BackgroundWith bundled payments and alternative reimbursement models expanding in scope and scale, reimbursements to hospitals are declining in value. As a result, cost reduction at the hospital level is paramount for the sustainability of profitable inpatient arthroplasty practices. Although multiple prior studies have investigated cost variation in arthroplasty surgery, it is unknown whether contemporary inpatient arthroplasty practices benefit from economies of scale after accounting for hospital characteristics and patient selection factors. Quantifying the independent effects of volume-based cost variation may be important for guiding future value-based health reform.Questions/purposesWe performed this study to (1) determine whether the cost incurred by hospitals for performing primary inpatient THA and TKA is independently associated with hospital volume and (2) establish whether length of stay and discharge to home are associated with hospital volume.MethodsThe primary data source for this study was the Medicare Provider Analysis and Review Limited Data Set, which includes claims data for 100% of inpatient Medicare hospitalizations. We included patients undergoing primary elective inpatient THA and TKA in 2019. Exclusion criteria included non–Inpatient Prospective Payment System hospitalizations, nonelective admissions, bilateral procedures, and patients with cancer of the pelvis or lower extremities. A total of 500,658 arthroplasties were performed across 2762 hospitals for 492,262 Medicare beneficiaries during the study period; 59% (288,909 of 492,262) of procedures were analyzed after the exclusion criteria were applied. Most exclusions (37% [182,733 of 492,262]) were because of non–Inpatient Prospective Payment System hospitalizations. Among the study group, 87% (251,996 of 288,909) of procedures were in patients who were 65 to 84 years old, 88% (255,415 of 288,909) were performed in patients who were White, and 63% (180,688 of 288,909) were in patients who were women. Elixhauser comorbidities and van Walraven indices were calculated as measures of patient health status. Hospital costs were estimated by multiplying cost-to-charge ratios obtained from the 2019 Impact File by total hospital charges. This methodology enabled us to use the large Medicare Provider Analysis and Review database, which helped decrease the influence of random cost variation through the law of large numbers. Hospital volumes were calculated by stratifying claims by national provider identification number and counting the number of claims per national provider identification number. The data were then grouped into bins of increasing hospital volume to more easily compare larger-volume and smaller-volume centers. The relationship between hospital costs and volume was analyzed using univariable and multivariable generalized linear models. Results are reported as exponential coefficients, which can be interpreted as relative differences in cost. The impact of surgical volume on length of stay and discharge to home was assesse...

Background The implications of two-stage revision on mental health are poorly understood. The purpose of this study is to determine (1) whether patients undergoing two-stage revision total hip and knee arthroplasty for prosthetic joint infection were more likely to get Patient-Reported Outcomes Measurement Information System (PROMIS) Depression scores consistent with major depressive disorder (MDD) than those undergoing aseptic revision and (2) whether these symptoms resolved after the procedure. Methods Records of all 366 patients that underwent revision total hip or knee arthroplasty from January 1, 2015, – June 20, 2019, were reviewed. Forty-two patients were excluded for missing PROMIS Depression scores or incomplete treatment. Preoperative (<3 months), early postoperative (2-8 weeks), and final postoperative (6-18 months) Depression scores were collected. Patients crossing the PROMIS Depression threshold equivalent to a Patient Health Questionnaire-9 score ≥10, indicative of MDD, were evaluated. Results More two-stage revision patients developed Depression scores indicative of MDD perioperatively than the aseptic cohort (20.0% vs 6.5%, P = .01). Two-stage revision patients had higher (worse) median Depression scores preoperatively (54.8 vs 51.3, P = .04) and at early follow-up (54.3 vs 49.9, P = .01), but not at final follow-up (50.4 vs 49.1, P = .39). Across all patients, Depression scores improved by 2.4 points at early follow-up (95% confidence interval:1.1–3.7; P < .001) and 3 points at final follow-up (95% confidence interval:1.5-4.5; P < .001; minimal clinically important difference 3.0). Conclusions Twenty percent of two-stage revision arthroplasty patients, compared to <7% of aseptic revision patients, developed PROMIS Depression scores consistent with MDD during treatment. At final follow-up, a clinically significant improvement in Depression scores from baseline was evident in both cohorts.

