The Arthroplasty Surgeon Growth Indicator: A Tool for Monitoring Supply and Demand Trends in the Orthopaedic Surgeon Workforce from 2020 to 2050

Total Hip Surgical Approach Efficiency Outside of Surgical Time in the Ambulatory Surgical Center

BACKGROUND

Rising demand for total hip arthroplasty (THA) in ambulatory surgery centers (ASCs) requires improved efficiency, considering varying surgical approach time requirements, to manage caseloads and ensure safe same-day discharge (SDD). This study examines care phase durations, SDD success and delays, and outcomes, including 90-day complication rates and 1-year patient-reported outcomes (PROs).

METHODS

A retrospective review of primary THA patients at a single ASC (January 2019 to January 2021) was conducted. Data on demographics, phase-of-care times, perioperative outcomes, 90-day complications, and PROs were stratified by surgical approach. Comparison was done using 2-tailed t-test and Fisher exact test. Stepwise regression controlled for age, gender, body mass index, assistive device use, class attendance, American Society of Anesthesia score, Charlson comorbidity index, and diagnosis.

RESULTS

Groups differed in age, BMI, assistive device use, class attendance, and preoperative Veterans Rand 12-Item Health Survey physical component scores. The direct anterior approach (DAA) and posterior approach (PA) cohorts showed significant differences in phase-of-care times, except for spinal-time, and total-physical therapy (PT)-time-in-postanesthesia care unit (PACU). DAA was faster in spinal-start-to-incision-time (26.8 versus 35.0; P < 0.001), set-up/take-down-time (20.5 versus 30.2; P < 0.001), operative time (OR; 37.5 versus 50.4; P < 0.001), total operating room time (57.8 versus 80.5; P < 0.001), and arrival-to-discharge-time (383.8 versus 418.4; P < 0.001). PA was faster in time-to-initiation-of-PT (46.3 versus 71.4; P < 0.001), PACU-arrival-to-PT-cleared-time (124.9 versus 144.3; P < 0.001), and total-PACU-time (127.8 versus 143.4; P < 0.001). Surgical approach, age, BMI, and preoperative assistive device use predicted time differences. Excessive spinal was the main cause of PT delays. No differences in 90-day complications or PROs were observed.

CONCLUSIONS

DAA showed shorter total OR and arrival-to-discharge-times compared to PA, with similar complications and PROs. Both approaches effectively achieved SDD. Operative and set-up/take-down-time drove DAA efficiency, but PT initiation was delayed due to standard spinal blocks with shorter OR times.

How to Manage Intraoperative Complications During Primary Total Knee Arthroplasty

BACKGROUND

Intraoperative complications are ideally prevented altogether, but are nevertheless an inherent and unavoidable risk in primary total knee arthroplasty (TKA).

METHODS

/Results: This article provides a review of a symposium on primary TKA intraoperative complications that was presented at the American Association of Hip and Knee Surgeons (AAHKS) 2024 Annual Meeting. The following four intraoperative complications were reviewed: 1) medial collateral ligament (MCL) injury; 2) neurovascular injury; 3) extensor mechanism injury; and 4) periprosthetic fracture.

CONCLUSION

As the nationwide and per-surgeon volume of primary TKA continues to increase, it is imperative for arthroplasty surgeons to be prepared to prevent, identify, and manage intraoperative complications during primary TKA.

Automatic Impactors in Total Hip Arthroplasty: A State-of-the-Art Review

BACKGROUND

Total hip arthroplasty (THA) is an increasingly common procedure that places considerable physical strain on orthopaedic surgeons over time. The procedure requires precise impaction for optimal implant fixation and long-term stability. Automated impactors have emerged as innovative tools to address the limitations of manual mallets, with efforts to improve surgeons' physical health, surgical efficiency, and patient outcomes. This review evaluates the specifications, clinical applications, ergonomic benefits, and occupational hazards such as noise of commercially available automated impactors, including KINCISE, Woodpecker, HAMMR, and orthodrive. This is compared to existing literature on the devices and supplemented with independent noise measurements. It aimed to provide actionable insights to guide device selection based on clinical scenarios and operating room needs.

METHODS

A systematic PubMed search (2013 to 2024) identified 147 relevant articles after excluding studies on impaction grafting and trauma. Product specifications and noise data were supplemented with patent information and manufacturer details. Noise mitigation strategies and ergonomic considerations were also explored. Sound levels of three of the discussed impactors were measured to supplement this review.

RESULTS

Automated impactors demonstrated significant reductions in femoral broaching time, improved consistency, and reduced surgeon fatigue compared to manual methods. Periprosthetic fracture risk was equal to or less than that of manual broaching. Each impactor exhibited unique strengths: KINCISE offered versatility, Woodpecker precision, HAMMR adjustability, and orthodrive the lowest noise production of the devices measured. However, trade-offs compared to the traditional mallet included cost, learning curves, and limited versatility in some devices. Time-weighted average (TWA) noise levels ranged from 57.37 to 67.47 dBA across devices, with maximum levels ranging from 101.2 to 107.3 dBA, remaining below the Occupational Safety and Health Administration TWA 85 dBA threshold and the World Health Organization (WHO) maximum threshold of 110 dBA.

CONCLUSIONS

Automated impactors enhance procedural efficiency and ergonomics in THA, but device selection should be tailored to specific surgical and institutional needs. Noise levels were similar across devices, though close to the WHO maximum threshold. Future research should focus on long-term patient outcomes and standardizing testing protocols for these devices.

Medicare Reimbursement for Primary and Revision Total Hip and Knee Arthroplasty: An Updated Analysis From 2000 to 2024

BACKGROUND

With physician reimbursements for primary and revision total hip (THA) and knee arthroplasty (TKA) remaining central to health care policy and payment reforms, an updated analysis of inflation-adjusted Medicare surgeon fees for these procedures is essential. Examining recent payment trends offers valuable insights for surgeons, payers, and health care policymakers to understand the evolving reimbursement landscape. This study aimed to analyze physician reimbursement trends for THA and TKA from 2000 to 2024.

METHODS

The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried to extract reimbursement data from 2000 to 2024 for primary THA and TKA and both-component revision TKA and THA. Utilizing the consumer price index, all monetary data were reported in 2024 United States dollars to account for inflation. For each procedure, both unadjusted and inflation-adjusted mean annual reimbursement rates, mean annualized percent change and total percent change, in reimbursement were calculated.

RESULTS

Between 2000 and 2024, the mean reimbursement decreased by 56% for primary THA and TKA and decreased by 51% for revision THA and TKA. The largest decrease in reimbursement was seen for primary TKA, with a decrease of 57% in inflation-adjusted dollars, while the smallest decrease was revision TKA, which decreased by 50%. The mean reduction in inflation-adjusted Medicare reimbursement for all procedures examined was 53%. For all procedures, the mean adjusted annualized reimbursement rate for all procedures decreased by 2% per year.

CONCLUSIONS

Physician reimbursement rates for both primary and revision THA and TKA procedures have declined substantially since 2000. These updated reimbursement models demonstrate that compensation needs to be adjusted, at the minimum with inflation, to accurately reflect the services rendered and resources employed by surgeons to maintain equitable access for all patients.

