Infection rates and risk factors with magnetic intramedullary lengthening nails

Introduction

Surgical site infection (SSI) related to magnetic intramedullary lengthening nails (MILNs) can lead to delayed consolidation or loss of limb function, resulting in deleterious effects to a patient's quality of life. With the rise of MILNs, we sought to determine the incidence rate and risk factors for infection during limb lengthening with MILNs.

Methods

We reviewed a consecutive series of patients who underwent femoral and/or tibial lengthening with an MILN at a single institution between 2012 and 2020 (n = 420). SSI was defined according to CDC-NHSN criteria (including superficial and deep infections) with postoperative surveillance time of 12 months. Demographic, health metrics, comorbidities, limb- and surgery-related factors, were assessed as potential risk mediators of SSI.

Results

Incidence of SSI was 3.3 % (14/420). This was divided into superficial (0.5 %,2/420) and deep (2.9 %, 12/420) infections. Of deep infections, 75 % (9/12) were osteomyelitis. Of the 14 limbs that developed SSI, 57 % (8/14) had a history of prior external fixation in the same limb and 38 % (5/14) had a previous infection of the same limb. A subanalysis of patients with a history of prior external fixation in the same bone was associated with SSI, as compared to those without previous external fixation. None of the surgery-related infection risk factors reached statistical significance.

Discussion and conclusion

The total incidence of infection with MILNs was 3.3 % at 24 months follow-up. The risk of deep infection was 2.9 %. Patients with a history of previous external fixation and prior infection show an independent association with increased rate of infection recurrence in the same bone. These patients could be considered a high-risk group for developing deep tissue infection. Potential algorithms include prolonged oral antibiotics after MILN insertion or simultaneous injection of absorbable antibiotic at the time of the nail insertion.

Outpatient limb lengthening using magnetic intramedullary nails: A single Institution's experience

Introduction

The advantages of outpatient surgery have been shown in other orthopedic subspecialities to be a means of driving down costs and reducing the average length of hospital stay. However, there is a scarcity of literature examining the utility of a specific, hospital-based facility performing such procedures for limb lengthening. Considering this, we aimed to investigate surgical factors, patient characteristics, and the incidence of outpatient postoperative complications for patients undergoing surgery and subsequent distraction osteogenesis utilizing the Precice® nail, a state-of-the-art magnetic intramedullary nail (MILN).

Methods

We performed a retrospective review of medical records pertaining to outpatient limb lengthening procedures occurring between January 2012 and September 2023 at a single institution, as performed by three surgeons. Variables of interest included baseline demographics, type of anesthesia, operative bone, laterality, preoperative diagnosis, osteotomy level, procedure performed, prosthesis, point of entry, nail diameter/length, goal length, goal achieved, postoperative complications, and elective nail removal.

Results

The cohort comprised 20 limbs, with an average age at index surgery of 24.8 (SD 7.96). There were no complications related to the outpatient nature of the procedure. Five of the 20 limbs had postoperative complications, including deep vein thrombosis (DVT), screw backout, and nail breakage.

Conclusion

Our initial investigation of outpatient limb lengthening at a specific, hospital-based facility demonstrated favorable postoperative outcomes for those patients undergoing limb lengthening procedures with an MILN. The field would certainly benefit from future research assessing outcomes of pediatric surgeries in the outpatient setting on a larger scale, as well as across hospital systems, the country, and globally. With the proven advances and benefits of MILNs, prioritizing examination of their efficacy in an outpatient population is imperative. Furthermore, the success of outpatient procedures in other orthopedic subspecialities, such as total joint arthroplasty, is a logical, driving precedent for this rationale.