BackgroundAlthough economic stability, social context, and healthcare access are well-known social determinants of health associated with more challenging recovery after traumatic injury, little is known about how these factors differ by mechanism of injury. Our team sought to use the results of social determinants of health screenings to better understand the population that engaged with psychosocial support services after traumatic musculoskeletal injury and fill a gap in our understanding of patient-reported social health needs.Question/purposeWhat is the relationship between social determinants of health and traumatic musculoskeletal injury?MethodsTrauma recovery services is a psychosocial support program at our institution that offers patients and their family members resources such as professional coaching, peer mentorship, post-traumatic stress disorder screening and treatment, educational resources, and more. This team engages with any patient admitted to, treated at, and released from our institution. Their primary engagement population is individuals with traumatic injury, although not exclusively. Between January 2019 and October 2021, the trauma recovery services team interacted with 6036 patients. Of those who engaged with this service, we considered only patients who experienced a traumatic musculoskeletal injury and had a completed social determinants of health screening tool. During the stated timeframe, 13% (814 of 6036) of patients engaged with trauma recovery services and had a complete social determinants of health screening tool. Of these, 53% (428 of 814) had no physical injury. A further 26% (99 of 386) were excluded because they did not have traumatic musculoskeletal injuries, leaving 4.8% (287) for analysis in this cross-sectional study. The study population included patients who interacted with trauma recovery services at our institution after a traumatic orthopaedic injury that occurred between January 2019 and October 2021. Social determinants of health risk screening questionnaires were self-administered prospectively using a screening tool developed by our institution based on Centers for Medicare and Medicaid Services social determinants of health screening questions. Mechanisms of injury were separated into intentional (physical assault, sexual assault, gunshot wound, or stabbing) and unintentional (fall, motor vehicle collision, or motorcycle crash). During the study period, 287 adult patients interacted with trauma recovery services after a traumatic musculoskeletal injury and had complete social determinant of health screening; 123 injuries were unintentional and 164 were intentional. Patients were primarily women (55% [159 of 287]), single (73% [209 of 287]), and insured by Medicaid or Medicare (78% [225 of 287]). Mechanism category was determined after a thorough medical record review to verify the appropriate category. An initial exploratory univariate analysis was completed for the primary outcome variable using the Pearson chi-squared test for categorical variables a...

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Granular cell tumors (GrCT) were recently found to be driven by inactivating mutations in vacuolar H+-ATPase (V-ATPase) genes, most frequently ATP6AP1 and ATP6AP2. Multifocal presentation is present in ~10% of cases; however, the relationship between multifocal tumors in a given patient has not been elucidated. We hypothesized that benign-appearing multifocal GrCT are molecularly distinct whereas paired primary and metastatic malignant GrCT share identical mutations. To test this, we conducted targeted next-generation sequencing of the V-ATPase genes in multifocal GrCT and whole exome and Sanger sequencing in paired primary and metastatic malignant GrCT. Thirteen patients with≥2 GrCT were identified (total of 43 tumors). Forty-two tumors were successfully sequenced. Tumors showed somatic mutations in 3 of the 10 targeted genes in 32 of 42 samples (76%). Twenty tumors showed mutations in ATP6AP1 (48%), 10 tumors had mutations in ATP6AP2 (24%), and 2 tumors showed mutations in ATP6V0A4 (5%). Predicted loss-of-function mutations were found in ATP6AP1 in 17 tumors (40%), in ATP6AP2 in 10 tumors (24%), and in ATP6V0A4 in 1 tumor (2%). In 8 patients, mutually exclusive mutations were detected in at least 2 tumors per patient. Two patients were identified with malignant GrCT with material available from both primary and metastatic sites. Identical frameshift insertions were found in ATP6AP1 in 1 case and the second case showed identical nonsense mutations in ATP6AP1. In conclusion, multifocal GrCT within an individual patient are molecularly distinct, while paired primary and metastatic GrCT share identical mutations.

Granular cell tumors are mesenchymal neoplasms of presumed schwannian differentiation that may present as solitary or multifocal lesions with excision usually being curative. A minority of cases, however, shows histological features associated with an increased risk for metastasis and are highly aggressive leading to death in about a third of cases 1 . While benign and malignant cases have been shown to harbor mutations in the H + ATPase genes, there is only limited data examining molecular aberrations associated with malignancy. The departmental archives were searched for cases of atypical/malignant granular cell tumor. Clinical and histopathological features were noted. Whole exome sequencing was performed. Three cases of malignant granular cell tumor and on atypical granular cell tumor were included. Three tumors metastasized to distant sites with a median disease-free survival of 16 months and an overall follow-up time of 32.5 months. Whole exome sequencing showed mutations involving TGFβ and MAPK pathways in all four tumors. Mutations involving the TGFβ and MAPK pathways may be associated with tumor progression or malignant transformation in granular cell tumor pathogenesis.

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