Time for an Update? A Look at Current Guidelines for Venous Thromboembolism Prophylaxis After Hip and Knee Arthroplasty and Hip Fracture

Venous thromboembolism is a well-established complication of total hip and knee arthroplasty and hip fracture surgery. Clinical practice guidelines have been proposed to help clinicians provide prophylaxis against this risk. However, most guidelines reference data that are becoming outdated because of new advances in perioperative protocols. Recent data would suggest that aspirin may be appropriate for most patients after total hip and knee replacement and a more potent chemoprophylaxis for higher risk patients. Low-molecular-weight heparin remains the recommended choice after hip fracture surgery, although there is a paucity of recent literature in this patient population. There are randomized trials currently underway in the arthroplasty population that may guide clinicians in the appropriate choice of chemoprophylaxis. These studies should inform updates to the current clinical practice guidelines

Implementation of patient-reported outcome measures in U.S. Total joint replacement registries: rationale, status, and plans

BACKGROUND: In the U.S. and abroad, the use of patient-reported outcome measures to evaluate the impact of total joint replacement surgery on patient quality of life is increasingly common. Analyses of patient-reported outcomes have documented substantial pain relief and functional gain among the vast majority of patients managed with total joint replacement. In addition, postoperative patient-reported outcomes are useful to identify persistent pain and suboptimal outcomes in the minority of patients who have them. The leaders of five U.S. total joint replacement registries report the rationale, current status, and vision for the use of patient-reported outcome measures in U.S. total joint replacement registries. METHODS: Surgeon leaders of the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement registry, American Joint Replacement Registry, California Joint Replacement Registry, Michigan Arthroplasty Registry Collaborative Quality Initiative, and Virginia Joint Registry report the rationale supporting the adoption of patient-reported outcome measures, factors associated with the selection and successful implementation of patient-reported outcome measures, and barriers to complete and valid data. RESULTS: U.S. registries are at varied stages of implementation of preoperative surveys and postoperative total joint replacement outcome measures. Surgeon leaders report unified rationales for adopting patient-reported outcome measures: to capture data on pain relief and functional gain following total joint replacement as well as to identify suboptimal implant performance. Key considerations in the selection of a patient-reported outcome measure include its ability to measure both joint pain and physical function while limiting any burden on patients and surgeons related to its use. Complete patient-reported outcomes data will be associated with varied modes of survey completion, including options for home-based completion, to ensure consistent timing and data capture. CONCLUSIONS: The current stage of implementation of patient-reported outcome measures varies widely among U.S. registries. Nonetheless, evidence from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement registry supports the feasibility of successful implementation of patient-reported outcome measures with careful attention to the selection of the outcome measure, mode and timing of postoperative administration, and minimization of any burden on the patient and surgeon

Greater Trochanteric Pain Syndrome

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135686/1/jum201635112413.pd

Characteristics of Fibromyalgia Independently Predict Poorer Long‐Term Analgesic Outcomes Following Total Knee and Hip Arthroplasty

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/111198/1/art39051.pd

PCBs and dioxins/furans in attic dust collected near former PCB production and secondary copper facilities in Sauget, IL

AbstractSamples of settled attic dust from fourteen buildings located within two miles of the Solutia W.G. Krummrich and Cerro Flow Products facilities in Sauget, Illinois were analyzed for PCBs and dioxins/furans using HRGC/HRMS. The facilities released vast quantities of PCBs and dioxins/furans into the environment over many decades. The concentrations and homologues present in the samples of attic dust and in samples of soil collected by U.S. EPA demonstrate atmospheric transport of PCBs and dioxins/furans from these manufacturing sites and local dumps contaminated with these pollutants. The results demonstrate that attic dust is a useful metric for assessing historical exposure to atmospheric emissions

The Reproducibility of a Kinematically-Derived Axis of the Knee versus Digitized Anatomical Landmarks using a Knee Navigation System

Component position is critical to longevity of knee arthroplasties. Femoral component rotation is typically referenced from the transepicondylar axis (TEA), the anterior-posterior (AP) axis or the posterior condylar axis. Other studies have shown high variability in locating the TEA while proposing digitization of other landmarks such as the AP axis as a less-variable reference. This study uses a navigation system to compare the reproducibility of computing a kinematically-derived, navigated knee axis (NKA) to digitizing the TEA and AP axis. Twelve knees from unembalmed cadavers were tested. Four arthroplasty surgeons digitized the femoral epicondyles and the AP axis direction as well as flexed and extended the knee repeatedly to allow for NKA determination. The variance of the NKA axis determined under neutral loading conditions was smaller than the variance of the TEA axis when the kinematics were measured in the closed surgical condition (P<0.001). However, varus, valgus, and internal loading of the leg increased the variability of the NKA. Distraction of the leg during knee flexion and extension preserved the low variability of the NKA. In conclusion, a kinematically-derived NKA under neutral or distraction loading is more reproducible than the TEA and AP axis determined by digitization

