A recent study conducted by researchers at HSS and presented at the American Association of Hip and Knee Surgeons (AAHKS) annual meeting demonstrated that there is a way for outcomes following hip and knee replacement surgeries to be measured more efficiently without compromising accuracy. Alexander S. McLawhorn, MD, MBA, hip and knee surgeon at HSS and one of the authors of the study, shared his perspective.

At HSS, we are dedicated to ensuring patient experience and safety remain our top priorities, while also reducing the unnecessary regulatory burden for the hospital. This study indicated that outcome measurement after hip and knee replacement can be accurate and reliable even if hospitals don’t collect PROMs for a majority of patients. More than 740,000 Medicare beneficiaries undergo primary total hip or knee replacement each year, that number is expected to increase to 1.2 million by the year 2030, making this a critical time to address this topic.

 Capturing feedback from as many patients as possible can become an administrative burden for everyone involved. There are many different stakeholders when it comes to PROMs, including regulatory, research and clinical teams. Each of these areas requests PROMs from patients at different points in their journey, uses PROMs differently, and requires different levels of reporting for their needs.

-Alexander S. McLawhorn, MD, MBA

Our proposed solution is collecting carefully chosen samples, which can still lead to accurate results. For very high-volume institutions like HSS, you are not losing any accuracy in terms of your measurement by measuring fewer patients. Our research also suggests that this more efficient approach could result in a significant overall reduction in administrative burden, particularly since most total hip and knee replacements are performed at high-volume centers. The net effect would be a large reduction in unnecessary data collection, an increase in operational efficiency and cost savings.

This approach is not applicable to all institutions. In fact, our findings revealed that lower-volume institutions may not experience the same benefit of a streamlined process. If a low-volume hospital only submits 50% of their cases, you may have very inaccurate assessment of quality. In some cases, you may need 100% reporting for some very low volume institutions.

HSS undertook this research because of our dedication to advancing patient safety and care quality. It is important that patients know the measures of quality for different institutions. What we are proposing is a strategy that will allow patients to receive information in a more efficient way. This research is intended to move a very important policy conversation forward. Changes involving CMS can take a significant amount to implement.  If we are able to adapt this common-sense approach patients and healthcare institutions everywhere will benefit.

HSS has been and will continue to be a leader in this space and instrumental in defining these tools now and well into the future.  

Treatments for a femoral neck fracture range from nonoperative management to total hip replacement. When hip replacement is the best treatment option, it can be performed with or without bone cement to secure the prosthesis.

“Femoral neck fractures are very common in the elderly and are a major cause of morbidity and mortality in this population,” explained Alexander McLawhorn, MD, a hip and knee orthopedic surgeon at HSS and study author. “Several national registry studies have demonstrated a lower risk of overall revision surgery, and specifically revision for periprosthetic fracture, with cemented femoral fixation. Despite this overwhelming data, many patients in the United States receive cementless fixation, including patients who have sustained femoral neck fractures.”

“To our knowledge, this was the first non-registry study comparing outcomes of cemented versus cementless total hip replacement for acute femoral neck fractures examining the influence of various patient factors, including bone quality,” explained Michael Kheir, MD, who presented the study at the AAOS meeting and played a leading role in the research during his fellowship at HSS. “The primary purpose was to compare complication rates between both groups, including periprosthetic fractures, aseptic revision, dislocation and mortality rates.” Dr. Kheir is currently an orthopedic surgeon specializing in hip and knee replacement at the University of Michigan.

The retrospective study analyzed 709 total hip replacement cases (199 cemented, 510 cementless) for femoral neck fractures from 2006 to 2020 at three large academic institutions: Hospital for Special Surgery, Indiana University Health and University Hospitals Cleveland Medical Center. Patient demographics, perioperative characteristics and x-rays were reviewed. The Dorr classification system, widely used to evaluate femoral bone quality, categorized patients with Dorr type A, B or C, with type C indicating the weakest bone. 

