Common Orthopedic Surgeries Research Articles

Time-Driven Activity-based Costing for Anterior Cruciate Ligament Reconstruction: A Comparison to Traditional Accounting Methods

PurposeThe primary purpose of this study was to compare the cost of care of one of the most common sports medicine surgical procedures, anterior cruciate ligament reconstruction (ACLR), using the time-driven activity-based costing (TDABC) method to traditional accounting methods such as activity-based costing (ABC). Our secondary purpose was to identify the main drivers of the cost of ACLR using both of these techniques.MethodsA process map of ACLR was constructed through direct observation in the clinical setting according to established techniques to identify drivers of fixed, direct variable, and indirect costs. An episode of care consisted of each step in the surgical process from admission to discharge. Personnel costs were combined with the process map to determine the cost drivers and overall cost of the procedure. The cost generated from the TDABC method was compared with the cost from our institution’s internal accounting system, which used an ABC method.ResultsThe total cost of ACLR was $5,242.25 when using TDABC versus $10,318 when using the traditional ABC method. The largest difference between the 2 methods was within the domain of direct variable costs.ConclusionsWhen compared with TDABC, the hospital’s traditional cost-accounting estimate for ACLR is nearly twice as costly. These findings highlight the variability of cost calculation for the same clinical episode between the 2 accounting methods. For the traditional accounting method, the direct variable cost was the main cost driver, whereas for the TDABC method, the direct fixed cost was the main cost driver.Clinical RelevanceThis study is important because it elucidates important cost drivers for one of the most common sports medicine orthopaedic surgical procedures and attempts to identify the true overall cost of the procedure.

Typical air kerma area product values for trauma orthopaedic surgical procedures.

BackgroundThe aim of study was to establish the typical radiation quantity values for the most common trauma orthopaedic surgical procedures and to compare them with reference values of equivalent procedures performed in other institutions. In addition, we assess the impact of image intensifier and flat panel detector technology used for fluoroscopically guidance on patient exposure.Materials and methodsFive most frequently performed fluoroscopically guided trauma orthopaedic procedures in University Medical Centre Ljubljana were analysed. Data on 199 cases over a 6 months period from December 2016 to June 2017 were gathered retrospectively. Study covered 40 dynamic hip screw fixations (DHS), 23 proximal femoral nail insertions (PFN), 20 proximal humeral nail insertions (PHN), 77 partial hip endoprosthesis implantations (PEP) and 39 percutaneous posterior spine fixations (PPS). The median and average along with the first and third quartile values of air kerma area product (KAP) for each procedure type were calculated as well as median and average value of fluoroscopy screening time.ResultsTypical KAP value for dynamic hip screw fixation was set at 0.52 Gycm2; for proximal femoral nail insertion at 0.53 Gycm2 and for proximal humeral nail insertion at 0.26 Gycm2. For implantation of partial endoprosthesis typical KAP value utilizing flat panel technology was set at 0.08 Gycm2 and at 0.21 Gycm2 when the image intensifier technology was used. Typical KAP value for percutaneous posterior spine fixation was set at 1.26 Gycm2, using flat panel technology and at 3.98 Gycm2 using image intensifier technology.ConclusionsEstablished typical KAP levels of surgical orthopaedic procedures in traumatology will serve as a valuable tool for further radiation exposure optimization.

Musculoskeletal pathology as an early warning sign of systemic amyloidosis: a systematic review of amyloid deposition and orthopedic surgery

BackgroundTransthyretin and immunoglobulin light-chain amyloidoses cause amyloid deposition throughout various organ systems. Recent evidence suggests that soft tissue amyloid deposits may lead to orthopedic conditions before cardiac manifestations occur. Pharmacologic treatments reduce further amyloid deposits in these patients. Thus, early diagnosis improves long term survival.Questions/purposesThe primary purpose of this systematic review was to characterize the association between amyloid deposition and musculoskeletal pathology in patients with common orthopedic conditions. A secondary purpose was to determine the relationship between amyloid positive biopsy in musculoskeletal tissue and the eventual diagnosis of systemic amyloidosis.MethodsWe performed a systematic review using PRISMA guidelines. Inclusion criteria were level I-IV evidence articles that analyzed light-chain or transthyretin amyloid deposits in common orthopedic surgeries. Study methodological quality, risk of bias, and recommendation strength were assessed using MINORS, ROBINS-I, and SORT.ResultsThis systematic review included 24 studies for final analysis (3606 subjects). Amyloid deposition was reported in five musculoskeletal pathologies, including carpal tunnel syndrome (transverse carpal ligament and flexor tenosynovium), hip and knee osteoarthritis (synovium and articular cartilage), lumbar spinal stenosis (ligamentum flavum), and rotator cuff tears (tendon). A majority of studies reported a mean age greater than 70 for patients with TTR or AL positive amyloid.ConclusionsThis systematic review has shown the presence of amyloid deposition detected at the time of common orthopedic surgeries, especially in patients ≥70 years old. Subtyping of the amyloid has been shown to enable diagnosis of systemic light-chain or transthyretin amyloidosis prior to cardiac manifestations.Level of evidenceLevel IV.

