Episode Transcript
[00:00:02] Speaker A: Welcome to your Cases on Hold, the JVGS podcast, hosted by Andrew Schoenfeld and Aisha Adkeen.
[00:00:08] Speaker B: Here we discuss the best of what each issue of JBJS has to offer with the usual dose of entertainment and pop culture.
[00:00:16] Speaker A: Take us with you in the gym, on the commute, and, as ever, whenever your case is on hold.
[00:00:26] Speaker B: Hello everyone. Welcome back to another episode of youf Case Is on hold, episode number one, 106. If you're listening, on the Day we drop, this is May the May 20 issue of JBJS. My name is Aisha Avdine. I'm Chief of the Division of Hip and Knee Arthroplasty at Boston Medical center and Associate professor of Orthopedic Surgery at Boston University, and I have with me my co host.
[00:00:51] Speaker A: I'm professor of Orthopedic Surgery at Harvard Medical School and Vice Chair of Education at Mass Johannesburg.
[00:00:59] Speaker B: As a reminder, the opinions expressed here are exclusively our own and do not represent those of jbjs, the Editorial Board of jbgs, the Board of Directors, or the affiliate journals of jbjs.
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What's New in Foot and Ankle Surgery by Halai this is permanently free Is the minimally clinically important CID still a reliable outcome? A Call for Conceptual Rethinking by Dhati and Associates Evaluating concordance between complex outcome measures Letter to the Editor regarding Satisfied but failed patient satisfaction Total knee arthroplasty success defined by the U.S. centers for Medicare and Medicaid Services by Riddle early subspecialization in Orthopedic Pathway to Expertise or compromise in Training by Marachi Team A Strategic Guide for Orthopedic Surgeons by Ballou and it's permanently free Measuring Value in Orthopedics, the US and UK Perspectives by Day this is a highlight and it's permanently free by Residual rotator cuff subregions Preserves glenohumeral mechanics in Partial and massive tears by Hoshikawa There's a comment and it's the highlight.
Now we'll get on to our headlines.
This will be presented the postoperative clopidogrel thromboprophylaxis in total joint arthroplasty. Increased risk of transfusion but similar venous thromboembolic risk compared with aspirin by Talang and Associates. There is a commentary and it's 30 days free.
[00:03:20] Speaker A: Okay, so this is an article that was conducted using the Premier Health database.
The premise for the study is that clopidine is an antiplatelet agent that acts as a P2Y12 receptor antagonist, often prescribed for secondary prevention in patients following MI or stroke.
And in other studies, not more.
Cardiac clopidogrel monotherapy has been found to offer comparable or superior outcomes to aspirin following coronary stenting.
And the authors present the pro premise here that, well, one, surgeons are probably going to be seeing more patients who are on clopidogrel, also called Flavix, and two, they might elect to just continue those patients on clopidogrel for thromboprophylaxis and after elective toe joint arthroplasty. Just to hear from your perspective and practice on this, do you, do you do something like that or.
[00:04:30] Speaker B: Yeah. So, you know, we are seeing more and more patients on clopidogrel and evidence. So I'm glad they took this topic because there's not a lot of evidence on what to do and it's very variable. And we do worry about the bleeding risks of Plavix postoperatively, particularly in total knees where you can get a hematoma. And so I usually do this on a patient, but really try to work with the cardiologist and see how long we can hold, hold it pre op and then post op until we're out of that phase where wound complications can be a problem.
Sometimes that might be two weeks or four weeks. And then we have to sort of have that compromise about what they're going to be on for antiplatelet activity because we're using aspirin as our preferred DVT prophylaxis in most patients of standard risk, then they would be on that to cover them for the antiplatelet activity. So there is huge variation in what we can do based on recommendations are unlimited, you know, evidence on this. So I'm glad they're taking this topic further.
[00:05:30] Speaker A: Yeah, but I, I wouldn't go walking out on the beach in the Hamptons in the cream slippers just yet on this work.
