Healthy but not osteoarthritic human meniscus-derived matrix scaffolds promote meniscus repair.

Meniscus tissue is commonly injured due to sports-related injuries and age-related degeneration and approximately 50% of individuals with a meniscus tear will develop post-traumatic osteoarthritis (PTOA). Given that the meniscus has limited healing potential, new therapeutic strategies are required to enhance meniscus repair. Porcine meniscus-derived matrix (MDM) scaffolds improve meniscus integrative repair, but sources of human meniscus tissue have not been investigated.

Synergistic roles of CBX4 chromo and SIM domains in regulating senescence of primary human osteoarthritic chondrocytes.

Background: Cellular senescence is a critical factor contributing to osteoarthritis (OA). Overexpression of chromobox homolog 4 (CBX4) in a mouse system was demonstrated to alleviate post-traumatic osteoarthritis (PTOA) by reducing cellular senescence. Additionally, replicative cellular senescence of WI-38 fibroblasts can be attenuated by CBX4.

Association of Dipeptidylpeptidase 4 (CD26) With Chondrocyte Senescence and Radiographic Progression in Knee Osteoarthritis.

Objective: To evaluate the association of dipeptidylpeptidase 4 (DPP-4; also known as CD26) with cellular senescence of human cartilage and progression of knee osteoarthritis (OA).

Methods: Articular cartilage sections and chondrocytes were acquired from 35 individuals undergoing total knee replacement for OA to evaluate the following: 1) the association between OA severity and established senescence markers (senescence-associated β-galactosidase activity and p16), which was quantified using immunohistochemistry and flow cytometry (n = 19 samples); 2) the coexpression of DPP-4 with established senescence markers, which was assessed using flow cytometry; and 3) expression levels of anabolic and catabolic genes, senescence-related genes, and senescence-associated secretory phenotypes in DPP-4+ and DPP-4- cells, which were isolated using fluorescence-activated cell sorting or magnetic-activated cell sorting (n = 16 samples). The concentration of soluble DPP-4 was measured in samples of synovial fluid and samples of plasma from the Prediction of Osteoarthritis Progression cohort and then evaluated for association with the severity of radiographic knee OA at baseline (n = 65 samples) and the progression of structural radiographic OA (n = 57 samples) over a 3-year period.

A Validated Pre-operative Risk Prediction Tool for Extended Inpatient Length of Stay Following Primary Total Hip or Knee Arthroplasty.

Background: As value-based reimbursement models mature, understanding the potential trade-off between inpatient lengths of stay and complications or need for costly postacute care becomes more pressing. Understanding and predicting a patient's expected baseline length of stay may help providers understand how best to decide optimal discharge timing for high-risk total joint arthroplasty (TJA) patients.

Methods: A retrospective review was conducted of 37,406 primary total hip (17,134, 46%) and knee (20,272, 54%) arthroplasties performed at two high-volume, geographically diverse, tertiary health systems during the study period.

A Preoperative Risk Prediction Tool for Discharge to a Skilled Nursing or Rehabilitation Facility After Total Joint Arthroplasty.

Background: Discharge to rehabilitation or a skilled nursing facility (SNF) after total joint arthroplasty remains a primary driver of cost excess for bundled payments. An accurate preoperative risk prediction tool would help providers and health systems identify and modulate perioperative care for higher risk individuals and serve as a vital tool in preoperative clinic as part of shared decision-making regarding the risks/benefits of surgery.

Methods: A total of 10,155 primary total knee (5,570, 55%) and hip (4,585, 45%) arthroplasties performed between June 2013 and January 2018 at a single institution were reviewed.

All-Polyethylene Tibia: An Opportunity for Value-Based Care in Bundled Reimbursement Initiatives.

Surgeons play a critical role in making cost-effective decisions that maintain high-quality patient outcomes, which is the current focus of the Centers for Medicare & Medicaid Services. All-polyethylene tibial (APT) components often cost less during total knee arthroplasty (TKA). The authors sought to determine the relative cost savings of APT, as well as their effect on 90-day quality outcome metrics.

The Calpain Gene is Correlated With Metal-on-Metal Hip Replacement Failures.

