Temporal Trends in Revision Total Hip and Knee Arthroplasty from 2008 to 2018: Gaps and Opportunities

Periprosthetic Joint Infection Mortality After Total Hip Arthroplasty is Comparable to 5-Year Rates of Common Cancers: A Meta-Analysis

BACKGROUND

Periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is a rare, but devastating complication with elevated morbidity and mortality. While associated with increased mortality, the reported range is broad and most often reported after 2-stage exchange arthroplasty. This study aimed to report the overall mortality after PJI following primary THA, PJI mortality at one, three, and 12 months, and mortality after common PJI treatments. We hypothesized that mortality after THA PJI would be high, increase over time, and be highest after a 2-stage exchange.

METHODS

A meta-analysis of articles from six databases, queried from inception to December 2023, was performed. Full-length articles reporting mortality following PJI after primary THA were included. Articles with oncologic, infectious, or traumatic THA indications were excluded. Articles investigating high-risk patient populations, including those who had solid organ transplants, active cancer diagnoses, and synchronous PJI, were excluded. There were two independent reviewers who reviewed articles. Mortality over time and after treatment (debridement, antibiotics, and implant retention [DAIR], 1- and 2-stage exchange arthroplasty) was collected. A meta-analysis of proportions with inverse-variance proportion models was constructed for overall mortality.

RESULTS

A total of 19,917 patients who had PJI after THA from 20 studies were included. Overall mortality was 11.0% (95% CI [confidence interval]: 5 to 18.8) at a mean follow-up of 40.3 months (range, one to 240). Pooled mortality at one, three, and 12 months was 1.1, 3.7, and 10.0%, respectively. Mortality following treatment with DAIR, 1-stage, and 2-stage exchange was 7.8% (95% CI: 2.3 to 15.9), 1.6% (95% CI: 0 to 14), and 9.2% (95% CI: 5.4 to 13.9), respectively. Considerable heterogeneity was present.

CONCLUSIONS

Mortality after THA PJI is high (11.0%) within three years of arthroplasty and comparable to 5-year rates of cancers such as breast (11%) and prostate (1%) cancers. A multidisciplinary approach, like those adopted in the treatment of cancer, is warranted to reduce the burden of this devastating complication.

Complications, Reoperations, and Readmissions After Common Arthroscopic Sports Medicine Procedures of the Knee: An Analysis of the ABOS Part II Oral Examination Case List Database

BACKGROUND

Arthroscopic knee surgeries are among the most commonly performed orthopaedic surgeries, yet complications of these procedures are relatively understudied.

PURPOSE

To determine the rate of complications, reoperations, and readmissions for arthroscopic knee surgeries by procedure, patient characteristics, and physician fellowship training status using a large national database.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Data were collected from the American Board of Orthopaedic Surgery (ABOS) database for early-career orthopaedic surgeons taking the ABOS Part II Oral Examination between 2003 and 2022. We queried the type and frequency of complications, unexpected 90-day reoperations, and readmissions for patients undergoing sports medicine knee arthroscopy. Chi-square test and analysis of variance were used to determine the effect of fellowship training status, geographic region of practice, patient age, and patient sex on outcomes of interest.

RESULTS

Of 138,823 knee arthroscopic procedures, 10,450 complications were self-reported, making for an overall complication rate of 7.53%. Unexpected 90-day reoperation and readmission rates were calculated to be 1.16% and 0.91%, respectively. Posterior cruciate ligament reconstruction had the highest complication rate (26.38%). Sports medicine fellowship-trained physicians had a significantly higher rate of complications (P < .001) compared with their non-sports medicine fellowship-trained peers (8.43% and 7.06%, respectively). Female patients had a higher complication rate (7.72%) than males (7.40%) (P = .02). Patients aged 20 to 29 had the highest rate of complications and reoperations (10.29% and 1.56%, respectively), whereas patients aged 70 to 79 had the highest rate of readmission (1.47%). Geographic regions of practice had significantly different complication and reoperation rates (P < .01). The rate of deep venous thrombus was 0.57%, and the rate of pulmonary embolism was 0.12%. Forty-two patients died, for an overall 0.03% mortality rate.

CONCLUSION

The overall rate of self-reported complications was 7.53%, and the 90-day rate of unexpected reoperation and unexpected readmission was 1.16% and 0.91%, respectively. Patient sex, patient age, sports medicine fellowship training status, and geographic region of practice all affected rates of complications, reoperations, and readmissions. Knee arthroscopy carries many risks of which patients should be aware before undergoing these procedures.

Neighborhood Socioeconomic Disadvantage is Associated With Increased Health Care Utilization After Septic and Aseptic Revision Total Hip Arthroplasty

BACKGROUND

A greater area deprivation index (ADI), a tool that gauges socioeconomic disadvantage at the neighborhood level, is associated with worse health care outcomes following primary total hip arthroplasty. However, its association with revision total hip arthroplasty (rTHA) is unknown. This study aimed to determine the association between ADI and rates of postoperative health care resource utilization following rTHA.

