Quantifying the Backlog of Total Hip and Knee Arthroplasty Cases: Predicting the Impact of COVID-19.
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ABSTRACT: Background
Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are two high-volume procedures that were delayed due to COVID-19.Questions/purposes
To help strategize an effective return to elective orthopedic surgery, we aimed to quantify the volume of THA and TKA cases delayed across the USA and estimate the time required to care for these patients when non-urgent surgery resumes.Methods
Population-level data was used to estimate monthly THA and TKA procedural volume from 2011 to 2017. Using linear regression, we used this data to project monthly procedural volumes for 2020 to 2023. Nine different permutations were modeled to account for variations in case delay rates (50%, 75%, 100%) and in resumption of non-urgent procedure timing. Two recovery pathways using the highest volume month as a surrogate for maximum operative capacity, and a second using the highest month + 20% were used to simulate a theoretical expansion of current capacity.Results
The projected national volume of delayed cases was 155,293 (mid-March through April; 95% CI 142,004 to 168,580), 260,806 (through May; 95% CI 238,658 to 282,952), and 372,706 (through June; 95% CI 341,699 to 403,709). The best- and worst-case scenarios for delayed cases were 77,646 (95% CI 71,002 to 84,290) and 372,706 (95% CI 341,699 to 403,709), respectively. The projected catch-up time varied between 9 and nearly 35 months for the best- and worst-case scenarios. The addition of 20% increased productivity decreased this time to between 3.21 and 11.59 months.Conclusion
The COVID-19 pandemic has generated a significant backlog of THA and TKA procedures. Surgeons, administrators, and policymakers should account for these modeled estimates of case volume delays and projected demands.
SUBMITTER: Wilson JM
PROVIDER: S-EPMC7640577 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundThe SARS-CoV-2 (COVID-19) pandemic caused a massive disruption in elective arthroplasty practice in the United States that to date has not been quantified. We sought to determine the impact of COVID-19 on arthroplasty volumes in the United States, how this varied across the country, and the resultant financial implications.MethodsWe conducted a retrospective analysis of Medicare fee-for-service beneficiaries undergoing primary and revision total knee arthroplasty (TKA) and total hip arthroplasty (THA) from January 1st through March 31st, 2020 with 74,080 TKAs and 54,975 THAs identified. We calculated the percent drop in average daily cases from before and after March 18, 2020. We then examined variation across states in arthroplasty case volumes as it related to reported COVID-19 cases, the impact of COVID-19 on length of stay and percentage of patients discharged home. Finally, we calculated the revenue impact on hospitals and surgeons.ResultsThere was a steep decline in TKA and THA volumes in mid-March of 94% and 92%, respectively. There was a significant variation for arthroplasty case volumes across states. We found minimal change in length of stay except for primary THAs with fracture going from 5 + days to 4 days. We saw an increasing trend in discharge to home with the greatest effect in primary THAs with fracture. The total daily hospital Medicare revenue for arthroplasty declined by 87% and surgeon revenue decreased by 85%.ConclusionThe beginning of the COVID-19 pandemic caused a significant decrease in arthroplasty volumes in the Medicare population with a resultant substantial revenue loss for hospitals and surgeons.
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Project description:BackgroundOperating room waste is disposed of in landfill sites, recycled, or undergoes costly, energy-intensive incineration processes. By assessing the quantity and recyclability of waste in primary hip (THA) and knee arthroplasty (TKA), we aim to identify strategies to improve sustainability.MethodsA prospective waste audit of 15 primary THA and 16 primary TKA cases was conducted at a tertiary orthopedic hospital between April and July 2022. Waste was categorized into nonhazardous, hazardous, recycling, sharps, and linens. Each category was weighed. Items disposed as nonhazardous waste were cataloged for a sample of 10 TKA and 10 THA cases. Recyclability of items was determined using packaging.ResultsAverage total waste generated for THA and TKA was 14.46 kg and 17.16 kg, respectively. TKA generated significantly greater waste (P < .05). Of all waste, 5.4% was recycled in TKA and just 2.9% in THA cases. The mean amount of recycled waste was significantly greater in TKA cases than that in THA cases, 0.93 kg and 0.42 kg, respectively.Hazardous waste made up the largest proportion for both TKA (69.2%) and THA (73.4%). Nonhazardous waste made up 15.1% and 11.3% of total waste for TKA and THA, respectively. In the nonhazardous waste, only 2 items (scrub-brush packaging and towel packaging) were recyclable.ConclusionsWe estimate hip and knee arthroplasty generates over 2.7 million kg of waste in the United Kingdom annually. Currently, only a small percentage of waste is recycled in hip and knee arthroplasty, which could improve through increased use of recyclable plastics and clear labeling of items as recyclable by medical suppliers.