Background: Metal-on-metal (MOM) total hip arthroplasty is associated with unacceptable failure rates secondary to metal ion reactions. Efforts to identify which patients will go on to failure have been limited; recently, there has been a suggestion for a potential genetic basis for the increased risk of revision in MOM hip replacements (MOMHRs). The purpose of this study is to determine whether certain immunologic genotypes are predictive of the need for revision in patients with MOM total hip implants.

Synovial cell cross-talk with cartilage plays a major role in the pathogenesis of osteoarthritis.

We elucidated the molecular cross-talk between cartilage and synovium in osteoarthritis, the most widespread arthritis in the world, using the powerful tool of single-cell RNA-sequencing. Multiple cell types were identified based on profiling of 10,640 synoviocytes and 26,192 chondrocytes: 12 distinct synovial cell types and 7 distinct articular chondrocyte phenotypes from matched tissues. Intact cartilage was enriched for homeostatic and hypertrophic chondrocytes, while damaged cartilage was enriched for prefibro- and fibro-, regulatory, reparative and prehypertrophic chondrocytes.

Roadmap for Transforming Preoperative Assessment to Preoperative Optimization.

Preoperative assessment typically equates to evaluating and accepting the presenting condition of the patient (unless extreme) and commonly occurs only a few days before the planned surgery. While this timing enables a preoperative history and examination and mitigates unexpected findings on the day of surgery that may delay throughput, it does not allow for meaningful preoperative management of modifiable medical conditions. Evidence is limited regarding how best to balance efforts to mitigate modifiable risk factors versus the timing of surgery.

Tranexamic acid or epsilon-aminocaproic acid in total joint arthroplasty? A randomized controlled trial.

Aims: Antifibrinolytic agents, including tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), have been shown to be safe and effective for decreasing perioperative blood loss and transfusion following total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, there are few prospective studies that directly compare these agents. The purpose of this study was to compare the benefits of intraoperative intravenous TXA with EACA.

Early to Midterm Clinical and Radiographic Survivorship of the All-Polyethylene Versus Modular Metal-Backed Tibia Component in Primary Total Knee Replacement.

The purpose of this study was to compare the all-polyethylene tibial component with the modular metal-backed component in primary total knee arthroplasty. A retrospective review of 1064 patients recorded clinical failure, as determined by need for revision surgery, range of motion, and impending radiographic loosening, as evaluated by the presence of radiolucent lines. Mean follow-up was 1.

Should Medical Severity-Diagnosis Related Group Classification Be Utilized for Reimbursement? An Analysis of Elixhauser Comorbidities and Cost of Care.

Background: The Center for Medicare and Medicaid Services (CMS) classifies reimbursement for total hip arthroplasty (THA) and total knee arthroplasty (TKA) based on Medical Severity-Diagnosis Related Groups (MS-DRGs) 469 (with major complication/comorbidity) and 470 (without major complication/comorbidity). The validated Elixhauser comorbidity index includes 31 variables that may be associated with MS-DRG 469. However, we hypothesized that these comorbidities may not be the most predictive of increased cost of care.

A Novel Risk Calculator Predicts 90-Day Readmission Following Total Joint Arthroplasty.

Background: A reliable prediction tool for 90-day adverse events not only would provide patients with valuable estimates of their individual risk perioperatively, but would also give health-care systems a method to enable them to anticipate and potentially mitigate postoperative complications. Predictive accuracy, however, has been challenging to achieve. We hypothesized that a broad range of patient and procedure characteristics could adequately predict 90-day readmission after total joint arthroplasty (TJA).

Characterizing Patient Preferences Surrounding Total Knee Arthroplasty.

Background: Episode-based bundled payments for total knee arthroplasty emphasize cost-effective patient-centered care. Understanding patients' perceptions of components of the total knee arthroplasty care episode is critical to achieving this care. This study investigated patient preferences for components of the total knee arthroplasty care episode.

Predicting Inpatient Dissatisfaction Following Total Joint Arthroplasty: An Analysis of 3,593 Hospital Consumer Assessment of Healthcare Providers and Systems Survey Responses.

Background: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, created by the Centers for Medicare and Medicaid, is directly tied to hospital reimbursement. The purpose of this study is to identify factors that are predictive HCAHPS survey responses following primary hip and knee arthroplasty.

