Systematic Review of Gender and Sex Terminology Use in Arthroplasty Research: There is Room for Improvement

BACKGROUND

There is increasing appreciation of the distinction between gender and sex as well as the importance of accurately reporting these constructs. Given recent attention regarding transgender and gender nonconforming (TGNC) and intersex identities, it is more necessary than ever to understand how to describe these identities in research. This study sought to investigate the use of gender- and sex-based terminology in arthroplasty research.

METHODS

The five leading orthopaedic journals publishing arthroplasty research were reviewed to identify the first twenty primary clinical research articles on an arthroplasty topic published after January 1, 2022. Use of gender- or sex-based terminology, whether use was discriminate, and whether stratification or adjustment based on gender or sex was performed, were recorded.

RESULTS

There were 98 of 100 articles that measured a construct of gender or sex. Of these, 15 articles used gender-based terminology, 45 used sex-based terminology, and 38 used a combination of gender- and sex-based terminology. Of the 38 articles using a combination of terminology, none did so discriminately. All articles presented gender and sex as binary variables, and two attempted to explicitly define how gender or sex were defined. Of the 98 articles, 31 used these variables for statistical adjustments, though only six reported stratified results.

CONCLUSIONS

Arthroplasty articles infrequently describe how gender or sex was measured, and frequently use this terminology interchangeably. Additionally, these articles rarely offer more than two options for capturing variation in sex and gender. Future research should be more precise in the treatment of these variables to improve the quality of results and ensure findings are patient-centered and inclusive.

Racial and Ethnic Minorities Underrepresented in Pain Management Guidelines for Total Joint Arthroplasty: A Meta-analysis

BACKGROUND

Total joint arthroplasty aims to improve quality of life and functional outcomes for all patients, primarily by reducing their pain. This goal requires clinical practice guidelines (CPGs) that equitably represent and enroll patients from all racial/ethnic groups. To our knowledge, there has been no formal evaluation of the racial/ethnic composition of the patient population in the studies that informed the leading CPGs on the topic of pain management after arthroplasty surgery.

QUESTIONS/PURPOSES

Using papers included in the 2021 Anesthesia and Analgesia in Total Joint Arthroplasty Clinical Practice Guidelines and comparing them with US National census data, we asked: (1) What is the representation of racial/ethnic groups in randomized controlled trials compared with their representation in the US national population? (2) Is there a relationship between the reporting of racial/ethnic groups and year of data collection/publication, location of study, funding source, or guideline section?

METHODS

Participant demographic data (study year published, study type, guideline section, year of data collection, study site, study funding, study size, gender, age, and race/ethnicity) were collected from articles cited by this guideline. Studies were included if they were full text, were primary research articles conducted primarily within the United States, and if they reported racial and ethnic characteristics of the participants. The exclusion criteria included duplicate articles, articles that included the same participant population (only the latest dated article was included), and the following article types: systematic reviews, nonsystematic reviews, terminology reports, professional guidelines, expert opinions, population-based studies, surgical trials, retrospective cohort observational studies, prospective cohort observational studies, cost-effectiveness studies, and meta-analyses. Eighty-two percent (223 of 271) of articles met inclusion criteria. Our original literature search yielded 27 papers reporting the race/ethnicity of participants, including 24 US-based studies and three studies conducted in other countries; only US-based studies were utilized as the focus of this study. We defined race/ethnicity reporting as the listing of participants' race or ethnicity in the body, tables, figures, or supplemental data of a study. National census information from 2000 to 2019 was then used to generate a representation quotient (RQ), which compared the representation of racial/ethnic groups within study populations to their respective demographic representation in the national population. An RQ value greater than 1 indicates an overrepresented group and an RQ value less than 1 indicates an underrepresented group, relative to the US population. Primary outcome measures of RQ value versus time of publication for each racial/ethnic group were evaluated with linear regression analysis, and race reporting and manuscript parameters were analyzed with chi-square analyses.