The average age of study participants was 71 years; 66.9% of patients were women. The prevalence of Dorr type bone was 21.1% type A; 66.3% type B; and 12.6% type C. Patients receiving cemented implants were older, had a lower BMI, were more often women and were more likely to have a pre-existing diagnosis of osteoporosis and Dorr C bone type.

Cementless implant stems had a higher all-cause aseptic femoral revision rate (5.1 versus 0.5%,) and periprosthetic femoral fracture rate (4.3 versus 0%). Bone classification played a major role: Each successive Dorr grade had a higher fracture rate with cementless implants (Dorr A =2.3%; Dorr B = 3.7%; Dorr C = 15.9%). There was no difference in rates of dislocation, revision due to infection or mortality rate between groups. The study found an equal distribution of male and female patients who sustained a fracture.

“While femoral fractures occurred in patients with all types of bone quality, Dorr C bone was particularly prone, with an alarmingly high fracture rate when using cementless stems,” Dr. Kheir noted. “All of the fractures requiring a revision surgery occurred in cementless cases, suggesting that cemented stems may minimize this complication, regardless of patient sex or Dorr classification.”

Authors: Alexander McLawhorn, MD, MBA; Emile-Victor Kuyl, BS, (HSS); George Ochenjele, MD, FAAOS, (UH Cleveland Medical Center); Jacob Speybroeck, MD; Julian Dilley, MD, (Indiana University Health); Michael M. Kheir, MD, (University of Michigan); R M. Meneghini, MD, FAAOS, (Indiana University Health Phys)

The researchers found that within two years of having had arthroscopy, about two-thirds of patients with hip arthritis had undergone a total hip replacement. They also found that prior hip arthroscopy was associated with significantly higher risks of revision hip replacement surgery, joint implant loosening and joint infection after hip replacement.

“Our study is the first to quantify the clinical outcomes and risks of complications from having hip arthroscopy before total hip replacement in patients with osteoarthritis,” says senior author Alexander S. McLawhorn, MD, MBA, a hip and knee surgeon at HSS. “Our results suggest that arthroscopy should be avoided in patients with hip arthritis, especially in those over the age of 65.”

This study is available online as part of the AAOS 2020 Virtual Education Experience and is currently published online on HIP International.

The use of hip arthroscopy has increased by more than 600% in the past 10 years. It is a minimally invasive surgical technique that involves the use of an arthroscope, a small fiber-optic tube attached to a camera that allows surgeons to view the hip joint. Surgeons use hip arthroscopy to diagnose joint problems and perform repairs, such as fixing a labral tear, correcting hip impingement or removing loose fragments of cartilage resulting from an injury.

Some surgeons have also used arthroscopy to treat patients with hip arthritis in an attempt to delay or eliminate the need for a hip replacement. “From previous patient-reported outcomes studies, we have been increasingly recognizing that these ‘clean-out procedures’ are not successful in patients with osteoarthritis. They tend to lead to joint replacements relatively soon after the arthroscopy because they do not solve the underlying problem,” says Dr. McLawhorn.

For their study, the investigators examined Medicare data from a large national insurance database called the PearlDiver Patient Records Database. They identified more than 5,200 patients with hip arthritis who had undergone a total hip replacement procedure between 2005 and 2016 and grouped them according to whether they had received hip arthroscopy before hip replacement. After matching to ensure there were no differences between groups in age, sex, smoking status, obesity or other health conditions, each group contained data for 2,600 patients. A majority, 82%, were over the age of 65.

Overall, a total of 1,790 (68%) patients who had received hip arthroscopy to treat osteoarthritis had undergone a total hip replacement procedure within two years. Patients who had a prior hip arthroscopy had 3.7 times greater risk of needing revision hip replacement surgery, 2.8 times greater risk of implant loosening and 1.9 times higher risk of joint infection after hip replacement, compared to patients who had not had hip arthroscopy prior to their hip replacement.

