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Two-stage revision total knee arthroplasty (TKA) is the standard of care for patients who require a revision procedure for the mangement of a late or chronic periprosthetic knee infection. A careful examination of two-stage revision TKA is warranted as the number of patients who require revision TKA in the United States continues to rise. Surgeons should understand the intricacies involved in two-stage revision TKA, including the indications, procedural variations, and current deliberations on two-stage revision TKA in the literature. Surgeons also should understand the alternative treatments for periprosthetic knee infections.

Background Compared to total knee arthroplasty (TKA) for primary osteoarthritis, conversion TKAs in the post-traumatic setting are associated with increased operative times, infection rates, and readmissions. We aim at determining how post-traumatic osteoarthritis and previous knee surgery influence postoperative outcomes in conversion TKA. Methods Seventy-two conversion TKA procedures with prior knee trauma at a single institution between April 2012 and 2016 were examined. Twenty-seven (37.5%) cases had a preoperative site-specific diagnosis such as fracture of the proximal tibia, distal femur, or patella whereas 45 (62.5%) cases had a preoperative diagnosis of significant soft-tissue trauma. These 2 groups were compared in terms of total implant cost, length of stay, complications, and readmission and reoperation rates. A subanalysis was conducted to evaluate the effects of previous knee surgery on surgical outcomes. Results The postfracture TKA cohort suffered significantly higher early surgical site complications (22% vs 4.4%, P = .02) and 90-day readmissions (14.8% vs 2.2%, P = .042) compared to the soft-tissue trauma cohort. Operative time, total implant costs, length of stay, medical complications, 30-day readmissions, and 90-day reoperation rates did not significantly differ. It was also found that patients with multiple prior knee surgeries compared to one prior knee surgery are younger (53.0 vs 63.1, P = .003), healthier, and receive significantly more expensive implants (1.72 vs 1.07, P = .026). In addition, patients with previous open reduction internal fixations experience more surgical site complications than patients with previous arthroscopies (31% vs 3.3%, P = .042). Conclusion Patients with previous site-specific fracture are more likely to experience surgical site complications and 90-day readmissions after conversion TKA than patients with previous soft-tissue knee trauma. Multiple previous knee surgeries appear to serve as an independent factor in the selection of costlier implants irrespective of preoperative diagnosis.

Background Many cost drivers of total knee arthroplasty (TKA) have been critically evaluated to meet the heightened quality-associated expectations of performance-based care. However, assessing the efficacy of the different modalities of skin closure has been an underappreciated topic. The present study aims to provide further insight by conducting a meta-analysis and systematic review evaluating the rates of common complications and perioperative quality outcomes associated with different suture and staple skin closure techniques after TKA. Methods The present study was conducted in accordance with both the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement and the Cochrane Handbook for meta-analyses and systematic reviews. Primary outcome measures evaluated rates of common complications associated with primary TKA. Secondary outcome measures evaluated wound closure time, direct surgical costs, and cosmetic and knee function outcomes. Results Our meta-analysis demonstrated that skin sutures had a higher likelihood of superficial and deep infections, abscess formation, and wound dehiscence. Conversely, staples had a higher tendency for prolonged wound discharge. A systematic review of wound closure times and overall resource utilization demonstrated that wound closure was faster and more cost-effective with skin staples than sutures. Conclusion Primary skin incision closure with staples demonstrated lower wound complications, decreased wound closure times, and an overall reduction in resource utilization. Given these outcomes, the use of staples after TKA may have several subtle clinical advantages over sutures.

Extensor mechanism complications involving the patella frequently result in total knee arthroplasty (TKA) failure. Postoperative patellar dislocation may be caused by soft tissue imbalance, improper sizing, and position of the prosthesis. This report describes a case of revision TKA requiring several rounds of soft tissue releases in an effort to treat the patient's chronic patellar dislocation. In the process, a novel surgical approach was developed for the surgical management of refractory chronic patellar dislocations. Postoperative follow-up at 1, 2, 6, 12, and 24 months indicated no complaints of patellar subluxation or dislocation. Plain films also demonstrated no effusion, fracture, or patellar dislocation on sunrise, anteroposterior, and lateral views. This novel anatomic repositioning of the vastus lateralis around the quadriceps tendon converted a pathologic lateralizing force into a medial stabilizer. On follow-up evaluations, successful patellar tracking without dislocation has been demonstrated. (Journal of Surgical Orthopaedic Advances.