I, I mean, I took it to, I read it as they were like, you know, it's postoperative day one. You were on clopidogrel before. Let's just get you back on that now and we'll ride it out.
You understood the same way, right?
[00:05:58] Speaker B: Yes, I did, but that's the issue. We know it's coming up. We know that they're meant to be resuming clopidogrel at some point, but in my practice I try to avoid that in the immediate post operative timeframe because of the concern that I have that they have a hematoma.
And that's why, you know, we're reluctant to get them back on that Plavix because of the bleeding risk. But then of course the cardiac risks are of course present and concerning.
[00:06:26] Speaker A: So they said, all right, from the premier health database, we're going to do a propensity score matching study to get to the bottom of this.
So some challenges on that front. One, this is claims based data reporting with situation like this, like everything you said about these patients in terms of your consideration, there's no way to unpack that through claims based data.
So the what they, they went to do city score matching approach and that's a causal inference test. We, we went over this fairly recently, a couple of episodes back. But for those who maybe didn't listen to that one or you know, it's always good to refresh these things.
The first thing about propensity score matching is for it to really work well and in the causal inference sense there has to be equipoise between the patients who got the treatment and those who didn't.
So that's their first violation. I think in this context it's a unique on Plavix beforehand, you certainly for a patient who isn't on Plavix beforehand and sorry, if I'm violating some kind of tenet by saying Plavix instead of clopidogrel, it just rolls off the tongue a little bit easier.
But comes in your office, they're not already on copitogrel, you're not like, well we could consider aspirin or Plavix or Enoxaparin or Coumadin or. Right, you're not.
[00:07:58] Speaker B: We're not.
[00:07:58] Speaker A: That right there is like the first violation for the tenants of real cause.
[00:08:05] Speaker B: Right.
[00:08:07] Speaker A: The second is that they do this one to seven match, which to me really makes no sense.
That's not the standard way that you do propensity score matching.
It's one. And certainly in propensity score matching you have a caliber and the caliper Is the precision of the match.
So I've used this analogy before. I think it's very effective as an illustration.
Are, you know, the paintings? Are you matching Picasso to Picasso?
That's going to be the closest match. Is it Picasso to Renoir? Is it Picasso to Van Gogh? Is it Picasso to Jackson Pollock? Now you're getting a little bit further away. Is it Picasso to a finger paint?
I was five. Well, those are both paintings. So if the caliper is wide enough, then yeah, we're matching them. But are they really similar? Is it the same thing? No, of course it isn't. And when you're trying to find seven matches per eligible case, that to me have good information on their caliber that just signals that they're putting in a lot of patients. The broader the caliper, the greater the potential for the residual confounding.
And I think that's a big concern here because what they say is that individuals roman received aspirin monotherapy for postoperative chemoprophylaxis on the basis of age, sex, procedure type, perioperative, tranexamic acid, known indications for clopidogrel, including mi coronary disease, stent placement, stroke, vascular disease. But now to me, that's getting outside the realm even of what would be considered for a low risk aspirin patient.
Somebody has a stroke and you're like, oh yeah, we're not going to use any of the heavy like we discussed last episode.
[00:10:00] Speaker B: Agree. But the move in our field is more towards aspirin. And all comers and less sites are doing this risk stratification. We still do risk stratification. We do it on the basis.
Yeah, exactly. But I think a lot of arthroplasty groups are not based on the evidence are using aspirin as a standalone.
And these factors wouldn't have changed their decision on that necessarily.
[00:10:25] Speaker A: It still doesn't, I think is equivalent to is basically you could have taken the whole cohort and just done a regression analysis and you're going to get the same results.
This is showing that there's not a value add from the propensity score piece comes where 90 day risk of postoperative bleeding and 90 day risk of thrombo and bot complications.
Another issue with their analytic approach is that they did the match and then they did multivariable regression analysis on top of the match.