LEVEL OF EVIDENCE

IV.

Aseptic Revision Total Knee Arthroplasty in Octogenarians: A Matched Cohort Comparison of Early Clinical Outcomes

BACKGROUND

With increasing volume and life expectancy of patients undergoing total knee arthroplasty (TKA), the incidence of octogenarian patients requiring revision TKA (rTKA) will similarly rise. There remains limited evidence regarding the safety of revision procedures in octogenarians who may carry an increased risk of medical and surgical complications. Therefore, the purpose of our analysis was to evaluate early clinical outcomes following rTKA in patients aged ≥ 80 years compared with younger matched controls.

METHODS

Patients who underwent aseptic all-component rTKA between 2010 and 2020 at a multiple-surgeon, single-site institution were reviewed. Patients aged ≥ 80 years were matched to cohorts of patients aged ≥ 40 to 59 years and ≥ 60 to 79 years undergoing rTKA based on sex, American Society of Anesthesiologists score, and body mass index. Multivariate regression analysis of 90-day postoperative medical and surgical complications, controlling for comorbidity burden, smoking status, and revision etiology, was conducted. A total of 210 patients (n = 70 per cohort) were evaluated.

RESULTS

There were no differences between octogenarians and younger patients for medical (odds ratio [OR]: 0.32; 95% confidence interval [CI]: 0.053 to 1.91; P = 0.2), surgical (OR: 1.61, 95% CI: 0.42 to 6.19; P = 0.5), and overall complications (OR: 0.52, 95% CI: 0.17 to 1.60; P = 0.3) at 90 days. Octogenarians had a statistically lower risk of reoperation relative to younger controls (OR: 0.22, 95% CI: 0.054 to 0.85; P = 0.03).

CONCLUSIONS

Octogenarians undergoing rTKA had comparable early postoperative clinical outcomes compared to younger matched controls. These findings suggest that appropriately indicated octogenarians requiring all-component rTKA may safely undergo these procedures. Adult reconstruction surgeons must consider both age and comorbidity burden when counseling these patients regarding the risks associated with revision surgery.

Medicare Reimbursement Trends for Common Hip Arthroplasty Procedures: A Generational Perspective, 2006 to 2024

BACKGROUND

This study aimed to assess the trends in Medicare reimbursement for common hip arthroplasty procedures from 2006 to 2024.

METHODS

This study analyzed data from the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule from 2006 to 2024 to identify payment trends for the most common orthopaedic procedures related to hip arthroplasty. The study calculated Medicare reimbursement by multiplying relative value units by a Centers for Medicare & Medicaid Services-determined conversion factor and adjusted reimbursement rates for inflation to 2024 U.S. dollars using the Consumer Price Index inflation calculator from the U.S. Department of Labor. Projections for future trends were derived from mean values from 2020 to 2024, with data visualizations created in Microsoft Excel.

RESULTS

From 2006 to 2024, total reimbursements for medical procedures dropped by 0.1%, while the Consumer Price Index increased by 55%. This caused the average reimbursement to fall by 35.5%. The biggest decrease was in primary total hip arthroplasty reimbursement, which fell by 40.7%. Additionally, the unadjusted work reimbursement rate for all procedures went down by 6.1%, resulting in a substantial inflation-adjusted decrease of 39.4%. If these trends continue, projections for 2029 suggest an additional projected decline in surgeon reimbursement of 33 to 42%, and work reimbursements could drop by 40 to 50%.

CONCLUSIONS

From 2006 to 2024, inflation-adjusted Medicare reimbursement for hip arthroplasty has dropped markedly, challenging orthopaedic practices' sustainability. This may lead health care providers to see more patients, risking burnout and affecting patient outcomes. Compensation for orthopaedic surgeons should reflect the patient value added. However, this study demonstrates a progressive decrease in physician reimbursement, which could lead to an unneeded financial burden on orthopaedic practices. The focus should be on advocating for better reimbursement policies to maintain practice integrity rather than just increasing patient volume.

Assessment of 90-Day Outcomes Following Total Joint Arthroplasty in Ambulatory Surgery Centers, Hospital Outpatient Departments, and Hospitals: A Michigan Arthroplasty Registry Collaborative Quality Initiative Analysis

Background

Total joint arthroplasty is shifting from hospitals to ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs). A Michigan Arthroplasty Registry Quality Collaborative Initiative quality improvement project examined readmissions, emergency room (ER) visits, periprosthetic joint infection (PJI), fracture, and dislocation after primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) across sites.

Methods

Primary TJAs between July 1, 2021, and June 30, 2022 (N = 41,696: 3910 ASC, 1,834 HOPD, and 35,952 hospital) were reviewed. Of 17,100 THAs, 9.5% (1,631) were at ASCs, 4.7% (798) at HOPDs, and 85.8% (14,671) at hospitals. Of 24,596 TKAs, 9.3% (2,279) were at ASC, 4.2% (1,036) at HOPDs, and 86.5% (21,281) at hospitals. Hospitals treated more elderly, women, non-White, obese, diabetics, smokers, and governmental insurance.

Results

For THAs, ASCs had the lowest 30-day (ASC 1%, HOPD 1.8%, hospital 3.4%, P < .001) and 90-day (ASC 1.7%, HOPD 3.4%, hospital 5.5%, P < .001) readmissions, 30-day ER visits (ASC 1.8%, HOPD 3.5%, hospital 5.3%, P < .001), and fractures (ASC 0.4%, HOPD 0.6%, hospital 1.2%, P < .001). Similar trends were observed for TKAs: 30-day readmissions (ASC 1.3%, HOPD 1.4%, hospital 3.1%, P < .001), 90-day readmissions (ASC 2.2%, HOPD 2.3%, hospital 5.2%, P < .001), and 30-day ER visits (ASC 3%, HOPD 6.5%, hospital 6.4%, P < .001). PJI (THA: P = .1, TKA: P = .6) and dislocation rates (P = .5) were similar across sites.

Conclusions

Patients receiving primary total joint arthroplasty at an ASC had the least postoperative hospital-based care despite similar rates of PJI and dislocation.

Factors Influencing Growth in Gender Diversity Within Orthopaedic Surgery

INTRODUCTION

Despite increasing numbers of female medical students, there is low female representation in orthopaedic residencies across the globe. It is unknown whether female representation in orthopaedics is lower than other specialties and whether regional presence relates to patient population or residency positions.

METHODS

The provider directory from the United States Centers for Medicare and Medicaid Services was reviewed from 2018 to 2023. Data for eight specialty subgroups (anesthesia, family medicine, gastroenterology, general surgery, internal medicine, obstetrics/gynecology, orthopaedics, and urology) were examined and grouped according to regions depicted by the Electronic Residency Application Service.

RESULTS

The mean percentage of female orthopaedic Centers for Medicare and Medicaid Services providers increased 1.49% over the 6-year period, at a markedly lower rate compared with general surgery (3.7%, P = 0.018) and obstetrics and gynecology (4.7%, P = 0.012). It was also lower compared with gastroenterology (3.73%), family medicine (3.52%), urology (3.10%), internal medicine (1.82%), and anesthesia (1.66%). Pacific-West and South-Atlantic regions demonstrated the greatest increase in representation. The number of female orthopaedic surgeons and growth in all orthopaedic surgeons in a state correlated with increased representation, whereas residency positions and patient population did not. Graduation year was 6 years later for female versus male students.