Collaborative Creation of Regional Opioid-Prescribing Guidelines in Orthopaedics: Description of a Process, Measurement of Its Effectiveness, and Impact on Patient Satisfaction at a Participating Institution.

Background:Interventions designed to decrease opioid prescribing in orthopaedics have been effective when employed by specific institutions, subspecialties, and procedures. The objectives of this study were to examine the effectiveness of developing regional guidelines on opioid-prescribing practices after common orthopaedic surgical procedures, to determine whether compliance with the guidelines varied by procedure, and to measure the effect of the guidelines on patient satisfaction. All objectives were assessed at 1 participating institution.Methods:In February 2018, 53 orthopaedic surgeons representing 8 practices in Western New York attended a summit meeting to collaboratively create regional opioid-prescribing guidelines for 70 common orthopaedic procedures; these guidelines were later distributed electronically to all orthopaedists in Western New York. We retrospectively examined opioid-prescribing practices for adults undergoing an orthopaedic surgical procedure performed by 1 large practice in October 2017, 4 months before the summit meeting (776 patients), and in July 2018, 5 months after the summit meeting (653 patients). The number of opioid pills prescribed postoperatively and patient satisfaction were compared before and after the summit meeting using t tests.Results:The overall mean number of opioid pills (and standard deviation) prescribed postoperatively decreased from 69.5 ± 45.5 pills before the summit to 43.3 ± 28.0 pills after the summit (p < 0.0001). Sports medicine surgeons reduced the number of pills prescribed for anterior cruciate ligament reconstruction, arthroscopic rotator cuff repair, knee arthroscopy with meniscectomy, and shoulder arthroscopy with decompression; and adult reconstruction surgeons reduced the number of pills prescribed for total hip and knee arthroplasty. There was no change in the number of pills prescribed for lumbar spine fusion or implant removal. Satisfaction with the provider did not differ from before to after the summit; 75% of patients in the pre-summit group and 76% of patients in the post-summit group reported receiving excellent service (p = 0.62).Conclusions:The creation of regional opioid-prescribing guidelines in a collaborative fashion was assessed at 1 participating institution and was found to be effective at reducing the number of opioid pills prescribed by the orthopaedic surgeons participating in the project without affecting patient satisfaction, but adherence to the guidelines varied by procedure.

A comparative retrospective analysis of indoor patients between 50 to 85 years of age suffering from osteoarthritis to determine the effectiveness of epidural and intravenous tramadol in pain relief and functional recovery after total knee replacement surgery

BACKGROUND: Total knee replacement surgery is among the most common major orthopedic surgery performed in cases of osteoarthritis on the knee joint. Total knee arthroplasty is considered to cause moderate-to-severe postoperative pain. No clear consensus in the available literature suggests a clear advantage between epidural tramadol and intravenous tramadol postoperatively due to the complications associated with an epidural catheter. AIM: This study aimed to determine the effectiveness of epidural tramadol and intravenous tramadol in pain relief and functional recovery in postoperative total knee replacement patients. MATERIALS AND METHODS: All cases operated for total knee replacement and postoperatively managed by epidural tramadol and intravenous tramadol were studied. This group included 20 patients of total knee replacement managed by epidural tramadol compared to 20 patients of total knee replacement managed by intravenous tramadol. RESULTS: Patients in the group managed postoperatively with intravenous tramadol for postoperative pain management showed a better functional outcome and pain relief as compared to patients managed with epidural tramadol. It was noted that in patients managed with intravenous tramadol, the knee range of motion and static and dynamic quadriceps exercises were started earlier and the patients were more compliant, which intern helped to achieve a better functional outcome posttotal knee replacement surgery. CONCLUSION: We would like to suggest in our limited 40 patient study group, the pain managed in patients by intravenous tramadol showed a better functional outcome as compared to the pain managed in the patients by epidural tramadol. Within our study group of 40 patients, it was noted that patient compliance and comfort was better in cases where tramadol was administered through an intravenous line as compared to an epidural catheter with no statistically significant difference in postoperative pain as well as functional outcome and recovery.