Methods: Prospectively collected HCAHPS responses from patients undergoing elective hip and knee arthroplasty between January 2013 and October 2017 at our institution were analyzed.

A Weighted Index of Elixhauser Comorbidities for Predicting 90-day Readmission After Total Joint Arthroplasty.

Background: Evolving reimbursement models increasingly compel hospitals to assume costs for 90-day readmission after total joint arthroplasty. Although risk assessment tools exist, none currently reach the predictive performance required to accurately identify high-risk patients and modulate perioperative care accordingly. Although unlikely to perform adequately alone, the Elixhauser index is a set of 31 variables that may lend value in a broader model predicting 90-day readmission.

Preoperative Optimization Checklists Within the Comprehensive Care for Joint Replacement Bundle Have Not Decreased Hospital Returns for Total Knee Arthroplasty.

Background: The Comprehensive Care for Joint Replacement (CJR) model has resulted in the evolution of preoperative optimization programs to decrease costs and hospital returns. At the investigating institution, one center was not within the CJR bundle and has dedicated fewer resources to this effort. The remaining centers have adopted an 11 metric checklist designed to identify and mitigate modifiable preoperative risks.

Predicting Costs Exceeding Bundled Payment Targets for Total Joint Arthroplasty.

Background: The Center for Medicare and Medicaid Services has instituted bundled reimbursement models for total joint arthroplasty (TJA), which includes target prices for each procedure. Some patients exceed these targets; however, currently there are no tools to accurately predict this preoperatively. We hypothesized that a validated comorbidity index combined with patient demographics would adequately predict excess cost-of-care prior to hospitalization.

Utilization of an Electronic Patient Portal Following Total Joint Arthroplasty Does Not Decrease Readmissions.

Background: At the investigating institution, an electronic messaging portal (MyChart) allows patients to directly communicate with their healthcare provider. As reimbursement models evolve, there is an increasing effort to decrease 90-day hospital resource utilization and patient returns, and secure messaging portals have been proposed as one way to achieve this goal. We sought to determine which patients utilize this portal, and to determine the impact of secure messaging on emergency department (ED) visits and readmissions within 90 days postoperatively.

Skilled Nursing Facilities After Total Knee Arthroplasty: The Time for Selective Partnerships Is Now!

Background: Bundled payment initiatives for total knee arthroplasty (TKA) patients are dramatically impacted by discharges to skilled nursing facilities (SNFs), making target prices set by the Center for Medicare and Medicaid Services difficult to achieve. However, we hypothesized that a granular examination of SNF discharges would reveal that some may disproportionately increase costs compared to others.

Methods: The institutional database was retrospectively queried for primary TKA patients under bundled payment initiatives.

Preoperative Patient Profile in Total Hip and Knee Arthroplasty: Predictive of Increased Medicare Payments in a Bundled Payment Model.

Background: The shift toward value-based bundled payment models in total joint arthroplasty highlights the need for identification of modifiable risk factors for increased spending as well as opportunities to mitigate perioperative treatment of chronic disease. The purpose of this study was to identify preoperative comorbidities that result in an increased financial burden using institutional data at a single institution.

Methods: We conducted a retrospective review of total joint arthroplasty patients and collected payment data from the Center for Medicare and Medicaid Services for each patient up to 90 days after surgery in accordance with the regulations of the Comprehensive Care for Joint Replacement initiative.

Association Between Pseudotumor Formation and Patient Factors in Metal-on-Metal Total Hip Arthroplasty Population.

Background: Pseudotumor formation from metal-on-metal (MoM) hip implants is associated with implant revision. The relationship between pseudotumor type and patient outcomes is unknown.

Methods: We retrospectively reviewed patients with a MoM total hip arthroplasty and metal artifact reduction sequence magnetic resonance imaging.

Conversion vs Primary Total Hip Arthroplasty: Increased Cost of Care and Perioperative Complications.

Background: With the increasing incidence of hip fractures and hip preservation surgeries, there has been a concomitant rise in the number of conversion total hip arthroplasties (THAs) performed. Prior studies have shown higher complication rates in conversion THA. However, there is a paucity of data showing differences in cost between these 2 procedures.