TKA Cost Efficiency Is Improving, But We Can Do Better
Wide variability in the cost and quality of health care in the US has led some to describe our system as “uniquely inefficient.” Consequently, we continue to study variability intensely, especially in the realm of joint arthroplasty. In the June 3, 2020 issue of The Journal, Schilling et al. elegantly analyze the variations in 90-day episode payments made by Medicare Part A for total knee arthroplasty (TKA) from 2014 to 2016. In so doing, they provide a snapshot of hospital cost performance and, just as importantly, they offer a methodology by which to measure future hospital-level cost performance with this very popular surgery.
The authors reviewed >700,000 TKAs in the Medicare population at a time prior to the full implementation of the Comprehensive Care for Joint Replacement (CJR) model, and they ranked >3,200 hospitals within 9 US regions to determine cost performance. Schilling et al. found that during those 3 years, the mean Medicare episode payment for TKA decreased significantly, due almost entirely to a >$1,500 per-case decrease in post-acute care payments, which included lower costs for skilled nursing facilities and inpatient rehabilitation. Also decreasing during that same period were length of hospital stay and 90-day readmission rates.
These findings highlight the improvements in care and cost efficiency that were occurring even before implementation of the CJR. In a Commentary on this study, Susan Odum, PhD suggests that “the improved value of TKA illustrated by Schilling et al. includes the successful impacts of the BPCI [Bundled Payments for Care Improvement] program,” an alternative payment model that Medicare rolled out beginning in 2013.
On the other hand, the authors also reveal a persistently high degree of variability in episode payments and resource utilization both across and within geographic regions. This strongly suggests the possibility of further improvement. Regardless of which, if any, alternative payment model we participate in, everyone in the orthopaedic community should think about how to become more efficient in our delivery of musculoskeletal care. And this study provides a conceptual framework and benchmarks for identifying where the room for improvement is.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
PROM ‘Crosswalks’ Are a Big Step Forward
Patient-reported outcome measures (PROMs) for orthopaedic procedures have long been used in clinical research. In the last decade, the use of PROMs has expanded to include quality-of-care assessments and, in some healthcare systems, to help calculate costs and reimbursements. All this has made PROMs increasingly visible to patients.
There are several validated and widely used PROMs for hip and knee arthroplasty. One problem with those is that the data from one PROM are not interchangeable with data from another. That disconnect limits the opportunity for meaningful data aggregation and thwarts large-scale population research.
In the June 3, 2020 issue of The Journal, Polascik et al. tackle this problem head-on. They report on a “crosswalk” system that allows back-and-forth conversion between 4 of the most commonly used PROMS—the Oxford hip and knee scores and the HOOS and KOOS short-form scores. The authors developed this tool by applying sophisticated statistical methods to data from a large cohort of hip and knee arthroplasty patients. The accuracy of the 4 crosswalks Polascik et al. developed was substantiated when they found minimal differences between the means of the known and crosswalk-derived scores.
This practical tool for converting scores is a substantial advance in patient-reported outcomes research. It will further facilitate the pooling of data for use in future clinical research, quality-of-care initiatives, and reimbursement systems. Patients, surgeons, researchers, and health systems alike all stand to benefit greatly.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
JBJS Announces 2019 EST Award Winners
JBJS Essential Surgical Techniques (EST) and The Journal of Bone and Joint Surgery (JBJS) give out two annual awards–one for the best Subspecialty Procedure (SP) article, and the other for the best Key Procedures (KP) video published during each calendar year.
We are pleased to announce the winners for 2019:
- Editor’s Choice Technique Award:
Patellofemoral Arthroplasty
by Anders Odgaard, MD, DMSc, FRCS; Jonathan Eldridge, MD, FRCS; and Frank Madsen, MD - Editor’s Choice Video Award:
Repair of Tibial Plateau Fracture (Schatzker II)
by Dylan T. Lowe, MD; Michael T. Milone, MD; Leah J. Gonzalez, BS; and Kenneth A. Egol, MD
Both articles are freely available online until the end of August 2020.
Submissions for the 2020 EST Awards are currently being accepted.
May 2020 Article Exchange with JOSPT
For the last 6 years, JBJS has participated in an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of May 2020, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Athletes with Bone-Patellar Tendon-Bone Autograft for ACL Reconstruction Were Slower to Meet Rehabilitation Milestones and Return-to-Sport Criteria than Athletes with Hamstring Tendon Autograft or Soft Tissue Allograft.”
