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Background: Given the inclusion of orthopaedic quality measures in the Centers for Medicare & Medicaid Services national hospital payment programs, the present study sought to assess whether the public reporting of total hip arthroplasty (THA) and total knee arthroplasty (TKA) risk-standardized readmission rates (RSRRs) and complication rates (RSCRs) was temporally associated with a decrease in the rates of these outcomes among Medicare beneficiaries.Methods: Annual trends in national observed and hospital-level RSRRs and RSCRs were evaluated for patients who underwent hospital-based inpatient hip and/or knee replacement procedures from fiscal year 2010 to fiscal year 2016. Hospital-level rates were calculated with use of the same measures and methodology that were utilized in public reporting. Annual trends in the distribution of hospital-level outcomes were then examined with use of density plots.Results: Complication and readmission rates and variation declined steadily from fiscal year 2010 to fiscal year 2016. Reductions of 33% and 25% were noted in hospital-level RSCRs and RSRRs, respectively. The interquartile range decreased by 18% (relative reduction) for RSCRs and by 34% (relative reduction) for RSRRs. The frequency of risk variables in the complication and readmission models did not systematically change over time, suggesting no evidence of widespread bias or up-coding.Conclusions: This study showed that hospital-level complication and readmission rates following THA and TKA and the variation in hospital-level performance declined during a period coinciding with the start of public reporting and financial incentives associated with measurement. The consistently decreasing trend in rates of and variation in outcomes suggests steady improvements and greater consistency among hospitals in clinical outcomes for THA and TKA patients in the 2016 fiscal year compared with the 2010 fiscal year. The interactions between public reporting, payment, and hospital coding practices are complex and require further study.Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Patients who experience a fragility hip fracture are at high risk for perioperative delirium. The purpose of the present study was to evaluate the impact, from a hospital perspective, of perioperative delirium on the length of the hospital stay and episode-of-care costs for elderly patients who underwent surgical treatment of a fragility hip fracture. Methods: A total of 242 patients sixty-five years of age or older (mean age, eighty-two years; range, sixty-five to 103 years) who underwent surgical treatment of a fragility hip fracture at a single center between January 2011 and December 2012 were evaluated. Demographic, clinical, surgical, and adverse-events data were extracted and analyzed. The confusion assessment method (CAM) was used prospectively to detect perioperative delirium. Results: One hundred and sixteen (48%) of the 242 patients developed perioperative delirium during their stay in the hospital. Compared with patients with no delirium, delirium was associated with a mean incremental total length of hospital stay of 7.4 days (95% confidence interval [CI] = 3.7 to 11.2 days; p < 0.001), a mean incremental length of stay following surgery of 7.4 days (95% CI = 3.8 to 11.1 days; p < 0.001), and a mean incremental episode-of-care cost (in 2012 Canadian dollars) of $8286 (95% CI = $3690 to $12,881; p < 0.001). The total incremental episode-of-care cost attributable to delirium over the study period was $961,131 in 2012 Canadian dollars. Conclusions: Nearly 50% of elderly patients who underwent surgery for a fragility hip fracture developed perioperative delirium, which was associated with a significant incremental in-hospital length of stay and significant incremental episode-of-care costs. These findings highlight the importance of implementing cost-effective interventions to reduce the prevalence of perioperative delirium in elderly patients with a low-energy hip fracture. [ABSTRACT FROM AUTHOR]

Background: Chronic use of opioid medications may lead to dependence or hyperalgesia, both of which might adversely affect perioperative and postoperative pain management, rehabilitation, and clinical outcomes after total knee arthroplasty. The purpose of this study was to evaluate patients who underwent total knee arthroplasty following six or more weeks of chronic opioid use for pain control and to compare them with a matched group who did not use opioids preoperatively. Methods: Forty-nine knees in patients who had a mean age of fifty-six years (range, thirty-seven to seventy-eight years) and who had regularly used opioid medications for pain control prior to total knee arthroplasty were compared with a group of patients who had not used them. Length of hospitalization, aseptic complications requiring reoperation, requirement for specialized pain management, and clinical outcomes were assessed for both groups. Results: Knee Society scores were significantly lower in the patients who regularly used opioid medications at the time of final follow-up (mean, three years; range, two to seven years); the opioid group had a mean of 79 points (range, 45 to 100 points) as compared with a mean of 92 points (range, 59 to 100 points) in the non-opioid group. A significantly higher prevalence of complications was seen in the opioid group, with five arthroscopic evaluations and eight revisions for persistent stiffness and/or pain, compared with none in the matched group. Ten patients in the opioid group were referred for outpatient pain management, compared with one patient in the non-opioid group. Conclusions: Patients who chronically use opioid medications prior to total knee arthroplasty may be at a substantially greater risk for complications and painful prolonged recoveries. Alternative non-opioid pain medications and/or earlier referral to an orthopaedic surgeon prior to habitual opioid use should be considered for patients with painful degenerative disease of the knee. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: An asymptomatic hip with osteonecrosis is typically discovered as the contralateral hip of a patient with one symptomatic joint. Treatment of the asymptomatic hip is controversial. While some authors claim a benign natural history, others have reported a rate of femoral head collapse exceeding 50%. The purpose of this report was to systematically review the published literature regarding asymptomatic osteonecrosis of the femoral head to evaluate the overall prevalence of progression to symptomatic disease and/or femoral head collapse as well as to determine whether various radiographic and demographic factors influence progression of the disorder.Methods: A comprehensive literature search was performed to identify prognostic studies evaluating asymptomatic hip osteonecrosis. Demographic, radiographic, and outcome data were extracted from all relevant studies. The prevalence of progression to symptomatic disease and/or femoral head collapse was determined. Next, outcomes were stratified by lesion size, lesion location, radiographic stage, associated risk factors and/or disease, and the level of evidence of the study.Results: Sixteen studies that included a total of 664 hips were available for an analysis of outcomes. Overall, 394 hips (59%) had progression to symptoms or collapse. Differences in outcomes based on lesion size, lesion location, and radiographic stage at the time of diagnosis were seen. Small, medially located lesions had the best prognosis, with a prevalence of collapse of <10%. Patients with sickle cell disease had the highest frequency of progression, and those with a history of systemic lupus erythematosus had the most benign course.Conclusions: Data extracted from previously published studies suggest that asymptomatic osteonecrosis has a high prevalence of progression to symptomatic disease and femoral head collapse. While small, medially located lesions have a low rate of progression, the natural history of asymptomatic medium-sized, and especially large, osteonecrotic lesions is progression in a substantial number of patients. For this reason, it may be beneficial to consider joint-preserving surgical treatment in asymptomatic patients with a medium-sized or large, and/or laterally located, lesion. [ABSTRACT FROM AUTHOR]