INTRODUCTION Hip fractures are a common source of morbidity, mortality, and cost burden for elderly patients. We conducted a retrospective analysis of patients with hip fracture treated during the day or night at a rural level I academic trauma center and compared the postoperative outcomes and resource utilization for both groups. METHODS Patients aged ≥55 years with hip fractures treated with definitive surgical fixation from April 2011 to April 2013 were included in this study. Patients who underwent surgery between 7 AM and 5 PM were included in the day cohort, while those who underwent surgery between 5 PM and 7 AM were included in the night cohort. A total of 441 patients met the study inclusion criteria. RESULTS Comparison of the baseline characteristics of the two cohorts did not demonstrate significant variance. Although postoperative outcomes and resource utilization trends varied between the day and night cohort, only in-hospital cost was significantly higher in the day cohort (P = 0.04). Postoperative variables, including blood loss, [INCREMENT]hematocrit level, length of surgery, length of stay, time to surgery, in-hospital mortality, and 30-day readmission, did not vary significantly. CONCLUSION Our study demonstrates a significantly higher cost associated with hip fracture procedures performed between 7 AM and 5 PM. In addition, perioperative blood loss and length of surgery were used as markers of physician fatigue; however, no statistically significant difference among these variables was found between hip fracture intervention performed during the day versus at night. LEVEL OF EVIDENCE III, retrospective observational study.

Health care cost is consuming a large portion of the nation's gross domestic product while placing added economic burdens on physicians and their patients. With total joint replacement being one of the early-targeted procedures in the evolving health care environment, knee surgeons will benefit from developing a critical knowledge on health care reforms and their financial implications. The Medicare Access and Children's Health Insurance Program Reauthorization Act represents a cohesive movement toward value-based payment reform and contains several unchartered rulings that require detailed attention by knee surgeons. In this article, we provide a contextual framework of health care legislation that has led to the formation of the current health policy, and present a comprehensive summary and update on the Merit-Based Incentive Payment Systems and Alternative Payment Models reimbursement models.

Total joint arthroplasty (TJA) has excellent outcomes in the majority of patients. However, periprosthetic joint infection (PJI) remains one of the most frequent and devastating complications. To minimize this risk, orthopaedic surgeons have implemented a host of prophylactic modalities including high flow ventilation systems, perioperative antibiotics, and intraoperative antiseptic agents, all with varying degrees of success.[1] Acute infections occurring within three months of surgery are of particular concern as these infections are believed to be acquired during the index procedure and may therefore be preventable.[2] In an effort to better address these early infections, orthopaedic surgeons have investigated the role of different types of wound dressing in the setting of TJA

Proper acetabular component positioning is dependent on multiple factors.Proper preoperative templating is of utmost importance, and the surgeon must take care to determine acetabular position and location, orientation (anteversion and inclination), and size, while also focusing on limb length and o

Surgical site infection in total joint arthroplasty is a challenging complication that warrants discussion with regard to prevention and management. Limiting postoperative infection rate is a paramount quest in the orthopedic community. Several preoperative risk factors have been identified in orthopedic literature with regards to likelihood of developing postoperative infection. This article evaluates several factors that predispose total joint arthroplasty patients to infection. Methods of patient surgical preparation designed to decrease postoperative infection, decreasing intraoperative traffic during procedural settings, and elaborate intraoperative prophylactic advancements are assessed. Approaches to decrease postoperative infection by discussing means of lowering rates of postoperative transfusion, wound drainage, and hematoma formation are analyzed.

Within the past 3 decades, a recent trend in the growth of musculoskeletal service lines has been seen nationally. Orthopedics offers an appealing concourse for implementation of service-line care. Within this review, the authors address the components involved in planning and building a musculoskeletal service line. The authors also address methods by which orthopedic surgeons can maintain the efficacy of their service lines by examining how orthopedic surgeons can navigate their service line through recent advents in health care reform. Finally, the authors review successful examples of musculoskeletal service lines currently in practice within the orthopedic community.

This article explores how integration of data from clinical registries and electronic health records produces a quality impact within orthopedic practices. Data are differentiated from information, and several types of data that are collected and used in orthopedic outcome measurement are defined. Furthermore, the concept of comparative effectiveness and its impact on orthopedic clinical research are assessed. This article places emphasis on how the concept of big data produces health care challenges balanced with benefits that may be faced by patients and orthopedic surgeons. Finally, essential characteristics of an electronic health record that interlinks musculoskeletal care and big data initiatives are reviewed.

Hospital readmission is a focus of quality measures used by the Center for Medicare and Medicaid (CMS) to evaluate quality of care. Policy changes provide incentives and enforce penalties to decrease 30-day hospital readmissions. CMS implemented the Readmission Penalty Program. Readmission rates are being used to determine reimbursement rates for physicians. The need for readmission is deemed an indication for inadequate quality of care subjected to financial penalties. This reviews identifies risk factors that have been significantly associated with higher readmission rates, addresses approaches to minimize 30-day readmission, and discusses the potential future direction within this area as regulations evolve.