Although the title reveals the findings of this retrospective cohort study, the authors emphasize that “athletes in the allograft and HT groups may be at higher risk of sustaining another knee injury when they return to sport…than those in the BPTB group.” Also, all 79 participants in the study were athletes planning to return to level 1 or 2 sporting activities, so these findings may not be generalizable to all athletes.
Stronger Hands Related to Better Outcomes in THA and TKA
This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.
Up to 33% of patients are dissatisfied with their outcome after a knee or hip replacement. It’s evident that successful recovery from lower-limb joint replacement is aided by leg strength and stamina, but handgrip strength has been proposed as a proxy for a person’s overall muscle strength. A recent prospective cohort study1 of 226 patients who underwent total hip arthroplasty (THA) and 246 patients who underwent total knee arthroplasty (TKA) investigated the association between handgrip strength measured preoperatively with a dynamometer and changes in preoperative versus 1-year postoperative patient-reported outcome scores. Researchers analyzed the data after adjusting for sex, body mass index, and baseline scores.
For both THA and TKA patients, handgrip strength was positively associated with most physical function, symptom, and quality-of-life scores measured with HOOS, KOOS, and SF-36 questionnaires. On the other hand, there was no association between grip strength and mental-component scores in either the THA or TKA group.
Based on a review of the literature and this study’s findings, the authors conclude that the association between handgrip strength and THA/TKA outcomes is partly dependent on the joint site. Although the mechanism to explain the association has not been elucidated, translating these findings into an informal dynamometer-based tool could help clinicians counsel prospective joint-replacement patients about the value of preoperative conditioning.
Reference
1. Meessen JMTA, Fiocco M, Tordoir RL, Sjer A, Verdegaal SHM, Slagboom PE, Vliet Vlieland TPM, Nelissen RGHH. Association of handgrip strength with patient-reported outcome measures after total hip and knee arthroplasty. Rheumatol Int. 2020 Apr;40(4):565-571. doi: 10.1007/s00296-020-04532-5. Epub 2020 Feb 18. PMID: 32072233
Impressive Long-term Outcomes in Revision TKA with Constrained Prostheses
Time is an enemy of all orthopaedic implants, just as it is the bane of native joints. It is therefore helpful to accurately measure how long and well specific implant types last. That is what Kim et al. have done with their 19-year follow up of 90 patients (107 knees) who underwent total knee arthroplasty (TKA) with a constrained condylar knee prosthesis. Their findings appear in the April 15, 2020 issue of The Journal of Bone & Joint Surgery.
Knee arthroplasty surgeons often choose constrained prostheses to improve joint stability in patients with ligament dysfunction, and the typically longer stems of these implants can also compensate for poor bone stock. Kim et al. evaluated the same patient population (mean age of 65 years; mean BMI of 26.9 kg/m2) that they reported on in an earlier study, finding the following outcomes after a mean follow-up of 19 years:
- 96% survival in terms of mechanical failure
- 91% survival in terms of reoperation for any reason
- Patient-reported outcome scores that remained significantly improved from pre-revision values
- Only 1 knee with osteolysis around a component
Among the few knees that required re-revision, 5 such operations were performed due to aseptic loosening and 4 due to infection. The authors note that these very good long-term results are similar to those in previous studies of revision TKAs using various implant types. Kim et al. attribute these findings to several possible factors:
- Low prevalence of comorbidities, including obesity, among the patients
- Excellent surgical technique, including good cementing and correct flexion and extension gaps
- Use of compression-molded polyethylene
How to Conduct a Virtual Orthopaedic Examination
For obvious reasons, the use of telemedicine has surged during the COVID-19 pandemic. If you are wondering what a “virtual” orthopaedic physical exam looks like, Tanaka et al. explain the process in words and images in a recent fast-tracked JBJS article.
At the time they schedule their virtual visit, patients are asked to confirm their audiovisual capabilities, and they receive specific instructions about camera positioning, body positioning, setting, and attire to improve the efficiency of the visit.
Tanaka et al. give step-by-step instructions for virtually evaluating the knee, hip, shoulder, and elbow. They describe how they measure range of motion using a web-based goniometer (see Figure), and they explain how to conduct virtual strength tests for each joint. To enable post-exam follow-up discussions with patients, the authors recommend using “the screen-sharing function that is presumably available on all interactive telehealth platforms.”
The authors acknowledge the limitations inherent in a virtual orthopaedic exam, such as the inability to directly palpate the joint or perform provocative tests. They also admit that the patient population that would potentially benefit the most from televisits—older patients with limited mobility and who are at higher risk for infection during the pandemic—are also those who may have the most difficulty implementing the technology.