METHODS

A total of 996 patients who underwent rTHA between 2016 and 2022 were enrolled in a prospective study. The primary outcomes assessed were nonhome discharge disposition (DD), length of stay (LOS) ≥ three days, 90-day emergency department (ED) visits, and 90-day hospital readmissions. The ADI was calculated using the patient's home address at the time of surgery, with greater ADI indicating greater socioeconomic disadvantage. We evaluated the mediation effect of patient race on ADI and postoperative health care utilization using a multivariable logistic regression model.

RESULTS

A higher median ADI was revealed for patients who experienced nonhome discharge (P = 0.001), extended LOS (P < 0.001), and ED readmission within 90 days of surgery (P = 0.045). When comparing septic versus aseptic rTHA patients, there were significant differences in health care resource utilization but no difference in ADI between the two groups. For aseptic rTHA, ADI significantly mediated the effect of race on both nonhome DD and LOS ≥ 3 (41 and 46% mediation, respectively). In septic rTHA, ADI mediated 31.1% of the effect of race on nonhome DD, but showed minimal mediation effect on LOS. The mediation effect of ADI on ED admission and hospital readmission was minimal for both groups.

CONCLUSIONS

Higher ADI scores are associated with increased health care utilization after rTHA, including longer hospital stays and more nonhome discharges. The ADI significantly mediates the effect of race on these outcomes, particularly in aseptic rTHA cases, suggesting that neighborhood socioeconomic factors play a crucial role in previously observed racial disparities.

Trends and Epidemiology in Revision Total Hip Arthroplasty: A Large Database Study

BACKGROUND

The clinical and financial burden of revision total hip arthroplasty (rTHA) continues to grow. Therefore, further investigation is needed to characterize case volume, reason for failure, and postoperative complications. The purpose of this study was to characterize contemporary indications for and complications following rTHA.

METHODS

Patients undergoing rTHA between 2010 and 2021 were identified within the PearlDiver database. Adjusted rTHA incidence was calculated by dividing the annual rTHA volume by the annual primary total hip arthroplasty (THA) and multiplying by 100,000. Mann-Kendall trend tests were utilized to trend revision volume, etiology, and 90-day postoperative complications. A total of 225,958 rTHAs were identified.

RESULTS

The annual volume of rTHA did not change over the study period (18,871 to 15,994; P = 0.064). However, the adjusted incidence of rTHA significantly decreased (20,169.3 to 13,061.2 per 100,000 THAs; P < 0.001). The most common causes of rTHA were aseptic implant loosening (21.5%), instability (19.8%), and infection (19.1%). The adjusted incidences of revision due to infection (4,659.9 to 2,596.1 per 100,000 THAs; P < 0.001) and aseptic implant loosening (4,651.4 to 2,493.2 per 100,000 THAs; P < 0.001) decreased over time. The adjusted rate of instability (3,149.8 to 3,245.3 per 100,000 THAs; P = 0.304) did not change. Rates of post-revision deep vein thrombosis, hematoma, surgical site infection, and transfusion significantly decreased over the study period (P < 0.05), while rates of emergency department visits and readmission did not change.

CONCLUSIONS

In addition to a decreased adjusted incidence of rTHA, our analysis demonstrated a decreased incidence of infection, aseptic loosening, and various postoperative complications. However, no difference in the adjusted incidence of instability and periprosthetic fracture was seen over our study period. Continued study is necessary to further decrease the need for rTHA with a focus on the etiologies and complications that have remained unchanged.

Discharge Disposition after Total Hip Arthroplasty: A 10-Year Analysis of Trends and Predictors of Nonhome Discharge (2011-2021)

BACKGROUND

Total hip arthroplasty (THA) practices are evolving under the influence of the current value-based healthcare system and bundled payment models. This study aimed to (1) evaluate national trends in discharge disposition and postoperative outcomes after THA, (2) compare discharge cohorts on episode-of-care parameters, and (3) determine predictors of nonhome discharge from 2011 to 2021.

METHODS

The National Surgical Quality Improvement Program database was queried for THA data from 2011 to 2021. A total of 328,380 patients undergoing THA were identified between 2011 and 2021. Of these patients, 276,710 were discharged home and 51,670 were discharged to nonhome locations. Trends of annual discharge disposition, healthcare utilization parameters, and proxies for postoperative complications were reported. A multivariable logistic regression analysis was conducted to identify potential risk factors for nonhome discharge.

RESULTS

The percentage of patients who were discharged to home increased from 70.20% in 2011 to 92.42% in 2021. In those discharged to home, 30-day readmission rates, 30-day major complication rates, length of stay, any wound complications, and need for transfusion all decreased within the past decade. The percentage of patients who were discharged to nonhome locations decreased from 29.80% in 2011 to 7.58% in 2021. In this group, major complication rates within 30 days, length of stay, and need for mechanical ventilation increased from 2011 to 2021. Greater age, female sex, body mass index of <18.5, race, smoking, higher comorbidity burden, and functional status were associated with greater odds ratios of nonhome discharge.

CONCLUSION

Home discharge after THA has increased substantially over the past decade, with more than 90% of patients now being discharged home. However, a small subset of higher-risk patients still requires nonhome discharge and experience worse outcomes. Focused efforts based on known discharge risk factors may allow implementing perioperative optimization strategies to further improve outcomes in this population.