DISCUSSION

This study demonstrated a statistically significantly lower rate of change in female representation within orthopaedics compared with other specialties. Presence of practicing female orthopaedic surgeons was associated with growth in certain geographic regions. Future work should investigate factors associated with regional growth if specialties seek to move toward sex representation that reflects the United States population.

Neighborhood Socioeconomic Disadvantage May Influence 1-Year Patient-Reported Outcome Measures After Total Hip Arthroplasty

BACKGROUND

The impact of socioeconomic status on achievement of clinically relevant patient-reported outcome measure (PROM) improvements and satisfaction after total hip arthroplasty (THA) is unknown. Area Deprivation Index (ADI) is a metric that can be used as a proxy for a patient's neighborhood socioeconomic status. This study aimed to assess the association between ADI and failure to achieve: (1) clinically relevant improvements in PROMs; and (2) self-reported satisfaction at 1 year following THA.

METHODS

A prospective cohort of 7,506 patients who underwent primary unilateral THA from January 2016 to July 2021 was included. The ADI was stratified into quintiles based on their distribution in our sample. Multivariable logistic regression models were created to investigate the effect of ADI on 1-year PROMs. The included PROMs were the Hip Disability and Osteoarthritis Outcome Score (HOOS) Pain, Physical Function Shortform (PS), and Joint Replacement (JR). Clinically relevant improvements were assessed through minimal clinically important difference and patient acceptable symptom state threshold achievement.

RESULTS

There was no significant association between ADI and failure to achieve minimal clinically important difference for HOOS pain (P = 0.42), PS (P = 0.91), or JR (P = 0.20). However, higher ADI scores were independently associated with increased odds of failing to achieve patient acceptable symptom state for HOOS Pain (P = 0.002), PS (P = 0.003), and JR (P = 0.017). The ADI was not associated with failure to achieve patient satisfaction at 1 year (P = 0.93).

CONCLUSIONS

Greater neighborhood socioeconomic disadvantage was associated with decreased odds of achieving clinically relevant improvement in patient-perceived symptomatic state, but not associated with patients' perception of their overall pain and function 1 year after THA. Targeted interventions to address access and care pathways for low socioeconomic status patients may present an opportunity to improve patient-perceived outcomes following THA.

LEVEL OF EVIDENCE

Level III.

Multimodal Analgesia and Small Opioid Prescriptions are the New Standard in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership

BACKGROUND

The purpose of this survey study was to assess the current analgesia and anesthesia practices used by total joint arthroplasty surgeon members of the American Association of Hip and Knee Surgeons (AAHKS) as well as identify changes in practice made by AAHKS members over time.

METHODS

A survey of 37 questions was created and approved by the AAHKS Research Committee. The survey was distributed to all 3,243 practicing adult reconstruction surgeon members of AAHKS in May 2023. Results were compared to a nearly identical survey sent out to all board-certified adult reconstruction surgeon members of AAHKS 5 years previously in November 2018.

RESULTS

There were 527 responses (16%) to the survey. Since 2018, the mean number of opioid pills prescribed after total joint arthroplasty has declined significantly from 49 to 32 pills after total knee arthroplasty (TKA) and from 44 to 18 pills after total hip arthroplasty (THA). The use of multimodal analgesics in addition to opioids has also increased over the past 5 years from 74 to 93%. The most common medications utilized include nonsteroidal anti-inflammatories (98%), acetaminophen (80%), and gabapentinoids (32%). A majority of surgeons (78%) still use a spinal for TKA and THA. However, there has been an increase in the number of surgeons using peripheral nerve blocks for TKA from 69% in 2018 to 84% in 2023. The routine use of periarticular injection or local infiltration anesthesia in THA and TKA has also increased over the past 5 years from 80 to 86%.

CONCLUSIONS

Since 2018, there has been increased adoption of multimodal analgesia and anesthesia, and improved consensus regarding the optimal regimen among surveyed arthroplasty surgeon members of AAHKS. The number of opioid pills prescribed after THA and TKA has declined significantly over the past 5 years.

Medical Causes Account for 75% of Readmissions After Primary Total Hip Arthroplasty: Differences in Episodes of Care

BACKGROUND

Recent reports have suggested that readmissions due to medical or orthopaedic surgical causes after total hip arthroplasty (THA) differ regarding risk factors and cost. Further work is needed to elucidate explanations for cost differences to develop targeted initiatives for improved quality of care and health care utilization surrounding THA. This study aimed to determine differences in episodes of care (EOC) between patients readmitted within 90 days of THA for medical and orthopaedic causes.

METHODS

The study included all patients who underwent elective, unilateral, primary THA at a tertiary medical center from 2016 to 2020 and were subsequently readmitted within 90 days. Readmissions were classified as related to medical or orthopaedic surgical causes. Demographic and clinical information related to the EOC for the readmission hospital stay was collected.

RESULTS

The 90-day readmission rate after THA was 5.6% (502 of 8,893 patients), with 75.1% (377 of 502) related to medical causes and 24.9% (125 of 502) related to orthopaedic causes. The EOC between the two groups differed in several ways. Patients readmitted for medical causes more frequently required intensive care unit admissions (12.0 versus 4.9%, P = 0.024), while a larger proportion of patients who had orthopaedic-related readmissions required blood product transfusions (36.3 versus 12.0%, P < 0.001), minimally invasive procedures (34.4 versus 18.9%, P < 0.001), and surgical interventions (79.2 versus 7.2%, P < 0.001).

CONCLUSIONS

Understanding differences in readmission EOC related to medical and orthopaedic causes after THA can help optimize health care allocation strategies and inform targeted quality improvement initiatives. As the demand for THA grows and reimbursement declines, insights into the predominance of medical readmissions and key differences in EOC are crucial for enhancing the quality and cost-effectiveness of THA care delivery models.

Validation of a Novel Landmark-guided Intra-articular Postero-medial Surgeon-administered Injection Technique

Background

This study aimed to define an intra-articular surgeon-administered technique that may be comparable to ultrasound (US)-guided adductor canal block (ACB).

Methods

Five cadaver lower limbs were examined. An anesthesiologist administered a US-guided ACB using 20 mL of dilute indocyanine dye. An orthopedic surgeon performed a medial parapatellar arthrotomy and introduced an 18-gauge needle 1-2 cm proximal to the palpated adductor tubercle angled posteromedially. Needle position and dye spread were fluoroscopically documented.

Results

This technique consistently reached the infrapatellar branch of the saphenous nerve, nerve to the vastus medialis muscle, and posterior capsule, with minimal proximal dye spread.

Conclusions

This technique may be an efficient complement to ACB or surgeon infiltration or an alternative to US-guided ACB when it is not available.

Justification of Body Mass Index cutoffs for hip and knee joint arthroplasty among California orthopedic surgeons

BACKGROUND

Many orthopedic surgeons choose not to perform joint arthroplasty on patients with a Body Mass Index (BMI) of 35 or above, citing poorer outcomes and increased procedure risk. Identifying and addressing factors surgeons use to determine procedure BMI cutoffs are necessary to increase access to orthopaedic care for this growing patient population. This will help reduce healthcare disparities while also identifying clinical facilities, equipment, training, and procedures that require improvements to accommodate larger individuals.