Antibiotic prophylaxis prior to colonoscopy with biopsy does not decrease risk of prosthetic joint infection in total knee arthroplasty recipients

Introduction

Prosthetic joint infection (PJI) risk continues to receive much attention given its associated morbidity and costs to patients and healthcare systems. It has been hypothesized that invasive colonoscopies may increase the risk of PJI. However, the decision to administer antibiotic prophylaxis lacks clinical guidance. In this study we aimed to compare PJI rates in patients undergoing colonoscopies with and without antibiotic prophylaxis against a control group, analyzing PJI occurrences at 90 days, 6 months, 9 months, and 1-year post-procedure and (2) assess the impact of antibiotic prophylaxis on PJI rates to inform clinical guidelines.

Methods

We queried a national, all-payer database to identify all primary total knee arthroplasty procedures without prior history of PJI between January 2010 and October 2020 (n = 1.9 million). All patients who had a diagnosis of PJI within one year of index procedure were excluded. There were three cohorts identified: colonoscopy with biopsy without antibiotic prophylaxis; colonoscopy with biopsy with antibiotic prophylaxis; and a control of no prior colonoscopy. Both colonoscopy cohorts were slightly younger and had higher comorbidities than the controls. The PJI diagnoses were identified at four separate time intervals within one-year after colonoscopy: 90-days; 6-months; 9-months; and 1-year. Chi-square analyses with odds ratios (ORs) and 95% confidence intervals were conducted for PJI rates between groups at all time-points.

Results

Among all cohorts, no significant differences in PJI rates were found at 90-days (P = 0.459), 6-months (P = 0.608), 9-months (P = 0.598), and 1-year (P = 0.330). Similarly, direct comparison of both colonoscopy groups, with and without antibiotic prophylaxis, demonstrated no PJI rate differences at 90-day (P = 0.540), 6-months (P = 0.812), 9-months (P = 0.958), and 1-year (P = 0.207). Ranges of ORs between the colonoscopy cohorts were 1.07-1.43.

Conclusion

Invasive colonoscopy does not increase the risk of PJI in patients who have pre-existing knee implants. Furthermore, antibiotic prophylaxis may not be warranted in patients undergoing colonoscopy who have a planned biopsy.

Timing Matters: Optimizing the Timeframe for Preoperative Weight Loss to Mitigate Postoperative Infection Risks in Total Knee Arthroplasty

BACKGROUND

We explore the incidence of periprosthetic infections post-total knee arthroplasty (TKA) in morbidly obese patients who achieved weight loss. Current American Academy of Orthopaedic Surgeons guidelines suggest a preoperative body mass index (BMI) below 40 for TKA. This study assesses infection risks in patients initially who had a BMI of 40-50 who reduced their BMI to under 35 at varying intervals prior to surgery.

METHODS

We reviewed a national, all-payer database, PearlDiver, for patients undergoing primary TKA. Patients were stratified based on initial BMI of 40 to 50 and reduction of BMI to less than 35 at 3 months (n = 1,932), 3 to 6 months (n = 794), 6 to 9 months (n = 2,233), and 9 to 12 months (n = 1,194) prior to TKA, as well as patients who had a BMI between 40 to 50 (n = 41,632) on the day of surgery. The nonobese group comprised of patients who had a BMI between 20 and 30 (n = 33,294). Multivariate analyses were performed at one-year follow-up.

RESULTS

We found an increased risk of PJI for patients who had achieved BMI reduction less than nine months prior to TKA, compared to the BMI 20 to 30 cohort at the one-year follow-up (P < .001). Patients who achieved BMI reduction nine to twelve months prior to TKA showed no significant difference in PJI risk compared to the matching nonobese cohort at one-year follow-up (P = .400).

CONCLUSIONS

In conclusion, our results suggest that weight loss should be achieved at least nine months before TKA to decrease infection risks. These findings have significant implications for surgical considerations in obese patients undergoing TKA.

Methodological Assessment of the 100 Most-Cited Articles in Total Knee Arthroplasty in the Last Decade Compared to the All-Time List

BACKGROUND

Recent advances in total knee arthroplasty (TKA) have been driven by a growing focus on evidence-based medicine. This transition is reflected in the critical appraisal of both, the quality of work and the potential impact on the orthopedic community. The purpose of our study was to (1) identify the top 100 most-cited articles in TKA in the last decade and from all-time, and (2) compare methodological rigor of the most-cited articles in TKA in the last decade to articles all-time by level of evidence.