Distinct Care Needs and Episodes of Care: Comparing Medical versus Orthopaedic Readmissions after Elective Primary Total Knee Arthroplasty

Hospital readmissions after primary total knee arthroplasty (TKA) significantly drive health care expenditure and resource utilization. Recent studies have suggested differences between medical and orthopaedic readmissions after TKA and their episodes of care (EOCs) but lack patient-level data reporting. This study aimed to compare EOCs for medical and orthopaedic-related readmissions regarding initial readmission wards, services consulted, intensive care unit (ICU) admissions, blood transfusions, surgical interventions, length of stay, and discharge disposition.All patients enrolled in a prospective data collection system at a tertiary medical center undergoing elective, unilateral, primary TKA from 2016 to 2020 and readmitted within 90 days of discharge were included. Readmissions were categorized as related to medical or orthopaedic causes. Patients' electronic medical records were reviewed to collect demographic and clinical information about EOC associated with the readmission hospital course.In total, 82.4% (580/704) of 90-day readmissions after elective, primary TKA were related to medical causes, with the remaining 17.6% (124/704) of readmissions due to orthopaedic causes. Medical readmissions most often pertained to gastrointestinal complaints, while wound complications accounted for most orthopaedic readmissions. Most readmissions (63.1%, 444/704) occurred within the first 30 days after TKA. Patients with medical and orthopaedic readmissions had differences in EOC, such that more medical readmissions required ICU care (10.6 vs. 1.6%, p < 0.001), and more patients with orthopaedic readmissions needed a surgical intervention (65.4 vs. 6.7%, p < 0.001).By understanding differences in EOC for medical and orthopaedic readmissions after TKA, targeted initiatives can be developed to deliver more efficient, cost-effective orthopaedic surgical care, as the orthopaedic surgical community continues to provide value-based care.

Identifying Critical Evidence Gaps in Wound Closure and Incision Management After Total Knee Arthroplasty: Delphi Panel Insights

BACKGROUND

Effective surgical wound management in total knee arthroplasty (TKA) is crucial for optimal healing and patient outcomes. Despite surgical advances, managing wounds to prevent complications remains challenging. This study aimed to identify and address evidence gaps in TKA wound management, including preoperative optimization, intraoperative options, and postoperative complication avoidance. Addressing these issues is vital for patient recovery and surgical success.

METHODS

This study used the Delphi method with 20 experienced orthopedic surgeons from Europe and North America. Conducted from April to September 2023, the process involved three stages: an initial electronic survey, a virtual meeting, and a concluding electronic survey. The panel reviewed and reached a consensus on 26 statements about TKA wound management based on a comprehensive literature review. Additionally, the panel aimed to identify critical evidence gaps in wound management practices.

RESULTS

The panel achieved consensus on various wound management practices but highlighted significant evidence gaps. Consensus was reached on wound closure methods, including mesh-adhesive dressings, skin glue, staples, barbed sutures, and negative pressure wound therapy. However, further evidence is needed to address the cost-effectiveness of these methods and develop best practices for patient outcomes. Identifying these gaps highlights the need for more research to improve TKA wound care.

CONCLUSIONS

Identifying major evidence gaps underscores the need for targeted research in TKA wound management. Addressing these gaps is crucial for developing effective, efficient, and patient-friendly wound care strategies. Future research should focus on comparative effectiveness studies and developing guidelines for emerging technologies. Bridging these gaps could improve patient outcomes, reduce complications, and enhance TKA surgery success.

Femoral stem extraction devices

INTRODUCTION

As the number of primary total hip arthroplasty (THA) procedures continues to increase, so too does the demand for revision surgery, with a 43-70% rise in revision THA anticipated by 2030. Femoral stem extraction in revision THA is particularly challenging and may lead to complications like femoral bone loss or fractures. However, increasing catalogue of femoral stems available for primary and revision THA has led technological advances in extraction devices to potentially overcome these limitations. This review aims to discuss the identification of femoral implants and the various femoral stem extraction devices currently available.

METHODS

A scoping review of current literature was conducted to explore currently available femoral extraction devices. The devices not available in literature but used in clinical practice have also been included. This review focused on the technical components, advantages, and limitations of different femoral extraction tools, including osteotomes, reciprocating saws, high-speed burrs, trephines, and extraction systems like the Watson Extraction System, Exodus Revision Hip System, Shukla Hip Universal Stem Extraction System, and DePuy Synthes Extractors.

RESULTS

Identifying femoral implants is a critical step in preoperative planning to allow for appropriate equipment to be available during revision surgery. The present review highlights that no single extraction device is universally applicable. Tools like flexible osteotomes, burrs, and trephines offer versatility but may risk bone damage. Advanced systems like the Watson Extraction System and Shukla Hip Universal Stem Extraction System provide more precise extraction, reducing the likelihood of cortical perforations and decreasing operative time.

CONCLUSIONS

Efficient femoral stem extraction in rTHA is essential for managing complications and preserving bone stock. While traditional tools remain valuable, the development of specialized extraction systems offers improved precision and efficiency. Preoperative planning, including accurate implant identification, and the selection of appropriate extraction devices are crucial for successful outcomes in revision hip arthroplasty.