METHODS

Orthopaedic surgeons were surveyed to identify surgeon-specific BMI cutoffs for hip and knee arthroplasty. The survey was circulated within the California Orthopaedic Association (COA) report during March 2023. Questions aimed to identify BMI cutoffs and justifications such as infection risk, co-morbidities, inadequate equipment, and the American Academy of Orthopaedic Surgeons (AAOS) guidelines. Data on decision making about BMI cutoffs and exceptions were also collected.

RESULTS

75% of respondents use BMI cutoffs for hip and knee arthroplasty. 91% of respondents indicated they are either wholly or partially responsible for setting procedure BMI cutoffs. Mean hip and knee arthroplasty BMI cutoffs were 40.5 and 41, respectively. Four categories for BMI cutoff justifications were identified: (1) risk of complications; (2) surgery logistics; (3) concerns about facilities or resources; and (4) surgeon perception.

CONCLUSIONS

BMI-based justifications for denial of care define key addressable areas of improvement that can increase access to care for life-changing orthopaedic surgeries such as THA and TKA. Insight from the queried surgeons will help drive future research areas to address this need.

Utilization of Total Knee Arthroplasty in the United States by Settlement Type: Is There Equity of Access?

INTRODUCTION

Total knee arthroplasty (TKA) is one of the most commonly performed orthopaedic surgeries in the United States, yet little information exists regarding its utilization in different settlement types. This study aimed to determine the number of TKA-performing surgeons by settlement type and assess trends in the volume of TKAs in urban, micropolitan, small town, and rural settings.

METHODS

Using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners database, the number of orthopaedic surgeons performing primary and revision TKAs from 2013 to 2020 was determined. The zip code where TKA was performed was used to identify the rural-urban commuting area codes (RUCA) and classify locations into one of four settlement types: urban/metropolitan, micropolitan (large town), small town, or rural. Correlations in surgeon number and TKA volume by settlement type were evaluated by Mann-Kendall tests.

RESULTS

Between the years of 2013 and 2020, TKAs were billed by up to 7,192 orthopaedic surgeons. The proportions of TKAs occurring in settlement types were the following: urban/metropolitan, 85.2%; micropolitan, 11.5%; small town, 2.6%; rural, 0.6%. Areas without RUCA data had 32.9 TKAs per surgeon per year, the highest overall median surgeries per year over the 8-year period. The median number of TKAs per surgeon per year was 28, 25.4, 21.4, and 20.7 for urban/metropolitan, micropolitan, small towns, and rural areas, respectively.

CONCLUSION

A considerable difference exists in both the number of surgeons and the proportion of TKAs conducted across various settlement types. Twenty percent of population in the United States lives in rural areas; however, only 0.6% of billed TKAs occurred in these areas over the study period, indicating a gap in orthopaedic care access. It is imperative to understand TKA surgeon distribution and focus on strategies aimed at attracting and retaining proficient surgeons to address the healthcare needs of these underserved regions.

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.

Trends in Payments for Ambulatory Surgery Center Facility Fees and Surgeon Professional Fees for Hip and Knee Arthroplasty

BACKGROUND

Ambulatory surgery centers (ASCs) have been shown to deliver high-quality care to patients at major cost savings to the health care system. The objective of this investigation was to examine trends in the Medicare facility and surgeon professional fee payments for hip and knee arthroplasty.

METHODS

Publicly available Medicare data were analyzed to determine professional and facility fee payments for unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), and total hip arthroplasty (THA) to ASCs and hospitals between 2018 and 2024. The Physician Fee Schedule Lookup Tool and the Medicare ASC payment rate files were used to determine professional fee payments and facility fee reimbursements, respectively. Descriptive statistics were used to calculate means and percent change over time. The compound annual growth rates were calculated.

RESULTS

After adjusting for inflation, Medicare professional fees declined significantly over the study period for UKA ($1,487.44 versus $1,147.50; P = 0.003), TKA ($1,738.99 versus $1,278.59; P = 0.003), and THA ($1,740.73 versus $1,280.52; P = 0.003). Medicare ASC facility fees also declined, albeit to a lesser degree for UKA ($9,007.62 versus $8,905.71; P = 0.764), TKA ($10,204.46 versus $9,048.76; P = 0.027), and THA ($9,982.66 versus $9,238.05; P = 0.308). Facility fee reimbursement decreased year over year, with annual percent change ranging from -0.19% for UKA to -2.49% for THA. Trends in Medicare hospital facility fees directly mirrored ASC facility fees over the study period. Professional fees also declined year over year, with annual percent changes ranging from -3.81% for UKA to -4.41% for TKA and THA.

CONCLUSIONS

The ASC facility fees and professional fees both declined over the study period, with declines in professional fees far outpacing those of facility fees. Urgent reform of the Medicare payment structure is needed to ensure orthopaedic practice solvency and access to high-quality care for beneficiaries.

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.

Effects of elevated body mass index on the success of total knee and total hip arthroplasty: a comprehensive overview

INTRODUCTION

The average body mass index (BMI) in the United States has tripled over the last five decades despite concerted population-based efforts for weight management. Elevated BMI and, in particular, obesity are risk factors for osteoarthritis. This trend has led to increased demands for total knee (TKA) and total hip arthroplasty (THA), necessitating an in-depth understanding of how elevated BMI impacts TKA and THA.

AREAS COVERED

This paper reviews the literature investigating the effects of elevated BMI, primarily obesity, on TKA and THA, focusing on preoperative, intraoperative, and postoperative considerations. It describes the associated risks, economic implications, and ethical considerations of patients with high BMIs undergoing TKA or THA. To ensure all relevant literature was included, Ovid Medline and Google Scholar databases were searched for the following terms, 'body mass index,' 'obesity,' 'knee,' 'hip,' and 'arthroplasty' for articles published from January 2019 through July 2024.

EXPERT OPINION

Despite the challenges of high BMI in TKA and THA, a deeper understanding of obesity as a chronic illness, coupled with advances in surgical techniques, can improve patient outcomes. A multidisciplinary approach and further research will optimize the care of patients with elevated BMIs undergoing total joint arthroplasty (TJA).

Stepping up recovery: integrating patient reported outcome measures and wearable technology for 90-day rehabilitation following total hip arthroplasty

INTRODUCTION

There is conflicting data in the literature regarding the clinical utility of wearable devices. This study examined the association between patient reported outcome measures (PROMs) and step and stair flight counts obtained from wearable devices in postoperative total hip arthroplasty (THA) patients.

METHODS

Data was collected from a multicenter prospective longitudinal cohort study from October 2018 to February 2022. A smartphone-based platform with smartwatch was utilized for collection of daily step and stair flight counts. Subjects (N = 1644) completed the Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) and numerical rating scale (NRS) pain scores preoperatively and at 1 and 3 months postoperatively. Patients who reported living in a multi-level home (N = 931) were included in analysis of stair flight counts. Pearson correlation coefficients were calculated to determine correlations between step and stair flight counts with NRS pain and HOOS JR scores.

