JAAOS, Volume 27, No. 1

Value-based Total Hip and Knee Arthroplasty: A Framework for Understanding the Literature

Since passage of the Patient Protection and Affordable Care Act of 2010, the current decade has witnessed an explosion of the value-based total hip and knee arthroplasty literature. Total hip arthroplasty and total knee arthroplasty are the most common inpatient surgeries for Medicare beneficiaries, and thus, it is no surprise that total joint arthroplasty is currently a prime target of efforts toward cost reduction and quality improvement. The purpose of this review was to provide a framework for understanding the rapidly growing quality and cost literature. Research efforts toward quality improvement are likely to be effective when they address the structure, process, and most importantly outcomes of total joint arthroplasty. Similarly, cost savings should be evaluated with an understanding of existing accounting methods, relationships to the entire cycle of osteoarthritis care, and the direct effect on the quality of care provided.

      • Subspecialty:
      • Adult Reconstruction

    Microinstability of the Hip—Gaining Acceptance

    The hip has generally been considered an inherently stable joint. However, the femoral head moves relative to the acetabulum. Although the bones are primarily important in hip stability, the importance of the soft tissues has recently been demonstrated. Symptomatic microinstability of the hip is defined as extraphysiologic hip motion that causes pain with or without symptoms of hip joint unsteadiness and may be the result of bony deficiency and/or soft-tissue damage or loss. Recent work has helped improve the ability to identify microinstability patients preoperatively. Initial management begins with activity modification and strengthening of the periarticular musculature. Failing nonsurgical management, surgical intervention can be beneficial, focusing on treatment of the underlying cause of microinstability, as well as associated intra-articular pathology. Bony deficiency may be treated with a redirectional osteotomy, whereas those with adequate bony coverage may be treated with capsular plication, capsular reconstruction, and/or labral reconstruction.

        • Subspecialty:
        • Adult Reconstruction

      Electrical Injuries of the Hand and Upper Extremity

      High-voltage electrical injuries are relatively rare injuries that pose unique challenges to the treating physician, yet the initial management follows well-established life-saving, trauma- and burn-related principles. The upper extremities are involved in most electrical injuries because they are typically the contact points to the voltage source. The amount of current that passes through a specific tissue is inversely proportional to the tissue's intrinsic resistance with electricity predominantly affecting the skeletal muscle secondary to its large volume in the upper extremity. Therefore, cutaneous burns often underestimate the true extent of the injury because most current is through the deep tissues. Emergent surgical exploration is reserved for patients with compartment syndrome; otherwise, initial débridement can be delayed for 24 to 48 hours to allow tissue demarcation. Early rehabilitation, wound coverage, and delayed deformity reconstruction are important concepts in treating electrical injuries.

          • Subspecialty:
          • Hand and Wrist

        Translating Orthopaedic Technologies Into Clinical Practice: Challenges and Solutions

        Despite the wealth of innovation in the orthopaedic sciences, few technologies translate to clinical use. By way of a 2-day symposium titled “AAOS/ORS Translating Orthopaedic Technologies into Clinical Practice: Pathways from Novel Idea to Improvements in Standard of Care Research Symposium,” key components of successful commercialization strategies were identified as a passionate entrepreneur working on a concept aimed at improving patient outcomes and decreasing the cost and burden of disease; a de-risking strategy that has due recognition of the regulatory approval process and associated costs while maximizing the use of institutional, state, and federal resources; and a well thought-out and prepared legal plan and high quality, protected intellectual property. Challenges were identified as a lack of education on the scale-up and commercialization processes; few opportunities to network, get feedback, and obtain funding for early stage ideas; disconnect between the intellectual property and the business model; and poor adoption of new technologies caused in part by un-optimized clinical trials. By leveraging the network of professional orthopaedic societies, there exists an opportunity to create an enlightened community of musculoskeletal entrepreneurs who are positioned to develop and commercialize technologies and transform patient care.