Application of a Causal Discovery Algorithm to the Analysis of Arthroplasty Registry Data

Improving the quality of care for hip arthroplasty (replacement) patients requires the systematic evaluation of clinical performance of implants and the identification of “outlier” devices that have an especially high risk of reoperation (“revision”). Postmarket surveillance of arthroplasty implants, which rests on the analysis of large patient registries, has been effective in identifying outlier implants such as the ASR metal-on-metal hip resurfacing device that was recalled. Although identifying an implant as an outlier implies a causal relationship between the implant and revision risk, traditional signal detection methods use classical biostatistical methods. The field of probabilistic graphical modeling of causal relationships has developed tools for rigorous analysis of causal relationships in observational data. The purpose of this study was to evaluate one causal discovery algorithm (PC) to determine its suitability for hip arthroplasty implant signal detection. Simulated data were generated using distributions of patient and implant characteristics, and causal discovery was performed using the TETRAD software package. Two sizes of registries were simulated: (1) a statewide registry in Michigan and (2) a nationwide registry in the United Kingdom. The results showed that the algorithm performed better for the simulation of a large national registry. The conclusion is that the causal discovery algorithm used in this study may be a useful tool for implant signal detection for large arthroplasty registries; regional registries may only be able to only detect implants that perform especially poorly

Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) Report: 2012-2016

The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) is a collaborative dedicated to improving the quality of care for hip and knee replacement patients in Michigan. It has three goals: (1) improve patient safety in Michigan by promoting better outcomes, (2) enable surgeons and hospitals across the state to work together to improve quality, and (3) make Michigan the best place in the world to have a joint replacement. MARCQI is founded on the belief that health care quality is best improved by data-driven collaboration. These data can then be used for development, sharing, and learning of best practices in a non-competitive self-empowering framework. MARCQI started in 2012 and has grown rapidly. The Collaborative currently includes data from sixty-one hospitals and surgical centers across Michigan and it collects more than 95% of the hip and knee replacement cases done in the state. Funding is provided by Blue Cross Blue Shield of Michigan/Blue Care Network. MARCQI is built on a patient registry that collects information on total hip and knee replacement cases performed in participating hospitals. As of the end of 2016, the registry contained 141,822 cases. The data are audited and linked across hospitals. Data elements include demographics, co-morbidities, outcomes, and implants. Outcomes such as infection, blood clots, and readmission are collected in a 90-day post-operative window. Re-operations required to remove or replace implants (“revision surgeries”) are tracked indefinitely. Risk-adjustment is performed to account for patient factors that affect outcomes, so comparisons between hospitals and between surgeons are not unduly affected by patient demographics. Quality improvement opportunities are identified through analyses of registry data. The resulting quality improvement initiatives are prioritized by the leadership in close collaboration with the executive and medical advisory committees. Risk-adjusted data are provided to Collaborative members with overall rates and averages for comparison across institutions. Reports are provided to each hospital and dashboards are available online. The most important and powerful quality improvement tool is the Collaborative meeting. These meetings occur three to four times a year, and they involve members coming together to share project successes and challenges. Quality improvement activities have been conducted in the areas such as blood transfusion, nursing home discharges, infection prevention, dislocation reduction, and venothromboembolism prevention. The transfusion and tranexamic acid initiative, for example, reduced the risk of transfusion for total knee and hip replacement patients across the state from 7.0% to 1.4% and 14.2% to 3.4%, respectively. MARCQI also conducts post-market surveillance of hip and knee implants, and this report provides implant-specific revision risks. Demographic and other relevant information (approach, head size, bearing, etc.) about the cases performed with each implant are provided. Reasons for revision are also captured and summarized for quality improvement. Patient-reported outcome surveys (PROS) are also collected to characterize patient function and well being before and after surgery and to track improvement. PROS data collection started at a few hospitals and has grown across the Collaborative. The goal is to collect these data from patients being treated at all participating hospitals. Pain measured on a 10-point scale is shown to rapidly drop from an average of 6.4 pre-operatively to 2.1 by six to twelve weeks following surgery for hip replacements and from 6.1 to 2.8 for knee replacements. General health, as measured by the PROMIS-10 questionnaire, rapidly returns to the population mean. Improving quality can also reduce costs by increasing appropriateness of care, reducing unnecessary utilization of resources, and reducing complications. For example, transfusion reduction has saved approximately $4 million annually. Reductions in readmissions and nursing home discharges have saved$1 million and $20 million annually, respectively. Quality improvement is a win-win activity for patients, providers, hospitals, and payers. This document describes the origin, operation, and successes of MARCQI; it is intended to be used for quality improvement. It reports on data collected between February 15, 2012, and December 31, 2016.Blue Cross Blue Shield of Michiganhttps://deepblue.lib.umich.edu/bitstream/2027.42/142403/1/MARCQI_Five-Year_Report_Nov2017.pdf102Description of MARCQI_Five-Year_Report_Nov2017.pdf : Five-year repor