METHODS

The top 100 cited articles were recorded for manuscripts from the last decade, January 1, 2012 to December 31, 2022, and manuscripts from all-time for TKA. We collected authors, year of publication, journal of the article, country of origin of authors, article type (basic science article, clinical research article), level of evidence, methodological index for non-randomized studies score, physiotherapy evidence database scale, and citation density (total citations/years published).

RESULTS

The largest number of studies for all-time TKA (53.0%) and decade TKA (42.0%) were Level III. The average methodological index for non-randomized studies score for comparative studies was 18.7 for all-time TKA and 20.7 for decade TKA (P < .001). The average physiotherapy evidence database score was 6.1 for all-time TKA and 8.1 for decade TKA (P > .05). The highest citation density for all-time TKA was 111 and for past decade was 63. The number of level II studies in TKA increased from 19.0% from all time to 38.0% from the last decade (P < .05).

CONCLUSIONS

Our findings of improved methodologies over time reflect positive steps toward evidence-based practice in TKA. A continued focus on producing methodologically sound studies may guide evidence-based clinical decision-making.

Cemented Versus Cementless Femoral Fixation for Total Hip Arthroplasty Following Osteoarthritis

BACKGROUND

The mode of femoral fixation for primary total hip arthroplasty (THA) is undetermined, with reported outcomes favoring different fixation methods. This study aimed to compare postoperative complications between cemented and cementless fixation at 90 days, 1 year, and 2 years in patients aged 65 years of age and older undergoing THA for osteoarthritis.

METHODS

Using an all-payer, national database, patients 65 years and older undergoing primary THA, either with cementless (n = 56,701) or cemented (n = 6,283) femoral fixation for osteoarthritis were identified. A 1:1 propensity-matched analysis for age, sex, comorbidity index, alcohol abuse, tobacco use, obesity, and diabetes was performed, resulting in n = 6,283 patients in each cohort. Postoperative outcomes, including postoperative periprosthetic joint infection, aseptic revision, surgical site infection, pulmonary embolism, venous thromboembolism, wound complications, dislocation, periprosthetic fracture, and aseptic loosening were assessed.

RESULTS

The cemented cohort had higher rates of infection (4.5 versus 0.8%, odds ratio [OR] 5.9, 95% confidence interval [CI] 4.33 to 7.93, P < .001), aseptic revision (2.9 versus 2.0%, OR 1.47, 95% CI 1.17 to 1.85, P = .001), venous thromboembolism (1.8 versus 1.3%, OR 1.40, 95% CI 1.05 to 1.87, P < .001), and aseptic loosening (1.5 versus 0.7%, OR 2.31, 95% CI 1.60 to 3.32, P < .001) at 90-days. At 1 and 2 years, the cemented cohort had higher rates of infection, aseptic revision, and aseptic loosening (all P < .001). Rates of periprosthetic fracture were similar at all time points (all P < .001).

CONCLUSIONS

Cemented fixation had higher rates of infection, aseptic loosening, and aseptic revision. This finding supports the current use of cementless fixation, but the ultimate decision regarding fixation type should be based on the proper optimization of the patient's comorbidities and bone quality.

The use of preoperative continuous positive airway pressure in patients with obstructive sleep apnea following total knee arthroplasty: a propensity score matched analysis

INTRODUCTION

Patients with sleep apnea, affecting up to 1 in 4 older men in the United States, may be at increased risk of postoperative complications after total knee arthroplasty (TKA), including increased thromboembolic and cerebrovascular events, as well as respiratory, cardiac, and digestive complications. However, the extent to which the use of CPAP in patients with sleep apnea has been studied in TKA is limited.