RESULTS

Step counts demonstrated a weak negative correlation to NRS pain scores at preoperative (r = - 0.15, p < 0.0001), 1-month (r = - 0.15, p < 0.0001), and 3-months follow-up (r = - 0.06, p = 0.05). Step counts demonstrated a weak positive correlation with HOOS JR scores at preoperative (r = 0.16, p < 0.0001), 1-month (r = 0.15, p < 0.0001), and 3-months (r = 0.13, p < 0.0001). Stair flight counts demonstrated a weak negative correlation with NRS pain preoperatively (r = - 0.19, p < 0.0001) and at 1-month (r = - 0.11, p = 0.003). Stair flight counts positively correlated with HOOS JR scores at preoperative (r = 0.24, p < 0.0001), 1-month (r = 0.15, p < 0.0001), and 3-months (r = 0.09, p = 0.02).

CONCLUSION

The utilization of wearable technology can enhance the evaluation of patient outcomes after THA, primarily due to the observed correlation between data collected from wearables and PROMs. Our study highlights the importance of the use of objective data, in addition to subjective patient reported data, when analyzing postoperative patient progress, which propels forward the field of postoperative THA patient care.

Trends in Gender Diversity Among Total Hip Arthroplasty Surgeons

INTRODUCTION

A pronounced gender imbalance is evident among orthopaedic surgeons. In the field of arthroplasty, there exists a dearth of comprehensive data regarding gender representation. This study aimed to analyze the gender diversity, or lack thereof, within the field of total hip arthroplasty (THA). In addition, this study used literature review to identify possible reasons for the gender disparity among THA surgeons and identify the best next steps to promote gender equity within orthopaedics.

METHODS

A retrospective analysis was conducted using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set to quantify orthopaedic surgeons who performed primary THA procedures from 2013 to 2020. To assess trends in the number of hip surgeons by sex and the evolving female-to-male ratio, two-sided correlated Mann-Kendall tests were conducted.

RESULTS

Overall, 3,853 to 4,550 surgeons billed for primary THA annually. Of this number, an average of 1.7% was female. The mean number of services billed for by male surgeons was 31.62 ± 24.78 per year and by female surgeons was 26.43 ± 19.49 per year. Trend analysis of female-to-male ratio demonstrated an increasing trend of statistical significance ( P = 0.009). The average number of procedures by female surgeons annually remained stable throughout the study, whereas there was a steady increase in that for male surgeons.

CONCLUSION

Results showed a notable and sustained upward trajectory from 2013 to 2020 in the number of female surgeons billing for THA along with the female-to-male ratio. However, female surgeons constitute a mere 2% of surgeons engaging in primary THA billing. Furthermore, the annual average number of THAs conducted by female surgeons exhibited constancy, whereas there was a gradual increase in the median number of annual procedures performed by their male counterparts. Future studies should aim to identify and resolve specific barriers prohibiting female medical students from pursuing and obtaining a career as an orthopaedic THA surgeon.

STUDY DESCRIPTION

Retrospective analysis using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set.

Physical activity and symmetry following total knee arthroplasty: Results of a pilot randomized trial

Objective

This pilot trial examined a Physical Activity and Symmetry (PAS) intervention focused on common deficits of physical inactivity and joint loading asymmetry following total knee arthroplasty (TKA).

Design

Participants (n ​= ​60) were enrolled during routine physical therapy (PT) following TKA and randomized to the PAS intervention or an attention (ATT) control group. The PAS intervention included physical activity counseling and balance exercise to address joint loading symmetry; content was delivered during 2 sessions at the end of routine PT plus supplemental sessions 4-weeks and 8-weeks following PT. The ATT control condition included supplemental sessions at 4-weeks and 8-weeks focused on general evaluation of surgical recovery benchmarks. Primary outcomes were weekly minutes of moderate to vigorous physical activity (MVPA), measured with an accelerometer, and peak force loading symmetry (limb symmetry index; LSI) during a 10 ​m walk, measured with a 3-sensor in-shoe device. General linear mixed models compared changes in outcomes between randomized groups at 3-month and 6-month follow-up.

Results

Both PAS and ATT groups increased MVPA, but there were no clinically meaningful between-group differences at 3- or 6-month follow-up (p ​> ​0.05). There were also no clinically meaningful between-group differences LSI at 3- or 6-month follow-up (p ​> ​0.05).

Conclusion

The PAS intervention did not yield improvements beyond ATT control. It is possible that PAS components were being delivered as part of routine PT, and a more intensive intervention (e.g., more visits, guidance for exercise progression) or targeted approach (e.g., those with deficits at end of routine care) may be needed to further improve outcomes.

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.

Effects of socioeconomic burden on opioid use following total shoulder arthroplasty

BACKGROUND

Preoperative opioid users experience worse outcomes and higher complication rates compared to opioid-naïve patients following shoulder arthroplasty. This study evaluates the effects of socioeconomic status, as measured by the Distressed Communities Index (DCI), on pre- and postoperative opioid use and its influence on clinical outcomes such as readmission and revision surgery.

METHODS

A retrospective review of patients who underwent primary shoulder arthroplasty (Current Procedural Terminology code 23472) from 2014 to 2022 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, Charlson Comorbidity Index, DCI, and clinical outcomes including 90-day readmission and revision surgery were collected. Patients were classified according to the DCI score of their zip code. Using the Prescription Drug Monitoring Program database, patient pre- and postoperative opioid use in morphine milligram equivalents was gathered.

RESULTS

Individuals from distressed communities used more opioids within 90 days preoperatively compared to patients from prosperous, comfortable, mid-tier, and at-risk populations, respectively. Patients from distressed communities also used significantly more opioids within 90 days postoperatively compared with prosperous, comfortable, and mid-tier, respectively. Of patients from distressed communities, 35.1% developed prolonged opioid use (filling prescriptions >30 days after surgery), significantly more than all other cohorts. Among all patients, 3.5% were readmitted within 90 days and were more likely to be prolonged opioid users (38.9 vs. 21.3%, P < .001). Similarly, 1.5% of patients underwent revision surgery. Those who underwent revision were significantly more likely to be prolonged opioid users (38.2 vs. 21.7%, P = .002).

CONCLUSIONS

Shoulder arthroplasty patients from distressed communities use more opioids within 90 days before and after their surgery and are more likely to become prolonged opioid users, placing them at risk for readmission and revision surgery. Identifying patients at an increased risk for excess opioid use is essential to employ appropriate strategies that minimize the detrimental effects of prolonged use following surgery.

Social Media Use by American Association of Hip and Knee Surgeons Members

INTRODUCTION

Social media offers physicians marketing opportunities previously unavailable. We sought to evaluate social media use and its correlation with public rankings among Association of Hip and Knee Surgeons members.

METHODS

A list of members and demographics was collected. Social media sites were reviewed for each surgeon, and a score was calculated based on active use. The US News and World Report (NWR) was used to determine rating and number of reviews. The Spearman correlation coefficient and independent samples t-test were used to measure correlation and compare means between the groups, respectively.