RESULTS

Two US-based studies reported race and ethnicity independently. Among the 24 US-based studies reporting race/ethnicity, the overall RQ was 0.70 for Black participants, 0.09 for Hispanic participants, 0.1 for American Indian/Alaska Natives, 0 for Native Hawaiian/Pacific Islanders, 0.08 for Asian participants, and 1.37 for White participants, meaning White participants were overrepresented by 37%, Black participants were underrepresented by 30%, Hispanic participants were underrepresented by 91%, Asian participants were underrepresented by 92%, American Indian/Alaska Natives were 90% underrepresented, and Native Hawaiian Pacific Islanders were virtually not represented compared with the US national population. On chi-square analysis, there were differences between race/ethnicity reporting among studies with academic, industry, and dual-supported funding sources (χ2 = 7.449; p = 0.02). Differences were also found between race/ethnicity reporting among US-based and non-US-based studies (χ2 = 36.506; p < 0.001), with 93% (25 of 27) of US-based studies reporting race as opposed to only 7% (2 of 27) of non-US-based studies. Finally, there was no relationship between race/ethnicity reporting and the year of data collection or guideline section referenced.

CONCLUSION

The 2021 Anesthesia and Analgesia in Total Joint Arthroplasty Clinical Practice Guidelines provide evidence-based recommendations that reflect the current standards in orthopaedic surgery, but the studies upon which they are based overwhelmingly underenroll and underreport racial/ethnic minorities relative to their proportions in the US population. As these factors impact analgesic administration, their continued neglect may perpetuate inequities in outcomes after TJA.

CLINICAL RELEVANCE

Our study demonstrates that all non-White racial/ethnic groups were underrepresented relative to their proportion of the US population in the 2021 Anesthesia and Analgesia in Total Joint Arthroplasty Clinical Practice Guidelines, underscoring a weakness in the orthopaedic surgery evidence base and questioning the overall external validity and generalizability of these combined CPGs. An effort should be made to equitably enroll and report outcomes for all racial/ethnic groups in any updated CPGs.

The Pregnant Arthroplasty Surgeon: A Women in Arthroplasty Committee Editorial

BACKGROUND

Women orthopaedic surgeons face unique challenges during their careers. There are extremely low numbers of women in the field, particularly in the specialty of adult reconstruction. Factors contributing to low numbers of women entering this subspecialty include increased perceived physical demand relative to other fields, occupational hazards during pregnancy such as exposure to radiation and polymethylmethacrylate bone cement, concerns for work-life balance, and limited number of women within the subspecialty. The following editorial provides a framework to understand and manage the potential occupational hazards to pregnant and lactating surgeons, parental leave, and postpartum return to work. We aim to dispel any unfounded myths and provide evidence-based education that may help overcome these barriers. In doing so, we hope to encourage more women to consider adult reconstruction as a potential career.

METHODS

Our primary method consisted of completing an extensive literature review on the past and current articles about the aforementioned barriers which may contribute to the low number of women entering adult reconstruction. After this literature search was completed, we composed a comprehensive editorial that provided evidence-based education and recommendations for medical professionals.

CONCLUSIONS

Issues pertaining to parenthood, pregnancy, and lactation pose barriers to success for women in orthopedic surgery. These concerns may dissuade talented women from pursuing a rewarding career in adult reconstruction. Education on these issues is needed to help our early-career colleagues plan and care for their families. Clearly stated and published policies should be made available in all training programs, fellowships, and clinical practices to allow understanding and unbiased implementation. By being more inclusive, adult reconstruction will have access to the best possible surgeons, which will benefit not only patients but the field as a whole.

Incidence of Rapidly Progressive Osteoarthritis Following Intra-articular Hip Corticosteroid Injection: A Systematic Review and Meta-Analysis

Background

The American Academy of Orthopedic Surgery recommends intra-articular corticosteroid injections (CSIs) for managing hip osteoarthritis (OA) based on short-term, prospective studies. Recent retrospective studies have raised concerns that CSIs may lead to rapidly progressive OA (RPOA). We sought to systematically review the literature of CSIs for hip OA to estimate the incidence of RPOA.

Methods

MEDLINE, Embase, and Cochrane Library were searched to identify original research of hip OA patients receiving CSIs. Overall, 27 articles involving 5831 patients published from 1988 to 2022 were included. Study design, patient characteristics, CSI details, follow-up, and cases of RPOA were recorded. Studies were classified by their ability to detect RPOA based on follow-up. Random effects meta-analysis was used to calculate the incidence of RPOA for studies able to detect RPOA.

Results

The meta-analytic estimate of RPOA incidence was 6% (95% confidence interval, 3%-9%) based on 10 articles classified as able to detect RPOA. RPOA definitions varied from progression of OA within 6 months to the presence of destructive changes. These studies were subject to bias from excluding patients with missing post-CSI radiographs. The remaining 17 articles were classified as unable to detect RPOA, including all of the studies cited in the American Academy of Orthopedic Surgery recommendation.