            • Subspecialty:
            • General Orthopaedics

          Trampoline-Related Injuries: A Comparison of Injuries Sustained at Commercial Jump Parks Versus Domestic Home Trampolines

          Introduction: The nature of trampoline injuries may have changed with the increasing popularity of recreational jump parks.

          Methods: A retrospective review was performed evaluating domestic trampoline and commercial jump park injuries over a 2-year period.

          Results: There were 439 trampoline injuries: 150 (34%) at jump parks versus 289 (66%) on home trampolines. Fractures and dislocations accounted for 55% of jump park injuries versus 44% of home trampoline injuries. In adults, fractures and dislocations accounted for 45% of jump park injuries versus 17% of home trampoline injuries. More lower extremity fractures were seen at jump parks versus home trampolines in both children and adults. Adults had a 23% surgical rate with jump park injuries versus a 10% surgical rate on home trampolines.

          Discussion: Trampoline-related injury distribution included a higher percentage of fractures/dislocations, lower extremity fractures, fractures in adults, and surgical interventions associated with jump parks versus home trampolines.

          Level of Evidence: Level III

              • Subspecialty:
              • Trauma

            Risk Factors for Prolonged Postoperative Opioid Use After Spine Surgery: A Review of Dispensation Trends From a State-run Prescription Monitoring Program

            Introduction: Opioid abuse and dependence have a detrimental effect on elective orthopaedic surgeries, yet pain control is an important predictor of postoperative satisfaction. We aimed at better defining risk factors for prolonged postoperative opioid requirements and risk factors for patients requiring higher doses of opioids after spine surgery.

            Methods: The Illinois Prescription Monitoring Program was queried to analyze opioid dispensation patterns at 3 and 6 months postoperatively for adult patients who had spine surgery at a tertiary care hospital by a single surgeon over a 5-year period. Patients were divided into three groups: group 1 patients had opioid dispensed to them 3 and 6 months preoperatively, group 2 patients had opioid dispensed to them only at 3 months preoperatively, and group 3 patients did not have preoperative opioid prescriptions. Demographic characteristics, psychiatric history, smoking status, alcohol use, body mass index, surgical region, and presence of multiple prescribers were abstracted. Statistical analysis included multivariate modified Poisson regression, linear regression, and chi-squared testing when appropriate.

            Results: Patients in group 1 were at significantly increased risk of continued opioid usage than those in group 2 (relative risk, 3.934; 95% confidence interval, 1.691 to 9.150; P = 0.0015) and those in group 3 (relative risk, 4.004; 95% confidence interval, 1.712 to 9.365; P = 0.0014) at 6 months postoperatively. Group 1 patients also had larger quantities of opioid dispensed to them relative to patients in group 2 or group 3 (P < 0.0001) at 6 months postoperatively.

            Discussion: Use of opioid medications at 6 months preoperatively is a risk factor for continued usage and at higher doses 6 months postoperatively.

            Level of Evidence: Level III: retrospective cohort study

                • Subspecialty:
                • Spine

              Median Nerve Ultrasonography Measurements Correlate With Electrodiagnostic Carpal Tunnel Syndrome Severity

              Introduction: The purpose of this study was to assess whether median nerve ultrasonography (US) measurements correlate with the severity scale of electrodiagnostic studies (EDS) of carpal tunnel syndrome (CTS).

              Methods: A retrospective review was conducted of patients aged ≥18 years who underwent both median nerve US and EDS. US measurements of the median nerve cross-sectional area at the distal wrist crease and forearm were used to calculate the median nerve wrist-to-forearm ratio. EDS severity was classified according to guidelines from the American Association of Electrodiagnostic Medicine.

              Results: A total of 112 wrists (n = 112) in 78 consecutive patients with a mean age of 59 (range, 26 to 88) years were included. Increased cross-sectional area at the distal wrist crease and wrist-to-forearm ratio were significantly correlated with increased EDS severity (P < 0.0001).