METHODS

A national, all-payer database was queried to identify all patients who underwent a primary TKA between 2010 and 2021. Patients who had any history of sleep apnea were identified and then stratified based on the use of CPAP. A propensity score match analysis was conducted to limit the influence of confounders. Medical complications, such as cardiac arrest, stroke, pulmonary embolism, transfusion, venous thromboembolism, and wound complications, were collected at 90-days, 1-year, and 2-years.

RESULTS

The bivariate analysis showed inferior outcomes for sleep apnea with CPAP use compared to sleep apnea with no CPAP use, in terms of length of stay (5.9 vs. 5.2, p < 0.001), PJI (1.31% vs. 1.14%, p < 0.001), stroke (0.97% vs. 0.82%, p < 0.001), VTE (1.04% vs. 0.82, p < 0.001), and all other complications at 90-days (p < 0.001) except cardiac arrest (0.14% vs. 0.11%, p = 0.052), and aseptic revision (0.40% vs. 0.39%, p = 0.832), PJI (1.81% vs. 1.55%, p < 0.001) and aseptic revision (1.25% vs. 1.06%, p < 0.001) at 1-year, and PJI (2.07 vs. 1.77, p < 0.001) and aseptic revision (1.98 vs. 1.17, p < 0.001) at 2-years.

CONCLUSION

Patients with sleep apnea have increased postoperative complications after undergoing TKA in comparison to patients without sleep apnea. More severe sleep apnea, represented by CPAP usage in this study led to worse postoperative outcomes but further analysis is required signify the role of CPAP in this patient population. Patients with sleep apnea should be treated as a high-risk group.

Cemented is not superior to cementless total knee arthroplasty for complications: a propensity score matched analysis

INTRODUCTION

There is continued debate regarding the survivorship and revision rate of cementless versus cemented total knee arthroplasty (TKA) prostheses. This includes the assessment of early revision surgery due to aseptic loosenings and periprosthetic joint infections (PJIs). Studies have not always taken into account the impact of comorbidities, such as diabetes, obesity, and tobacco. Therefore, we compared revisions in a large population of patients undergoing cemented or cementless TKAs at 90 days, 1 year, and 2 years.

METHODS

A review of an administrative claims database was used to identify patients undergoing primary TKA, either cementless (n = 8,890) or cemented (n = 215,460), from October 1, 2015 to October 31, 2020. Revision surgery for PJI and aseptic loosening were identified with diagnosis and associated procedural codes at 90 days, 1 year, and 2 years and then compared between groups. A propensity matched-analysis was performed for age, sex, Charles Comorbidity Index (CCI) > 3, alcohol abuse, tobacco use, obesity, and diabetes. Chi square tests assessed statistical significance of differences in the matched cohorts using odds ratios (ORs) with 95% confidence intervals (CIs). A P < 0.05 was defined as statistically significant.

RESULTS

Cementless TKA was associated with similar revisions rates due to PJIs at 90 days (OR, 1.04, 95% CI 0.79-1.38, p = 0.83), 1 year (OR, 0.93, 95% CI 0.75-1.14, p = 0.53, and 2 years (OR, 0.87, 95% CI 0.73-1.05, p = 0.17) in comparison to the cemented TKA cohort. The odds ratio of revision due to aseptic loosening was similar as well at 90 days (OR, 0.67, 95% CI 0.34-1.31, 0.31), 1 year (OR, 1.09, 95% CI 0.73-1.61, p = 0.76), and 2 years (OR, 1.00, 95% CI 0.73-1.61, p = 0.99).

CONCLUSIONS

This study found a comparable risk of PJI and aseptic loosening in cementless and cemented TKA when controlling for several comorbidities, such as tobacco, diabetes, and alcohol. Therefore, with proper patient selection, cementless TKAs can be performed with expectation of low risks of infections and aseptic loosenings.

