independent association between costs/clinical outcomes and treatment strategy (staged vs simultaneous). RESULTS: Simultaneous bilateral patients had significantly lower personnel, supply, and total facility costs compared with staged patients with no difference in 90-day complications between the groups. Multivariate analyses showed that overall facility costs were $1,210 lower in simultaneous bilateral THA (P < .001) and $704 lower in TKA (P < .001). Despite lower costs, margin for the facility was lower in the simultaneous group ($6,569 vs $9,225 for THA; $6,718 vs $10,067 for TKA; P < .001). CONCLUSION: Simultaneous bilateral TKA and THA had lower facility costs than staged procedures because of savings associated with a single hospitalization. With the increased Medicare reimbursement for 2 unilateral procedures, however, margin was higher for staged procedures. In the era of value-based care, policymakers should not penalize facilities for performing cost-effective simultaneous bilateral arthroplasty in appropriately selected patients.

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BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) now requires hospitals to publish charges for commonly performed procedures. This study aimed to evaluate compliance with the price transparency mandate and to determine if there is a correlation between hospital charges and episode-of-care claims costs and outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: We identified a consecutive series of 2476 Medicare patients who underwent primary THA or TKA from 2018 to 2019 at one of 18 hospitals. Each hospital website was explored to assess compliance with the new price transparency requirements. Demographics, comorbidities, complications, and readmissions were recorded. Ninety-day episode-of-care claims costs were calculated using CMS claims data. Multivariate regression was performed to determine whether hospital charges had any association with complications, readmissions, or episode-of-care costs. RESULTS: There was no correlation between published hospital charges and inpatient costs (r = 0.087), postacute care costs (r = 0.126), or episode-of-care costs (r = 0.131). When controlling for demographics and comorbidities, there was no association between published charges and complications (P = .433) or readmissions (P = .141). All hospitals posted some shoppable services information online, but only 7 (39%) were fully compliant by publishing all price data. Of the 11 hospitals (61%) publishing hospital THA and TKA charges, the mean charge was $48,325 (range, $12,625-$79,531). CONCLUSION: Published charges for TKA and THA had no correlation with episode-of-care claims costs and were not associated with clinical outcomes. Despite efforts by CMS to increase price transparency, few hospitals were fully compliant, and a wide range in published charges was found.

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INTRODUCTION: In an attempt to improve price transparency, the Centers for Medicare & Medicaid Services (CMS) now requires hospitals to post clear, accessible pricing data for common procedures. We aimed to determine how many top orthopaedic hospitals are compliant with the new regulation and whether there was any correlation between hospital charges and outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: The hospital websites of the top 101 orthopaedic hospitals per the US News & World Report 2020-2021 were explored to assess compliance with the price transparency requirement. We recorded the gross inpatient charge, cash price, payer-specific negotiated charge, and deidentified maximum and minimum payer rates for THA and TKA. Outcome metrics included hospital ranking and Medicare risk-adjusted arthroplasty readmission and complication rates. RESULTS: Although 94 hospitals (93%) posted some shoppable service information as required by CMS, only 21 hospitals (20%) were fully compliant. The mean inpatient charge for THA and TKA was $72,111 (range, $14,716 to $195,264), cash price was $39,027 (range, $2,920 to $110,858), and minimum and maximum payer rates were $16,140 and $57,949, respectively. Better hospital ranking was weakly correlated with higher charges (coefficient 0.223; P = 0.049). No correlation between charges and complications (P = 0.266) or readmissions (P = 0.735) was observed. CONCLUSION: Few hospitals are fully compliant with the new CMS price transparency regulations. We found a wide range of hospital charges for THA and TKA without correlation with complications or readmissions. Although efforts by CMS to increase price transparency should be welcomed, increased costs should be justified by quality in the era of value-based care.