Patients with psychiatric diagnoses have increased odds of morbidity and mortality in elective orthopedic surgery

Psychiatric diagnoses (PD) present a significant burden on elective surgery patients and may have potentially dramatic impacts on outcomes. As ailments of the spine can be particularly debilitating, the effect of PD on outcomes was compared between elective spine surgery patients and other common elective orthopedic surgery procedures. This study included 412,777 elective orthopedic patients who were concurrently diagnosed with PD within the years 2005 to 2016. 30.2% of PD patients experienced a post-operative complication, compared to 25.1% for non-PD patients (p < 0.001). Mood Disorders (bipolar or depressive disorders) were the most commonly diagnosed PD for all elective Orthopedic procedures, followed by anxiety, then dementia (p < 0.001). Logistic regression analysis found PD to be a significant predictor of higher cost to charge ratio (CCR), length of stay (LOS), and death (all p < 0.001). Between, hand, elbow, and shoulder specialties, spine patients had the highest odds of increased CCR and unfavorable discharge, and the second highest odds of death (all p < 0.001).

Public Interest in Elective Orthopedic Surgery Following Recommendations During COVID-19: A Google Trends Analysis

IntroductionPrecautions issued by organizations such as the American Academy of Orthopaedic Surgeons (AAOS) recommending against any elective, or non-essential, surgical procedures have significantly affected healthcare resource utilization by the public during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. In this study, we demonstrate the value of the Google Trends (GT) interface to characterize and monitor in real-time the response in public interest toward various elective orthopedic procedures.MethodsSearch volume databases were generated from January 2015 to May 2020 for keywords related to anterior cruciate ligament (ACL) reconstruction, elbow arthroplasty, hip arthroplasty, knee arthroplasty, and rotator cuff repair. To measure the immediate effects on public interest, the percent change was calculated from the AAOS, and Centers for Medicare and Medicaid Services (CMS) defined a 30-day pre-recommendations period to a 30-day post-recommendations period. To measure long-term effects, mean search volumes from January 1, 2015, to February 29, 2020, were compared to mean search volumes from March 1, 2020, to May 21, 2020.ResultsIn the 30-day period following statements by the AAOS and CMS, interest in all search terms except “partial knee arthroplasty” decreased as follows: “ACL reconstruction” (-32.7%); “ACL repair” (-22.6%); “anterior cruciate ligament reconstruction” (-39.8%); “elbow arthroplasty” (-17.2%); “elbow joint replacement” (-15.1%); “total elbow arthroplasty” (-40.0%); “hip arthroplasty” (-23.0%); “hip replacement” (-41.2%); “total hip arthroplasty” (-23.0%); “knee arthroplasty” (-43.0%); “total knee arthroplasty” (-33.3%); “rotator cuff repair” (-34.2%); “rotator cuff surgery” (-50.6%); “shoulder arthroplasty” (-26.7%).DiscussionGT data have previously demonstrated utility in characterizing and anticipating shifts in real-world healthcare utilization, making it an invaluable tool for physicians to anticipate and address the emerging needs of our patient population. Our study further illustrates the value of GT in localizing rapidly recovering interest in several of the most common elective orthopedic surgeries, enabling surgeons with up-to-date actionable data to guide the management of practices and healthcare facilities as the US slowly emerges from precautions endorsed during the COVID-19 pandemic.

The Impact of State Level Public Policy, Prescriber Education, and Patient Factors on Opioid Prescribing in Elective Orthopedic Surgery: Findings From a Tertiary, Academic Setting

BackgroundThe United States is in the midst of an opioid misuse epidemic. There have been recent changes to North Carolina’s public policy leading to institutional education attempting to reduce high-risk opioid prescribing. This study investigated whether state-level and institutional efforts were associated with provider-level changes in opioid prescriptions after common orthopedic surgeries. Patients and MethodsSix-week post-operative opioid prescribing in patients 18 years or older undergoing high-volume elective surgeries were reviewed retrospectively. Three patient cohorts from equivalent calendar year periods were included in this analysis; preceding policy implementation (January 1, 2017, to March 31, 2017), immediately after policy implementation (January 1, 2018, to March 31, 2018), and 1 year after policy implementation (January 1, 2019, to March 31, 2019). Multivariable models were constructed to evaluate the effects of public policy and institutional education on postoperative opioid prescribing. ResultsThe mean (standard deviation) amount of oxycodone 5-mg equivalents prescribed at discharge decreased from 75.6 (53.2) in 2017 to 55.7 (36.2) in 2018 and then 45.6 (32.6) in 2019 (P < .05). Similarly, 6-week postoperative cumulative oxycodone 5-mg equivalents prescribed also significantly decreased from 123.3 (145.8) in 2017 to 84.1 (90.3) in 2018 and to 80.2 (150.1) in 2019. Other outcomes including prescription duration and rates of outlier prescribing showed similar trends. ConclusionIn a North Carolina tertiary academic hospital, opioid prescribing decreased after public policy implementation and an institutional response of education for prescribers within a national context of changing practices in opioid prescribing. State-level public policy and prescriber education could be important avenues for decreasing postoperative opioid prescription in orthopedic settings.