Chronic knee pain following infrapatellar/suprapatellar magnetic intramedullary lengthening nails versus external fixators in limb length discrepancy: A retrospective review

Aims & objectives

Prior to the popularization of magnetic intramedullary nails (MILNs), gradual deformity correction using external fixation was the norm in limb lengthening. Trauma literature has shown MILN via a suprapatellar approach (SP) to be associated with less knee pain than either an infrapatellar entry (IP) or external fixation. Yet, no research has investigated chronic knee pain and MILNs. We assessed differences in chronic knee pain following lengthening via an IP or SP approach with an MILN versus external fixation.

Materials & methods

We reviewed 147 limbs (55 MILN/IP, 22 MILN/SP, 71 external fixator) in 124 patients who underwent tibial lengthening with ≥12 months follow-up between February 2012 and July 2020. Knee pain was assessed pre- and postoperatively at 6 and 12 months, with the Lysholm Knee Scoring Scale (LKSS) and numeric pain scale (0-10). Differences in knee pain outcomes were compared across methods, with subgroup analysis of MILN/SP and MILN/IP.

Results

Mean LKSS was 96.3 for external fixation and 88.5 for MILN (P = .011). In the MILN subgroups, mean LKSS was 91.7 for IP and 85.3 for SP. The IP group reported a lesser mean pain score (0.6 versus 2.1) at 12 months. Bilateral nail recipients demonstrated no knee pain differences versus unilateral. At 12 months postoperative, external fixation had better knee outcomes.

Conclusion

Tibial lengthening with external fixation was associated with less chronic anterior knee pain and better functional outcomes than MILN overall. In terms of MILN approach, IP surpassed SP on subjective pain scores. Larger tibial lengthening and knee pain studies are warranted.

Impact of Reporting Bias, Conflict of Interest, and Funding Sources on Quality of Orthopaedic Research

BACKGROUND

Influence of factors like reporting outcomes, conflicts of interest, and funding sources on study outcomes, particularly positive outcomes in orthopedics, remains underexplored. As transparency of partnerships in orthopaedic surgery through conflicts of interest statements has increased over the years, there has been a lack of focus on the value of these partnerships in influencing study outcomes. We aimed to investigate the associations between reporting outcomes, conflicts of interest, and sources of funding on study outcomes.

METHODS

We reviewed articles published in 1 year in The Journal of Bone and Joint Surgery, The American Journal of Sports Medicine, and The Journal of Arthroplasty. The abstracts were examined for appropriate inclusion, while the authors' names, academic degrees, funding disclosures, and departmental and institutional affiliations were redacted. There were a total of 1,351 publications reviewed from January 1, 2021 to December 31, 2021.

RESULTS

A significant association was found between positive outcomes and reported conflicts of interest (75% versus 25%, P < .001). Likewise, conflicts of interest showed significant association with industry-sponsored studies (88% versus 12%, P < .001) and evidence level > II (72% versus 28%, P < .001). Industry-sponsored research accounted for the highest percentage of studies involving a conflict of interest (88%) and level I studies (12%).

CONCLUSIONS

Conflicts of interest are significantly associated with positive outcomes in orthopaedics. Sponsored studies were more inclined to have conflicts of interest and accounted for the majority of level I studies.

Open versus arthroscopic treatment of the rheumatoid elbow arthritis: a comparison of complications at two years utilizing a nationally representative database

PURPOSE

Symptomatic rheumatoid arthritis (RA) can be addressed surgically with open procedures or elbow arthroscopy. Previous studies comparing outcomes of open to arthroscopic arthrolysis for the management of RA did not utilize a large database study. The aim was to compare demographics and two-year complications, in RA patients undergoing open or arthroscopic elbow arthrolysis.

METHODS

A retrospective, cohort study was performed utilizing a private, nationwide, all-payer database. We queried the database to identify patients undergoing open (n = 578) or arthroscopic (n = 379) arthrolysis for elbow RA. The primary goal of the study was to compare complications at two-years. Categorical variables were assessed utilizing the chi-squared test; while, continuous variables were analyzed using the Student's t-test. Multivariable logistic regression was performed to assess risk factors for infection following open or arthroscopic arthrolysis.