              Discussion: Median nerve US measurements not only distinguished between normal and abnormal EDS but also correlated with the category of EDS severity.

              Level of Evidence: Diagnostic III

                  • Subspecialty:
                  • Hand and Wrist

                Increasing Rate of Surgical Fixation in Four- and Five-year-old Children With Femoral Shaft Fractures

                Background: The purpose of this study was to identify temporal trends in the management of pediatric femoral shaft fractures in 4- and 5-year-old children.

                Methods: The Kids' Inpatient Database was used to extract data on patients aged 4 and 5 years with closed femoral shaft fractures. The frequency of nonsurgical and surgical management was calculated, and temporal trends were evaluated.

                Results: Between 1997 and 2012, the absolute increase in surgical fixation was 35% and 58% in 4- and 5-year-old patients, respectively. The surgical rate increased every 3 years by 13.8% in 4-year-old patients and 7.6% in 5-year-old patients. Significant associations were noted based on demographics, comorbidities, and hospital characteristics with management decisions.

                Conclusions: A clear and significant increase was noted in internal fixation for pediatric femoral shaft fractures in 4- and 5-year-old children, and the lower age limit for surgical management of these fractures is decreasing.

                Level of Evidence: Level III. Retrospective comparative study

                    • Subspecialty:
                    • Trauma

                    • Pediatric Orthopaedics

                  Day of Admission is Associated With Variation in Geriatric Hip Fracture Care

                  Introduction: The transition to bundled payment reimbursement for geriatric hip fractures has incentivized the identification of avoidable inefficiencies in the cost and quality of care. Although a “weekend effect” has been described with regard to hip fracture mortality, measures of efficiency according to the day of hip fracture admission are currently unclear.

                  Methods: We identified 62,303 patients aged 65 years or older with a primary diagnosis of femoral neck or intertrochanteric hip fracture in the New York Statewide Planning and Research Cooperative System between 2009 and 2014. Outcome measures included preoperative delay, postoperative length of stay (LOS), and cost of admission.

                  Results: Preoperative delay was longer for weekend admissions, but shorter for admissions on Wednesday, Thursday, and Friday. Postoperative LOS was longer for admissions on Tuesday, Wednesday, and Thursday. Discharge rates varied considerably according to the day of admission, ranging from 12% to 43% by hospital day 4 and 53% to 72% by hospital day 6. No differences in cost according to day of admission were found once preoperative delay and postoperative LOS were accounted for.

                  Discussion: Notable variation exists in hospitalizations for geriatric hip fracture depending on the day of admission. Our data suggest the presence of a weekend effect, in which changes in staffing of surgical, medical, and ancillary services lead to increased waiting times for surgery for new admissions and delays in discharge of early- and mid-week admissions.

                  Level of Evidence: Level III, retrospective study

                      • Subspecialty:
                      • Trauma

                      • Adult Reconstruction

                    Biomechanical Analysis of Fixation Devices for Basicervical Femoral Neck Fractures

                    Introduction: Basicervical femoral neck fractures are challenging fractures in geriatric populations. The goal of this study was to determine whether compression hip screw (CHS) constructs are superior to cephalomedullary constructs for the treatment of basicervical femoral neck fractures.

                    Methods: Thirty cadaver femurs were osteotomized and received a CHS with derotation screw, a long cephalomedullary nail (long Gamma nail), or a short cephalomedullary nail (short Gamma nail). All constructs were loaded dynamically in compression until dynamic failure.

                    Results: All failed CHS constructs demonstrated superior femoral head cutout. In the long Gamma nail and short Gamma nail groups, constructs failed by nail cutout through the medial wall of the trochanter or rotationally. Normalized fluoroscopic distance was found to increase markedly with an increasing cycle count when considering all treatment groups.

                    Conclusions: Given our results and those of previous studies, we could not determine superiority of one implant and recommend that surgeons select fixation constructs based on the individual patient's anatomy and the surgeon's comfort with the implant.

                        • Subspecialty:
                        • Trauma