RESULTS

A total of 2436 members were analyzed. The average social media score was 4.14. The average US NWR score was 4.25. A strong correlation was observed between social media and US NWR scores (r = 0.74, P < 0.01) but not with the number of reviews (r = 0.40, P = 0.17). A strong association with US NWR rating (r = 0.74, P = 0.04) and a weak correlation with the total number of reviews (r = 0.61, P = 0.06) were found.

CONCLUSIONS

Social media use is correlated with US NWR scores. Association of Hip and Knee Surgeons members may be underutilizing social media for the promotion of their practices. Future studies are needed to evaluate whether it affects patient volume and outcomes.

Safety and efficacy of an allogeneic adipose-derived mesenchymal stem cell preparation in the treatment of knee osteoarthritis: A Phase I/IIa randomised controlled trial

Objectives

To assess the safety and efficacy of an allogeneic adipose-derived mesenchymal stem cell preparation (MAG200) in the treatment of knee osteoarthritis over 12 months.

Design

A single-centre, double-blind, ascending dose, randomised controlled trial. 40 participants with moderate knee osteoarthritis were randomised to receive a single intra-articular injection of MAG200 (dose cohorts:10, 20, 50, 100 ​× ​106 ​cells) or placebo. Primary objectives were safety and efficacy according to a compound responder analysis of minimal clinically important difference in pain (numerical pain rating scale [NPRS]) and function (Knee Injury and Osteoarthritis Outcome Score - Function in Daily Living subscale [KOOSADL]) at month 12. Secondary efficacy outcomes included changes from baseline in patient reported outcome measures and evaluation of disease-modification using quantitative MRI.

Results

Treatment was well tolerated with no treatment-related serious adverse events. MAG200 cohorts reported a greater proportion of responders than placebo and demonstrated clinical and statistically significant improvement in pain and clinically relevant improvement in all KOOS subscales. MAG200 demonstrated a reproducible treatment effect over placebo, which was clinically relevant for pain in the 10 ​× ​106 dose cohort (mean difference NPRS:-2.25[95%CI:-4.47,-0.03, p ​= ​0.0468]) and for function in the 20 ​× ​106 and 100 ​× ​106 dose cohorts (mean difference KOOSADL:10.12[95%CI:-1.51,21.76, p ​= ​0.0863] and 10.81[95%CI:-1.42,23.04, p ​= ​0.0810] respectively). A trend in disease-modification was observed with improvement in total knee cartilage volume in MAG200 10, 20, and 100 ​× ​106 dose cohorts, with progression of osteoarthritis in placebo, though this was not statistically significant. No clear dose response was observed.

Conclusion

This early-phase study provides supportive safety and efficacy evidence to progress MAG200 to later-stage trial development.

Trial registration

ACTRN12617001095358/ACTRN12621000622808.

Titanium nanoparticles released from orthopedic implants induce muscle fibrosis via activation of SNAI2

Titanium alloys represent the prevailing material employed in orthopedic implants, which are present in millions of patients worldwide. The prolonged presence of these implants in the human body has raised concerns about possible health effects. This study presents a comprehensive analysis of titanium implants and surrounding tissue samples obtained from patients who underwent revision surgery for therapeutic reasons. The surface of the implants exhibited nano-scale corrosion defects, and nanoparticles were deposited in adjacent samples. In addition, muscle in close proximity to the implant showed clear evidence of fibrotic proliferation, with titanium content in the muscle tissue increasing the closer it was to the implant. Transcriptomics analysis revealed SNAI2 upregulation and activation of PI3K/AKT signaling. In vivo rodent and zebrafish models validated that titanium implant or nanoparticles exposure provoked collagen deposition and disorganized muscle structure. Snai2 knockdown significantly reduced implant-associated fibrosis in both rodent and zebrafish models. Cellular experiments demonstrated that titanium dioxide nanoparticles (TiO2 NPs) induced fibrotic gene expression at sub-cytotoxic doses, whereas Snai2 knockdown significantly reduced TiO2 NPs-induced fibrotic gene expression. The in vivo and in vitro experiments collectively demonstrated that Snai2 plays a pivotal role in mediating titanium-induced fibrosis. Overall, these findings indicate a significant release of titanium nanoparticles from the implants into the surrounding tissues, resulting in muscular fibrosis, partially through Snai2-dependent signaling.

Medicare's Post-Acute Care Reimbursement Models as of 2023: Past, Present, and Future

ABSTRACT

The Centers for Medicare & Medicaid Services is continually working to mitigate unnecessary expenditures, particularly in post-acute care (PAC). Medicare reimburses for orthopaedic surgeon services in varied models, including fee-for-service, bundled payments, and merit-based incentive payment systems. The goal of these models is to improve the quality of care, reduce health-care costs, and encourage providers to adopt innovative and efficient health-care practices.This article delves into the implications of each payment model for the field of orthopaedic surgery, highlighting their unique features, incentives, and potential impact in the PAC setting. By considering the historical, current, and future Medicare reimbursement models, we hope to provide an understanding of the optimal payment model based on the specific needs of patients and providers in the PAC setting.

Stepping Up Recovery: Integrating Patient-reported Outcome Measures and Wearable Technology for Rehabilitation Following Knee Arthroplasty

Improvement after knee arthroplasty (KA) is often measured using patient-reported outcome measures (PROMs). However, PROMs are limited due to their subjectivity. Therefore, wearable technology is becoming commonly utilized to objectively assess physical activity and function. We assessed the correlation between PROMs and step/stair flight counts in total (TKA) and partial knee arthroplasty (PKA) patients.Analysis of a multicenter, prospective, longitudinal cohort study investigating the collection of average daily step and stair flight counts, was performed. Subjects (N = 1,844 TKA patients and N = 489 PKA patients) completed the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and provided numerical rating scale pain scores pre- and postoperatively. Only patients who reported living in a multilevel home environment (N = 896 TKA patients and N = 258 PKA patients) were included in analysis of stair flight counts. Pearson correlation coefficients were calculated to determine correlations between variables.Among TKA patients, pain scores demonstrated a negative correlation to mean step counts at preoperative (r = -0.14, p < 0.0001) and 1-month follow-up (r = -0.14, p < 0.0001). Similar negative correlations were true for pain and stair flight counts at preoperative (r = -0.16, p < 0.0001) and 1-month follow-up (r = -0.11, p = 0.006). KOOS JR scores demonstrated weak positive correlations with mean step counts at preoperative (r = 0.19, p < 0.0001) and 1-month postoperative (r = 0.17, p < 0.0001). Similar positive correlations were true for KOOS JR scores and stair flight counts preoperatively (r = 0.13, p = 0.0002) and at 1-month postoperatively (r = 0.10, p = 0.0048). For PKA patients, correlations between pain and KOOS JR with step/stair counts demonstrated similar directionality.Given the correlation between wearable-generated data and PROMs, wearable technology may be beneficial in evaluating patient outcomes following KA. By combining subjective feedback with the objective data, health care providers can gain a holistic view of patients' progress and tailor treatment plans accordingly.

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.

Reasons and Risk Factors for Same-Day Discharge Following Total Joint Arthroplasty: A Systematic Review

Background

Nowadays, emphasis is being given to same-day discharge (SDD) following total joint arthroplasty. Unfortunately, despite a high degree of success, there are instances of failed SDD. Therefore, we aim to conduct a systematic review to evaluate factors contributing to failed SDD after total joint arthroplasty.