Within two years of total hip replacement, 3.4% of patients in the arthroscopy group required revision surgery compared to 2.1% in the non-arthroscopy group. In the same period, rates of complications were higher for the arthroscopy group compared to the non-arthroscopy group as follows: dislocation 3.2% versus 2.3%; joint infections 2.9% versus 1.6%; and joint loosening 2.3% versus 1.0%, respectively.

“These risk percentages may seem small, but they are critically important. The goal is to drive complications down to as close to zero as possible,” says Dr. McLawhorn. “No patient should undergo an unnecessary procedure, even if the downstream risk of a complication is small. A joint replacement infection, for example, is a life-altering event.”

Alexander S. McLawhorn, MD, MBA, hip and knee surgeon at HSS, published a study in Orthopedics that compared overall patient satisfaction ratings for orthopedic surgeons from provider-based surveys with those found online. His team found that provider-initiated surveys had a higher number of patient ratings and higher satisfaction rates than those found online (such as on Healthgrades, Vitals, etc.).

"Surveys tend to capture the processes and outcomes of the entire care team and care environment, and they can be contingent on patient variables, such as comorbidities and patient behavior," Dr. McLawhorn says. "However, these outcomes are often not adequately risk-adjusted when they are reported."

Bradford S. Waddell, MD, hip and knee surgeon at HSS, who was also involved in the study, explains that government ratings provide a more comprehensive data set than crowdsourced ones. 

"Health care provider ratings are an anonymous survey given to all patients after care with the physician and are required by the government," Dr. Waddell says. "This automatically includes a larger and more robust representation of the physician's patients. This will give a more accurate representation of the care provided by the physician."

"As with everything, there is the possibility of bias in the health care provider reporting, and this should be properly guarded against by the care system to provide the most accurate results," he adds.

Dr. McLawhorn notes that further studies are needed to understand the parameters around crowdsourced care. "Patient-reported outcomes measures, or PROMs, like the Knee injury and Osteoarthritis Outcome Score are other potential candidate measures of quality, but we do not yet know how best to analyze these outcome scores so that they can be interpreted reliably as quality measures," he says. "Certainly, to use them as quality measures at this time would be premature and ahead of the science as well as our understanding of the links between PROMs and quality of care."

Read the full article at Healio.com/Rheumatology.

HSS hip and knee surgeon Alexander S. McLawhorn, MD, MBA, explained that cracking in the knees, also known as crepitus, could be caused by "tendons or ligaments popping over prominent ridges on the bones around the knee or hip joint" or "bubbles within the joint fluid".

"These forms of crepitus can be totally normal and harmless," he added.

This article originally appeared on Furthermore.equinox.com.

"For osteoarthritis, early treatment and prevention begins with modifying recreational activities to decrease the frequency of impact sports such as running and competitive athletics. You can adapt non-impact activities, such as an elliptical, aquatic-based exercises and cycling, into your exercise routine," Dr. McLawhorn wrote.

Additionally, Dr. McLawhorn explained that a person could be prescribed exercise or physical therapy before surgery depending on their level of pain.

Read the full article at Brookfield.dailyvoice.com.

Orthopedic surgeons often encourage obese patients considering knee replacement to try to lose weight before the procedure. The study, known as SWIFT (Surgical Weight-Loss to Improve Functional Status Trajectories Following Total Knee Arthroplasty), is enrolling patients at a number of hospitals nationwide, including HSS. The goal is to compare outcomes in individuals who have bariatric surgery versus those who do not have weight loss surgery before joint replacement. Researchers also aim to determine if losing a significant amount of weight could enable patients to hold off on knee replacement or postpone it indefinitely.

"This is the first prospective study of its kind," explained Alexander McLawhorn, MD, an orthopedic surgeon and lead investigator at HSS. "We hypothesize that weight loss resulting from bariatric surgery prior to knee replacement will improve joint replacement outcomes in obese patients with painful arthritis. It will also be interesting to see if weight loss and reduced stress on their joints will result in less pain and improved mobility, which may enable patients to postpone knee replacement surgery."

