These Are the Highlights of the AAOS Annual Meeting

    In case you missed them, here are the top paper and posters in adult reconstruction, shoulder and elbow, sports medicine/arthroscopy, and practice management/rehabilitation, as judged by the 2015 Program Committee.

    Of the 1,400 or so abstracts accepted for podium and poster presentation at the American Academy of Orthopaedic Surgeon’s 2015 Annual Meeting in Las Vegas, a handful were singled out by members of 2015 Program Committee for special note during the session, “Annual Meeting Highlights.”

    Here we’ll look at the presentations selected in adult reconstruction hip, adult reconstruction knee, shoulder and elbow, sports medicine/arthroscopy, and practice management/rehabilitation.

    Adult Reconstruction Hip

    Out of 225 total presentations (podium and poster), the adult reconstruction hip subcommittee selected 3 podium presentations and 1 poster for the Highlights session. They were presented by the chairman of the subcommittee, David C. Ayers, MD.

    Title: 10 Year Results of Total Hip Arthroplasty with Highly Cross-linked Polyetheylene in Patients 50 years and Less (Paper 007)
    Authors: Frank C. Bohnenkamp, MD; James A. Keeney, MD; Jeffrey B. Stambough, MD; John M. Martell, MD; Gail Pashos; John C. Clohisy, MD

    Conclusion: A cobalt chromium femoral head with a highly cross-linked polyethylene liner appears to be an excellent choice for patients younger than age 50 who need a primary total hip arthroplasty, with less polyethylene wear and osteolysis compared with a conventional acetabular liner.

    Title: Cementless Fixation has Better Outcomes in Younger Patients (Paper 408)
    Authors: Stephen Graves, MD; David Davidson, MD; Richard De Steiger, MD; Peter L. Lewis, MB; Robyn Vial, MSc; Ann Tomkins; Elizabeth C. Griffith, BA; Michelle Lorimer; Yen-Liang Liu

    Conclusion: After eliminating prostheses-related confounding factors (metal-on-metal implants, modular neck femoral components, and non-cross-linked polyethylene bearings), cementless fixation was found to be superior to cemented or hybrid fixation in patients age 60 years and younger, with a lower revision rate at 2.5 years following surgery.

    Title: Does Neuraxial Anesthesia Decrease the Rate of Postoperative Complications and Blood Transfusions? (Paper 485)
    Authors: Bryan Haughom, MD; William W. Schairer, MD; Michael D. Hellman, MD; Benedict U. Nwachukwu, MD, MBA; Brett R. Levine, MD

    Conclusion: Using date from the National Surgical Quality Improvement Database, the authors were able to demonstrate that neuraxial anesthesia is associated with shorter operative times and fewer overall and medical complications following total hip arthroplasty than general anesthesia. The also found a link between neuraxial anesthesia and a reduction in the need for postoperative blood transfusions.

    Title: Increased Patient Satisfaction with Mobile Compression Pumps for Venous Thromboembolism Prophylaxis (Poster P020)
    Authors: Ryan Nunley, MD; Denis Nam, MD; James A. Keeney, MD; John C. Clohisy; Staci Johnson, MEd; Douglas J. McDonald, MD; Robert L. Barrack, MD

    Conclusion: A mobile compression device (MCD) and warfarin work equally well in preventing venous thromboembolism: The VTE rate was 0.6% in the standard-risk group and 0.4% in the high-risk group. The type of procedure – hip vs. knee – did not make a difference in the VTE rate.

    Adult Reconstruction Knee

    Michael A. Kelly, MD, presented the 4 papers and 1 poster selected from the 150 papers and 90 posters in the adult reconstruction knee category.

    Title: Aspirin as Prophylaxis Against Venous Thromboembolism Leads to Lower Incidence of Periprosthetic Joint Infection (Paper 187)
    Authors: Ronald Huang, MD; Patrick S. Buckley, MD; Javad Parvizi, MD, FRCS; James J. Purtill, MD

    Conclusion: Aggressive anticoagulant therapy has been associated with a higher incidence of wound drainage, hematoma formation, and reoperation – all of which may increase the risk for infection following total joint arthroplasty. In this study, patients who received aspirin for venous thromboembolism prophylaxis had fewer wound-related problems than those who received warfarin, which may explain the lower rate of periprosthetic joint infections in the aspirin group.

    Title: Transfusion Cost and Time Savings with Tranexamic Acid in Primary Total Knee (Paper 663)
    Authors: Joseph T. Moskal, MD; Ryan Harris, DO; Susan G. Capps, PhD

    Conclusion: The use of topical tranexamic acid resulted in a more than 50% savings in facility costs compared with costs for a blood transfusion following total knee arthroplasty. The cost savings was substantially smaller (less than 3%) with intravenous tranexamic acid. Employee time was also significantly reduced.