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Project description:IntroductionThe objective of this study was to assess the number and magnitude of preoperative expectations and to correlate them with the degree of satisfaction expressed one year after Total Hip Arthroplasty (THA) or Total Knee Arthroplasty (TKA), in patients with severe and painful osteoarthritis (OA).Materials and methodsPreoperative expectations (within 20 days prior to surgery) and postoperative satisfaction (one year after the intervention) were measured using the previously validated French version of the Hospital for Special Surgery Hip or Knee Replacement Expectations Survey. Postoperative satisfaction was measured using a specific scale, following the same methodology as that used for the assessment of expectations. Prediction of the satisfaction of the patients was performed using multivariate linear regression modelling.ResultsA total of 138 patients (80 THA and 58 TKA) completed the two parts of the study. The expectations score (mean ± SD) (range 0-100) was 72.58 ± 12.63 before THA and 69.10 ± 13.72 before TKA (p = 0.13). The number of expectations expressed was 14.34 ± 1.32 (out of a potential maximum of 18) before THA and 14.70 ± 2.29 (out of a potential maximum of 19) before TKA. After 1 year, THA generated a significantly higher degree of satisfaction compared to TKA (69.70 ± 14.46 v 60.44 ± 17.54, p<0.001) (range 0-100). The pre-operative expectations score was the single best positive predictor of the post-surgery satisfaction assessment both for TKA and THA.ConclusionPatients undergoing total joint arthroplasty for end-stage OA have a high level of expectations, before both THA and TKA. While both types of interventions significantly improve essential and non-essential activities, the rate of satisfaction is significantly greater post THA. Preoperative expectations are a major contributor to the final degree of satisfaction, one year after surgery. These results re-emphasize the need for an optimal preoperative interaction between health care providers and patients, to allow patients a chance to foresee a reasonable outcome after TJA.
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Project description:BackgroundAs America's third highest opioid prescribers, orthopedic surgeons have contributed to the opioid abuse crisis. This study evaluated opioid use after primary total joint replacement. We hypothesized that patients who underwent total hip arthroplasty (THA) use fewer opioids than patients who underwent total knee arthroplasty (TKA) and that both groups use fewer opioids than prescribed.MethodsA prospective study of 110 patients undergoing primary THA or TKA by surgeons at an academic center during 2018 was performed. All were prescribed oxycodone 5 mg, 84 tablets, without refills. Demographics, medical history, and operative details were collected. Pain medication consumption and patient-reported outcomes were collected at 2 and 6 weeks postoperatively. Analysis of variance was performed on patient and surgical variables.ResultsSixty-one patients scheduled for THA and 49 for TKA were included. THA patients consumed significantly fewer opioids than TKA patients at 2 weeks (28.1 tablets vs 48.4, P = .0003) and 6 weeks (33.1 vs 59.3, P = .0004). Linear regression showed opioid use decreased with age at both time points (P = .0002). A preoperative mental health disorder was associated with higher usage at 2 weeks (58.3 vs 31.4, P < .0001) and 6 weeks (64.7 vs 39.2, P = .006). Higher consumption at 2 weeks was correlated with worse outcome scores at all time points.ConclusionsTKA patients required more pain medication than THA patients, and both groups received more opioids than necessary. In addition, younger patients and those with a preexisting mental health disorder required more pain medication. These data provide guidance on prescribing pain medication to help limit excess opioid distribution.