RESULTS

RA patients undergoing open elbow arthrolysis were older (55 vs. 49 years, p < 0.001), predominately female (61.6% vs 60.9%, p = 0.895), and likely to have chronic kidney disease (20.4 vs. 12.9%), and DM (45.2 vs. 32.2%) (both p < 0.005). Open elbow arthrolysis was also associated with higher rates of infection (31.7 vs. 4.7%) and wound complications (26.8 vs. 3.4%) (both p = 0.001). Nerve injury rates were found to be similar (8.3 vs. 9.0%, p = 0.81). On multivariable logistic regression, open elbow procedures were associated with the highest risk for infection (OR: 8.43).

CONCLUSIONS

Patients undergoing open arthrolysis for RA were at a higher risk of infection and wound complications compared to arthroscopic arthrolysis utilizing a nationally representative database. While there appears to be a difference in outcomes following these two procedures, higher level evidence is needed to draw more definitive conclusions.

LEVEL OF EVIDENCE

Retrospective, Level III.

Innovative Hip Distraction Approaches for Total Hip Arthroplasty in Crowe IV Developmental Dysplasia or Similar High-Riding Patients

BACKGROUND

Total hip arthroplasty (THA) for dislocated hips (Crowe IV dysplasia) presents unique challenges. Conventional approaches involve subtrochanteric osteotomies, but are complex with additional fixation and potentially lead to limb length discrepancies, nerve palsies, and other complications. An alternative strategy is a staged approach, where the femoral head (or remnant) is gradually lowered (distraction technique) to align with the true acetabulum over a period of time, followed by a second-stage anatomically acetabular-positioned THA. External fixation distraction and telescoping internal lengthening devices have been utilized to achieve preoperative alignment. We evaluated these techniques, including the types, time, and amount of distraction needed, as well as outcomes and complication rates.

METHODS

In this retrospective case series, 14 patients (9 women, 5 men), who had a mean age of 32 years (range, 16 to 67), underwent staged surgical interventions using hip distraction using external fixators or internal lengthening devices for hip dysplasia and other pathologies (Perthes disease, osteonecrosis) in preparation for a second-stage anatomically placed THA. The mean follow-up duration for external-fixation patients was 10 years (range, 6.5 to 13.4).

RESULTS

Staged treatment involved external fixators (n = 8) or internal lengthening devices (n = 6) with a device placement mean of 48 days (range, 42 to 71). The amount of distraction ranged from 6 to 12 cm. There were 2 patients who required uncomplicated revision of the internal lengthening devices, and another patient had a temporary peroneal nerve palsy. There was 1 patient who underwent an acetabular revision at 7 years.

CONCLUSIONS

We focused on a challenging patient cohort that emphasizes the efficacy of staged interventions in managing Crowe Type IV dysplasia and similar cases. Favorable outcomes were found with the immediate transition to THA after device removal that effectively addressed soft-tissue contractures and femoral migration. Despite the need for further validation via larger, prospective studies, this innovative approach may pave the way toward optimizing this strategy for these difficult hip pathologies.

Appropriateness of Frequently Asked Patient Questions Following Total Hip Arthroplasty From ChatGPT Compared to Arthroplasty-Trained Nurses

BACKGROUND

The use of ChatGPT (Generative Pretrained Transformer), which is a natural language artificial intelligence model, has gained unparalleled attention with the accumulation of over 100 million users within months of launching. As such, we aimed to compare the following: 1) orthopaedic surgeons' evaluation of the appropriateness of the answers to the most frequently asked patient questions after total hip arthroplasty; and 2) patients' evaluation of ChatGPT and arthroplasty-trained nurses responses to answer their postoperative questions.

