Pelvic flexion/extension and its impact on functional acetabular alignment and stability following total hip replacement.

Purpose: Dislocation following total hip arthroplasty (THA) remains a significant clinical problem and can occur even with optimal implant alignment. We hypothesized that different patterns of pelvic flexion/extension (PFE) during daily activities may influence acetabular alignment and contribute to impingement and instability following THA. Recently, there has been an increased interest in spinopelvic alignment and its impact on THA.

Optimizing PROM Implementation in Orthopedic Clinics for Longitudinal Outcome Monitoring: Lessons from a Multisite Study.

Background: Systematic patient-reported outcome measure (PROM) collection is challenging for clinics, particularly when patients are not in the office. The Arthritis care through Shared Knowledge (ASK) study deployed multimodal approaches to collect PROMs using a clinical microsystem framework.

Conceptual Model: Informed by the clinical microsystem model, the authors coached 12 orthopedic practices to implement shared processes to support best practices for PROM collection and use.

Predictors of Adverse Local Tissue Reaction in a High-Risk Population.

Background: Adverse local tissue reaction (ALTR) is a recognized complication of total hip arthroplasty (THA) with metal-on-polyethylene (MoP) bearing surface implants. Specific models of THA implants have been identified as having a higher incidence of ALTR. The purpose of this study is to determine if serum metal levels, patient symptoms, implant factors, and imaging findings can be predictive of ALTR within this high-risk population.

Comparison of Asymptomatic and Symptomatic Adverse Local Tissue Reaction in Patients With Head-Neck Taper Corrosion.

Background: Diagnosis of adverse local tissue reaction (ALTR) in metal-on-polyethylene (MoP) total hip arthroplasty (THA) secondary to head-neck taper corrosion is challenging. The purpose of this study is to compare differences between asymptomatic and symptomatic ALTR in an observational cohort, including presentation, metal ion differences, and metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) findings.

Methods: We performed a retrospective review of an observational cohort of 492 MoP THA patients at increased risk of developing ALTR.

Effectiveness of Later-Stage Exercise Programs vs Usual Medical Care on Physical Function and Activity After Total Knee Replacement: A Randomized Clinical Trial.

Importance: Several functional limitations persist after total knee replacement (TKR). Intensive exercise programs could resolve these limitations but are not well tolerated by many patients until a later stage (>2 months) after surgery. Evidence for exercise at a later stage after TKR is limited.

Trunnion Failure of the Recalled Low Friction Ion Treatment Cobalt Chromium Alloy Femoral Head.

Background: Gross trunnion failure (GTF) is a rare complication in total hip arthroplasty (THA) reported across a range of manufacturers. Specific lots of the Stryker low friction ion treatment (LFIT) anatomic cobalt chromium alloy (CoCr) V40 femoral head were recalled in August 2016. In part, the recall was based out of concerns for disassociation of the femoral head from the stem and GTF.

Effect of Comprehensive Behavioral and Exercise Intervention on Physical Function and Activity Participation After Total Knee Replacement: A Pilot Randomized Study.

Objective: To test the feasibility of a comprehensive behavioral intervention (CBI) program that combines intense exercises with an education program, to be implemented at a later stage (3 months) following total knee replacement (TKR), and to get a first impression of the effects of the CBI as compared to a standard of care exercise (SCE) program on the outcomes of physical function and physical activity.

Methods: A total of 44 subjects participated in a 3-month program of either CBI or SCE, followed by 3 months of a home exercise program. Outcomes of physical function and physical activity were measured at baseline and at 6-month followup.

Drivers of the Variation in Prosthetic Implant Purchase Prices for Total Knee and Total Hip Arthroplasties.

Background: Previous studies have documented wide variation in health care spending and prices; however, the causes for the variation in supply purchase prices across providers are not well understood. The purpose of this study was to determine the drivers of variation in prosthetic implant purchase prices for primary total knee and hip arthroplasties (TKA and THA, respectively) across providers.

Methods: We obtained retrospective data from 27 hospitals on the average prosthetic implant purchase prices for primary TKAs and THAs over the 12 months ending September 30, 2013, as well as data on a range of independent potential explanatory variables.

A case for integrating the Patient and Family Centered Care Methodology and Practice in Lean healthcare organizations.

Many healthcare organizations using Lean are becoming interested in the Patient and Family Centered Care Methodology and Practice (PFCC M/P). We suggest that integrating the two approaches can accelerate the pace of improvement and provide a powerful mechanism to keep the patient and family as the primary focus of improvement activities. We describe the two approaches and note the ways in which they are complementary.

Determining the True Cost to Deliver Total Hip and Knee Arthroplasty Over the Full Cycle of Care: Preparing for Bundling and Reference-Based Pricing.

The Affordable Care Act accelerates health care providers' need to prepare for new care delivery platforms and payment models such as bundling and reference-based pricing (RBP). Thriving in this environment will be difficult without knowing the true cost of care delivery at the level of the clinical condition over the full cycle of care. We describe a project in which we identified true costs for both total hip and total knee arthroplasty.

Dose-Associated Changes in Gait Parameters in Response to Exercise Programs after Total Knee Arthroplasty: Secondary Analysis of Two Randomized Studies.

Background: Rehabilitation plays an important role to improve the outcomes of total knee arthroplasty (TKA). Evidence about the appropriate dose of exercise to recover gait dysfunction after TKA is limited. We posed the research question: In patients during the post-acute stage after TKA, is increased dose of exercise associated with larger improvements in gait parameters such as step length and single support time?