Background: The mini-subvastus and the mini-midvastus approaches are among the most common alternatives to the medial parapatellar approach for total knee arthroplasty. The purpose of this study was to compare the early clinical outcomes of these two approaches. Methods: In this prospective, randomized study of fifty-one patients who underwent bilateral total knee arthroplasty, the mini-subvastus approach was used in one knee and the mini-midvastus approach, in the contralateral knee. There were forty-two women and nine men who had a mean age of seventy years at the time of the index arthroplasties, and they were followed for two years postoperatively. Clinical outcome was assessed and compared with use of the Knee Society pain and function scores, the straight-leg-raising test, range of motion, and isokinetic strength testing. Operating time and blood loss for each approach were also compared. In addition, patients were surveyed concerning which knee they preferred. Results: Comparisons of postoperative Knee Society scores between both approaches at the time of the two-year follow-up did not yield a significant difference in outcome. Isokinetic strength testing at twelve weeks postoperatively revealed no significant differences in muscle strength, with a mean extensor peak torque-to-body weight ratio of 0.14 Nm/kg for both groups. No significant difference was found with respect to total blood loss, straight-leg-raising test, range of motion, or patient preference. There was no clinically relevant difference in operative times between the two approaches. Conclusions: The minimally invasive subvastus and midvastus approaches for total knee arthroplasty were both associated with excellent short-term clinical results. Some surgeons believe that the subvastus approach completely avoids damage to the quadriceps mechanism and therefore would be associated with improved muscle function. This prospective series did not identify a substantive difference between the two approaches. We believe that the decision between these surgical approaches should be based on surgeon preference and experience. [ABSTRACT FROM AUTHOR]

The article presents a study on the evaluation of patients using the criteria-based on survey on practicing orthopedic surgeons, patient outcomes, and published literature in the U.S. It mentions the defined contraindications by the U.S. Food and Drug Administration for hip resurfacing in which only trained surgeons can perform the procedure. Moreover, a survey through a two-day course has been conducted among the participants and has been evaluated using a wireless electronic response system.

The article presents abstracts on primary total knee arthroplasty which includes the discussion on cruciate-retaining knees and on posterior stabilized knees, the proper management of extra-articular deformities of the lower extremity in primary total knee arthroplasty, and the reported evidence for mobile-bearing total knee arthroplasty.

The article presents abstracts on total knee arthroplasty topics which include the importance of cement fixation process in total knee replacement, the issue of sex differences among patients undergoing the surgery considering the difference of each gender with regards to their knees as well as the evidence for sex-based total knee arthroplasty.

The article presents abstracts on hip resurfacing topics which include the benefits of hip resurfacing arthroplasty on patients, the importance of patient selection and surgical technique in hip resurfacing arthroplasty as well as the unique complications of surface replacement arthroplasty as compared with the operation's benefits to patients.

An abstract of the article "Treatment Algorithm for Osteonecrosis," by Michael A. Mont, Michael G. Zywiel and Mike S. McGrath is presented.

There is continued pressure for the development of innovative orthopaedic surgical devices and techniques to meet the demands of increasingly younger and more active patients. However, as demonstrated by several recent or-thopaedic implant withdrawals and recalls, clinically important unknown modes of failure for newly introduced devices may not become apparent for several years after widespread adoption, affecting a large number of patients. Different reasons have been implicated for this problem, including weaknesses in the United States medical device approval process, as well as deficiencies in mechanisms for postapproval implant performance monitoring. Several remedies have been proposed over the past decades. We aim to stimulate discussion concerning the adoption of orthopaedic technology by describing the concept of a graduated implant approval process for orthopaedic devices that builds on recommendations previously made by other authors; by explaining how this will benefit patients, surgeons, and device manufacturers; and by clarifying why the time has come for the orthopaedic community to reconsider the adoption of such a process. [ABSTRACT FROM AUTHOR]