Also kind of a violation of best practices. The match is supposed to be the analytic component. What they were essentially doing is they were trying to put together a group of patients and they're using the. So it's now not a causal inference test, it's just PRISM through which you found matches for your patients to trim down the overarching cohort.
I think that creates a lot of potential for residual confounding, which is a big concern from my stand this paper. In the end, what they found, not surprisingly, patients who received clopidogrel were at an increased risk for postoperative blood transfusion acute anemia relative to patients receiving aspirin. No significant difference in the risk of DVT mi, hematoma or hemorrhage were found.
They conclude the increased risk of postoperative bleeding complications, but a similar risk of thromboembolic complications compared with patients who received aspirin. And the decision to resume clopidogrel for post op, you know, VTAD prophylaxis should balance the antiplatelet activity with the risk of bleeding complications.
And in high risk cardiovascular patients, that's a complete non sequitur.
That went without saying before Ready? And that's what a lot of conclusions end up being with these types of like, it's like we're going to tell you something you already knew and be like, see, we should look what we showed you.
I'm just worried that a lot of what they're seeing in terms of blood transfusion is the effect of. Is not the effect of clitogril, it's the effect of unmeasured factors.
That is the reason the patient was on clopidogrel in the first place.
[00:12:47] Speaker B: Yes. And the reason you're likely right on that is because despite having fusion risks, there were no problems at the local surgical site. There were no increased hematomas or wound complications or anything of that nature. There were increased transfusions, but not bleeding at the surgical site, which I thought was interesting.
[00:13:09] Speaker A: Yeah, that.
So if you read the conclusion of the actual paper and you read the conclusion of the abstract, there's an additional piece that they kind of throw in. The conclusion of the paper is that postoperative clopidogrel monotherapy was associated with increased increased transfusion and acute anemia, While risks of VTE cardiovascular events remain comparable.
But then in the abstract, they're saying in the result difference between the cohorts in the risk of DVT, PE, stroke, MI hematoma or hemorrhage.
So there's a little bit of a disconnect there.
[00:13:50] Speaker B: Exactly.
And you can take it with a grain of salt. Just being studies where we don't have granular detail on the types of bleeding complications that occurred. We also don't know what dose of ASA was used and there could be some heterogeneity there because we currently use low dose aspirin 81mg bid but high dose was widely used 325 bid until the landmark paper showed that this increased GI side effects without any improved rates of VT prevention.
We don't know if the patients were on the higher dose.
It being a database study, I think it really should be emphasized that clopidogrel is not included in in the ACCP guidelines and the authors indicate that as well in their discussion. It's not an agent used for DBT prevention after total.
So you know we most likely be seeing this, as you mentioned, as a monotherapy in patients that happen to be on at a baseline and someone decides to use it postoperatively. But in essence I think these findings sort of galvanize my current approach which is basically trying to stop the clopidogrel post op stop and continue aspirin in its place for antiplatelet activity to reduce bleeding complications postoperatively.
I think on a case by case basis talking to the cardiologist and optimizing the patient and trying to figure out a safe window to hold their clopidogrel and giving aspirin in its place would be the way that I would still approach these patients.
[00:15:21] Speaker A: Sounds good.
I think that settles it.
[00:15:26] Speaker B: Okay, so moving on to the paper that I'm going to discuss today.
Assessment of custom made acetabular implants for complex revision Total lip arthroplasty A concise follow up at a minimum of five years by Delora and associates. There is a commentary visual summary and it is permanently free.
One of the major challenges in revision total lip arthroplasty is managing massive defects in the pelvis bone loss.
It can be difficult to achieve stable fixation of acetabular components due to loss of bone and pelvic discontinuity loss of the cell and this can lead to instability and dislocation of the implant.
This paper essentially looked at using custom 3D acetabular components which they made an acronym of CMAI to deal with massive bone loss such as in Peroski 3A and B defects.