METHODS

We prospectively created 60 questions to address the most commonly asked patient questions following total hip arthroplasty. We obtained answers from arthroplasty-trained nurses and from the ChatGPT-3.5 version for each of the questions. Surgeons graded each set of responses based on clinical judgment as 1) "appropriate," 2) "inappropriate" if the response contained inappropriate information, or 3) "unreliable" if the responses provided inconsistent content. Each patient was given a randomly selected question from the 60 aforementioned questions, with responses provided by ChatGPT and arthroplasty-trained nurses, using a Research Electronic Data Capture survey hosted at our local hospital.

RESULTS

The 3 fellowship-trained surgeons graded 56 out of 60 (93.3%) responses for the arthroplasty-trained nurses and 57 out of 60 (95.0%) for ChatGPT to be "appropriate." There were 175 out of 252 (69.4%) patients who were more comfortable following the ChatGPT responses and 77 out of 252 (30.6%) who preferred arthroplasty-trained nurses' responses. However, 199 out of 252 patients (79.0%) responded that they were "uncertain" with regard to trusting AI to answer their postoperative questions.

CONCLUSIONS

ChatGPT provided appropriate answers from a physician perspective. Patients were also more comfortable with the ChatGPT responses than those from arthroplasty-trained nurses. Inevitably, its successful implementation is dependent on its ability to provide credible information that is consistent with the goals of the physician and patient alike.

A Comparison Between Polyethylene Exchange and Full Revision for Arthrofibrosis Following Total Knee Arthroplasty

BACKGROUND

Arthrofibrosis is a debilitating postoperative complication and a major cause of patient dissatisfaction following total knee arthroplasty (TKA). There is no consensus regarding the optimal treatment for stiffness after TKA. For cases not amenable to manipulation under anesthesia (MUA), one component or full revision are both suitable options. In a value-based healthcare era, maximizing cost-effectiveness with optimized clinical outcomes for patients remains the ultimate goal. As such, we compared (1) Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement (KOOS, JR), (2) range of motion (ROM), as well as (3) complication rates, including MUA and lysis of adhesions (LOA), between polyethylene exchange and full component revision for TKA arthrofibrosis.

METHODS

Patients were queried from an institutional database who underwent revision TKA for arthrofibrosis between January 1, 2015, and April 31, 2021. There were 33 patients who underwent full revision and 16 patients who underwent polyethylene exchange. Demographics and baseline characteristics between the cohorts were analyzed. Postoperative outcomes included MUA, LOA, and re-revision rates as well as KOOS, JR, and extension and flexion ROM at a mean follow-up of 3.8 years. Baseline comorbidities, including age, body mass index, alcohol use, tobacco use, and diabetes, were comparable between the full revision and polyethylene exchange revision cohorts (P > .05). The one and full component revisions had similar preoperative KOOS, JR (43 versus 42, P = .85), and flexion (81 versus 82 degrees, P = .80) versus extension (11 versus 11 degrees, P = .87) ROM.

RESULTS

The full component revision had higher KOOS, JR (65 versus 55, P = .04), and flexion (102 versus 92 degrees, P = .02), but similar extension (3 versus 3 degrees, P = .80) ROM at final follow-up compared to the polyethylene exchange revision, respectively. The MUA (18.2 versus 18.8%, P = .96) and LOA (2.0 versus 0.0%, P = .32) rates were similar between full component and polyethylene exchange revisions. There was one re-revision (3.0%) for the cohort of patients who initially underwent full revision. There were four full re-revisions (25.0%) and two polyethylene exchange re-revisions (12.5%) performed in the cohort of patients who initially underwent a polyethylene exchange revision.

CONCLUSIONS

The full component revision for stiffness after TKA showed favorable KOOS, JR, ROM, and outcomes in comparison to the polyethylene exchange revision. While the optimal treatment for stiffness after TKA is without consensus, this study supports the use of the full component revision when applied to the institutional population at hand. It is imperative that homogeneity exists in preoperative definitions, preoperative baseline patient demographics, ROM and function levels, outcome measures, and preoperative indications, as well as the inclusion of clinical data that assesses complete exchange, single exchange, and tibial insert exchange.