The rapid rise of telemedicine in orthopaedics has occurred due to unexpected necessity, but many expect that its widespread use will continue post-pandemic. Tanaka et al. cite future directions for the technology, including the development of validated, modified examination techniques and advancements that will improve interactivity during the physical examination. For now, though, these experience-based guidelines should help orthopaedists optimize the quality and efficiency of their upcoming virtual visits for common musculoskeletal conditions.
What’s New in Sports Medicine 2020
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of OrthoBuzz summaries of these “What’s New” articles. This month, co-author Christopher Y. Kweon, MD selected the 5 most clinically compelling findings from the 40 studies summarized in the April 15, 2020 “What’s New in Sports Medicine.”
ACL Graft Choice
—A randomized controlled trial (RCT) comparing bone-tendon-bone autograft, quadrupled hamstring tendon autograft, and double-bundle hamstring autograft for ACL reconstruction in young adults found the following:
- No between-group differences in patient-reported quality-of-life scores at 5 years
- Significantly higher rates of traumatic graft reinjuries in the hamstring-tendon and double-bundle groups
- Relatively low (37%) return to preinjury level of activity for the entire population, with no significant between-group differences
Meniscal Repairs with Bone Marrow Venting
—A double-blinded RCT1 of patients with complete, unstable, vertical meniscal tears compared isolated meniscal repair to meniscal repair with a bone marrow venting procedure (BMVP). Meniscal healing, as assessed with second-look arthroscopy at a mean of 35 weeks, was 100% in the BMVP group and 76% in the control group (p = 0.0035). Secondary pain and function measures at 32 to 51 months were also better in the BMVP group.
Rotator Cuff Repair Rehab
—A multisite RCT2 among >200 patients who received arthroscopic repair of a full-thickness rotator cuff tear compared standard rehabilitation (patients wore a sling at all times except when performing prescribed exercises) and early mobilization (patients wore a sling only when needed for comfort). Early mobilizers showed significantly better forward flexion and abduction at 6 weeks, but no subjective or objective differences (including retear rate) were found at any other time points.
Remplissage for Anterior Shoulder Instability
—A systematic review3 of studies investigating arthroscopic Bankart repair with and without remplissage found significantly higher instability-recurrence rates with isolated Bankart repair. Overall, the addition of remplissage appears to yield better patient-reported function scores compared with isolated Bankart repair alone.
Syndesmotic Ankle Injuries
—A meta-analysis of 7 RCTs (335 patients)4 comparing dynamic versus static fixation for syndesmotic injuries of the ankle found that the overall risk of complications was significantly lower in the dynamic fixation group. Reoperation rates were similar in the two groups, but implant breakage or loosening was reduced with dynamic fixation devices. Compared with static fixation, the dynamic fixation group also had higher AOFAS scores and lower VAS scores at various time points.
References
- Kaminski R, Kulinski K, Kozar-Kaminska K, Wasko MK, Langner M, Pomianowski S. Repair augmentation of unstable, complete vertical meniscal tears with bone marrow venting procedure: a prospective, randomized, double-blind, parallel-group, placebo-controlled study. Arthroscopy.2019 May;35(5):1500-1508.e1. Epub 2019 Mar 20.
- Sheps DM, Silveira A, Beaupre L, Styles-Tripp F, Balyk R, Lalani A, Glasgow R, Bergman J, Bouliane M; Shoulder and Upper Extremity Research Group of Edmonton (SURGE). Early active motion versus sling immobilization after arthroscopic rotator cuff repair: a randomized controlled trial. Arthroscopy.2019 Mar;35(3):749-760.e2.
- Lazarides AL, Duchman KR, Ledbetter L, Riboh JC, Garrigues GE. Arthroscopic remplissage for anterior shoulder instability: a systematic review of clinical and biomechanical studies. Arthroscopy.2019 Feb;35(2):617-28. Epub 2019 Jan 3.
- Grassi A, Samuelsson K, D’Hooghe P, Romagnoli M, Mosca M, Zaffagnini S, Amendola A. Dynamic stabilization of syndesmosis injuries reduces complications and reoperations as compared with screw fixation: a meta-analysis of randomized controlled trials. Am J Sports Med.2019 Jun 12. [Epub ahead of print].
PT More Effective than Steroid Injections for Knee OA
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent study in The New England Journal of Medicine, the following commentary comes from Jaime L. Bellamy, DO.