Historically we used structural allograft. However graft incorporation can be challenging.
Metal implants such as cages and rings are also not as commonly used anymore and have been augments in custom implants such as the ones used in these papers. In this paper the same authors previously reported on this cohort at three years and this paper is a report of the five nine year follow up.
Surgical planning and technique the acetabular bone loss was assessed in this paper using an implant based analysis.
The design process began by virtually modeling the implant to fill the defect. The implant geometry, phalanges and screw holes prioritized the restoration of including the center of rotation and offsets.
Dissection through the gluteal muscle depended on the exposure required. The acetabular cavity was fully exposed and sequentially reamed with hemispheric reamers.
All patients were treated with a single manufacturer printed titanium custom implant by Innovis. It incorporated a dual mobility type of bearing featuring either a 40 millimeter in 50 percent of the patients or a 42 millimeter in 50% of the patients with a polyethylene liner and a 28 millimeter.
Patients with infection underwent a two stage procedure and in cases where the femoral stem was well fixed the stem was retained rather than revised.
The post op imaging included radiographs and a CT scan immediately postoperatively and annually thereafter to assess radiolucencies, implant stability and congruency. Additional imaging was obtained if the implant was found to migrate.
Boning growth was assessed radiographically and defined as the presence of trabecular bone extension or spot welds and this assessment was performed systematically for all implants on sequential radiographs and CT scans.
CT data was used to compute relative 3D comparisons between the component position immediately post op and at log assess the bone implant contact area and a nuclear spec. CT was performed if loosening was suspected.
Implant survival was calculated using the Kaplan Meier method with all cause revision as the endpoint and failure was defined as a revision or implant and functional outcomes were assessed using the Oxford Hipp score.
The authors used a Pearson test to assess correlations between the deviation of the center of rotation and the body mass index. Age, sex and pelvic discontinuity and Kaplan Meier curves were used.
The authors indicate that they included 30 patients of diverse ethnic backgrounds but no further detail was given on ethnicity or racial specifics.
The distributions were 21 female patients so 70% were female with purpose type 3. The including 26 patients from a previous study and they were followed for a median of 84 months and the mean age was 70 years old. Pelvic discontinuity was confirmed intraoperatively for four patients which cohort and preoperative pelvic MRIs were available for 47% of the patients and revealed mild to extensive Fatty atrophy of the gluteal complex with intact tendons. In most cases, CT scanning was performed immediately post op and at one year postoperatively.
Instead, standard radiographs were taken at all visits immediately postoperatively. Bone implant contact was found to be partial. On average 15% of the implant was in contact with bone and bone formation was observed in 20 of the patients. At more than one year follow up there were no component breakages and no major implant migration at more than five years except in one patient and this patient developed hip pain at three years post op and the SPECT CT at one year post op. None of the implants had migrated more than five millimeters in any direction. At three years post op the deviation of the center of rotation from one year postoperatively was a median of 0 millimeters. So essentially was no migration of the components except in the one patient they find beyond three years. Both two dimensional and three dimensional analyses confirmed negligible additional migration within the measurement error of less than 1 millimeter and only 3 minor residual migration.
With regard to the implant survival as all cause revision, the overall Kaplan Meier survival rate was 96.3% and there was one revision due to infection.
With regard to functional outcomes, the mean Oxford hip score increased from 8 preoperatively to 32 postoperatively and the difference was significant.
The score remained essentially unchanged at the most recent follow up.
Mobility scores were recorded pre and post op including at the most recent follow up and they improved significantly by a mean of 1.4 points. With one patient's mobility having declined because of unrelated spinal and knee issues. You would have to blame the spine.
One patient experienced two dislocations at one and six months. Both managed with closed reduction and their Oxford hip score was 27 at 1 year and the mobility score improved from 4 to 6 and this patient died at 49 months postoperatively.
Causes to the hip rate revision.