A previous retrospective study at HSS found that in severely obese patients, bariatric surgery performed prior to a total hip or knee replacement reduced complications while patients were in the hospital and in the first 90 days after joint replacement surgery.

In the current study, researchers will divide enrolled patients into two groups. One group will undergo bariatric surgery prior to knee replacement, and the other group will have knee replacement only. Patients who choose to have weight loss surgery will have the procedure at New York Presbyterian Hospital. All knee replacement surgeries will take place at HSS.

Approximately 9 to 13 months after bariatric surgery, participants in the first group will be evaluated to determine if they still wish to go ahead with knee replacement; if they feel the surgery can be delayed; or if they believe they no longer need it. Those who choose to have a knee replacement will complete nine research visits over the course of 3.5 to 4 years, in addition to the standard of care visits required for bariatric surgery and knee replacement. Research visits will include the completion of questionnaires to measure pain, physical functioning, quality of life and patient satisfaction; vital sign measurements; and physical function assessments, including the ability to walk a quarter of a mile and climb stairs.

Participants in the control group will undergo a total knee replacement without weight loss surgery and will complete six research visits over the course of 2.5 to 3 years, in addition to the standard of care visits required for knee replacement surgery. The research visits for this group will include the same evaluation activities as those in the bariatric surgery group.

The study is open to individuals with knee osteoarthritis up to age 75 with a body mass index ≥ 40 or a BMI >35 with a qualifying co-existing condition such as obstructive sleep apnea or diabetes. Anyone wishing to receive more information on the study is invited to email Ethan Krell: KrellE@hss.edu.

"While significant progress has been made collecting PROMs data for joint replacements, no guidelines exist on the most accurate way to analyze these data to objectively measure and improve performance," said lead author Stephen Lyman, PhD, associate scientist at HSS. "Before policies are enacted, clinicians and payers must reach a consensus about which measures reflects the meaningful improvement in joint-related health."

PROMs are considered the gold standard for evaluating the effectiveness of hip or knee replacement procedures. Two of the most commonly utilized PROMs for the hip and knee are the Hip Disability and Osteoarthritis Outcomes Survey (HOOS), the Knee Injury and Osteoarthritis Outcomes Survey (KOOS), respectively, and their short form versions HOOS, JR. and KOOS, JR., respectively. The Centers for Medicare and Medicaid Services (CMS) have adopted these surveys in their Comprehensive Care for Joint Replacement (CJR) Model, which is a bundled payment plan for all primary elective total joint replacements performed in eligible Medicare patients.

This study, performed at HSS, included 2,323 people who underwent a total hip replacement procedure, and 2,630 people who underwent a total knee replacement procedure. Meaningful change of PROMs can be assessed using three measures: Minimal Detectable Change (MDC), Minimal Clinically Important Change, and Substantial Clinical Benefit. Answers from the HOOS and KOOS (original or JR.) are used to score these measures and currently several different methods can be applied to calculate the total score.

The results showed that there is wide variability in benchmarks when these methods are used to calculate them:

• Distribution-based approach, which relies on distribution of the data and assumes a normal distribution of responses and does not include patient input.
• Anchor-based approach, a patient-centric approach where an anchor question on the HOOS/KOOS regarding patient perception of a change in health is used to assess the change in PROMs scores.
• Anchor-based ROC approach, which uses the area under the ROC curve to determine the optimal delta score that best predicts those who experienced a minimal improvement and those who did not and does not include patient input.

"We believe meaningful use of PROMs to assess care delivery and quality requires an understanding of how much change over time should be expected and how much change matters to patients," Alexander McLawhorn, MD, MBA, an orthopedic surgeon at HSS. "The anchor-based assessment is the only method that accounts for the patients’ perspective."

