Risk Adjustment is Necessary for Bundled TKA Patients With health care costs in the United States rising at an exponential rate, providers, payers, and policymakers have all sought to develop alternative payment models to seek value in care. For procedures such as total knee arthroplasty (TKA), which accounts for Medicare’s largest inpatient expenditure, the Centers for Medicare and Medicaid Services (CMS) and private insurers have introduced bundled payment programs aimed at reducing cost and improving the quality of patient care. Although traditionally, TKA has been reimbursed by Medicare through a fee-for-service model rewarding quantity of services provided versus quality of service, the Bundled Payments for Care Improvement Initiative (BPCI) and the Comprehensive Care for Joint Replacement Model (CJR) seek to align incentives among providers and health care systems by providing a single payment for all services rendered during an episode of care for TKA. Although early published data from these programs suggests substantial cost savings to CMS without an increase in complications, concerns exist regarding access to care for patients who may utilize more resources in an episode of care. Without appropriate risk adjustment, providers are disincentivize to perform TKA on patients at risk for complications and readmissions. Alternative payment models have reduced costs and improved patient outcomes by incentivizing providers to optimize modifiable risk factors before elective TKA, including glycemic control, smoking, body mass index, and malnutrition. Several studies, however, have shown that nonmodifiable risk factors including advanced age, lower socioeconomic status, and several medical and orthopaedic comorbidities are costlier to the health care system following TKA. These patients may face difficulty obtaining quality arthroplasty care with the expansion of bundled payment programs. In order to protect access to care, alternative payment models should not penalize surgeons and hospitals for caring for complex patients and instead provide appropriate, fair, risk-adjusted payments.

Avoiding Complications Associated With Anemia Following Total Joint Arthroplasty As the number of total knee arthroplasty surgeries exponentially rise over the next decade, there will be a parallel rise in the complications observed. Patients who undergo total knee arthroplasties will be at an increased risk for postoperative anemia and allogenic blood transfusions (ABTs). The range of complications associated with perioperative anemia and ABTs include increased length of stay (LOS) in the hospital, increased surgical site infections/periprosthetic joint infections, and mortality. There are many perioperative blood conservation strategies that can be utilized to help optimize a patient, prevent excessive bleeding, and reduce the need for possible ABTs. Although there is extensive research on this topic, there is a lack of consensus on the best strategy to help prevent perioperative anemia and the complications associated with it. Surgeons should be able to recognize perioperative anemia and utilize the information in this section to prevent its unnecessary complications.

What is the Status? A Systematic Review of Nutritional Status Research in Total Joint Arthroplasty Malnutrition has been previously associated with impaired wound healing, slower locomotion, and poorer outcomes following elective surgery. Although academic societies dedicated to perioperative recovery have published evidence-based guidelines for malnutrition, no consensus exists within orthopedics for screening and treating malnutrition in patients undergoing total joint arthroplasty (TJA). Following PRISMA guidelines, we performed a systematic review to determine: (1) how is malnutrition defined; (2) what is the prevalence of malnutrition among patients with TJA; (3) what perioperative complications are associated with malnutrition; (4) what strategies are successful in managing malnourished patients with TJA. Eight hundred ninety-five articles were identified in the literature, with 53 fulfilling criteria for analysis. Albumin <3.5 g/dL was the most commonly used parameter to define malnutrition. Total lymphocyte count (<1500 cell/mm3) and vitamin D (<20 to <12 ng/mL) were the second most commonly used parameters. Prevalence of malnutrition tended to be under 15% of primary patients with TJA in studies with over 10,000 patients. Morbidly obese patients and patients undergoing revision TJA were found to have significantly higher rates of malnutrition. Significant associations were found with malnutrition before TJA and higher rates of postoperative length of stay, readmission, reoperation, surgical site infection, and mortality. Malnutrition and obesity were not consistently found to have a synergistic effect on complication rates. To date, no formal preoperative treatments of malnourished patients with TJA have been studied. Protein supplementation has been shown to reduced length of stay in 3 TJA studies, but supplementation strategies varied and study patients were well nourished.

New York Arthroplasty Council (NYAC) Consensus on Reducing Risk in Total Joint Arthroplasty: Obesity Obesity is an epidemic in the United States and a growing concern for adult reconstructive surgeons. Patients with obesity are significantly more likely to require total joint arthroplasty (TJA) compared with nonobese counterparts. In addition to being an independent risk factor for the development of complications after TJA, obesity is associated with numerous comorbidities that increase the risk of complicated TJA. Preoperative optimization of both body mass index and comorbidities is essential to reducing the risk burden imposed by this prevalent disease. In recent decades, bariatric surgery has been considered as an experimental technique to alleviate lower extremity osteoarthritic symptoms, obviate the need for TJA, and optimize body mass index in obese patients before TJA. This article reviews the literature related to these topics, and focuses on the reduction of risk in TJA in relation to obesity in general.