Another patient developed transient sciatic nerve palsy. Overall, three patients died at 38, 49 and 61 months, all for reasons unrelated to the hip.
Midterm follow up is typically an arthroplasty. Because midterm follow up is 5, 10 years and long term follow up is 10. It's semantics. They term this as long term follow up, but this is more in the midterm range.
It is commendable to get this duration of follow up in this group.
Complex problem.
I think another limitation would be the use of custom implants. That was not discussed here at the time of revision. There could be substantial bone loss after removal of the prior implant. So this is one of my hangups with custom implants is that sure, everything after the anatomy that you currently have preoperatively, but you know, with well fixed implants there can be substantial iatrogenic bone losses. The anatomy can change based on the soft tissues intraoperatively and what you have templated for. And expense of a large implant such as this may not fit absolutely perfectly. And historically because of those reasons and the soft tissue changes and the deficiencies, there's a really high dislocation risk typically with these implants. But in this particular cohort they had excellent success and very low rate of instability.
It can be a gamble when using custom implants. And as mentioned, there's a tremendous cost to custom implants.
So my preference still remains using off the shelf augments pages when applicable and cupcake constructs which are the other alternative to this. So I haven't sort of completely bought into the concept of having these 3D constructs, but they have a very commendable know midterm follow up results in their experience with this implant.
[00:23:52] Speaker A: Andrew I think they're very transparent. It's a rote clinical retrospective of their experience. A limited number of patients, it's level four. They recognize that indication expertise bias as is inherent to all studies or reports of this kind of design.
I, I would, you know, I bring this up quite regularly and hopefully, you know, enough people hear it that I, I, I, you know, when you're doing something like this, they give all these point estimates, but those are unlikely to hold for everyone. So if you can account for your limited sample and just provide a 95% confidence interval around those estimates, it can show what the variation might be. You know, some of these figures that they have here, for example, you know, the, the bone ingrowth occurred in 90 of the patients. Well, it's 27 out of 30, so that could actually be, you know, the range might be like 73% to 99%. You know, like just, just things like that. I mean it's, it's, you know, it's, for all the reasons that you mentioned, I, it definitely adds value.
These are obviously just minor points, but very good points.
[00:25:12] Speaker B: Now we'll move to our your case is on hold featurette.
And this is entitled Satisfied but failed patient satisfaction compared with total knee arthroplasty success.
U.S. centers for Medicare and Medicaid Services. This is by Zhang and Associates. There is a commentary, this is the lead article, there is an infographic and it is 30 days free.
This is a very interesting and in my opinion, impactful study.
It comes from the University of Massachusetts Chan Medical school in Worcester, Massachusetts.
The senior author is Dr. David Ayers who founded the Force Total Joint Replacement the Function and Outcomes Research for Comparative Effectiveness and Total Joint Replacement.
The premise of this study is to address the updated requirements for the U.S. centers for Medicare and Medicaid Services or CMS in total knee arthroplasty as of July 1, 2024 that mandate patient reported outcomes measures be reported preoperatively 90 days and postoperatively from 300 to 420 days post op for total hip and knee arthroplasty with a goal to have complete data on more than 50% of patients in all centers.
Substantial clinical benefit rather is defined by CMS as 22 points for the hip dysfunction and osteoarthritis outcome score for total joint replacement, improve in total hip arthroplasty and 20 points for the knee injury and osteoarthritis outcome score for total joint replacement or the KOOS Junior Arthroplasty. This study focused on total knee arthroplasty. There is a CMS defined goal for hospitals to achieve an SCB of more than or equal to 60% of patients.
There are penalties for non compliance affecting all Medicare reimbursement and this is on the knee measure.
The study sought to examine concordance between the CMS measure of total knee arthroplasty success or achieving the SCB of 20 point increase for the COOs junior score and patient reported satisfaction.
Reasons for discordance leading to suggestions about how CMS total knee Arthroplasty performance measure could be improved.