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BACKGROUND: Cemented total knee arthroplasty (TKA) has been shown to have higher failure rates in obese patients, and cementless TKA may provide more durable fixation. This study compared outcomes and survivorship of obese patients undergoing cemented and cementless TKA of the same modern design. METHODS: We identified a consecutive series of 406 primary cementless TKA performed in obese patients with body mass index (BMI) ≥35 kg/m2 in 2013-2018. Each case was matched 1:1 with 406 cemented TKA based on age, sex, BMI, bearing surface, and year of surgery. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement and Short Form-12 were collected preoperatively, at 6 months and 2 years. Implant survivorship was recorded at mean 4.0 years (range 2.0-7.8). RESULTS: There was no difference in mean BMI between the cemented (38.6 ± 3.4 kg/m2; range, 35-60) and cementless cohorts (38.7 ± 3.3 kg/m2; range, 35-54; P = .706). Both groups had similar final postoperative scores and improvement in scores at 2 years. Furthermore, a similar percentage met the minimal clinically important difference (Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, 70.0% vs 71.2%, P = .700; Short Form-12 Physical, 74.1% vs 70.4%, P = .240). Both groups demonstrated high 7-year survivorship free from aseptic revision (99.0% vs 99.5%, P = .665). CONCLUSION: Obese patients with BMI ≥35 kg/m2 undergoing cementless and cemented TKA of the same modern design had similar outcomes and survivorship at early to mid-term follow-up. Continued surveillance of this high-risk population is necessary.

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BACKGROUND: Most studies on cementless total knee arthroplasty (TKA) have excluded patients >75 years due to concerns that older patients have poorer bone mineral density and osteogenic activity. This study compared the midterm outcomes and survivorship of cemented and cementless TKA of the same modern design performed in patients >75 years. METHODS: We identified a consecutive series of 120 primary cementless TKA performed in patients >75 years. Each case was propensity score matched 1:3 with 360 cemented TKA of the same modern design based on age, sex, body mass index, Charlson Comorbidity Index, bilateral procedures, liner type, and year of surgery. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and Short Form-12 (SF-12) were collected preoperatively, at 6 months and 2 years. Implant survivorship was recorded at mean 4.2 years (range, 2.0-7.9). RESULTS: Mean age was 79.0 ± 3.4 years (range, 75-92) in the cemented cohort and 78.9 ± 3.5 (range, 75-91) in the cementless cohort (P = .769). There was no difference in final postoperative scores or improvement in scores at 2 years. The percentage of patients that met the minimal clinically important difference was also similar (KOOS-JR, 68.9% vs 69.2%, P = .955; SF-12 Physical, 71.7% vs 66.7%, P = .299). Seven-year survivorship free from aseptic revision was 99.4% for cemented knees and 100% for cementless knees (log-rank, P = .453). CONCLUSION: Patients over 75 years undergoing cementless or cemented TKA of the same modern design had comparable outcomes and survivorship in the midterm. The theoretical risks of cementless fixation in this age group were not realized in this study.

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BACKGROUND: Preoperative coagulopathy is a risk factor for perioperative blood loss. The antifibrinolytic effects of tranexamic acid (TXA) could negate the association between preoperative coagulopathy and adverse outcomes in patients undergoing total joint arthroplasty (TJA). However, no studies have evaluated this relationship. This study compared the perioperative outcomes of coagulopathic patients undergoing TJA who did and did not receive TXA. METHODS: We retrospectively reviewed 2123 primary TJAs (975 knees and 1148 hips) performed in patients with a preoperative coagulopathy. Coagulopathy was defined as international normalized ratio >1.2, partial thromboplastin time >35 seconds, or platelet count <150,000/µL. TXA was administered in 240 patients and not administered in 1883 patients. Demographics, comorbidities, and surgical details including operative time, blood loss, and thromboprophylaxis agent were recorded. Multivariate regression was used to identify factors associated with 90-day outcomes. RESULTS: Patients who received TXA had less intraoperative blood loss and 2.3 times decreased risk of 90-day complications (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.20-0.85, P = .021), especially cardiovascular (2.92% vs 12.1%, P <.001) and wound complications (0.0% vs 1.59%, P = .042). TXA was also associated with shorter length of stay (beta 0.74, 95% CI 0.67-0.82, P <.001) and decreased risk of nonhome discharge (OR 0.50, 95% CI 0.29-0.83, P = .009). There was no difference in mortality or 90-day readmissions between the groups. CONCLUSION: TXA administration decreased the incidence of perioperative complications and resource utilization in patients undergoing arthroplasty with a preoperative coagulopathy identified on preadmission testing. These findings support the broader adoption of TXA in patients undergoing TJA, particularly when the patient has a preoperative coagulopathy.