A majority of patients I see for knee osteoarthritis (OA) want a quick fix. Many would like to skip conservative treatment–activity modification, weight loss, physical therapy (PT), anti-inflammatory medication, and intra-articular steroid injections–and go straight to surgical management. Regarding nonoperative management of knee OA, the most recent AAOS Clinical Practice Guidelines “strongly” recommend that patients participate in PT and “inconclusively” recommend intra-articular steroid injections.1 Yet, in my clinical practice, I confess to typically offering a knee injection first, before PT.
I may change that practice in light of the randomized controlled trial (RCT) by Deyle et al. in the April 9, 2020 issue of The New England Journal of Medicine. The trial compared PT to glucocorticoid knee injections among 156 primary-care knee OA patients within a military health system. The primary outcome measure was the WOMAC score at 1 year. Secondary outcomes included the Alternate Step Test and the Timed Up and Go test.
Seventy-eight patients randomly assigned to each group were included in the analysis. The PT intervention included detailed home-exercise instructions and 8 sessions with a therapist over the initial 4- to 6-week period. Patients could also attend 1 to 3 PT sessions at the 4-month and 9-month reassessments. Knee-injection patients received 1 ml of triamcinolone acetonide (40 mg per milliliter) and 7 ml of 1% lidocaine up to three times in one year.
The mean baseline WOMAC scores were similar between the groups. However, at 1 year, the authors found a mean between-group difference of 18.8 points in WOMAC scores, favoring PT over injections. Secondary outcomes also favored PT over knee injections.
Regardless of this RCTs limitations, such as the lack of reporting on knee-injection techniques, the findings serve as a reminder to orthopaedists to recommend PT as an effective nonoperative treatment option for knee OA. Additionally, our primary care colleagues can use this data to help convince patients with knee OA that they do not need to rush in to see a surgeon.
Jaime L. Bellamy, DO (@jaimelbellamyDO) is an orthopaedic surgeon specializing in hip and knee reconstruction in Fort Bragg, NC and a member of the JBJS Social Media Advisory Board.
Reference
- AAOS Clinical Practice Guidelines, Treatment of Osteoarthritis of the Knee, 2nd Edition (2013), http://www.orthoguidelines.org/topic?id=1005, accessed 4/14/2020.
Does Computer-Assisted Surgery Drive Better TKA Outcomes?
Computer-assisted surgery (CAS) for total knee arthroplasty (TKA) has become popular largely based on claims that the technology improves accuracy of component positioning and alignment. Theoretically, that leads to superior patient-reported outcomes. However, the use of CSA has not reliably yielded improvements in implant survival or clinical outcomes. A large registry study by Roberts et al. in the April 1, 2020 issue of The Journal sheds additional light on this perplexing question.
An earlier study by the same author group used data from the same New Zealand Joint Registry and showed no difference in functional outcomes or implant survival between TKAs performed with and without CAS.1 However, that study did not account for the potential bias introduced by surgeons who use CAS only for complex cases.
In this study, Roberts et al. analyzed data from 2 carefully selected groups of surgeons: those who used CAS in 90% of their TKAs (“routine CAS” surgeons) and those who used CAS in <10% of their TKAs (“routine conventional” surgeons). Further limiting their analysis to surgeons with >50 TKAs recorded in the registry between 2006 and 2018, Roberts et al. identified 25 “routine CAS” surgeons and 22 “routine conventional” surgeons. This allowed a comparison between 9,501 TKAs performed by routine CAS surgeons and 7,672 TKAs performed by routine conventional surgeons. While analyzing revision rates and Oxford Knee Scores (OKS) at 6 months, 5 years, and 10 years, the authors also controlled for confounding variables such as age, body-mass index, and implant type.
With a mean follow-up of 4.5 years, the authors found a revision rate per 100 component-years of 0.437 in the group operated on by routine CAS surgeons, compared to a mean 4.9-year revision rate of 0.440 in the group operated on by routine conventional surgeons (p=0.724). When stratifying outcomes of patients <65 years old, the authors again found no statistical difference in revision rates. They also found no between-group differences in OKS within the full and <65 cohorts at 6 months, 5 years, or 10 years.
The findings prompt the authors (and I) to wonder whether continually improving design and durability of modern implants make it difficult to discern any advantage from computer assistance in implant positioning.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Reference
- Roberts TD, Clatworthy MG, Frampton CM, Young SW. Does computer assisted navigation improve functional outcomes and implant survivability after total knee arthroplasty? J Arthroplasty. 2015 Sep; 30(9)Suppl: 59-63.
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