Patients with abnormal microarchitecture have an increased risk of early complications after spinal fusion surgery.

Spine fusion is one of the most common orthopedic surgeries, with more than 400,000 cases performed annually. While these procedures correct debilitating pain and deformities, complications occur in up to 45%. As successful fusion rests upon early stability of hardware in bone, patients with structural skeletal deficits may be at particular risk for complications. Few studies have investigated this relationship, and none have used higher order imaging to evaluate microstructural mechanisms for complications. Standard DXA measurements are subject to artifact in patients with spinal disease and therefore provide limited information. The goal of this prospective study was to investigate pre-operative bone quality as a risk factor for early post-operative complications using high resolution peripheral QCT (HR-pQCT) measurements of volumetric BMD (vBMD) and microarchitecture. We hypothesized that patients with low vBMD and abnormal microarchitecture at baseline would have more skeletal complications post-operatively. Conversely, we hypothesized that pre-operative DXA measurements would not be predictive of complications. Fifty-four subjects (mean age 63years, BMI 27kg/m2) were enrolled pre-operatively and followed for 6months after multi-level lumbar spine fusion. Skeletal complications occurred in 14 patients. Patients who developed complications were of similar age and BMI to those who did not. Baseline areal BMD and Trabecular Bone Score by DXA did not differ. In contrast, HR-pQCT revealed that patients who developed complications had lower trabecular vBMD, fewer and thinner trabeculae at both the radius and tibia, and thinner tibial cortices. In summary, abnormalities of both trabecular and cortical microarchitecture were associated the development of complications within the first six months following spine fusion surgery. Our results suggest a mechanism for early skeletal complications after fusion. Given the burgeoning number of fusion surgeries, further studies are necessary to investigate strategies that may improve bone quality and lower the risk of post-operative complications.

Patient Opioid Requirements Are Often Far Less Than Their Discharge Prescription After Orthopaedic Surgery: the Results of a Prospective Multicenter Survey.

Evidence-based, procedure-specific guidelines for opioid prescribing after orthopaedic surgery are urgently needed to standardize care and minimize excess opioids. We developed a prospective, multicenter survey study conducted from March 2017 to January 2018 including 7 common elective orthopaedic surgical procedures (total knee arthroplasty, total hip arthroplasty, lumbar fusion, lumbar laminectomy, rotator cuff repair, arthroscopic meniscectomy, and carpal tunnel release). Phone surveys were conducted between 21 and 35 days postoperatively. We aimed to document both the amount and length of time patients consumed opioid medications to inform further improvements in opioid management and prescribing. Among the 919 orthopaedic patients who completed the survey, 94.3% received opioids at discharge with a median of 388 oral morphine equivalents (OMEs) (interquartile range [IQR] 225 to 675). A median of 128 (IQR 23 to 360) OME were consumed with 77% of patients having leftover opioids. Sixty percent of prescribed opioids were unused; 18.2% of patients used no opioids, and 34.7% required <50 OME. In comparison to departmental guidelines, 50.2% of patients consumed <50% of the recommended prescription maximum per procedure. Most patients used far fewer opioids after orthopaedic surgery than prescribed. These data have informed further improvement of our opioid prescription guidelines to more precisely align with anticipated procedure- and patient-specific requirements.

Improvement in Postoperative Pain Control and Length of Stay With Peripheral Nerve Block Prior to Distal Radius Repair.

Distal radius repair is a common orthopedic surgery often performed at outpatient surgical centers. To date, little is known regarding optimal pain control in this setting. In this study, the authors evaluated patients who underwent distal radius open reduction and internal fixation (ORIF) in an outpatient surgery center setting. Comparisons between 2 surgical groups, peripheral nerve block without general anesthesia vs general anesthesia only, were recorded in terms of postoperative length of stay (LOS) in phase I, total LOS, and patient-reported pain level at discharge. The authors identified 80 patients undergoing distal radius ORIF from March to August 2016. A total of 37 (46.3%) patients received general anesthesia only and 43 (53.8%) patients received peripheral nerve block without general anesthesia. Overall, patients in the nerve block only group showed a statistically significant decrease in pain at discharge, as well as decreased phase I and total LOS. Although the power of the data is low relative to the number of distal radius procedures performed every year, there is a trend of better pain control and decreased LOS when using nerve blocks instead of general anesthesia. [Orthopedics. 2020;43(6):e549-e552.].

Hospital Payments Increase as Payments to Surgeons Decrease for Common Inpatient Orthopaedic Procedures.