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BACKGROUND: As a procedure with lower surgical morbidity, unicompartmental knee arthroplasty (UKA) may present a practical solution for elderly patients with unicompartmental arthritis. However, few studies have analyzed the results of UKA in the extreme elderly. This study compared the functional and perioperative outcomes between octogenarians and age-appropriate controls undergoing UKA. METHODS: Prospectively collected data of 44 patients aged ≥80 years who underwent unilateral UKA were analyzed. Each octogenarian was matched 1:3 with 132 patients aged 65-74 years using propensity scores adjusting for gender, body mass index, Charlson comorbidity index, and preoperative scores. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement and Short Form-12 were collected preoperatively and 2 years postoperatively. Complications, reoperations, readmissions, and unplanned visits were recorded up to 1 year postoperatively. RESULTS: The mean age was 70.0 ± 2.7 years in the control group and 83.0 ± 3.0 years in the octogenarian group (P < .001). The percentage of outpatient procedures was comparable (control 50.0%; octogenarian 45.5%; P = .601). With the exception of poorer Short Form-12 physical scores in octogenarians at 2 years (39.4 ± 14.1 vs 44.9 ± 9.2, P = .028), there was no difference in final postoperative scores or improvement in scores between the groups. The rate of complications, reoperations, readmissions, and emergency room visits was also similar. The five-year survivorship was 97% in the control group and 93% in the octogenarian group (P = .148). CONCLUSION: Octogenarians undergoing UKA can experience clinical outcomes that are similar to those of their younger counterparts. The clinical trajectory outlined may help clinicians provide valuable prognostic information to elderly patients and guide preoperative counseling.

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BACKGROUND: Optimizing surgical trays to improve operating room efficiency and reduce costs in instrument processing is an under-appreciated strategy for cost containment. This study aimed to assess the economic impact of instrument tray optimization in total joint arthroplasty. METHODS: Thirty-five randomly selected elective primary total knee arthroplasty and total hip arthroplasty performed by 4 fellowship-trained surgeons were analyzed. Type and number of instruments used as well as timing of different steps in the sterilization process were recorded by an independent observer. Using Lean methodology, surgeons identified redundant or underutilized instruments and agreed upon the fewest number needed for each tray. Instrument utilization rates and processing time were analyzed before and after tray modifications. Annual cost savings were calculated based on a processing factor of $0.59-$11.52 per instrument. RESULTS: Only 45.5% of instruments opened for total knee arthroplasty were utilized. After optimization, 28 of 87 (32.2%) instruments were removed and the remainder could be stored in one tray. Mean set-up time decreased from 20.7 to 14.2 minutes, while 40-75 minutes were saved during the sterilization process. For total hip arthroplasty, only 36.0% of instruments were utilized. Using Lean methods, 46 of 112 (41.1%) instruments were removed and tray count was reduced to 2 trays. Mean set-up time decreased from 27.9 to 18.6 minutes, while 45-150 minutes were saved during processing. Average annual savings amounted to $281,298.05. CONCLUSION: Lean methodology can be used to eliminate redundant or underutilized instruments in total joint arthroplasty, improving surgical efficiency and generating substantial cost savings.

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BACKGROUND: Instability remains the most common complication after revision total hip arthroplasty (THA) and presents a unique treatment dilemma for the orthopedic surgeon. Dual mobility (DM) bearing articulations have been used in France since the 1970s, but have only become more widely adopted in the United States over the last decade. The purpose of this symposium was to discuss the role for DM bearings in revision THA. METHODS: We reviewed the existing literature on outcomes after DM bearing articulations in revision THA. We also report several case examples of the use of DM in difficult revision THA cases, including acetabular bone loss, failed constrained liner, and adverse local tissue reaction. Finally, we briefly discuss the limitations associated with the use of DM. RESULTS: Several large retrospective series demonstrate that DM bearings reduce the incidence of dislocation after revision THA when compared with conventional single bearing THA. Specific complications related to DM bearings including polyethylene wear, loosening, intraprosthetic dislocation, and corrosion remain a concern, but appear to have drastically improved over time with modern implant designs. CONCLUSION: Contemporary DM designs have been established as an effective bearing option to reduce instability in revision THA, although concerns do exist. High-quality prospective studies are necessary to further define the role this bearing option has in the coming years.

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