Genomic Insights into Host Susceptibility to Periprosthetic Joint Infections: A Comprehensive Literature Review

Periprosthetic joint infection (PJI) is a multifactorial disease, and the risk of contracting infection is determined by the complex interplays between environmental and host-related factors. While research has shown that certain individuals may have a genetic predisposition for PJI, the existing literature is scarce, and the heterogeneity in the assessed genes limits its clinical applicability. Our review on genetic susceptibility for PJI has the following two objectives: (1) Explore the potential risk of developing PJI based on specific genetic polymorphisms or allelic variations; and (2) Characterize the regulatory cascades involved in the risk of developing PJI. This review focused on clinical studies investigating the association between genetic mutations or variations with the development of PJI. The genes investigated in these studies included toll-like receptors and humoral pattern recognition molecules, cytokines, chemokines, mannose-binding lectin (MBL), bone metabolism molecules, and human leukocyte antigen. Among these genes, polymorphisms in IL-1, MBL, vitamin D receptors, HLA-C, and HLA-DQ might have a relevant impact on the development of PJI. The literature surrounding this topic is limited, but emerging transcriptomic and genome-wide association studies hold promise for identifying at-risk genes. This advancement could pave the way for incorporating genetic testing into preoperative risk stratification, enhancing personalized patient care.

Recognizing the Sex Disparity in Surgeons Performing Total Knee Arthroplasty

BACKGROUND

There is an unambiguous sex disparity in the field of orthopaedic surgery, with women making up only 7.4% of practicing orthopaedic surgeons in 2022. This study seeks to evaluate the sex distribution among orthopaedic surgeons engaged in primary total knee arthroplasty (TKA) between 2013 and 2020, as well as the procedural volume attributed to each provider.

METHODS

We retrospectively queried the Medicare dataset to quantify all physicians reporting orthopaedic surgery as their specialty and performing primary TKA from 2013 to 2020. Healthcare Common Procedure Coding System codes for primary TKA procedures were used to extract associated utilization and billing provider information. Trend analyses were performed with 2-sided correlated Mann-Kendall tests to evaluate trends in the number of surgeons by sex and the women-to-men surgeon ratio.

RESULTS

During the study period, 6,198 to 7,189 surgeons billed for primary TKA. Of this number, an average of 2% were women. The mean number of procedures billed for by men was 39.02/y (standard deviation: 34.54), and by women was 28.76/y (standard deviation: 20.62) (P < .001). There was no significant trend in the number of men or women surgeons who billed for primary TKA during the study period. Trend analysis of the women-to-men ratio demonstrated an increasing trend of statistical significance (P = .0187).

CONCLUSIONS

There was a significant upward trend in the women-to-men ratio of surgeons who billed for primary TKA. However, there remains a colossal gender gap, as women only made up 2.4% of surgeons who billed for the procedure. The current study raises awareness of the notable discrepancy in the average number of TKAs performed by women as compared to men. The orthopaedic community should aim to determine ways to increase the number of women arthroplasty surgeons along with the opportunities that women have to perform TKAs.

Diamond-like carbon (DLC) surface treatment decreases biofilm burden by S. aureus on titanium alloy in vitro- a pilot study

PURPOSE

Periprosthetic joint infection is a complication of total joint arthroplasty with treatment costs over $1.6 billion dollars per year in the US with high failure rates. Therefore, generation of coatings that can prevent infection is paramount. Diamond-like carbon (DLC) is an ideal coating for implants as they are wear-resistant, corrosion-resistant, inert, and have a low friction coefficient. The purpose of this study was to test the efficacy of DLC surface treatment in prevention of biofilm on titanium discs infected with Staphylococcus aureus in vitro.

METHODS

Titanium alloy discs (n = 4 non-coated and n = 4 DLC-coated) were infected with 5 × 105 colony-forming units (CFU) of S. aureus for 2 weeks then analysed via crystal violet and scanning electron microscopy (SEM).

RESULTS

Crystal violet analysis yielded differences in the appearance of biofilm on implant surface where DLC-coated had a clumpier appearance but no difference in biofilm quantification. Interestingly, this clumpy appearance did lead to differences in SEM biofilm coverage where significantly less biofilm coverage was found on DLC-coated discs (81.78% vs. 54.17%, p < 0.003).

CONCLUSION

DLC-coated titanium alloy implants may have preventative properties in S. aureus infection. Observing differences in biofilm coverage does warrant additional testing including CFU titration and biofilm kinetics with eventual use in an animal model of periprosthetic joint infection.

Revision Arthroplasty Among Medicare Patients in the United States - Arthroplasty Surgeons are Doing More for Less

BACKGROUND

Previously documented trends of major joint arthroplasty demonstrate increasing volume and decreasing reimbursement for primary total knee and total hip arthroplasty procedures. As such, the purpose of this study was to evaluate trends in revision knee and hip arthroplasty volume and true Medicare reimbursements to physicians.

METHODS

The publicly accessible Centers for Medicare and Medicaid files were evaluated. Data were retrieved from the Part B National Summary Data File and queried for revision knee and hip arthroplasty billed to Medicare from 2000 to 2021. The total charge submitted to Medicare, Medicare reimbursement, number of revision arthroplasty surgeries performed, and average reimbursement per surgery were collected for each year. All monetary data were adjusted for inflation to 2021 dollars.