Methods: This was a secondary analysis from two randomized studies on exercise after TKA to investigate dose-dependence of gait parameters in response to exercise.

Topical versus intravenous tranexamic acid in total knee arthroplasty.

The objective of this study is to compare the effectiveness of intravenous versus topical application of tranexamic acid in patients undergoing knee arthroplasty. All patients who underwent primary knee arthroplasty at our total joint center over a 12-month period were included in the study. One surgeon utilized 1 g of IV TXA at time of incision in all patients (n=373) except those with a documented history of venous thromboembolism (VTE).

Turning patient-centeredness from ideal to real: lessons from 2 success stories.

The Institute of Medicine's 2001 Crossing the Quality Chasm report established patient-centeredness as 1 of 6 core principles for health system redesign. Yet, turning aspiration into accomplishment has proven arduous. Patient-centered care has components that challenge established professional norms, and the term itself has not always been clearly defined.

Developing a pathway for high-value, patient-centered total joint arthroplasty.

Background: Total joint arthroplasty (TJA) is one of the most widely performed elective procedures; however, there are wide variations in cost and quality among facilities where the procedure is performed.

Questions/purposes: The purposes of this study were to (1) develop a generalizable clinical care pathway for primary TJA using inputs from clinical, academic, and patient stakeholders; and (2) identify system- and patient-level processes to provide safe, effective, efficient, and patient-centered care for patients undergoing TJA.

Methods: We used a combination of quantitative and qualitative methods to design a care pathway that spans 14 months beginning with the presurgical office visit and concluding 12 months after discharge.

Integrating patient- and family-centered care with health policy: four proposed policy approaches.

Achieving patient-centeredness in health care delivery has been difficult, in large part due to the lack of a replicable methodology. We describe the Patient- and Family-Centered Care Methodology and Practice (PFCC M/P), designed specifically for health care, to establish and sustain patient-centeredness in any care setting. The PFCC M/P meets the needs of all stakeholders--patients, families, providers, payers, and government--in improving the patient experience, patient safety, and clinical outcomes while decreasing waste and cost.

Utilizing complexity science to drive practice change through patient- and family-centered care.

Complexity science applied through a 6-step patient- and family-centered care methodology provides a practical framework for achieving meaningful change in organizations. This approach was used to improve the preoperative preparation experience of patients undergoing total joint arthroplasty in an orthopedic specialty hospital.

Digital video recording in the inpatient setting: a tool for improving care experiences and efficiency while decreasing waste and cost.

The need to significantly improve patient centeredness and efficiency, while reducing waste and cost, in health care is an area of focus for health policy leaders. We employed digital video recording on a postsurgical inpatient unit as a method of understanding care delivery through the eyes of patients, families, and caregivers. Key findings of the study included identification of the total number of staff (by function)-to-patient contacts and the percentage of time patients spent in their room during recovey.

Care experience-based methodologies: performance improvement roadmap to value-driven health care.

Background: The literature contains proposals for creating value by creating exceptional patient experiences rather than simply improving services. However, few articles describe replicable applications focused on the patient experience.

Questions/purposes: We (1) describe the refinement and exportation of an approach that focuses on the patient and family experience; and (2) report changes in patient satisfaction, infection rates, length of stay, mortality rates, clinical indicators, staff turnover, and cost.

Contribution of hip abductor strength to physical function in patients with total knee arthroplasty.

Background: Investigating modifiable factors that contribute to functional limitations in patients with total knee arthroplasty (TKA) may guide changes in rehabilitation protocols and improve functional outcomes. Whereas quadriceps muscle weakness has been demonstrated to contribute to functional limitations in TKA, the role of hip abductor weakness has not received attention.

Objective: The purpose of this study was to determine whether hip abductor strength (force-generating capacity) contributes to physical function beyond what can be explained by quadriceps muscle strength in patients after a TKA.

Patient and family shadowing: creating urgency for change.

The Patient- and Family-Centered Care (PFCC) method and practice has been developed over the past 4 years as a means of improving care experiences by viewing all aspects of a patient's care experience through the eyes of the patient and family. One of the most powerful components of the method, evaluating care through patient and family shadowing and the accompanying care experience flow mapping, is described. An overview of the PFCC method can be found in the authors' article in the December 2010 issue.

A patient-centered model to improve metrics without cost increase: viewing all care through the eyes of patients and families.

The need for patient-centeredness in care delivery has been articulated for decades, yet meaningful progress toward patient-centered healthcare has been hobbled by the lack of a replicable patient-centered care model and method. The authors describe the patient- and family-centered care method, built around viewing every care experience through the eyes of the patient and family, and its outcomes proving the approach is replicable and sustainable while improving outcomes without additional cost. A follow-up article on patient and family shadowing will be published in the January 2011 issue.

A balance exercise program appears to improve function for patients with total knee arthroplasty: a randomized clinical trial.

Background: Patients with total knee arthroplasty (TKA) have impaired balance and movement control. Exercise interventions have not targeted these impairments in this population.

Objectives: The purposes of this study were: (1) to determine the feasibility of applying a balance exercise program in patients with TKA, (2) to investigate whether a functional training (FT) program supplemented with a balance exercise program (FT+B program) could improve physical function compared with an FT program alone in a small group of individuals with TKA, and (3) to test the methods and calculate sample size for a future randomized trial with a larger study sample.