The Qi 4 so the quality improvement, Function and outcomes research for comparative effectiveness part of the Force Total Joint Arthroplasty.
The study evaluated patients with advanced knee osteoarthritis who underwent primary total knee arthroplasty by more than 110 surgeons involved in the database. Patients were included if they completed both pre op and one year post op questionnaires.
Language was either English or Spanish. The study excluded 24% of otherwise eligible patients because they did not complete the one year questionnaire resulting in 76% completion rate and that exceeds the 60% benchmark sent by the International Registries or ISAR for research purposes.
Patient satisfaction was measured at one year using the single question quote how satisfied are you with the result of your surgery?
With a 5 point Likert scale for answers very satisfied, dissatisfied and very dissatisfied. This measure was validated by the Swedish Joint Arthroplasty Registry and was subsequently adopted by the International Society of Arthroplasty Registries for assessing patient satisfaction after total joint arthroplasty in the study cohort. In this paper, 5% were satisfied with the total knee arthroplasty, whereas only 64.3% of surgeries met the CMS defined success for threshold. Furthermore, the better a patient's baseline function, the more likely that they were to be satisfied, but the less likely be successful. By the CMS definition, among surgeries in patients with high baseline Coos junior more than 60, 65.4% were deemed to have failed although only 11.7% of the baseline Coos junior scores were not satisfied. In marked contrast, among those with low baseline scores less than 40, just 16.7% of surgeries were deemed to have failed although 19.8 of the patients were not satisfied.
So satisfaction and surgical success 29% of satisfied patients underwent surgeries that were considered to have failed. Of the satisfied patients, less than 10% with low baseline scores were deemed to have undergone failed surgery compared with more than 60% with high baselines.
Predictors of surgical failure included age, lower health literacy, back pain for severe compared with none, pain in the contralateral knee, diabetes, mental health, and baseline coos junior score.
These study findings aligned with the CMS recognized factors for risk adjustment including back pain, pain in the contralateral knee health, literacy, diabetes, and poor mental health scores.
The study found that there is a significant discordance between patient satisfaction definition of surgical success 84% of patients reported satisfaction with surgery, but only 64% were deemed successful, the better the patient baseline function was more likely that they were to be satisfied and ironically more likely the surgery was considered to be a failure. Again by cmd, the authors make an astute observation that any binary outcome, success or failure obscures important details on how helpful surgery was. And while it's prudent to use patient reported outcome measures such as the Koos Jr. The 20 point absolute very different meaning for patients with low versus high baseline scores.
Others use minimally clinically important difference or the MCID or the patient acceptable symptom state which is acronym pass. But these are also dichotomous.
One of the main issues is the ceiling effect whereby patients with high pre op scores more than 60 or higher than a score of 60 failed because they improved by less than 20 points.
So essentially that's a successful operation, but it's not being deemed successful because they didn't achieve that they were so high to begin with at baseline.
So the authors reiterate their long term goal to improve total knee arthroplasty quality in the U.S. they suggest that these findings support critically reevaluating the CMS measure of success to develop a measure that accounts for baseline knee pain quality of life that will better align with satisfaction.
I thought this study had a very important premise and the findings are very impactful. The one issue I have from my vantage point working in a health safety net hospital where we have a very diverse patient population and those with significant disparities including socioeconomic vulnerabilities.
The patient population in this study was predominantly white and there was alignment with the factors used by CMS for risk adjustment. Conversely, in a more diverse patient population, determinants of health that contribute to functional outcomes and may need to be factored into the risk adjustment. So you know, they concluded that the risk adjustment factors are fine. But I would contend that that's not necessarily the case and they do need to consider social determinants of health in that also in populations where English is not the first language and where there are disparities social determinants of health, there are barriers to obtaining the survey completion. So there are validated instruments for Koos Jr. In Spanish and English, but beyond that there are no valid translations that can be a barrier in some of the social net health safety net hospitals as well as it is for us obtaining completion of the 50% requirement, 50% of patients need to be completing these can be very challenging.