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Project description:BackgroundEfficient resource management is becoming more important as the demand for total hip arthroplasty (THA) increases. The purpose of this study is to evaluate the ability of linear regression and Bayesian statistics in predicting implant size for THA using patient demographic variables.Material and methodsA retrospective, single-institution joint-replacement registry review was performed on patients who underwent primary THA from 2005 to 2019. Demographic information was obtained along with primary THA implant data. A total of 11,730 acetabular and 8536 femoral components were included. A multivariable regression model was created on a training cohort of 80% of the sample and applied to the validation cohort (remaining 20%). Bayesian posterior probability methods were applied to the training cohort and then tested in the validation cohort to determine the 1%, 5%, and 10% error tolerance thresholds.ResultsThe most predictive regression model included height, weight, and sex (cup: R2 = 0.57, all P < .001; stem mediolateral size [M/L]: R2 = 0.32, all P < .001). Removing weight had a minimal effect and resulted in a more parsimonious model (cup: R2 = 0.56, all P < .001; stem M/L: R2 = 0.32, all P < .001). Applying the posterior probability estimate to the validation cohort in the Bayesian model using height, weight, and sex demonstrated high accuracy in predicting the range of required implant sizes (95.3% cup and 90.4% stem M/L size).ConclusionImplant size in THA is correlated with demographic variables to accurately predict implant size using Bayesian modeling. Predictive models such as linear regression and Bayesian modeling can be used to improve operating room efficiency, supply chain inventory management, and decrease costs associated with THA.
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Project description:Total knee arthroplasty (TKA) in the setting of previous hip fusion is rare with a paucity of evidence in the orthopaedic literature. Traditionally, TKA is performed supine, with the aid of knee-positioning devices allowing for hip flexion and range of motion of the knee to facilitate ease of surgical intervention. However, TKA using traditional positioning would not be possible in the presence of ipsilateral hip arthrodesis preventing hip motion. This case report describes a TKA performed for a 72-year-old woman with end-stage osteoarthritis of the right knee, ipsilateral hip arthrodesis, and leg-length discrepancy as the sequelae of slipped capital femoral epiphysis. We describe novel surgical positioning to be used to facilitate TKA in the absence of ipsilateral hip motion with bed modifications and the use of an extremity positioning device.
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Project description:Ischaemic preconditioning is a method of protecting tissue against ischaemia-reperfusion injury. It is an innate protective mechanism that increases a tissue's tolerance to prolonged ischaemia when it is first subjected to short burst of ischaemia and reperfusion. It is thought to provide this protection by increasing the tissue's tolerance to ischaemia, therby reducing oxidative stress, inflammation and apoptosis in the preconditioned tissue. We used microarrays to investigate the genomic response induced by ischaemic preconditioning in muscle biopsies taken from the operative leg of total knee arthroplasty patients in order to gain insight into the ischaemic preconditioning mechanism. Patients undergoing primary knee arthroplasty were randomised to control and treatment (ischaemic preconditioning) groups. Patients in the treatment group received a preconditioning stimulus immediately prior to surgery. The ischaemic preconditioning stimulus consisted of three five-minute periods of tourniquet insufflation on the lower operative limb, interrupted by five minute periods of reperfusion. All patients had a tourniquet applied to the lower limb after the administration of spinal anaesthesia, as per normal protocol for knee arthroplasty surgery. Muscle biopsies were taken from the quadriceps muscle of the operative knee at the immediate onset of surgery (T0) and at 1 hour into surgery (T1). Total RNA was extracted from biospies of four control and four treatment patients and hybridised to the Affymetrix Human U133 2.0 chip.
