Background Alternative payment models, such as the Centers for Medicare & Medicaid Services (CMS) Bundled Payment for Care Improvement (BPCI) initiative, aim to decrease overall costs for hip and knee arthroplasties. Questions/purposes We asked: (1) Is there any difference in the CMS episode-of-care costs, hospital length of stay, and readmission rate from before and after implementation of our bundled-payment program? (2) Is there any difference in reimbursements and resource utilization between revision THA and TKA at our institution? (3) Are there any independent risk factors for patients with high costs who may not be appropriate for a bundled-payment system for revision total joint arthroplasty (TJA)? Methods Between October 2013 and March 2015, 218 patients underwent revision TKA or THA in one health system. Two hundred seventeen patients were reviewed as part of this study, and one patient with hemophilia was excluded from the analysis as an outlier. Our institution began a BPCI program for revision TJA during this study period. Patients' procedures done before January 1, 2014 at one hospital and January 1, 2015 at another hospital were not included in the bundled-care arrangement (70 revision TKAs and 56 revision THAs), whereas 50 revision TKAs and 41 revision THAs were performed under the BPCI initiative. Patient demographics, medical comorbidities, episode-of-care reimbursement data derived directly from CMS, length of stay, and readmission proportions were compared between the bundled and nonbundled groups. Results Length of stay in the group that underwent surgery before the bundled-care arrangement was longer than for patients whose procedures were done under the BPCI (mean 4.02 [SD, 3.0

Looft-Wilson RC, Ashley BS, Billig JE, Wolfert MR, Ambrecht LA, Bearden SE. Chronic diet-induced hyperhomocysteinemia impairs eNOS regulation in mouse mesenteric arteries. Am J Physiol Regul Integr Comp Physiol 295: R59 -R66, 2008. First published April 30, 2008 doi:10.1152/ajpregu.00833.2007.-Hyperhomocysteinemia (HHcy) impairs endothelium-dependent vasodilation by increasing reactive oxygen species, thereby reducing nitric oxide (NO ⅐ ) bioavailability. It is unclear whether reduced expression or function of the enzyme that produces NO ⅐ , endothelial nitric oxide synthase (eNOS), also contributes. It is also unclear whether resistance vessels that utilize both NO ⅐ and non-NO ⅐ vasodilatory mechanisms, undergo alteration of non-NO ⅐ mechanisms in this condition. We tested these hypotheses in male C57BL/6 mice with chronic HHcy induced by 6-wk high methionine/low-B vitamin feeding (Hcy: 89.2 Ϯ 49.0 M) compared with age-matched controls (Hcy: 6.6 Ϯ 1.9 M), using first-order mesenteric arteries. Dilation to ACh (10 Ϫ9 -10 Ϫ4 M) was measured in isolated, cannulated, and pressurized (75 mmHg) arteries with and without N G -nitro-L-arginine methyl ester (L-NAME) (10 Ϫ4 M) and/or indomethacin (10 Ϫ5 M) to test endothelium-dependent dilation and non-NO ⅐ -dependent dilation, respectively. The time course of dilation to ACh (10 Ϫ4 M) was examined to compare the initial transient dilation due to non-NO ⅐ , non-prostacyclin mechanism and the sustained dilation due to NO ⅐ . These experiments indicated that endothelium-dependent dilation was attenuated (P Ͻ 0.05) in HHcy arteries due to downregulation of only NO ⅐ -dependent dilation. Western blot analysis indicated significantly less (P Ͻ 0.05) basal eNOS and phospho-S1179-eNOS/eNOS in mesenteric arteries from HHcy mice but no difference in phospho-T495-eNOS/eNOS. S1179 eNOS phosphorylation was also significantly less in these arteries when stimulated with ACh ex vivo or in situ. Real-time PCR indicated no difference in eNOS mRNA levels. In conclusion, chronic dietinduced HHcy in mice impairs eNOS protein expression and phosphorylation at S1179, coincident with impaired NO ⅐ -dependent dilation, which implicates dysfunction in eNOS post-transcriptional regulation in the impaired endothelium-dependent vasodilation and microvascular disease that is common with HHcy.

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The use of metal-on-metal (MoM) bearings in total hip arthroplasty (THA) was popularized due to its enhanced wear profile and the ability to use large femoral heads to reduce post-operative instability. However, enthusiasm for the bearing declined following serious complications encountered at the primary articulation. This review discusses the development of MoM and the subsequent unexpected downstream challenges, most notably elevated serum metal ion levels, aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL), pseudotumor formation, and subsequent soft tissue and bone destruction. Both patient centered risk factors as well as component design led to high early failure rates resulting in product recalls and an overall decline in the use of MoM. In 2016, there is not a role for large-head MoM bearing in THA. Alternatively, the bearing has shown promise in hip resurfacing procedures for carefully selected patients.

Background: Defining the appropriate threshold at which to initiate a fever workup is imperative to promote patient safety, appropriate resource utilization, and antibiotic stewardship. Our group performed a systematic review of the available literature on perioperative fever (POF) workups in orthopaedic patients to evaluate the frequency, timing and utility of blood cultures (BC) and other investigations in the POF workup, to determine the clinical relevance of any infections and to evaluate their cost effectiveness. Methods: Studies were identified by searching MEDLINE, EMBASE, Pubmed, Cochrane and Google Scholar for articles through September 2016. Forty-nine articles were retrieved and 22 articles met the pre-determined inclusion criteria. Proportions of positive studies were noted and averaged using random effects analysis. Results: Post-operative pyrexia ranged in prevalence between 8.1% and 87.3%. The studies routinely performed during a fever workup had wide ranges of diagnostic yield, including chest X-rays from 0% to 40%, urinalyses from 8.2% to 38.7%, urine cultures from 0% to 22.4% and BC from 0% to 13.3%. Only two patients with positive BC developed clinical sepsis. Cost per fever evaluation ranged from $350 to $950. Conclusion: The findings of this review suggest that early post-operative fever is an expected event following orthopaedic surgery. Based on the available literature, any kind of workup in the absence of localizing symptoms in the third post-operative day or before is unwarranted and is an inappropriate use of hospital resources.