Introduction:As healthcare costs continue to increase in the United States, it is important to understand the trends in the allocation of healthcare spending for common orthopaedic surgical procedures. We investigated the recent trends in (1) total net payments (for episode of care), (2) payments to hospitals, (3) payments to physicians, (4) payments to physicians as a percentage of total net payments, and (5) regional variation in hospital and physician payments for four common orthopaedic procedures.Methods:Using a private insurance claims database, we analyzed the payments to US hospitals and physicians from 2010 to 2016 for primary total hip arthroplasty (THA) (n = 128,269), total knee arthroplasty (TKA) (n = 223,319), 1-level anterior cervical diskectomy and fusion (ACDF) (n = 51,477), and 1-level lumbar-instrumented posterior spinal fusion (PSF) (n = 45,680). Regional variations in payments were also assessed. Trends were analyzed using linear regression models adjusting for age, sex, comorbidities, duration of hospital stay, and inflation (alpha = 0.05).Results:Inflation-adjusted total net payments for the episode of care increased by the following percentages per year: 5.2% for ACDF, 3.2% for PSF, 2.9% for TKA, and 2.6% for THA. Annual inflation-adjusted hospital payments increased significantly for all 4 procedures, whereas annual inflation-adjusted physician payments decreased by −2.2%/year for PSF, −1.5%/year for TKA, −1.1%/year for THA, and −0.4%/year for ACDF (all, P < 0.001). As a percentage of total net payments, physician payments decreased markedly for ACDF (−4.6%), PSF (−3.1%), TKA (−2.1%), and THA (−1.8%). Hospital and physician payments varied significantly by region and were both highest in the West (P < 0.001).Conclusions:From 2010 to 2016, inflation-adjusted total net payments for 4 common orthopaedic surgical procedures increased markedly, as did payments to the US hospitals for these procedures. Payments to orthopaedic surgeons for these procedures decreased markedly during the same period.

AMBULATORY SURGERY TRENDS IN PEDIATRIC ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: WHERE’S IT HAPPENING AND HOW MUCH CAN WE SAVE?

Background:Benefits of ambulatory surgery include more efficient operations, lower cost, and patient preference. The national frequency of anterior cruciate ligament (ACL) reconstruction in children has increased three-fold compared other pediatric orthopaedic procedures, a trend that is likely attributable to an increased rate of ACL tears associated with year-round training and competition in young athletes.Hypothesis/Purpose:The goal of this study was to utilize the Pediatric Health Information System (PHIS) to analyze the national trends towards ambulatory surgery for ACL reconstruction procedures and quantify the cost savings associated with the trend.Methods:The PHIS database was queried using Common Procedural Terminology (CPT) and International Classification of Disease (ICD-9 and 10) codes for ACL reconstruction from 2009-2017. Patient information including gender, age at surgery, region (Northeast, South, Midwest, West) and hospital cost data for each procedure was collected. Cases were classified as ambulatory or non-ambulatory (inpatient or observation). Annual rates of ambulatory surgery were calculated for each procedure regionally for hospitals with cases included in each year of the query. The Consumer Price Index (CPI) was used to adjust procedural costs for inflation. Ambulatory and non-ambulatory costs were analyzed with the Wilcoxon Signed-Rank test. Trends in rates of ambulatory surgery were compared using joinpoint regression and annual percent change (APC).Results:A total of 21,582 cases of ACL Reconstruction were identified from 33 different children’s hospitals from 2009-2017. More than half (50.3%) of the patients were female, and the average age at surgery was 15.4 years (± 2.1 years). The overall rate of ambulatory pediatric ACL reconstructions across the United States increased by 14.7% (APC 1.6%, 95% C.I. 0.8-2.4, p<0.01) from 2009 to 2017. Overall, this trend was most significant in the West (APC 2.0%, 95% C.I. 1.2-2.7, p<0.01), however in more recent years (2012-2017), there has been a similar significant increase in ambulatory pediatric ACL reconstruction in the South (APC 3.0%, 95% C.I. 1.7-4.3, p<0.01). The mean difference in median procedural cost between ambulatory and non-ambulatory ACL reconstructions was $3,145 ($13,866 vs. $10,721, p<0.01). This corresponds to national annual savings of 4.1% associated with the shift towards ambulatory surgery.Conclusions:From 2009-2017, there was a national trend towards performing pediatric ACL reconstruction in the ambulatory setting, which was accompanied by an annual 4.1% procedural cost savings. The feasibility of ambulatory surgery for other common pediatric orthopaedic surgeries should be explored in order to reduce healthcare costs.Figure 1.Comparison of National Ambulatory Pediatric ACL Reconstruction Rates and Procedural Costs over Time

A prospective study of persistent postsurgical pain at 1 year after total knee arthroplasty in a Japanese tertiary hospital