Methods

Pubmed, Scopus, Cochrane, and Google Scholar were searched. The Newcastle Ottawa score was used for the quality assessment of selected studies. All the studies were evaluated through a narrative synthesis. A total of 11 studies evaluating 157,045 patients were selected. The mean age of patients was 62.5 years.

Results

Elderly patients (odds ratio [OR] 1.01 to OR 3.13), women (OR 1.63 to OR 2.87), non-white race (OR 1.31 to OR 2.19), hypertension (OR 1.11 to OR 1.41), diabetes (OR 1.25 to OR 4.06), cardiovascular diseases (OR 1.67 to OR 12.06), chronic obstructive pulmonary disease (OR 1.30 to OR 1.96), bleeding disorders (OR 1.32 to OR 1.52), obesity (OR 1.35 to OR 3.30), steroid use (OR 1.23 to OR 1.52), late procedure start time (OR 1.22 to OR 5.16), higher postoperative pain (OR 1.93 to OR 5.85), high American Society of Anesthesiologists score (OR 0.92 to OR 3.50) were major predictors of failed SDD.

Conclusions

Through our review, we highlighted that elderly patients, women, non-white race, hypertension, diabetes, cardiovascular diseases, chronic obstructive pulmonary disease, bleeding disorders, obesity, steroid use, late procedure start time, higher postoperative pain, and high American Society of Anesthesiologists score were major predictors of a failed SDD. Many factors evaluated in our study were presented in one or two studies only; therefore, high-quality studies are required to supplement our findings.

Preoperative and Postoperative Weight Change has Minimal Influence on Health Care Utilization and Patient-Reported Outcomes Following Total Knee Arthroplasty

As obesity becomes more prevalent, more patients are at risk of lower extremity osteoarthritis and subsequent total knee arthroplasty (TKA). This study aimed to test (1) the association of preoperative weight change with health care utilization and (2) the association of pre- and postoperative weight changes with failure to achieve satisfaction and minimal clinically important difference (MCID) in Knee injury and Osteoarthritis Outcome Score for pain (KOOS-Pain) and function (KOOS-PS) 1 year after TKA. Prospectively collected monocentric data on patients who underwent primary TKA were retrospectively reviewed. Multivariable logistic regression assessed the influence of BMI and weight change on outcomes while controlling for confounding variables. Outcomes included prolonged length of stay (LOS >3 days), nonhome discharge, 90-day readmission rate, satisfaction, and achievement of MCID for KOOS-Pain and KOOS-PS. Preoperative weight change had no impact on prolonged LOS (gain, p = 0.173; loss, p = 0.599). Preoperative weight loss was associated with increased risk of nonhome discharge (odds ratio [OR]: 1.47, p = 0.003). There was also increased risk of 90-day readmission with preoperative weight gain (OR: 1.27, p = 0.047) and decreased risk with weight loss (OR: 0.73, p = 0.033). There was increased risk of nonhome discharge with obesity class II (OR: 1.6, p = 0.016) and III (OR: 2.21, p < 0.001). Weight change was not associated with failure to achieve satisfaction, MCID in KOOS-Pain, or MCID in KOOS-PS. Obesity class III patients had decreased risk of failure to reach MCID in KOOS-Pain (OR: 0.43, p = 0.005) and KOOS-PS (OR: 0.7, p = 0.007). Overall, pre- and postoperative weight change has little impact on the achievement of satisfaction and clinically relevant differences in pain and function at 1 year. However, preoperative weight gain was associated with a higher risk of 90-day readmissions after TKA. Furthermore, patients categorized in Class III obesity were at increased risk of nonhome discharge but experienced a greater likelihood of achieving MCID in KOOS-Pain and KOOS-PS. Our results raise awareness of the dangers of using weight changes and BMI alone as a measure of TKA eligibility.

Testosterone Replacement Therapy in Orthopaedic Surgery

Testosterone replacement therapy (TRT) is an indicated treatment of several medical conditions including late-onset hypogonadism, congenital syndromes, and gender affirmation hormonal therapy. Increasing population age, medical benefits, and public awareness of TRT have resulted in increased prevalence of its utilization. However, TRT is not without concern for adverse risks including venous thromboembolic complications, cardiovascular events, and prostate issues. In the field of orthopaedic surgery, research is beginning to delineate the complex relationship between TRT and the development of orthopaedic conditions and potential effects on surgical interventions and outcomes. In this review, we discuss current literature surrounding TRT and subsequent development of osteoarthritis, incidence of total joint arthroplasty, musculotendinous pathology, postoperative infection risk, improvements in postoperative rehabilitation metrics, enhancement of osseous healing, and increased bone-implant integration. The authors suggest future areas of investigation that may provide guidance on how surgeons can mitigate adverse risks while optimizing benefits of TRT in the orthopaedic patient.

Is Arthroscopic Meniscectomy Associated With an Increased Risk of Total Knee Arthroplasty for Claimants in the Workers' Compensation System? A 10-Year Study of Workers' Compensation Claims From a Large Nationwide Workers' Compensation Insurance Carrier

BACKGROUND

Total knee arthroplasty (TKA) is a commonly performed knee surgery and prior arthroscopic meniscectomy (AM) has been linked to an increased risk of TKA in the general population.

OBJECTIVE

To study the relationship between AM and TKA among injured workers whose medical care is paid for under workers' compensation (WC).

METHOD

A total of 17,247 lost-time claims depicting all arthroscopic knee surgical procedures performed from 2007 to 2017 were followed to the end of 2022 and analyzed.

RESULTS

The odds ratio of undergoing a TKA for those with a preceding AM is 2.20, controlling for age, sex, and attorney involvement.

CONCLUSIONS

Undergoing an AM is associated with an increased risk of TKA in WC claimants.

Trends in Orthopaedic Surgery Workforce Diversity: Analyzing Changes Over Time

INTRODUCTION

There are many reasons why orthopaedic surgeons move or change careers. We asked the questions: (1) What is the geographic distribution of orthopaedic surgeons with respect to age, sex, and race and ethnicity? (2) How has our workforce changed over time with regard to these factors? (3) Are there any patterns or trends detected regarding policy or regulatory events that coincide with these differences?

METHODS

The American Academy of Orthopaedic Surgeons surveys over 30,000 members, collecting data on demographics, age, race sex, and practice statistics. We calculated geographic distributions and evaluated these differences over time-potential influences from malpractice suits or tort reform were investigated.

RESULTS

Overall surgeon density increased over time. The largest negative changes were noted in District of Columbia, Wyoming, and North Dakota and positive changes in Colorado, South Dakota, and West Virginia. Age across all states increased (mean 1.7 years). Number of female surgeons increased in most states (4.6% to 5.7%). Number of  African Americans increased from 1.6% to 1.8%, Hispanic/LatinX from 1.8% to 2.2%, Asian from 5.5% to 6.7%, and multiracial from 0.8% to 1.2%. No change was noted in the percentage of Native American surgeons.