Vulnerable hospitals at higher risk for penalties.
That's the world from my lens. But overall this paper gets two thumbs up for me on my end and the case is not on hold.
What are your thoughts, Andrew?
[00:33:08] Speaker A: Well, I have a little bit more of a nuanced perspective here and I recognize that I'm working from the privilege of not dealing with the stresses of the challenge arthroplasty on a daily basis. But we are seeing some of these things in spine as well, particularly with the new team roll out.
And so I'm going to say some things here that I think are are I I'm saying them as people think about these things. I don't want people to send hate mail to jb, JS or us and be like, you know, there's a trigger warning right off the bat like the things that I'm saying. I want to kind of put these out there as, as sort of kind of ideas and not necessarily this is exactly what I think or how I, I don't work for cms. I don't work for the federal government. And I don't plan to in any way, shape or form. But I, I, you know, I, I, I, I, I, I kind of want to just talk about these things from, from the perspective of a health policy or health econometric standpoint, which are areas that, that I spend a lot of time thinking about and have great deal of interest.
I think all this is fair. And from the standpoint of just what should you be factoring into account when deciding what's a success and what's a failure? I think from just the academic conversation, the author's 100%, nothing on hold there, lots of patience, great analytic approach. Great.
No problems on that front whatsoever.
But we have a new paradigm, it's called the tuition payment paradigm.
So, you know, it's like if we were working in a system where the patient shows up, they've got $20,000 in a bag, they hand the bag over or arthroplasty and you, and they figure out if it's been successful or not perfect. And you can educate them on, well, you know, we have scoring systems, but we're going to look at how you're doing and how you feel and what your perceptions are taken into account. And that's great. But the reality is in US health system today, and especially in this context, we're talking about cms, the patients really aren't paying for it. The system is paying for the majority of it in most situations. Right, right, right. Yeah. So the taxpayer is paying for it, the federal government is paying for it. And this is where the college tuition paradigm comes into play. And I think you'll like it. So we'll just pick on my, where I work, many aspersions. You know, the undergraduate tuition at Harvard is about $85,000 now or something to that effect.
And if my child comes to me and says, you know, I got into Harvard, we're going to pay $85,000 a year plus all the, like that.
And my major is going to be, you know, Byzantine emperors in the 14th century.
That's going to be my like, focus and I'm do this. And what are you going to do after?
Well, I'll just come home and live in the basement. That's my, I'm gonna, you know, this is important for me. I'm interested in this. It's gonna add value to my life and I'm just gonna, I'm probably not gonna be able to, like, you're just gonna have to keep paying for me after.
Like I'm just gonna be home and they might be very happy with that situation.
They might be like hey I got a BA from Harvard in Byzantine emperors in the 14th century and but I'm not happy with that.
Right.
I mean I think that's some of where like some of this conversation gets lost and a lot of these initiatives are there. There is a baked in component of value to society or value to the payer. And I think that is illustrated when we look at their factors, the subsection factors that predict surgical failure among satisfied patients. So here are the patients who they're satisfied but CMS saying this wasn't successful. So age plays into it, literacy plays into it which is some of the piece that you're bringing in. If they have back pain, if they have pain in the other knee, if they're diabetic, if they have mental health issues and their baseline performance status and this along with team and other things I think is, is intended to make the indications stricter. We want patients who are going to get the tone that not we but CMS wants patients who have the total knee replacements. They want them based and if they're not home runs it's for a valid like reason not.
And I think this gets at the scope of practice for some surgeons who are more liberal in their indications.
It gets at the desire amongst patients who when they have very little skin in the game if they're motivated for surgery and you're like well I'm not sure how good the outcome is going to be and they're like I don't care, I want this done, then you go ahead and do it but then it leads to downstream impacts and effects unnegligible especially in the CMS population.