    Title: Tranexamic Acid Benefits Total Joint Arthroplasty Patients Regardless of Preoperative Hemoglobin Value
    Authors: Daniel Whiting, MD; Christopher Duncan, MD; Hugh M. Smith, MD, PhD; Rafael J. Sierra, MD

    Conclusion: Is there a hemoglobin level at which tranexamic acid no longer provides any benefit? The answer is no. The authors found significant patient benefits regardless of hemoglobin level, including a fourfold to ninefold reduction in transfusions following total knee or total hip arthroplasty and a significant reduction in length of stay compared with patients who required a transfusion.

    Title: Effect of Discharge Destination on Primary Total Knee Replacement Outcomes
    Authors: Douglas E. Padgett, MD; Amethia Holmes, BA; Yuo-Yu Lee, MS; Steven B. Haas, MD; Stephen Lyman, PhD

    Conclusion: Patients who are discharged home after knee replacement and receive physical therapy at home do as well as those who are discharged to an in-patient rehabilitation facility. No difference in complication rates within 6 months of knee replacement was found between groups, and 2 years after surgery, both groups had similar outcomes in terms of pain and function.

    Title: Routine Examination of Tissue from Total Knee Arthroplasty Is Not Cost Efficient and Does Not Affect Patient Care (Poster P107)
    Authors: David Liebelt, MD, PhD; Joseph Greene, MD; Theofanis Zois, PA-C; and Didi Omiyi, MD; Fred D. Cushner, MD; Giles R. Scuderi, MD

    Conclusion: The authors advocate leaving the decision to send tissue for pathology in the hands of the surgeon; it should not be routine. In their study, the pathologic examination and clinical diagnosis concurred 98.7% of the time (1,698 of 1,720 cases). The total cost of pathology for the 1,720 patients was $108,876, with a cost per discrepant diagnosis (of which there were 22) of $4,949.

    Shoulder and Elbow

    The shoulder and elbow subcommittee selected 105 abstracts for podium presentation and 60 abstracts for poster presentation at the Annual Meeting. Keith Kenter, MD, discussed the 3 top papers in this category.

    Title: Reverse Total Shoulder Arthroplasty: Results of 240 Consecutive Prosthesis with a Follow Up of Ten Years (Paper 346)
    Authors: Guillaume Bacle, MD; Laurent Nove Josserand, MD; Gilles Walch, MD

    Conclusion: The authors had performed 240 reverse total shoulder arthroplasty procedures before 2003 using a monocentric reverse prosthesis. They concluded from this 10-year follow-up that “reverse shoulder arthroplasty provides reliable and high long-term outcomes and survivorship.” The 10-year analysis included 106 patients, and in this group, the authors found 7 late complications: loosening of the prosthesis in 4 cases and infection in 3 cases. Scapular notching had also progressed. The overall survivorship was 89.8%.

    Title: Biologic Augmentation of Rotator Cuff Repair with Mesenchymal Stem Cells Improves Healing and Prevents Re-Tears (Paper 533)
    Authors: Philippe Hernigou, PhD; Alexandre Poignard, MD

    Conclusion: Patients with rotator cuff tears of 1 to 4 cm who received an injection of iliac crest bone marrow-derived mesenchymal stem cells (MSCs) were more likely to heal and less likely to experience a re-rupture than patients who did not receive the stem cell injection. This was true at 6 months after surgery and 10 years after surgery. By 6 months after surgery, all patients who had MSC augmentation had healed, compared with 30 (67%) of the repairs without MSC treatment. At 10 years, 39 (87%) of patients in the MSC augmentation group still had intact rotator cuffs, compared with 20 (44%) in the control group.

    Title: Economic and Outcomes Analysis of TSA vs. Hemiarthroplasty for Young Patients with Shoulder Arthritis (Paper 692)
    Authors: Suneel B. Bhat, MD; Mark D. Lazarus, MD; Charles L. Getz, MD; Gerald R. Williams Jr, MD; Surena Namdari, MD, MSc

    Conclusion: The authors used pooled probability and outcomes data from the literature to determine that total shoulder arthroplasty is preferable to hemiarthroplasty for young patients (age 30 to 50 years) with end-stage glenohumeral osteoarthritis. Total shoulder arthroplasty is a more cost-effective procedure that avoids many of the revisions associated with hemiarthroplasty in this patient population and provides greater patient satisfaction.

    Sports Medicine/Arthroscopy

    Dean Matsuda, MD, shared the 2 papers and 1 poster selected by the sports medicine arthroscopy subcommittee from the 120 papers and 75 posters presented at the Annual Meeting.