Conclusions

The incidence of RPOA after CSIs remains unknown due to variation in definitions and follow-up. While RPOA following CSIs may be 6%, many cases are not severe, and this may reflect selection bias. Further research is needed to understand whether clinically significant RPOA is incident enough to limit CSI use.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

Medicaid Patients Undergo Total Joint Arthroplasty at Lower-Volume Hospitals by Lower-Volume Surgeons and Have Poorer Outcomes

BACKGROUND

Medicaid insurance coverage among patients undergoing total hip arthroplasty (THA) or those undergoing total knee arthroplasty (TKA) has been associated with worse postoperative outcomes compared with patients without Medicaid. Surgeons and hospitals with lower annual total joint arthroplasty (TJA) volume have also been associated with worse outcomes. This study sought to characterize the associations between Medicaid insurance status, surgeon case volume, and hospital case volume and to assess the rates of postoperative complications compared with other payer types.

METHODS

The Premier Healthcare Database was queried for all adult patients who underwent primary TJA from 2016 to 2019. Patients were divided on the basis of their insurance status: Medicaid compared with non-Medicaid. The distribution of annual hospital and surgeon case volume was assessed for each cohort. Multivariable analyses were performed accounting for patient demographic characteristics, comorbidities, surgeon volume, and hospital volume to assess the 90-day risk of postoperative complications by insurance status.

RESULTS

Overall, 986,230 patients who underwent TJA were identified. Of these, 44,370 (4.5%) had Medicaid. Of the patients undergoing TJA, 46.4% of those with Medicaid were treated by surgeons performing ≤100 TJA cases annually compared with 34.3% of those without Medicaid. Furthermore, a higher percentage of patients with Medicaid underwent TJA at lower-volume hospitals performing ≤500 cases annually, 50.8% compared with 35.5% for patients without Medicaid. After accounting for differences among the 2 cohorts, patients with Medicaid remained at increased risk for postoperative deep vein thrombosis (adjusted odds ratio [OR], 1.16; p = 0.031), pulmonary embolism (adjusted OR, 1.39; p < 0.001), periprosthetic joint infection (adjusted OR, 1.35; p < 0.001), and 90-day readmission (adjusted OR, 1.25; p < 0.001).

CONCLUSIONS

Patients with Medicaid were more likely to undergo TJA performed by lower-volume surgeons at lower-volume hospitals and had higher rates of postoperative complications compared with patients without Medicaid. Future research should assess socioeconomic status, insurance, and postoperative outcomes in this vulnerable patient population seeking arthroplasty care.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Total Joint Arthroplasty Patient Demographics Before and After Coronavirus Disease 2019 Elective Surgery Restrictions

Background

In 2020, the coronavirus disease 2019 (COVID-19) pandemic caused the cessation of nonemergent total joint arthroplasty (TJA, referring to total hip and total knee arthroplasty) operations between mid-March and April 2020. The purpose of this study is to analyze the effects and potential disparities in access to care due to the COVID-19 restrictions.

Methods

A database was used to examine the demographics of patients undergoing TJA from May to December 2019 (pre-COVID-19) and from May to December 2020 (post-COVID-19 restrictions). Categorical covariates were summarized by reporting counts and percentages and compared using Fisher exact tests. Continuous covariates were summarized by reporting means and standard deviations. Two-sample t-tests were used for continuous covariates. The equality of TJA counts by year was tested using a test of proportions.

Results

There were more TJA procedures performed during the post-COVID-19 period in 2020 than in the pre-COVID-19 period (1151 vs 882, P < .001). There was an increase in the relative percentage of THAs vs TKAs performed in 2020 vs 2019 (26.9% vs 18.8%, P < .001) and an increase in patients with Medicaid with a decrease in private insurance (P = .043). The average length of stay was shorter in 2020 with a greater percentage of TJAs performed outpatient (P < .001). There were no differences in patient sex, race, body mass index, smoking status, or age between the 2 periods.

Conclusions

A relative increase in THA procedures, an increase in patients with Medicaid and decrease in private insurance, and a a decreased length of stay were seen after COVID-19 restrictions. These trends may reflect pandemic-related changes in insurance status as well as the growing shift to same-day discharge.