RESULTS

There were 492,360 revision total knee arthroplasty surgeries and 424,163 revision hip arthroplasty procedures billed to Medicare from 2000 to 2021. Medicare was billed a total of $919,603,674.86 for revision knee and $862,979,761.57 for revision hip arthroplasty during that time. Medicare reimbursed physicians an average of $1,499.89 per knee revision and $1,603.32 per hip revision surgery. The total volume of revision knee arthroplasty increased by 9,380 (62%) and revision hip decreased by 1,743 (9%) from the year 2000 to 2021. However, there was a decrease of average reimbursement per procedure of more than 37% ($1,987.14 to 1,254) and 39% ($2,149.87 to 1,311.17), respectively.

CONCLUSIONS

Despite a notable increase in the volume of revision total knee and stagnant revision hip arthroplasty, total billings to and reimbursements from Medicare for these procedures have not changed markedly per year. Importantly, this means that physicians are conducting more of these high-impact procedures yearly, while being reimbursed per procedure at a declining rate. This may indicate a need to re-assess billing and reimbursement rates for revision arthroplasty, in the context of the ever-increasing inflation rate.

The Mark Coventry Award: PhotothermAA Gel Combined With Debridement, Antibiotics, and Implant Retention Significantly Decreases Implant Biofilm Burden and Soft-Tissue Infection in a Rabbit Model of Knee Periprosthetic Joint Infection

BACKGROUND

Chronic periprosthetic joint infection (PJI) is a major complication of total joint arthroplasty. The underlying pathogenesis often involves the formation of bacterial biofilm that protects the pathogen from both host immune responses and antibiotics. The gold standard treatment requires implant removal, a procedure that carries associated morbidity and mortality risks. Strategies to preserve the implant while treating PJI are desperately needed. Our group has developed an anti-biofilm treatment, PhotothermAA gel, which has shown complete eradication of 2-week-old mature biofilm in vitro. In this study, we tested the anti-biofilm efficacy and safety of PhotothermAA in vivo when combined with debridement, antibiotics and implant retention (DAIR) in a rabbit model of knee PJI.

METHODS

New Zealand white rabbits (n = 21) underwent knee joint arthrotomy, titanium tibial implant insertion, and inoculation with Xen36 (bioluminescent Staphylococcus aureus) after capsule closure. At 2 weeks, rabbits underwent sham surgery (n = 6), DAIR (n = 6), or PhotothermAA with DAIR (n = 9) and were sacrificed 2 weeks later to measure implant biofilm burden, soft-tissue infection, and tissue necrosis.

RESULTS

The combination of anti-biofilm PhotothermAA with DAIR significantly decreased implant biofilm coverage via scanning electron microscopy compared to DAIR alone (1.8 versus 81.0%; P < .0001). Periprosthetic soft-tissue cultures were significantly decreased in the PhotothermAA with DAIR treatment group (log reduction: Sham 1.6, DAIR 2.0, combination 5.6; P < .0001). Treatment-associated necrosis was absent via gross histology of tissue adjacent to the treatment area (P = .715).

CONCLUSIONS

The addition of an anti-biofilm solution like PhotothermAA as a supplement to current treatments that allow implant retention may prove useful in PJI treatment.

High Risk of Readmission After THA Regardless of Functional Status in Patients Discharged to Skilled Nursing Facility

BACKGROUND

The postoperative period and subsequent discharge planning are critical in our continued efforts to decrease the risk of complications after THA. Patients discharged to skilled nursing facilities (SNFs) have consistently exhibited higher readmission rates compared with those discharged to home healthcare. This elevated risk has been attributed to several factors but whether readmission is associated with patient functional status is not known.

QUESTIONS/PURPOSES

After controlling for relevant confounding variables (functional status, age, gender, caregiver support available at home, diagnosis [osteoarthritis (OA) versus non-OA], Charlson comorbidity index [CCI], the Area Deprivation Index [ADI], and insurance), are the odds of 30- and 90-day hospital readmission greater among patients initially discharged to SNFs than among those treated with home healthcare after THA?

METHODS

This was a retrospective, comparative study of patients undergoing THA at any of 11 hospitals in a single, large, academic healthcare system between 2017 and 2022 who were discharged to an SNF or home healthcare. During this period, 13,262 patients were included. Patients discharged to SNFs were older (73 ± 11 years versus 65 ± 11 years; p < 0.001), less independent at hospital discharge (6-click score: 16 ± 3.2 versus 22 ± 2.3; p < 0.001), more were women (71% [1279 of 1796] versus 56% [6447 of 11,466]; p < 0.001), insured by Medicare (83% [1497 of 1796] versus 52% [5974 of 11,466]; p < 0.001), living in areas with greater deprivation (30% [533 of 1796] versus 19% [2229 of 11,466]; p < 0.001), and had less assistance available from at-home caregivers (29% [527 of 1796] versus 57% [6484 of 11,466]; p < 0.001). The primary outcomes assessed in this study were 30- and 90-day hospital readmissions. Although the system automatically flags readmissions occurring within 90 days at the various facilities in the overall healthcare system, readmissions occurring outside the system would not be captured. Therefore, we were not able to account for potential differential rates of readmission to external healthcare systems between the groups. However, given the large size and broad geographic coverage of the healthcare system analyzed, we expect the readmissions data captured to be representative of the study population. The focus on a single healthcare system also ensures consistency in readmission identification and reporting across subjects. We evaluated the association between discharge disposition (home healthcare versus SNF) and readmission. Covariates evaluated included age, gender, primary payer, primary diagnosis, CCI, ADI, the availability of at-home caregivers for the patient, and the Activity Measure for Post-Acute Care (AM-PAC) 6-clicks basic mobility score in the hospital. The adjusted relative risk (ARR) of readmission within 30 and 90 days of discharge to SNF (versus home healthcare) was estimated using modified Poisson regression models.

