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Background: In the era of value-based care, pressures lead to cherry-picking healthier patients and lemon-dropping riskier patients to higher levels-of-care. This study examined whether "lemon-dropped" primary total joint arthroplasty (pTJA) patients require increased health care resources and experience worse outcomes., Methods: This was a retrospective cohort study of all pTJAs at one tertiary care center in 2022, excluding bilaterals, acute fractures, oncologic cases, and conversion hips. Patients were classified via referral pattern as simple or complex (referred for medical or surgical complexity). Primary outcomes were implant costs and any emergency department visit, readmission, reoperation, or complication within 90 days. Secondary outcomes were distance traveled to the hospital, anesthesia type, estimated blood loss, case duration, time in the recovery unit, length of stay, and discharge disposition. Outcomes were assessed via electronic medical record review and analyzed via Fisher's exact and unpaired Welch's t-tests., Results: In total 641 pTJAs (322 hips, 319 knees) met inclusion criteria; 10.3% were complex referrals. Complex patients were younger (59 versus 66 years, P < .05) and more often non-White (41 versus 31%, P < .001), non-English speaking (11 versus 7%, P < .001), and had nonprimary osteoarthritis as a surgical indication (59 versus 12%, P < .001), but had similar Charlson Comorbidity Index and American Society of Anesthesiologists scores. Complex patients had increased odds of 90-day emergency department visits (OR [odds ratio] = 2.11, P = .04), 90-day complications (OR = 2.63, P < .001), and non-home discharge (OR = 2.60, P = .006); higher mean relative implant costs (1.31x, P < .001); longer time in the operating room (181 versus 158 minutes P < .001), time in surgery (125 versus 105 minutes, P < .001), and length of stay (3.2 versus 1.7 days, P = .005)., Conclusions: "Lemon-dropped" pTJAs had worse early clinical outcomes and higher health care utilization, despite a control group with patients ill enough to utilize a tertiary care center as their medical home. Reimbursement models and evaluation metrics must account for these differences., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: While racial and ethnic disparities are well documented in access to total joint arthroplasty (TJA), little is known about the association between having limited English proficiency (LEP) and postoperative care access. This study seeks to correlate LEP status with rates of revision surgery after hip and knee arthroplasty., Methods: This was a retrospective cohort study of patients aged ≥ 18 years who underwent either total hip or total knee arthroplasty between January 2013 and December 2021 at a single academic medical center. The predictor variable was English proficiency status, where LEP was defined as having a primary language that was not English. Multivariable regressions controlling for potential demographic and clinical confounders were used to calculate adjusted odds ratios of undergoing revision surgery within 1 and 2 years after primary arthroplasty for patients who have LEP, compared to English proficient patients., Results: A total of 7,985 hip and knee arthroplasty surgeries were included in the analysis. There were 577 (7.2%) patients who were classified as having LEP. Patients who have LEP were less likely to undergo revision surgeries within 1 year (1.4% versus 3.2%, P = .01) and 2 years (1.7% versus 3.9%, P = .006) of primary TJA. Patients who have LEP had adjusted odds ratios of 0.45 (confidence interval: 0.22-0.92, P = .03) and 0.44 (confidence interval: 0.23-0.85, P = .01) of receiving revision surgery within 1 and 2 years, respectively., Conclusion: Patients who have LEP, compared to English proficient patients, were less likely to undergo revision surgeries at the same institution up to 2 years after hip and knee arthroplasty. These findings suggest that patients who have LEP may face barriers in accessing postoperative care., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Although obesity is a risk factor for periprosthetic joint infection (PJI) after total knee arthroplasty (TKA), the role of soft tissue thickness (STT) at the surgical site has not been well studied. This study examined if increased STT in the medial and anterior aspects of the knee are independent risk factors for PJI., Methods: A retrospective study was conducted on 206 patients who underwent 2-stage exchange arthroplasty for PJI from 2000 to 2015. They were matched 1:3 to a control group of primary, noninfected TKA patients with minimum 2 years infection-free survival by age, gender, age-adjusted Charlson Comorbidity Index, date of surgery, and body mass index (BMI). Two blinded orthopedic surgeons measured the medial STT from the medial aspect of the knee at the level of the joint line on an anteroposterior radiograph, and anterior STT 8 cm above the joint line on a lateral radiograph from the skin to the quadriceps tendon., Results: Increased STT was significantly associated with a higher risk for PJI. The mean anterior STT was 29.74 ± 13.76 mm in the PJI group and 24.88 ± 9.76 mm in the control group. The mean medial STT was 42.42 ± 14.66 mm for PJI and 37.27 ± 12.51 mm for control. Both STT measurements were significantly higher in PJI cases with BMI <30 kg/m 2 vs control patients with BMI <30 kg/m 2 ., Conclusion: Anterior and medial knee STT was an independent risk factor for PJI after primary TKA and represents a simple radiographic method to assess postoperative infection risk. Excess adipose tissue around the surgical site can predispose patients to PJI after TKA regardless of BMI., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Currently, the decision to resurface the patella is often made irrespective of the presence of patellar arthritis. The purpose of this study is to utilize the existing literature to assess cost-utility of routinely vs selectively resurfacing the patella., Methods: Prospective randomized studies of patella resurfacing vs non-resurfacing in total knee