Purpose: Total knee arthroplasty (TKA) is one of the most common and successful orthopaedic surgeries performed throughout the world. Although good pain relief can be achieved with TKA, significant proportion of patients experience persistent postsurgical pain (PPSP). A systematic review of recent studies from Europe and United States showed that 10-34% of patients complain of PPSP. However, since no prospective studies have ever been conducted in Japan, the prevalence of PPSP in the Japanese population is unknown. The aim of this prospective study was to elucidate the prevalence and preoperative risk factors of PPSP after TKA in a Japanese tertiary hospital. Methods: Between April 2012 to March 2018, patients were recruited in a Japanese tertiary hospital. Four hundred twenty-six TKAs were performed in patients during the period. Two hundred eighty-eight patients underwent unilateral TKA while 30 patients underwent simultaneous bilateral TKA. Preoperative diagnosis was osteoarthritis in 394 knees, rheumatoid arthritis in 28 knees, and osteonecrosis in 4 knees. Exclusion criteria were as follows: dementia, symptomatic venous thrombosis, periprosthetic join infection, and mal-positioned TKA (≧3 degrees error in sagittal and/or coronal plane). Preoperative evaluation included pain visual analog scale (VAS) at rest and at walk, WOMAC, Knee Society Score (KSS), EQ-5D, pain catastrophizing scale, pain DETECT. All TKA were performed under both general anesthesia and ultrasound-guided femoral nerve block. Postoperative pain was evaluated using a 100mm VAS. Patients were instructed to express their pain around the replaced knee while rest and walking during the past week by putting a mark on the 100mm VAS by themselves. PPSP was defined as a VAS score of >30 while walking at 1 year follow up. The prevalence of PPSP was calculated from patients followed at 1 year after surgery. The preoperative risk factors for PPSP were analyzed from patients who completed preoperative questionnaires. Statistical comparison between with and without PPSP was analyzed by Mann-Whitney U test and Chi-squared test. To determine the risk factors for PPSP, logistic regression analysis was used from among those factors which had significant difference (p<0.05) in univariate analysis. Results: Of 318 patients who underwent TKA, 346 knees of 254 patients were followed at 1 year after surgery. The prevalence of PPSP was 8.4% (19 of 346 knees). Two hundred and forty-six knees of 190 patients completed preoperative questionnaires. The mean age at surgery was 74 years old (range 43-90). Univariate analysis showed that patients with PPSP had significantly higher VAS at rest, WOMAC pain score, WOMAC stiffness score, WOMAC function score, WOMAC total score and lower EQ-5D compared with those without. Logistic regression analysis showed that WOMAC function score significantly affected PPSP (odds ratio = 1.078, 95% confidence interval 1.035-1.123). Conclusions: The rate of persistent pain was 8.4%. This result is lower than past reports from Europe and United States. In our department, surgeons basically take postoperative follow by themselves at 6 weeks, 3, 6, 12 months after surgery and every year. When we find patients who have something wrong around the replaced knee, we diagnose what is going on and treat appropriately. For example, we treated with steroid injection for infrapatellar saphenous neuralgia and pregabalin medication for lumber radiculopathy at some point. Recent studies have found that PPSP is associated with preoperative knee pain, younger patient, catastrophizing and mental health, while our findings showed the predictive factor of PPSP was WOMAC function score. This is the first report of prospective study for PPSP after TKA in Japan.Table 1.Comparison between patients with and without PPSP.PPSP (-) n=224 kneesPPSP (+) n=22 kneesP valueAge at surgery (years)73 [68-79]76 [72.5-79]0.116Sex (men/women)52 / 1723 / 190.304VAS at rest (mm)20 [5-40]30 [11.3-70]0.045VAS at walk (mm)20 [50-80]70 [54.8-80]0.295WOMAC pain9 [7-11]12 [10-13]0.001WOMAC stiffness5 [4-6]6 [4.3-6]0.036WOMAC function29 [20-39]41 [36.5-49]<0.001WOMAC total44 [32-56]60.5 [52.3-67.3]<0.001KSS knee score50 [39-61]50 [45-60]0.074KSS function score50 [45-60]45 [45-60]0.999EQ-5D0.631 [0.536-0.649]0.562 [0.495-0.596]0.002PCS27 [18.5-32]29.5 [18.8-33]0.243painDETECT10 [6-14]8 [7-16.5]0.946Data are median [IQR]. Statistical comparison between with and without PPSP was analyzed by Mann-Whitney U test and Chi-squared test. Open table in a new tab Data are median [IQR]. Statistical comparison between with and without PPSP was analyzed by Mann-Whitney U test and Chi-squared test.

Access to Elective Orthopaedic Surgery After the Affordable Care Act Medicaid Expansion: The New York State Experience.