RESULTS

After adjusting for the 6-clicks mobility score, age, gender, ADI, OA versus non-OA, living environment, CCI, and insurance, patients discharged to an SNF were more likely to be readmitted within 30 and 90 days compared with home healthcare after THA (ARR 1.46 [95% CI 1.01 to 2.13]; p= 0.046 and ARR 1.57 [95% CI 1.23 to 2.01]; p < 0.001, respectively).

CONCLUSION

Patients discharged to SNFs after THA had a slightly higher likelihood of hospital readmission within 30 and 90 days compared with those discharged with home healthcare. This difference persisted even after adjusting for relevant factors like functional status, home support, and social determinants of health. These results indicate that for suitable patients, direct home discharge may be a safer and more cost-effective option than SNFs. Clinicians should carefully consider these risks and benefits when making postoperative discharge plans. Policymakers could consider incentives and reforms to improve care transitions and coordination across settings. Further research using robust methods is needed to clarify the reasons for higher SNF readmission rates. Detailed analysis of patient complexity, care processes, and causes of readmission in SNFs versus home health could identify areas for quality improvement. Prospective cohorts or randomized trials would allow stronger conclusions about cause-and-effect. Importantly, no patients should be unfairly "cherry-picked" or "lemon-dropped" based only on readmission risk scores. With proper support and care coordination, even complex patients can have good outcomes. The goal should be providing excellent rehabilitation for all, while continuously improving quality, safety, and value across settings.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Knotless suture in revision total joint arthroplasty: a prospective randomized controlled trial

INTRODUCTION

The use of barbed sutures for wound closure in primary total joint arthroplasty (TJA) has been shown to be effective and safe. However, their effectiveness and safety in revision TJA procedures has not been thoroughly studied. This study aims to evaluate the efficacy and safety of using barbed suture closure in revision TJA setting.

METHODS

A total of 80 patients undergoing revision TJA between September 2020 and November 2022 were included in this randomized controlled trial study. Following informed consent, patients were computer-randomized to the treatment arm (barbed suture wound closure) or to the control arm (conventional wound closure). Closure duration, closure rate, number of sutures used and wound related outcomes including complication rates and Patient and Observer Scar Assessment Scale (POSAS) score were compared between groups.

RESULTS

The use of barbed sutures decreased closure time by 6 min (30.1 vs. 36.1 min, P = 0.008) with a higher wound closure rate (6.5 vs. 5.5 mm/minute, P = 0.013). Additionally, the number of sutures used for wound closure in the barbed group was significantly lower than in the control group (6.2 vs. 10.1, respectively, P < 0.001). There were no significant differences in the rate of postoperative wound complications (P = 0.556) or patient and observer POSAS scores (P = 0.211, P = 297, respectively) between the two groups at 3-month follow-up.

CONCLUSION

Closure of revision TJA surgical wound utilizing barbed sutures reduced closure time and the number of needles handled by operative staff, with no significant increase in intra- or post-operative complications rate when compared to traditional closure technique.

LEVEL OF EVIDENCE

I.

Comparing outcomes in revision total hip arthroplasty in inpatient versus outpatient setting: a matched cohort analysis

BACKGROUND

As the population ages, revision total hip arthroplasty (rTHA) is becoming more common. However, there is a paucity of literature regarding perioperative outcomes following inpatient versus outpatient rTHA. Our study aims to compare perioperative complications and readmission rates associated with rTHA in a large national cohort.

METHODS

A retrospective, propensity-matched cohort study was conducted using the National Surgical Quality Improvement Program database from 2006 to 2020. Patients undergoing rTHA in the inpatient setting were propensity matched to patients receiving rTHA in the outpatient setting. Following 1:1 matching, multivariate analyses were performed to compare perioperative complications and readmission.

RESULTS

A total of 207,102 patients were identified, including 181,164 outpatient primary THA, 25,466 inpatient rTHA, and 492 outpatient rTHA patients. Following propensity matching, outpatient primary THA versus outpatient rTHA had 210 patients and inpatient rTHA versus outpatient rTHA had 214 patients. Patients in the outpatient rTHA had a significantly higher operative time (132.4 ± 73.2 versus 90.9 ± 32.7, p < 0.001) and length of stay (1.6 ± 1.6 vs. 0.9 ± 1.0, p < 0.001) compared to outpatient primary THA. When comparing inpatient versus outpatient rTHA, the outpatient cohort had lower operative time (131.1 ± 70.9 vs. 145.4 ± 71.5, p = 0.038), total length of stay (1.7 ± 1.8 vs. 3.6 ± 4.1, p < 0.001), and bleeding complications (6% vs. 18%, p < 0.001).