So I do think that there is some of the intention here isn't just to set a benchmark that's purely objective success or failure but it's also we're trying to the margins of people who are going to be eligible because there are certain individuals who and if you elect to do that and you're able because through your skill and whatever you're able to take somebody who has a 85% chance of failure and get them success, well great, we'll pay for that. But if you can't, we're not going to eat the cost of you took a risk and it didn't play out when we all knew what the odds were of the success.
So when, when they're party entity that's paying for the things and it's a zero sum game and the writing is on the wall as far as where the health care economy is headed, it can't just be like, I'll tell you if it's.
Thanks. Just make sure you keep paying for the $85,000 tuition.
[00:39:54] Speaker B: Yeah. I mean, definitely. We have to keep that in mind. I am very conservative in my indications and I like to think that vast majority.
I read this in a slightly different light, but you do have to be careful on that.
It's not on our bill, it's on the patient's bill. We do have to be cost conscious, but I think what they're getting at is that there are people that are going to benefit from this operation that we're going to exclude from this if we in their terms and that there can be further refinement of how we define success and that they're missing the mark in some respects. Right, right.
[00:40:29] Speaker A: Yeah. And I agree that they're missing the mark in some respects, but I believe it's intentionally so. So you're. You're thing that they don't know through this.
[00:40:38] Speaker B: Right.
How much do they care?
[00:40:42] Speaker A: Right.
I mean, you know, it's a nameless, faceless bureaucratic entity. Like it's not designed to care, nor can it really.
Right.
[00:40:54] Speaker B: Okay.
[00:40:54] Speaker A: Food for thought. That's it. Don't act.
[00:40:57] Speaker B: I love it. That is. Yeah, I like it. Okay, so now we will move on to this paper is entitled. Mild lateral femoral condyle cartilage damage does not affect outcomes of medial unicompartmental knee arthroplasty. A mean six year follow up study by Du and colleagues.
The aim of the study was to ascertain cartilage damage of the lateral condyle of the femur influences midterm clinical outcomes and in medial unicompartmental knee arthroplasty and exacerbates the progression of arthritis in the lateral compartment.
Patients with normal cartilage or mild cartilage damage in the lateral femoral conduit grade less than 2 or equal to 2 underwent medial unicomartmental knee arthroplasty between March 2016 and December 2020 were retrospectively divided into four groups. A normal cartilage group and a cartilage damage group that was subdivided on the basis in the weight bearing area, the posterior weight bearing and the medial side of the lateral condyle.
Patients with postoperative overcorrection of limb alignment or preoperative lateral meniscus extrusion were excluded and outcomes were compared among the groups.
Hip knee angle, the lateral compartment or KL grade, the Oxford knee score the Forgotten joint score, the KAJALA score, Patient satisfaction and complications there were 203 knees in 177 patients, majority were female, 177 were East Asian and the mean age was 68 with a mean follow up of 70.8 months.
The post op Oxford knee Score, Forgotten Joint score and KAJALA score showed no significant differences among midterm full length standing radiographs of the lower limbs were obtained with a mean follow up of 54 months and of the 90 knees, 26 showed an increase of 1 KL grade in the lateral compartment and 73 remained unchanged. Three knees from the normal group experienced complications including one periprosthetic fracture, one bearing dislocation and one bearing rotation, but none required conversion to total knee arthroplasty. The authors concluded that in patients in whom post operative, overcorrected and preoperative lateral meniscus function is intact, mild cartilage damage that is outer bridge grade 1 or 2 of the lateral femoral condyle does not impact the midterm clinical results of medial unit compartmental knee arthroplasty and the progression of osteoarthritis in the lateral compartment okay, so there you have it. We now conclude episode 106 of your Cases on hold. If you like what you heard and you want to hear more of the top articles in jbjs, tune in and like and subscribe. Thank you for listening.
[00:43:51] Speaker A: Thanks everyone.