Patients From Distressed Communities Who Undergo Surgery for Hip Fragility Fractures Are Less Likely to Have Advanced Care Planning Documents in Their Electronic Medical Record

BACKGROUND

Advanced care planning documents provide a patient's healthcare team and loved ones with guidance on patients' treatment preferences when they are unable to advocate for themselves. A substantial proportion of patients will die within a few months of experiencing a hip fracture, but despite the importance of such documents, patients undergoing surgery for hip fracture seldom have discussions documented in the medical records regarding end-of-life care during their surgical admission. To the best of our knowledge, the proportion of patients older than 65 years treated with surgery for hip fractures who have advanced care planning documents in their electronic medical record (EMR) has not been explored, neither has the association between socioeconomic status and the presence of those documents in the EMR. Determining this information can help to identify opportunities to promote advanced care planning.

QUESTIONS/PURPOSES

(1) What percentage of patients older than 65 years who undergo hip fracture surgery have completed advanced care planning documents uploaded in the EMR before or during their surgical hospitalization, or at any timepoint (before admission, during admission, and after admission)? (2) Are patients from distressed communities less likely to have advanced care planning documents in the EMR than patients from wealthier communities, after controlling for economic well-being as measured by the Distressed Communities Index? (3) What percentage of patients older than 65 years with hip fractures who died during their hospitalization for hip fracture surgery had advanced care planning documents uploaded in the EMR?

METHODS

This was a retrospective, comparative study conducted at two geographically distinct hospitals: one urban Level I trauma center and one suburban Level II trauma center. Between 2017 and 2021, these two centers treated 850 patients for hip fractures. Among those patients, we included patients older than 65 years who were treated with open reduction and internal fixation, intramedullary nailing, hemiarthroplasty, or THA for a fragility fracture of the proximal femur. Based on that, 83% (709 of 850) of patients were eligible; a further 6% (52 of 850) were excluded because they had codes other than ICD-9 820 or ICD-10 S72.0, and another 2% (17 of 850) had incomplete datasets, leaving 75% (640 of 850) for analysis here. Most patients with incomplete datasets were in the prosperous Distressed Communities Index category. Among patients included in this study, the average age was 82 years, 70% (448 of 640) were women, and regarding the Distressed Communities Index, 32% (203 of 640) were in the prosperous category, 25% (159 of 640) were in the comfortable category, 15% (99 of 640) were in the mid-tier category, 5% (31 of 640) were in the at-risk category, and 23% (145 of 640) were in the distressed category. The primary outcome included the presence of advanced care planning documents (advanced directives, healthcare power of attorney, or physician orders for life-sustaining treatment) in the EMR before surgery, during the surgical admission, or at any time. The Distressed Communities Index was used to indicate economic well-being, and patients were identified as being in one of five Distressed Communities Index categories (prosperous, comfortable, mid-tier, at-risk, and distressed) based on ZIP Code. An exploratory analysis was conducted to determine variables associated with the presence of advanced care planning documents in the EMR. A multivariate regression was then performed for patients who did or did not have advanced care planning documents in their medical record at any time. The results are presented as ORs with the associated 95% confidence interval (CI).

RESULTS

Nine percent (55 of 640) of patients had advanced care planning documents in the EMR preoperatively or during their surgical admission, and 22% (142 of 640) of patients had them in the EMR at any time. After controlling for potential confounding variables such as age, laterality (left or right hip), hospital type, and American Society of Anesthesiologists (ASA) classification, we found that patients in Distressed Communities Index categories other than prosperous had ORs lower than 0.7, with patients in the distressed category (OR 0.4 [95% CI 0.2 to 0.7]; p < 0.01) and comfortable category (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.01) having a substantially lower odds of having advanced care planning documents in their EMR. Patients aged 86 to 95 years (OR 1.9 [95% CI 1.1 to 3.4]), those 96 years and older (OR 4.0 [95% CI 1.7 to 9.5]), and those with a higher ASA classification (OR 1.6 [95% CI 1.1 to 2.3]) had a higher odds of having advanced care planning documents in the EMR at any time. Among 14 patients who experienced in-hospital mortality, two had advanced care planning documents uploaded into their EMR, whereas 12 of 14 who died in the hospital did not have advanced care planning documents uploaded into their EMR.