2010-04-12 | E-GEOD-21164 | biostudies-arrayexpress
Project description:The purpose of this study was to develop a preliminary decision algorithm predicting functional performance outcomes to aid in the decision of when to undergo total knee arthroplasty (TKA). One hundred and nineteen patients undergoing primary unilateral TKA were evaluated before and 6 months after TKA. A regression tree analysis using a recursive partitioning function was performed with the Timed Up and Go (TUG) time, Six-Minute Walk (6MW) distance, and Stair Climbing Test (SCT) time as measured 6 months after TKA as the primary outcomes. Preoperative measures of functional performance, joint performance, anthropometrics, demographics, and self-reported status were evaluated as predictors of the primary outcomes 6 months after surgery. Individuals taking ≥10.1 s on the TUG and aged 72 years or older before surgery had the poorest performance on the TUG 6 months after surgery. Individuals walking <314 meters on the 6MW before surgery had the poorest performance on the 6MW test 6 months after surgery. Individuals taking ≥17 s to complete the SCT and scoring <40 on the SF-36 mental component score before surgery had the poorest performance on the SCT 6 months after surgery. Poorer performance preoperatively on the 6MW, SCT, and TUG, was related to poorer performance in the same measure after TKA. Age and decreased mental health were secondary predictors of poorer performance at 6 months on the TUG and SCT, respectively. These measures may help further develop models predicting thresholds for poor outcomes after TKA.
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Project description:BackgroundSurgical site infection (SSI) after total hip arthroplasty (THA) is associated with increased morbidity, mortality, and healthcare expenditures. Our institution intensified hygiene standards during the COVID-19 pandemic; hospital staff exercised greater hand hygiene, glove use, and mask compliance. We examined the effect of these factors on SSI rates for primary THA (pTHA) and revision THA (rTHA).MethodsA retrospective review was performed identifying THA from January 2019 to June 2021 at a single institution. Baseline characteristics and outcomes were compared before (January 2019 to February 2020) and during (May 2020 to June 2021) the COVID-19 pandemic and during the first (May 2020 to November 2020) and second (December 2020 to June 2021) periods of the pandemic. Cohorts were compared using the Chi-squared test and independent samples t-test.ResultsA total of 2,682 pTHA (prepandemic: 1,549 [57.8%]; pandemic: 1,133 [42.2%]) and 402 rTHA (prepandemic: 216 [53.7%]; Pandemic: 186 [46.2%]) were included. For primary and revision cases, superficial and deep SSI rates were similar before and during COVID-19. During COVID-19, the incidence of all (-0.43%, P = .029) and deep (-0.36%, P = .049) SSIs decreased between the first and second periods for rTHA. pTHA patients had longer operative times (P < .001) and shorter length of stay (P = .006) during COVID-19. Revision cases had longer operative times (P = .004) and length of stay (P = .046). Both pTHA and rTHA were discharged to skilled nursing facilities less frequently during COVID-19.ConclusionDuring COVID-19, operative times were longer in both pTHA and rTHA and patients were less likely to be discharged to a skilled nursing facility. Although intensified hygienic standards may lower SSI rates, infection rates did not significantly differ after our hospital implemented personal protective guidelines and a mask mandate.
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Project description:Computer assisted surgery was pioneered in early 1990s. The first computer assisted surgery (CAS) total knee replacement with an imageless system was carried out in 1997. In the past 25 years, CAS has progressed from experimental in vitro studies to established in vivo surgical procedures.A comprehensive body of evidence establishing the advantages of computer assisted surgery in knee and hip arthroplasty is available. Established benefits have been demonstrated including its role as an excellent research tool. Its advantages include dynamic pre-operative and per-operative assessment, increased accuracy in correction of deformities, kinematics and mechanical axis, a better alignment of components, better survival rates of prostheses and a better functional outcome. Adoption of computer navigation in the hip arthroplasty is still at an early stage compared to knee arthroplasty, though the results are well documented. Evidence suggests improved accuracy in acetabular orientation, positioning, hip offset and leg length correction.Among the orthopaedic surgeons, navigated knee arthroplasty is gaining popularity though slowly. The uptake rates vary from country to country. The Australian joint registry data shows increased navigated knee arthroplasty from 2.4% in 2003 to 28.6% in 2015 and decreased revision rates with navigated knee arthroplasty in comparison with traditional instrumented knee arthroplasty in patient cohort under the age of 55 years.Any new technology has a learning curve and with practice the navigation assisted knee and hip arthroplasty becomes easy. We have actively followed the evidence of CAS in orthopaedics and have successfully adopted it in our routine practice over the last decades. Despite the cautious inertia of orthopaedic surgeons to embrace CAS more readily; we are certain that computer technology has a pivotal role in lower limb arthroplasty. It will evolve to become a standard practice in the future in various forms like navigation or robotics.
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