Perioperative Management of Diabetes for Total Joint Arthoplasty: A Consensus Article Diabetes mellitus (DM) is an increasingly prevalent comorbidity among patients undergoing total joint arthroplasty. Uncontrolled DM is a known risk factor for a multitude of postoperative complications, the most dreaded of which is periprosthetic joint infection, but also includes wound complications, deep venous thrombosis, and worse functional outcomes. Given that uncontrolled DM is a modifiable risk factor, it would be prudent for the surgeon to do all that is possible to minimize perioperative risks related to DM while also avoiding unnecessary surgical delays. In this article, we review risk mitigating measures including surgical screening, cutoff thresholds for hemoglobin A1C and maintaining good perioperative glycemic control. We recommend that all presurgical patients be screened for DM by measuring A1C. A value of 8.0% is a reasonable cutoff in surgical candidates and those falling above this value should be referred for glucose optimization before proceeding with surgery. Hemoglobin A1C has not been found to be a good predictor of postoperative complications and thus a strict A1C cutoff should be evaluated on a case by case basis. Maintaining tight glucose control, specifically avoiding hyperglycemia and large glucose fluctuations, is beneficial in the perioperative period and striving for a glucose goal between 80 and180 mg/dL is recommended.

Acute and Chronic Renal Insufficiency in the Total Joint Arthroplasty Patient With the projected increase in joint replacement in the next few decades, along with the increased prevalence of renal insufficiency, arthroplasty surgeons must have a good understanding of the routine management of renal impairment in the perioperative setting. Multiple studies have demonstrated significant effect on arthroplasty outcomes, morbidity, and mortality. We highlight several key strategies in the perioperative management of both acute and chronic renal insufficiency. A multidisciplinary approach should be pursued in the perioperative management of renal disease, with important considerations for cardiovascular, hematopoietic, anesthetic, and infection prevention.

Reducing Risk in Total Joint Arthroplasty: Immunocompromised Patients Immunodeficiency limits the body’s natural ability to fight infection, thus increasing the patient’s risk of postoperative complications. Moreover, rates of immunosuppression in the United States are on a steady climb secondary to the duality of greater life expectancy of the immunosuppressed and expanding indications for immunosuppressant use. Taken together, these 2 factors foreshadow the growing challenge orthopedic surgeons will face, as higher rates of immunocompromised patients will inevitably present for procedures in the decade ahead. These patients present with the 3-fold effect of a weakened ability to heal, fight infections, and maintain homeostasis. In the surgeon’s armamentarium must be a thorough understanding of the mechanisms behind the immunocompromised state, the complications to remain vigilant of, and the consequences of failure. The surgeon should seek assistance from other specialists early and make sure the patient is informed of elevated risks before proceeding. Further research is needed to optimize the care of this patient population.

The Effects of Smoking on Postoperative Complications After Total Joint Arthroplasty The evidence that preoperative smoking cessation provides decreased postoperative morbidity and complications is continuing to develop and offer stronger results. Although the intensity of the intervention required for a long-term positive impact remains unknown, direct communication between the physician and their patient in combination with nicotine replacement therapy seems to offer the greatest reduction in postoperative morbidity. With many institutions now implementing group classes to prepare patients for their upcoming surgery, adding a smoking cessation group therapy component may further offer patients mutual support to stop smoking before total joint arthroplasty. Preoperative smoking cessation programs not only offer health benefits to the patient by decreasing their risk for periprosthetic joint infection or other complications but also may also lower the cost of care.

Consensus on Reducing Risk in Total Joint Arthroplasty: Narcotic Use Because of the potential adverse events associated with opioid use, the purpose of this consensus was to provide guidelines to help reduce the risks when performing lower extremity joint arthroplasty. Specifically, the authors addressed: (1) the use of nonopioid pain management; (2) national and state guidelines; (3) the role of pain management specialists; and (4) multimodal pain management options for total hip and knee arthroplasty. A literature search was performed utilizing the PubMed database focused on total hip and knee arthroplasty pain managed with opioids. The authors recommend that patients be started with nonopioid-based pharmacological treatments, such as acetaminophen and nonsteroidal anti-inflammatories. If opioids are necessary, the lowest dose for the shortest duration should initially be prescribed. Appropriate preoperative optimization, intraoperative local analgesic injections, and perioperative multimodal agents, such as long-acting injections, physical therapies, and co-management with pain specialists should all be performed. By following these guidelines, the authors believe that it will help reduce the use of opioids after hip and knee arthroplasty, all while still meeting our patient’s pain control expectations.