CONCLUSION

Orthopaedic surgeons should counsel patients regarding the risk for postoperative complications after fragility hip fracture surgery and engage in shared decision-making regarding advanced care planning documents with patients or, if the patients are unable, with their families. Additionally, implementing virtual education about advanced care planning documents and using easy-to-read forms may facilitate the completion of advanced care planning documents by patients older than 65 years, especially patients with low economic well-being. Limitations of this study include having a restricted number of patients in the at-risk and mid-tier Distressed Communities Index categories and a restricted number of patients identifying as non-White races/ethnicities. Future research should evaluate the effect of advanced care document presence in the EMR on end-of-life care intensity in patients treated for fragility hip fractures.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Hemoglobinopathy is Associated With Total Hip Arthroplasty Indication Even Beyond Sickle Cell Anemia

Background

The extent to which hemoglobinopathies other than sickle anemia (HbSS) are associated with hip osteonecrosis is unknown. Sickle cell trait (HbS), hemoglobin SC (HbSC), and sickle/β-thalassemia (HbSβTh) may also predispose to osteonecrosis of the femoral head (ONFH). We sought to compare the distributions of indications for a total hip arthroplasty (THA) in patients with and without specific hemoglobinopathies.

Methods

PearlDiver, an administrative claims database, was used to identify 384,401 patients aged 18 years or older undergoing a THA not for fracture from 2010 to 2020, with patients grouped by diagnosis code (HbSS N = 210, HbSC N = 196, HbSβTh N = 129, HbS N = 356). β-Thalassemia minor (N = 142) acted as a negative control, and patients without hemoglobinopathy as a comparison group (N = 383,368). The proportion of patients with ONFH was compared to patients without it by hemoglobinopathy groups using chi-squared tests before and after matching on age, sex, Elixhauser Comorbidity Index, and tobacco use.

Results

The proportion of patients with ONFH as the indication for THA was higher among those with HbSS (59%, P < .001), HbSC (80%, P < .001), HbSβTh (77%, P < .001), and HbS (19%, P < .001) but not with β-thalassemia minor (9%, P = .6) than the proportion of patients without hemoglobinopathy (8%). After matching, the proportion of patients with ONFH remained higher among those with HbSS (59% vs 21%, P < .001), HbSC (80% vs 34%, P < .001), HbSβTh (77% vs 26%, P < .001), and HbS (19% vs 12%, P < .001).

Conclusions

Hemoglobinopathies beyond sickle cell anemia were strongly associated with having osteonecrosis as the indication for THA. Further research is needed to confirm whether this modifies THA outcomes.

Total Knee Arthroplasty After Ipsilateral Below-knee Amputation: A Review of the Literature and Surgical Techniques

Patients with knee osteoarthritis in the setting of ipsilateral below-knee amputation present a challenge in terms of patient positioning, intraoperative assistance, implant alignment, postoperative rehabilitation, and prosthesis adjustment. This is a report of a patient with a history of below-knee amputation with ipsilateral knee pain due to osteoarthritis, treated with elective total knee arthroplasty. This was done using custom cutting blocks made via preoperative computed tomography scans, and a single assistant as well as a large hip bump and lateral support were used for positioning. The patient was weight-bearing as tolerated in his regular below-knee prosthesis starting from postoperative day 1, with 1 prosthetic adjustment made during the first week of rehabilitation. The patient was pain-free with full range of motion at 1-year follow-up.

Operating Room Fire During Total Knee Arthroplasty Tibial Impaction

A fire in the operating room is a rare but potentially deadly occurrence. We present an operating room fire during an elective total knee arthroplasty with an unclear ignition source. Flames were visualized originating from the excess bone cement while impacting the tibial component. The electrocautery device was not in use during impaction and was in a plastic sheath at the head of the bed. To our knowledge, this is the first reported case of an operating room fire involving bone cement not caused by an electrocautery device.

Gout in primary total knee arthroplasty: Prevalent but not independently associated with complications

BACKGROUND

Gout is a common synovial pathology, but its prevalence in patients undergoing total knee arthroplasty (TKA) and potential association with complications such as periprosthetic infection (PJI) and revision are unknown.

METHODS

Medicare data from 2009 to 2013 was retrospectively reviewed using PearlDiver. All patients 65 years of age or older and undergoing primary TKA with at least 3 years of pre-TKA records were included. The prevalence of gout was based on ICD-9 codes. Univariable associations of gout with PJI and revision at 1 year were assessed using odds ratios with 95% confidence intrervals (C.I.). To control for potential confounding, patients with a history of gout were matched on age, gender, smoking history, and Elixhauser Comorbidity Index (ECI) to patients without gout and associations reassessed.