DISCUSSION

Surgeon density increased from 2012 to 2018; the cause for this change was not evident. Small increases in surgeon population, female surgeons, and in some underrepresented minorities were seen.

Sphingolipid-Induced Bone Regulation and Its Emerging Role in Dysfunction Due to Disease and Infection

The human skeleton is a metabolically active system that is constantly regenerating via the tightly regulated and highly coordinated processes of bone resorption and formation. Emerging evidence reveals fascinating new insights into the role of sphingolipids, including sphingomyelin, sphingosine, ceramide, and sphingosine-1-phosphate, in bone homeostasis. Sphingolipids are a major class of highly bioactive lipids able to activate distinct protein targets including, lipases, phosphatases, and kinases, thereby conferring distinct cellular functions beyond energy metabolism. Lipids are known to contribute to the progression of chronic inflammation, and notably, an increase in bone marrow adiposity parallel to elevated bone loss is observed in most pathological bone conditions, including aging, rheumatoid arthritis, osteoarthritis, and osteomyelitis. Of the numerous classes of lipids that form, sphingolipids are considered among the most deleterious. This review highlights the important primary role of sphingolipids in bone homeostasis and how dysregulation of these bioactive metabolites appears central to many chronic bone-related diseases. Further, their contribution to the invasion, virulence, and colonization of both viral and bacterial host cell infections is also discussed. Many unmet clinical needs remain, and data to date suggest the future use of sphingolipid-targeted therapy to regulate bone dysfunction due to a variety of diseases or infection are highly promising. However, deciphering the biochemical and molecular mechanisms of this diverse and extremely complex sphingolipidome, both in terms of bone health and disease, is considered the next frontier in the field.

Selenium Nanoparticles Attenuate Cobalt Nanoparticle-Induced Skeletal Muscle Injury: A Study Based on Myoblasts and Zebrafish

Cobalt alloys have numerous applications, especially as critical components in orthopedic biomedical implants. However, recent investigations have revealed potential hazards associated with the release of nanoparticles from cobalt-based implants during implantation. This can lead to their accumulation and migration within the body, resulting in adverse reactions such as organ toxicity. Despite being a primary interface for cobalt nanoparticle (CoNP) exposure, skeletal muscle lacks comprehensive long-term impact studies. This study evaluated whether selenium nanoparticles (SeNPs) could mitigate CoNP toxicity in muscle cells and zebrafish models. CoNPs dose-dependently reduced C2C12 viability while elevating reactive oxygen species (ROS) and apoptosis. However, low-dose SeNPs attenuated these adverse effects. CoNPs downregulated myogenic genes and α-smooth muscle actin (α-SMA) expression in C2C12 cells; this effect was attenuated by SeNP cotreatment. Zebrafish studies confirmed CoNP toxicity, as it decreased locomotor performance while inducing muscle injury, ROS generation, malformations, and mortality. However, SeNPs alleviated these detrimental effects. Overall, SeNPs mitigated CoNP-mediated cytotoxicity in muscle cells and tissue through antioxidative and antiapoptotic mechanisms. This suggests that SeNP-coated implants could be developed to eliminate cobalt nanoparticle toxicity and enhance the safety of metallic implants.

Arthrofibrosis After Total Knee Arthroplasty: A Critical Analysis Review

» Arthrofibrosis after total knee arthroplasty (TKA) is the new formation of excessive scar tissue that results in limited ROM, pain, and functional deficits.» The diagnosis of arthrofibrosis is based on the patient's history, clinical examination, absence of alternative diagnoses from diagnostic testing, and operative findings. Imaging is helpful in ruling out specific causes of stiffness after TKA. A biopsy is not indicated, and no biomarkers of arthrofibrosis exist.» Arthrofibrosis pathophysiology is multifactorial and related to aberrant activation and proliferation of myofibroblasts that primarily deposit type I collagen in response to a proinflammatory environment. Transforming growth factor-beta signaling is the best established pathway involved in arthrofibrosis after TKA.» Management includes both nonoperative and operative modalities. Physical therapy is most used while revision arthroplasty is typically reserved as a last resort. Additional investigation into specific pathophysiologic mechanisms can better inform targeted therapeutics.

Trends in Racial, Ethnic, and Gender Diversity in Orthopaedic Surgery Adult Reconstruction Fellowships From 2007 to 2021

BACKGROUND

Orthopaedic surgery has seen improvement in its representation of women, whereas the representation of racial/ethnic minorities has remained stagnant over the past decade. Overall, the surgical field lags behind other specialties in sex and racial/ethnic parity. Although demographic disparities within orthopaedics have been analyzed for both residents and faculty members, information for adult reconstruction fellows remains limited.

METHODS

Sex and race/ethnicity demographics for adult reconstruction orthopaedic fellowship matriculants were collected via a database published by the Accreditation Council for Graduate Medical Education (ACGME) from 2007 to 2021. Statistical analyses, including descriptive statistics and significance testing, were performed.

RESULTS

During the 14-year time frame, men trainees remained high with an overall average percentage of 88% and demonstrated increasing representation (P trend = .012). White non-Hispanics, Asians, Blacks, and Hispanics represented on average 54%, 11%, 3%, and 4%, respectively. White non-Hispanics (P trend = .039) and Asians (P trend = .030) saw increasing and decreasing representation, respectively. Women, Blacks, and Hispanics remained relatively stagnant throughout the observation period as no trends were appreciable (P trend >.05, each).

CONCLUSION

Using publicly available demographic data from the Accreditation Council for Graduate Medical Education (ACGME) from 2007 to 2021, we found relatively limited progress in the representation of women and those from traditionally marginalized groups seeking additional training in adult reconstruction. Our findings mark an initial step in measuring the demographic diversity among adult reconstruction fellows. Further research is needed to ascertain specific factors likely to attract and retain members from minoritized groups into orthopaedics.

Why Treat Patients with a Major Orthopaedic Surgery Only to Send Them Back to the Vulnerable Conditions That Made Them Sick in the First Place? A Conceptual Scenario to Improve Patient's Journey

Individuals with severe cartilage degeneration of the hip or knee or collapsed vertebrae that cause spine deformities can suffer from joint and neuropathic pain in the back, disuse of the affected limb, and restriction of movements. Surgical intervention is the most widespread and successful solution to date. There is a general belief that eating healthy and staying physically and mentally active might have a preventive role against musculoskeletal disease occurrence, while instead, we are more certain of the benefits deriving from a healthy diet and exercise therapy after major orthopaedic procedures. These aspects are in fact vital components in enhanced recovery after surgery programmes. However, they are applied in hospital settings, are often centre-dependent, and lack primary and tertiary preventive efficacy since end once the patient is discharged. There is the lack of initiatives at the territorial level that ensure a continuum in the patient's journey towards orthopaedic surgery, home transition, and a healthy and long-lasting life. The expert panel advocates the integration of an intermediate lifestyle clinic that promotes healthy eating, physical activity, and sleep hygiene. In this facility directed by professionals in enhancing recovery after surgery, patients can be referred after the surgical indication and before home discharge. Surgery is in fact a moment when individuals are more curious to do their best to heal and stay healthy, representing a timepoint and opportunity for educating patients on how lifestyle changes may optimise not only their surgical recovery but also long-term future health state.