"We hope this analysis sparks important discussions about how quality and appropriateness are measured," said senior author Catherine H. MacLean, MD, PhD, chief value medical officer at HSS. "The orthopedic community must be careful before we start using PROMs scores for performance evaluations, and as a next step HSS researchers plan to explore in depth the care experience and broad outcomes of patients in relation to changes in their patient reported outcome scores."

Investigators found a much higher number of reviews and more favorable physician ratings overall on the hospital websites. The research was presented today at the American Academy of Orthopaedic Surgeons Annual Meeting in New Orleans. The study was also published in the journal Orthopedics in August 2017.

Consumer-driven healthcare and an increasing emphasis on quality measures have encouraged patient engagement in the rating of doctors and the care they provide. Independent commercial physician rating websites such as Healthgrades.com have become a popular outlet for patients to express their satisfaction or dissatisfaction.

A number of hospitals and medical practices have also started to publicly report the results of their own patient satisfaction surveys, which are often administered by a third party such as Press Ganey.

"The purpose of our research was to compare overall patient satisfaction ratings for orthopedic surgeons derived from hospital surveys with those posted on commercial physician rating websites. We also sought to determine which physician characteristics resulted in higher ratings," explained Bradford Waddell, MD, an orthopedic surgeon at Hospital for Special Surgery.

The study included 12 hospitals or medical practices that were publicly reporting patient satisfaction data collected for their orthopedic surgeons as of August 2016. Investigators identified 415 orthopedic surgeons with online patient ratings at the following institutions: Duke University, Midwest Orthopedics at Rush, Vanderbilt University, Northwell Health, Cleveland Clinic, University of Utah, University of Arkansas, Stanford University, University of Pittsburgh, Wake Forest University, Southern California Orthopedic Institute and Piedmont Healthcare.

The hospital surveys were administered at the time of the office visit or sent to randomly selected patients by email or regular mail. Independent third parties experienced in the creation and evaluation of health care surveys were used by most hospitals to gather the information. Patient response rates ranged from 18 percent to 30 percent. Most institutions required a minimum of 30 ratings within the past 12 to 18 months for the physician’s ratings to be made public.

For each orthopedic surgeon, the type of institution (academic setting versus private practice), sex, years in practice, geographic location and subspecialty training were recorded. The number of individual survey questions ranged from 6 to 20, depending on the institution, and most included questions on communication, trust in provider decision-making, time spent with the patient and willingness to recommend the physician to others. At all of the hospitals, an overall physician rating was reported on a scale of 1 to 5, with 5 as the highest rating.

Most of the institutions had a stated policy of publishing all physician ratings, including negative reviews and comments, as long as no offensive, profane, or slanderous remarks were made and there was no violation of patient privacy or confidentiality.

Researchers compared the ratings reported for each doctor posted on the hospital websites with the physician’s ratings on four commercial websites: Healthgrades.com, Vitals.com, RateMDs.com and UCompareHealthCare.com.

"Compared to commercial ratings websites, we found that provider-initiated patient satisfaction surveys yielded a higher number of ratings for each doctor, higher average patient satisfaction scores and a lower percentage of negative comments," said Alexander McLawhorn, MD, an orthopedic surgeon at HSS. "We saw a small association between increased years in practice and the likelihood of a negative rating, while academic practice settings and those in the Northeast had a lower percentage of negative comments."

"While hospital surveys are distributed to patients who received care from a specific doctor, ratings on sites such as Healthgrades and Vitals are often anonymous, and you really don’t know who is posting a review," Dr. Waddell noted. "We believe hospital surveys filled out by patients provide data of a higher quality and are a better indication of patient satisfaction."

Feedback from patients can also provide valuable information to physicians, according to Dr. Waddell, who believes increasing the use and reporting of patient satisfaction surveys could benefit the orthopedic community. "In contrast to a limited number of random online reviews, healthcare provider surveys can gain insights from a much larger population of patients. The more information we have, the more we can improve patient care."