RESULTS

The prevalence of gout in Medicare patients undergoing primary TKA was 5.7%. On univariable analysis, patients with a history of gout were more likely to develop PJI (O.R., 1.58; 95% C.I., 1.45-1.72) and undergo revision (O.R., 1.33; 95% C.I., 1.25-1.41) at 1 year. After matching for confounders, a history of gout was no longer associated with developing PJI (O.R., 0.98; 95% C.I., 0.90-1.06) or undergoing revision (O.R., 0.94; 95% C.I., 0.89-1.00) at 1 year.

CONCLUSIONS

Gout is a relatively common pathology in patients undergoing TKA. While gout is associated with increased complications, this appears to be driven by confounding through its association with other medical comorbidities. Gout does not appear to be an independent risk factor for complications following TKA.

Dual Antibiotic Therapy with Vancomycin and Cefazolin for Surgical Prophylaxis in Total Knee Arthroplasty

Background: Perioperative administration of intravenous antibiotics is a routine part of total knee arthroplasty.  Antibiotic selection is a matter of controversy, and the potential risks and benefits associated with each antibiotic selection need to be considered.  The objective of this study is to examine the effects of routine dual antibiotic prophylaxis with both cefazolin and vancomycin on infection and renal failure after primary total knee arthroplasty (TKA) compared with cefazolin alone.Methods: We performed a retrospective review of primary TKA patients for two years before and two years after routine dual antibiotic prophylaxis was implemented at our institution. 1502 patients were included (567 cefazolin-only and 935 dual prophylaxis).  Results: 2 patients (0.4%) in the cefazolin-only group had a deep surgical site infection, compared with 13 patients (1.4%) in the dual prophylaxis group (p=0.06). 46 patients (8.1%) in the cefazolin-only group had postoperative renal failure, compared with 36 patients (3.9%) in the dual prophylaxis group (p=0.0006).Discussion and Conclusion: Our results did not support the routine use of vancomycin in primary total joint arthroplasty to decrease periprosthetic joint infection. However, we also did not see any clear harm due to renal failure in the routine use of dual antibiotic prophylaxis. 

Thromboembolic Disease in Patients with Metastatic Femoral Lesions: A Comparison Between Prophylactic Fixation and Fracture Fixation

BACKGROUND

We are not aware of any previous studies that have compared the rate of venous thromboembolic events in patients who underwent prophylactic intramedullary nailing because of an impending fracture with the rate in patients who underwent intramedullary nailing after a pathological fracture. The objective of the present study was to determine if the rate of venous thromboembolic events varies between patients who are managed with prophylactic fixation and those who are managed with fixation after a pathological fracture.

METHODS

We performed a retrospective comparative study in which the Nationwide Inpatient Sample database was used to identify all patients who had undergone femoral stabilization, either for a pathological femoral fracture or for prophylactic fixation of femoral metastatic lesion, over a period of 10 consecutive years (between 2002 and 2011) in the United States. Demographic data, comorbidities, venous thromboembolic event rates, and other common postoperative complications were compared between the 2 groups.

RESULTS

Patients who were managed with prophylactic fixation had significantly higher rates of pulmonary embolism (p < 0.001; adjusted odds ratio, 2.1) and deep-vein thrombosis (p = 0.03; adjusted odds ratio, 1.5). Patients who were managed with fixation after a pathological fracture had a significantly greater need for blood transfusion, higher rates of postoperative urinary tract infection, and a decreased likelihood of being discharged to home (p < 0.001 for all).

CONCLUSIONS

Patients with metastatic disease who undergo prophylactic intramedullary nailing have higher observed rates of venous thromboembolic events than those who undergo nailing for the treatment of a pathological fracture and should be actively and vigilantly managed in the postoperative period.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Elbow Pain After a Fall: Nursemaid's Elbow or Fracture?

Nursemaid's elbow and elbow fractures are both common causes of acute elbow pain, but the mechanism of injury is quite different. In children, falls frequently go unwitnessed and children are often inaccurate when recounting the sequences of a fall, making the mechanism difficult to ascertain. A common clinical mistake is to treat all elbow injuries as a nursemaid's elbow. When the mechanism of injury is unknown, radiographs should be used to help make the diagnosis. Occult fractures, also known as "hairline" elbow fractures, may not be visible on initial X-rays, but clues to the diagnosis, especially the posterior fat pad, can be helpful in evaluation. When an occult fracture is suspected based on history and radiographic findings, the patient's elbow should be immobilized, not manipulated. This article also reviews successful reduction maneuvers for nursemaid's elbow. [Pediatr Ann. 2016;45(6):e214-e217.].