As health care reforms continue to improve quality of care, significant emphasis will be placed on evaluation of orthopedic patient outcomes. Total joint arthroplasty (TJA) has a proven track record of enhancing patient quality of life and are easily replicable. The outcomes of these procedures serve as a measure of health care initiative success. Specifically, length of stay, will be targeted as a marker of quality of surgical care delivered to TJA patients. Within this review, we will discuss preoperative and postoperative methods by which orthopedic surgeons may enhance TJA outcomes and effectively reduce length of stay.

Osteolysis is a process mounted by the host immune system that relies on several variables, including patient-related factors, type of insert material, modes of wear, and implant design. Imaging techniques such as radiography, computed tomography (CT) scans, magnetic resonance imaging (MRI), and tomosynthesis aid in diagnosing osteolysis. Surgical options for the treatment of osteolysis include the insertion of bone grafts, bone cement, and prosthetic augmentation. Although no approved pharmacological therapies for the specific treatment of osteolysis exist, the use of bisphosphonates and statins decreases the risk of osteolysis.

Different biomechanical designs are incorporated into various total knee arthroplasty (TKA) implants. The posterior-stabilized prosthesis design utilizes a polyethylene post and femoral cam in place of the posterior cruciate ligament. This produces a more stable component interface, increased range of motion, and potentially a less technical procedure. This study aimed to assess the short-term (>2 year) outcomes associated with the Vega System posterior-stabilized knee prosthesis (Aesculap Implant Systems, Center Valley, Pennsylvania) based on postoperative radiographs using the Knee Society Roentgenographic Evaluation and Scoring System (KSRESS). Thirty-seven TKA patients who had received the Vega posterior-stabilized knee prosthesis and had postoperative radiographs at each follow-up for a minimum of 2 years were enrolled, retrospectively. Two independent observers evaluated the radiographs using KSRESS. Descriptive statistics were used to analyze the data. The average age and body mass index of patients enrolled was 67 years (range, 51–89 years) and 38.5 kg/m 2 (range, 21.2–54 kg/m 2 ), respectively. Patients had radiographic follow-up for an average of 36 months (range, 24–58 months). Comparison between first and last available postoperative radiographs revealed a stable femoral and tibial interface with no significant change in prosthesis alignment over the follow-up period. Assessment of the short-term survivorship of the Vega posterior-stabilized prosthesis using KSRESS revealed no significant change in alignment after 2 years of follow-up; however, mid- to long-term studies assessing this junction are needed. A future prospective study using KSRESS in combination with clinical follow-up is recommended to allow comparison of the Vega posterior-stabilized to other prostheses. [ Orthopedics . 2016; 39(3):S56–S60.]

With the large number of total knee arthroplasties being performed and expectations that these numbers will be on the rise over the coming decades, efforts to provide cost-efficient care are of greater interest. The preferred design of knee arthroplasty implants has changed over time, with the original all-polyethylene tibial (APT) design being replaced by metal-backed tibial (MBT) components, as well as more recent considerations of newer APT designs. Modern APT components have been shown to have similar or superior outcomes than MBT components. Despite their limitations, APT components can be used to reduce the economic burden to the provider, medical institution, and health care system as a whole. There is a paucity of evidence-based literature directly comparing the cost associated with APT and MBT components. The purpose of this report is to review the literature to assess the available data regarding direct and indirect costs of both designs so that orthopedic surgeons can account for economic differences in everyday practice. [ Orthopedics . 2016; 39(3):S61–S66.]

Diabetes mellitus is one of the most common chronic conditions worldwide, affecting an estimated 422 million individuals (1). Disrupted insulin production and resistance to insulin leads to aberrant carbohydrate metabolism. Left untreated, chronically elevated blood sugars damages capillary walls and causes severe end-organ damage.

Patients and physicians continue to work together to make complex medical decisions. Healthcare providers continue to make efforts to enhance the different decision-making models and tools available to improve this process. While decision-making models such as paternalistic and informative, may have their advantages, shared decision-making (SDM) has proven to be the current ideal approach, resulting in increased patient satisfaction. In addition, technological advancements offer further opportunities for patients and surgeons to implement innovative decision-making models. In this review, we will define the three decision-making models and discuss the potential for modern tools available to increase information available for patients and enhance the communication between patients and physicians allowing for more informed clinical decisions, using total joint replacement as an example.

Ligamentous knee injuries are common and costly, both in financial terms and time missed from work and recreational activities. Furthermore, ligamentous injuries appear to predispose patients to future osteoarthritis and other morbidities. Therefore, prevention strategies are important in limiting the potential impact of these injuries. Knee braces are one of the most often prescribed devices in the billion-dollar orthotic industry. Despite widespread use of prophylactic and functional knee braces, the evidence supporting their efficacy in reducing and/or preventing injury remains limited. Knee braces have been shown to be more effective in preventing medial collateral ligament injuries than anterior cruciate ligament injuries in both cadaveric and clinical studies. The use of functional braces after anterior cruciate ligament reconstruction has been supported and refuted in both postoperative and long-term studies.