As part of the Patient Protection and Affordable Care Act, states were given the option of expanding Medicaid coverage to include adults younger than age 65 years with income at or below 138% of the federal poverty level. Although this expansion was intended to provide health care coverage to an estimated 20 million Americans, several studies have shown increased coverage does not equate to increased access to care by specialty providers. We queried the New York Statewide Planning and Research Cooperative System database and identified all patients who underwent the 10 most common elective orthopaedic surgeries from January 1, 2012, through March 31, 2016. Medicaid monthly enrollment for the 4-year study period was obtained from NY Department of Health Medicaid Managed Care Enrollment Reports. Our query identified 700,159 patients who underwent the investigated orthopaedic surgeries. Of these, 60,786 were Medicaid recipients. During the 4-year study period, Medicaid enrollment and the number of procedures reimbursed by Medicaid increased significantly (P < 0.001 for both). Affordable Care Act-supported Medicaid expansion was associated with an increase in Medicaid enrollment and a concomitant increase in the utilization of orthopaedic surgery by Medicaid beneficiaries in New York State.

Implementation of Procedure-Specific Opioid Guidelines: A Readily Employable Strategy to Improve Consistency and Decrease Excessive Prescribing Following Orthopaedic Surgery.

Background:Evidence-based, procedure-specific guidelines for prescribing opioids are urgently needed to optimize pain relief while minimizing excessive opioid prescribing and potential opioid diversion in our communities. A multidisciplinary panel at our institution recently developed procedure-specific guidelines for discharge opioid prescriptions for common orthopaedic surgical procedures. The purpose of this study was to evaluate postoperative opioid prescription quantities, variability, and 30-day refill rates before and after implementation of the guidelines.Methods:This retrospective cohort study was conducted at a single academic institution from December 2016 to March 2018. Guidelines were implemented on August 1, 2017, with a recommended maximum opioid prescription quantity for 14 common orthopaedic procedures. Patients who underwent these 14 procedures during the period of December 2016 to May 2017 made up the pre-guideline cohort (n = 2,223), and patients who underwent these procedures from October 2017 to March 2018 made up the post-guideline cohort (n = 2,300). Opioid prescription quantities were reported as oral morphine equivalents (OME), with medians and interquartile ranges (IQRs). Four levels were established for recommended prescription maximums, ranging from 100 to 400 OME.Results:In the pre-guideline cohort, the median amount of prescribed opioids across all procedures was 600 OME (IQR, 390 to 863 OME), which decreased by 38% in the post-guideline period, to a median of 375 OME (IQR, 239 to 400 OME) in the post-guideline cohort (p < 0.001). The 30-day refill rate did not change significantly, from a rate of 24% in the pre-guideline cohort to 25% in the post-guideline cohort (p = 0.43). Multivariable analysis demonstrated that guideline implementation was the factor most strongly associated with prescriptions exceeding guideline maximums (odds ratio [OR] = 9.9; p < 0.001). Age groups of <80 years (OR = 2.0 to 2.4; p < 0.001) and males (OR = 1.2; p = 0.025) were also shown to have higher odds of exceeding guideline maximums.Conclusions:Procedure-specific guidelines are capable of substantially decreasing opioid prescription amounts and variability. Furthermore, the absence of change in refill rates suggests that pain control remains similar to pre-guideline prescribing practices. Evidence-based guidelines are a readily employable solution that can drive rapid change in practice and enhance the ability of orthopaedic surgeons to provide responsible pain management.

Coverage of exposed bone and hardware of the medial malleolus with tibialis posterior artery perforator flap after ankle fracture surgery complications.

Ankle fractures are among the most common orthopaedic surgical procedures. Skin-related complications of these surgeries are difficult to reconstruct due to the inadequacy of soft tissue in the region. Although free flaps are generally considered as the first choice in reconstruction of this area, free flaps may not be a suitable option especially in patients with advanced age and comorbidities. Perforator flaps offer a fast and safe alternative in lower extremity reconstruction. In the literature, there are a limited number of studies using perforator flaps in managing the postoperative complications of the lower extremity trauma surgeries. In our study, we report our experience with reconstruction of soft-tissue defects of medial malleolar region using posterior tibial artery perforator flap for postoperative complications of ankle fracture-related surgeries.

New Long-Term Opioid Prescription-Filling Behavior Arising in the 15 Months After Orthopaedic Surgery.