    Title: Revision Risk After Allograft Anterior Cruciate Ligament Reconstruction: Graft and Patient Associations (Paper 246)
    Authors: Sam G. Tejwani, MD; Jason Chen, MA; Tadashi T. Funahashi, MD; Rebecca Love, BSN, RN; Maria C. Inacio, PhD; Gregory B. Maletis, MD

    Conclusion: The authors sought to determine if there are graft processing techniques, patient characteristics, or graft types that are associated with higher failure rates when allografts are used for anterior cruciate ligament reconstruction. The answer, they said, is yes. In what they believe is the largest study of its kind, the authors found that patients were more likely to need a revision procedure in the following situations: graft irradiation over 1.8 Mrad, BioCleanse graft processing, younger patient age, and bone-patellar tendon-bone allograft.

    Title: High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Asymptomatic Shoulders (Paper 770)
    Authors: Randy S. Schwartzberg, MD; Bradd Burkhart, MD; Bryan L. Reuss, MD; Matthew Butterfield, MD

    Conclusion: Surgery to repair superior labral tears may be unnecessary, at least in the middle-aged population. The authors asked 2 radiologists to review MRIs of the shoulders of 53 middle-aged adults (age 45 to 60 years) who had never had a shoulder injury or surgery. Although all subjects were asymptomatic, the radiologists – who were blinded to the study’s purpose – found the MRIs to be consistent with superior labral tears in 55% and 72% of subjects. According to the authors, “These findings call into question the clinical relevance of superior tears diagnosed by MRI in this patient population.”

    Title: Factors Influencing Pain Relief after Intra-articular Anesthetic Injection of the Hip (Poster P410)
    Authors: Kyle Alpaugh, MS; Kirstin M. Small, MD; Nehal Shah, MD; Peters T. Otlans, BA, MA, MPH; Scott D. Martin, MD

    Conclusion: A positive response (pain relief) to an intra-articular injection of an anesthetic has a high predictive value in determining if a patient has intra-articular pathology (labral tear) and is a candidate for hip arthroscopy. In this study, the positive response correlated with a labral tear in 93% of cases. A negative response (worse pain) correlated with the absence of a labral tear in only 46% of cases. The authors concluded that “a positive response to the anesthetic injection is useful for confirming an intra-articular pain generator, specifically labral tears. For patients with a clinical history consistent with labral pathology, a negative response to anesthetic injection has less diagnostic utility…”

    Practice Management/Rehabilitation

    Thomas A. Malvitz, MD, presented top 2 papers and 1 poster from among the 45 papers and 20 posters selected by the Practice Management/Rehabilitation subcommittee.

    Title: Is Physician Quality Reported Outcomes Worth the Cost to Report to CMS? (Paper 331)
    Authors: Stephen T. Duncan, MD; Kyle Leyshon, MS; Cale Jacobs, PhD; Christian P. Christensen, MD; William B. Macaulay, MD

    Conclusion: A proposal by the Centers for Medicare and Medicaid Services (CMS) would require surgeons to report patient outcomes of their total joint arthroplasty patients or face a penalty of 1.5% of their reimbursement in 2015 and 2% in 2016. The authors found that put in terms of real dollars, the additional costs related to collecting and reporting the data would be significantly more than the amount of the penalty, making this requirement unsustainable for most surgeons.

    Title: Is Hemoglobin A1c Predictive of Periprosthetic Joint Infection or Death Following Primary Total Joint Replacement? (Paper 154)
    Authors: Christopher E. Pelt, MD; Jesse Chrastil, MD; Mike Anderson, MS, ATC; Vanessa Stevens, PhD; Rahul Anand, MD; Scott Duvall, PhD; Christopher L. Peters, MD

    Conclusion: Hemoglobin A1c (HbA1c) “does not appear to be a direct marker that predicts” periprosthetic joint infections (PJI) in patients undergoing total joint arthroplasty. Although the authors noted an association between preoperative hyperglycemia and PJI, they did not find a significant link between the HbA1c level and PJI. They did find a higher risk of death 2 years following surgery in patients with an HbA1c greater than 7%.

    Title: The Economics of Delay of Discharge to Post-Acute Facilities in a Bundled Payment Environment (Poster P272)
    Authors: James D. Slover, MD; Richard Iorio, MD; Joseph A. Bosco III, MD

    Conclusion: The cost of post-acute care following total joint arthroplasty is significant, especially when the patient is discharged from the hospital to an inpatient rehabilitation facility. The authors found that, assuming an average length of stay following surgery, they could extend the hospital stay by 5.2 days and still spend less than discharging patients to an inpatient facility. They concluded, “Extended acute hospital care in a bundled payment environment, to allow more patient progress towards independence and discharge home, is financially feasible, provided other parameters, such as readmission rates, do not increase.”

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    Susan Doan-Johnson is the Director of Editorial Content for ICJR.net.