CONCLUSION

There were no difference in the odds of complications between outpatient primary and revision THA. Additionally, rTHA performed in an outpatient setting did not show any increase in immediate compared to inpatient settings. These findings suggest that rTHA can be safely performed on certain patients.

International Delphi Study on Wound Closure and Dressing Management in Joint Arthroplasty: Part 1: Total Knee Arthroplasty

BACKGROUND

The purpose of this modified Delphi study was to obtain consensus on wound closure and dressing management in total knee arthroplasty (TKA).

METHODS

The Delphi panel included 20 orthopaedic surgeons from Europe and North America. There were 26 statements identified using a targeted literature review. Consensus was developed for the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of ≥ 75% was required for consensus.

RESULTS

All 26 statements achieved consensus after three rounds of anonymous voting. Wound closure-related interventions that were recommended for use in TKA included: 1) closing in semi-flexion versus extension (superior range of motion); 2) using aspirin for venous thromboembolism prophylaxis over other agents (reduces wound complications); 3) barbed sutures over non-barbed sutures (lower wound complications, better cosmetic appearances, shorter closing times, and overall cost savings); 4) mesh-adhesives over other skin closure methods (lower wound complications, higher patient satisfaction scores, lower rates of readmission); 5) silver-impregnated dressings over standard dressings (lower wound complications, decreased infections, fewer dressing changes); 6) in high-risk patients, negative pressure wound therapy over other dressings (lower wound complications, decreased reoperations, fewer dressing changes); and 7) using triclosan-coated over non-antimicrobial-coated sutures (lower risks of surgical site infection).

CONCLUSIONS

Using a modified Delphi approach, the panel achieved consensus on 26 statements pertaining to wound closure and dressing management in TKA. This study forms the basis for identifying critical evidence supported by clinical practice for wound management to help reduce variability, advance standardization, and ultimately improve outcomes during TKA. The results presented here can serve as the foundation for knowledge, education, and improved clinical outcomes for surgeons performing TKAs.

Are All Patients Going Home after Total Knee Arthroplasty? A Temporal Analysis of Discharge Trends and Predictors of Nonhome Discharge (2011-2020)

Value-based orthopaedic surgery and reimbursement changes for total knee arthroplasty (TKA) are potential factors shaping arthroplasty practice nationwide. This study aimed to evaluate (1) trends in discharge disposition (home vs nonhome discharge), (2) episode-of-care outcomes for home and nonhome discharge cohorts, and (3) predictors of nonhome discharge among patients undergoing TKA from 2011 to 2020. The National Surgical Quality Improvement Program database was reviewed for all primary TKAs from 2011 to 2020. A total of 462,858 patients were identified and grouped into home discharge (n = 378,771) and nonhome discharge (n = 84,087) cohorts. The primary outcome was the annual rate of home/nonhome discharges. Secondary outcomes included trends in health care utilization parameters, readmissions, and complications. Multivariable logistic regression analyses were performed to evaluate factors associated with nonhome discharge. Overall, 82% were discharged home, and 18% were discharged to a nonhome facility. Home discharge rates increased from 65.5% in 2011 to 94% in 2020. Nonhome discharge rates decreased from 34.5% in 2011 to 6% in 2020. Thirty-day readmissions decreased from 3.2 to 2.4% for the home discharge cohort but increased from 5.6 to 6.1% for the nonhome discharge cohort. Female sex, Asian or Black race, Hispanic ethnicity, American Society of Anesthesiology (ASA) class > II, Charlson comorbidity index scores > 0, smoking, dependent functional status, and age > 60 years were associated with higher odds of nonhome discharge. Over the last decade, there has been a major shift to home discharge after TKA. Future work is needed to further assess if perioperative interventions may have a positive effect in decreasing adverse outcomes in nonhome discharge patients.

International Delphi Study on Wound Closure and Incision Management in Joint Arthroplasty Part 2: Total Hip Arthroplasty

BACKGROUND

This modified Delphi study aimed to develop a consensus on optimal wound closure and incision management strategies for total hip arthroplasty (THA). Given the critical nature of wound care and incision management in influencing patient outcomes, this study sought to synthesize evidence-based best practices for wound care in THA procedures.

METHODS

An international panel of 20 orthopedic surgeons from Europe, Canada, and the United States evaluated a targeted literature review of 18 statements (14 specific to THA and 4 related to both THA and total knee arthroplasty). There were 3 rounds of anonymous voting per topic using a modified 5-point Likert scale with a predetermined consensus threshold of ≥ 75% agreement necessary for a statement to be accepted.

RESULTS

After 3 rounds of voting, consensus was achieved for all 18 statements. Notable recommendations for THA wound management included (1) the use of barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); (2) the use of subcuticular sutures over skin staples (lower risk of superficial infections and higher patient preferences, but longer closing times); (3) the use of mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); (4) for at-risk patients, the use of negative pressure wound therapy over other dressings (lower wound complications and reoperations, as well as fewer dressing changes); and (5) the use of triclosan-coated sutures (lower risk of surgical site infection) over standard sutures.

CONCLUSIONS

Through a structured modified Delphi approach, a panel of 20 orthopedic surgeons reached consensus on all 18 statements pertaining to wound closure and incision management in THA. This study provides a foundational framework for establishing evidence-based best practices, aiming to reduce variability in patient outcomes and to enhance the overall quality of care in THA procedures.