arthroplasty (TKA) were identified through literature review. Data from these studies represented probabilities of varied outcomes following TKA dependent upon patella resurfacing. Using previously validated utility scores from the McKnee modified Health Utilities Index, endpoint utility values were provided for each potential outcome., Results: Literature review yielded a total of 14 studies with 3,562 patients receiving 3,823 TKAs, of which 1,873 (49.0%) patellae were resurfaced. Persistent postoperative anterior knee pain occurred in 20.9% vs 13.2% (P < .001) and patella reoperation was performed in 3.7% vs 1.6% (P < .001) of unresurfaced and resurfaced patella, respectively. In studies excluding those with arthritic patellae, the incidence of anterior knee pain was equivalent between groups and reoperation decreased to 1.2% vs 0% (P = .06). Patella resurfacing provided marginally improved quality-adjusted life-years (QALY) for both selective and indiscriminate patella resurfacing. When including all studies, the incremental cost per QALY was $3,032. However, when analyzing only those studies with nonarthritic patellae, the incremental cost per QALY to resurface the patella increased to $183,584., Conclusion: Patellar resurfacing remains a controversial issue in TKA. Utilizing data from new prospective randomized studies, this analysis finds that routinely resurfacing arthritis-free patellae in TKA are not cost-effective., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The purpose of this study is to determine whether episode Target Prices in the Bundled Payment for Care Improvement (BPCI) initiative sufficiently match the complexities and expenses expected for patients undergoing hip arthroplasty for femoral neck fracture (FNF) as compared to hip degenerative joint disease (DJD)., Methods: Claims data under BPCI Model 2 were collected for patients undergoing hip arthroplasty at a single institution over a 2-year period. Payments from the index hospitalization to 90 days postoperatively were aggregated by Medicare Severity Diagnosis-Related Group (469 or 470), indication (DJD vs FNF), and categorized as index procedure, postacute services, and related hospital readmissions. Actual episode costs and Target Prices were compared in both the FNF and DJD cohorts undergoing hip arthroplasty to gauge the cost discrepancy in each group., Results: A total of 183 patients were analyzed (31 with FNFs, 152 with DJD). In total, the FNF cohort incurred a $415,950 loss under the current episode Target Prices, whereas the DJD cohort incurred a $172,448 gain. Episode Target Prices were significantly higher than actual episode prices for the DJD cohort ($32,573 vs $24,776, P < .001). However, Target Prices were significantly lower than actual episode prices for the FNF cohort ($32,672 vs $49,755, P = .021)., Conclusion: Episode Target Prices in the current BPCI model fall dramatically short of the actual expenses incurred by FNF patients undergoing hip arthroplasty. Better risk-adjusting Target Prices for this fragile population should be considered to avoid disincentives and delays in care., (Copyright © 2018 Elsevier Inc. All rights reserved.)

This study stratifies complication risk in primary total joint arthroplasty (TJA) based on body mass index (BMI). Demographics, co-morbidities, perioperative variables, and complications were reviewed for 22,808 patients. Chi-squared, one-way ANOVA, univariate and multivariable regression analysis were performed. Increasing BMI led to an increase (P<0.05) in combined complications, acute kidney injury (AKI), cardiac arrest (CA), reintubation, reoperation, and superficial infection (SI). Univariate analysis for BMI>40 revealed an increase in combined complications (15.21-vs-17.40%), AKI (1.93-vs-3.87%), CA (0.22-vs-0.57%), reintubation (0.47-vs-0.95%), reoperation (2.36-vs-3.37%), and SI (0.82-vs-1.65%). Multivariable regression showed BMI>40 as an independent predictor for combined complications (OR=1.18), AKI (OR=1.79), CA (OR=3.94), reintubation (OR=2.56), reoperation (OR=1.44), and SI (OR=2.11). Morbid obesity confers increased risk for complications in TJA., (Published by Elsevier Inc.)

The purpose of this study was to identify the specific comorbidities and demographic factors that are independently associated with an increased risk of periprosthetic joint infection (PJI) in total hip arthroplasty (THA) patients. A case-control study design was used to compare 88 patients who underwent unilateral primary THA and developed PJI with 499 unilateral primary THA patients who did not develop PJI. The impact of 18 comorbid conditions and other demographic factors on PJI was examined. Depression, obesity, cardiac arrhythmia, and male gender were found to be independently associated with an increased risk of PJI in THA patients. This information is important to consider when counseling patients on the risks associated with elective THA, and for risk-adjusting publicly reported THA outcomes., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The purpose of this study is to examine the characteristics and costs of postoperative fever diagnostic evaluations after total joint arthroplasty. All patients who underwent hip and knee arthroplasty (n = 1100) at a single institution for a 2-year period were included. Fever (temperature > or = 38.5 degrees C) occurred in 15% of patients. The rate of positive tests was as follows: chest radiograph (2%), blood culture (6%), urine culture (22%), and urinalysis (23.7%). Fever occurring after postoperative day 3 (odds ratio [OR] 23.3; P < .001) and multiple days febrile (OR, 8.6; P = .003) are independent predictors of a positive workup, and patients with a maximum temperature of 39.0 degrees C or higher (25.4% vs 6.9%; P = .001) had a significantly higher rate of positive fever evaluations. The total direct cost associated with fever evaluations was $73 878, and cost per change in clinical management was $8209. Fever is a common occurrence after hip and knee arthroplasty, and many elements of an infectious evaluation are costly and clinically unnecessary., (Copyright © 2010. Published by Elsevier Inc.)