The opioid crisis is a well-known public health issue. The risk of new long-term opioid prescription-filling behavior has been investigated after certain spinal procedures and total knee and hip arthroplasty. However, this has not been examined after many other common orthopaedic procedures. The purpose of this study was to determine the rates of long-term opioid prescription-filling behavior after common orthopaedic surgical procedures in patients who were not taking opioids preoperatively. This study utilized the Virginia All-Payer Claims Database (APCD), an insurance claims database with data from 3.7 to 4 million patients per year. Patients who underwent orthopaedic procedures and who had not filled an opioid prescription in the time period from 2 weeks to 1 year preceding the surgical procedure were selected for evaluation in our study. The percentage of these patients who then filled at least 10 prescriptions or a 120-day supply of opioids in the time period from 90 to 455 days following the surgical procedure was calculated for the 50 most commonly billed orthopaedic surgical procedures. The rate of long-term opioid prescription-filling behavior in patients who were not taking opioids preoperatively for the 50 most common orthopaedic procedures was 5.3% (95% confidence interval, 5.1% to 5.5%). The highest rates were observed after spinal procedures. The lowest rates were seen after anterior cruciate ligament (ACL) reconstruction. Revision surgical procedures were found to have a significantly higher rate than primary procedures (p < 0.05). The rate was also related to increasing case complexity. New long-term opioid prescription-filling behavior is common after orthopaedic surgical procedures in patients who were not taking opioids preoperatively. Risk factors include spine surgery, revision surgery, and cases with increased complexity. Orthopaedic surgeons need to be aware of this risk. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Expression of Galectins-1 in Rat Traumatic Osteoarthritis and Its Regulation Mechanism

Traumatic arthritis is a common orthopedic surgery disease that seriously affects the health of patients. The expression and role of Galectins in traumatic osteoarthritis remains unclear. SD rats were divided into control group and osteoarthritis model group. Real-time PCR and ELISA were used to analyze Galectins-1 expression. Chondrocytes were isolated and cultured and divided into control group, Galectins-1 siRNA group and Galectins-1 group followed by analysis of proliferation of chondrocytes by MTT assay, cell migration by Transewell chamber, expression of RUNX2 and ADAMTS-4/5 by Real-time PCR, and PI3K/Akt by Western blot. Galectins-1 mRNA and secretion in synovial fluid was significantly reduced in model group compared to control (P &lt; 0.05). Transfection of Galectins-1-pcDNA3.1 plasmid into chondrocytes of osteoarthritic rats significantly increased the expression of Galectins-1, promoted chondrocyte proliferation and cell migration, and downregulated RUNX2 and ADAMTS-4/5 (P &lt; 0.05). Up-regulation of Galectins-1 blocked the expression of PI3K/Akt signaling pathway. Transfection of Galectins-1 siRNA significantly reduced the expression of Galectins-1, inhibited chondrocyte proliferation and cell migration, and upregulated RUNX2 and ADAMTS-4/5 (P &lt; 0.05). Down-regulation of Galectins-1 up-regulated PI3K/Akt signaling pathway. Galectins-1 expression is reduced in joint tissues in rat model of traumatic osteoarthritis. Up-regulation of Galectins-1 expression can promote chondrocyte proliferation and migration by regulating PI3K/Akt signaling pathway, which may reduce chondrocyte damage in rats with traumatic osteoarthritis.

Orthopedic Surgeon Decision-Making Processes for Postsurgical Opioid Prescribing.

Acute pain and chronic pain are significant burdens in the Department of Defense, compounded by the ongoing opioid crisis. Given the ubiquity of (leftover) opioid prescriptions following orthopedic surgery, it is essential to identify feasible and acceptable avenues of opioid risk mitigation efforts. The present quality improvement project builds on recent studies by evaluating factors related to opioid prescribing decisions in a sample of orthopedic surgery providers. This quality improvement project received a Determination of Not Research and was conducted through a collaboration between the Department of Orthopaedic Surgery and the Department of Anesthesiology and Pain Management at Walter Reed National Military Medical Center. Providers in the Department of Orthopaedic Surgery completed an anonymous online survey assessing opioid prescribing education, factors influencing prescribing practices, opioid-safety practices, and perspectives on potential opioid safety initiatives. In total, 39 respondents completed surveys. There was variability in exposure to different types of opioid prescribing education, with some variation between attendings/physician assistants and residents. Patients' acute postsurgical pain, using a standardized amount for most patients, and prescription histories were the three most influential factors. Concern of patients running out and fear of patient dissatisfaction were the least influential factors. Respondents commonly reported engagement in promoting nonpharmacological pain management, as well as coordinating with chronic pain providers when applicable, but did not commonly report educating patients on leftover opioid disposal. Respondents indicated that a barrier to opioid risk mitigation was the difficulty of accessing appropriate electronic health record data to inform decisions. Lastly, they reported openness to proposed opioid safety initiatives. The results of this quality improvement project identified several target areas for future initiatives focused on improving opioid prescribing practices. This included a provider training program, improved patient education system, increased awareness and use of opioid tracking databases, and development of a standardized (but adaptable per patient characteristics and history) recommended dose for common orthopedic surgeries. Future projects will target tailored development, implementation, and evaluation of such efforts.