Team Approach: Bone Health Optimization in Orthopaedic Surgery

» Bone health optimization (BHO) has become an increasingly important consideration in orthopaedic surgery because deterioration of bone tissue and low bone density are associated with poor outcomes after orthopaedic surgeries.» Management of patients with compromised bone health requires numerous healthcare professionals including orthopaedic surgeons, primary care physicians, nutritionists, and metabolic bone specialists in endocrinology, rheumatology, or obstetrics and gynecology. Therefore, achieving optimal bone health before orthopaedic surgery necessitates a collaborative and synchronized effort among healthcare professionals.» Patients with poor bone health are often asymptomatic and may present to the orthopaedic surgeon for reasons other than poor bone health. Therefore, it is imperative to recognize risk factors such as old age, female sex, and low body mass index, which predispose to decreased bone density.» Workup of suspected poor bone health entails bone density evaluation. For patients without dual-energy x-ray absorptiometry (DXA) scan results within the past 2 years, perform DXA scan in all women aged 65 years and older, all men aged 70 years and older, and women younger than 65 years or men younger than 70 years with concurrent risk factors for poor bone health. All women and men presenting with a fracture secondary to low-energy trauma should receive DXA scan and bone health workup; for fractures secondary to high-energy trauma, perform DXA scan and further workup in women aged 65 years and older and men aged 70 years and older.» Failure to recognize and treat poor bone health can result in poor surgical outcomes including implant failure, periprosthetic infection, and nonunion after fracture fixation. However, collaborative healthcare teams can create personalized care plans involving nutritional supplements, antiresorptive or anabolic treatment, and weight-bearing exercise programs, resulting in BHO before surgery. Ultimately, this coordinated approach can enhance the success rate of surgical interventions, minimize complications, and improve patients' overall quality of life.

Diagnosis, Treatment, and Outcomes of Crystalline Arthropathy in the Setting of Total Knee Arthroplasty: A Critical Analysis Review

» Emerging evidence suggests the prevalence of crystalline arthropathy (CA) in the setting of total knee arthroplasty (TKA) is increasing, and diagnosis of CA is often intricate because of symptom overlap with other common postoperative complications such as periprosthetic joint infection (PJI). Consequently, an accurate and timely diagnosis becomes pivotal in guiding the choice of treatment.» CA includes gout and calcium pyrophosphate deposition (CPPD) disease, and accurate diagnosis in patients with prior TKA requires a multifaceted approach. The diagnosis algorithm plays a critical role in determining the appropriate treatment approach.» Management of CA typically involves a conservative strategy, encompassing the administration of nonsteroidal anti-inflammatory drugs, colchicine, and steroids, regardless of whether patients have undergone prior TKA.» There is conflicting evidence on the effect CA has on the surgical outcomes in postoperative TKA patients. While these patients may expect excellent functional outcomes and pain relief, they may be at a higher risk of complications such as infections, medical complications, and revision procedures.» Additional research is required to fully comprehend the impact of CA on postoperative TKA outcomes and to establish effective strategies for enhancing patient care and optimizing long-term joint function.

Tibial Bushing Wear at 28 Years of Follow-up After Rotating-Hinge Distal Femoral Replacement: A Case Report

CASE

A 58-year-old woman presented with swelling, stiffness, and pain of the right knee 28 years after rotating-hinge distal femoral replacement after osteosarcoma resection. She underwent revision. There was wear through the entire thickness of the polyethylene tibial sleeve bushing, and the implant was well-fixed. The knee was reassembled with new bushings, sleeves, yoke, axle, poly, and a locking pin.

CONCLUSION

This is the first described case of tibial sleeve bushing wear. It highlights the importance of early detection of potential complications and implant surveillance because it can enable surgeons to intervene with minor procedures, avoiding eventual catastrophic failure.

Hip Abductor Reconstruction with the Use of Mesh and Distal Cerclage Cable Fixation: A Case Report and Surgical Technique

CASE

This is a case of a 71-year-old female patient with recurrent instability and complex hip abductor deficiency after total hip arthroplasty (THA) who was treated successfully with an abductor reconstruction with gluteal transfer with mesh reconstruction. The patient returned to nonassisted ambulation with no further THA dislocations at the 1-year follow-up.

CONCLUSION

Abductor deficiencies after THA are complex and have a high potential for long-term disability if not properly diagnosed and treated. A modified gluteal transfer with mesh reconstruction and distal fixation with cerclage cable allowed for sustained restoration of functional hip abduction and stability after revision THA.

[Patient optimization before hip revision arthroplasty: : How to handle comorbidities]

Preoperative optimization of the therapeutic regime of comorbidities can lead to an improvement of the postoperative outcome and has the potential to reduce the financial burden on the health care system in revision hip arthroplasty. Patient-related factors and an increasing incidence of comorbidities lead to a higher risk of implant failure and revision for all causes. Important and potentially modifiable risk factors like preoperative anemia, coagulopathy, infectious disease (dental status, urinary tract infections, colonization with staphylococcus), metabolic conditions (obesity, malnutrition, diabetes mellitus, osteoporosis), and smoking need to be addressed. To achieve an optimal preoperative condition a multidisciplinary approach should be applied.