Neighborhood socioeconomic disadvantages associated with increased rates of revisions, readmissions, and complications after total joint arthroplasty

INTRODUCTION

Low socioeconomic status based on neighborhood of residence has been suggested to be associated with poor outcomes after total joint arthroplasty (TJA). The area deprivation index (ADI) is a scale that ranks (zero to 100) neighborhoods by increasing socioeconomic disadvantage and accounts for median income, housing type, and family structure. We sought to examine the potential differences between high (national median ADI = 47) and low ADI among TJA recipients at a single institution. Specifically, we assessed: (1) 30-day emergency department visits/readmissions; (2) 90-day and 1-year revisions; as well as (3) medical and surgical complications.

METHODS

A consecutive series of primary TJAs from September 21, 2015, through December 29, 2021, at a tertiary healthcare system were reviewed. A total of 3,024 patients who had complete ADI data were included. Patients were divided into groups below the national median ADI of 47 (n = 1,896) and above (n = 1,128). Multivariable regressions to determine independent risk factors accounting for ADI, race, age, sex, American Society of Anesthesiologists Classification grade, body mass index, diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease, hypertension, chronic kidney disease, alcohol abuse, substance abuse, and tobacco use. The primary outcomes of interest include evaluation of the independent association of ADI with total postoperative complications (at 30 days, 90 days, and 1 year) after adjusting for multiple relevant cofactors.

RESULTS

After adjusting for multiple relevant cofactors, at 90 days, ADI > 47 (OR, 1.36, 95% CI 1.00-1.83, P = 0.04), men versus women (OR, 0.73, 95% CI 0.54-0.99, P = 0.039), and CHF (OR, 1.90, 95% CI 1.18-3.06, P = 0.009) were independently associated with increased total complications. The ADI was not associated with increased total complications at 30 days or 1-year (All P > 0.05).

CONCLUSION

Our findings of higher complications of the ADI > 47 cohort at 90 days, reaffirm the complex relationship between ADI, patient demographics, and additional socioeconomic parameters that may influence postoperative outcomes and complications after TJA. This study utilizing ADI demonstrates potential areas of intervention and further investigation for assessing arthroplasty outcomes.

Treatment of 2-part, 3-part, and 4-part proximal humerus fractures from 2016 to 2020: A nationally-representative database

Introduction

Complex proximal humerus fractures pose challenges in elderly patients, as this common scenario can lead to unpredictable outcomes, regardless of treatment method. Given the evolving nature of the treatment for 3-and-4-part proximal humerus fractures, an epidemiological analysis offers a way to minimize the gap between appropriate understanding and effective intervention. As such, we aimed to i) evaluate the trends of nonoperative and operative management; and ii) compare the complication rates of ORIF to conversion ORIF (to RTSA).

Methods

We utilized a national, all-payer database to include patients who underwent open reduction and internal fixation for 2-part (n = 2783), 3-part (n = 2170), 4-part (n = 1087) proximal humerus fractures between April 2016 to December 2022. Patients who failed ORIF to RTSA included n = 108 for 2-part fractures, n = 123 for 3-part fractures, and n = 128 for 4-part fractures. We collected demographic and postoperative medical and surgical complications at 90-days, in addition to time-interval between ORIF and RTSA.

Results

The malunion and nonunion rates for ORIF between different types of proximal humerus fractures were similar (2-part fractures: 1.8 %, 4.7 %; 3-part fractures: 1.8 %, 3.5 %; 4-part fractures: 2.4 %, 3.7 %). The conversion rates of failed ORIF to RTSA were 1.9 %, 2.8 %, and 5.9 % for 2-part, 3-part, and 4-part fractures, respectively. The time interval from failed ORIF to RTSA was 190 days for 2-part fractures, 169 days for 3-part fractures, and 129 for 4-part fractures.

Conclusion

An epidemiological analysis of proximal humerus fractures by fracture type demonstrated an increase in RTSA for 2-part, 3-part, and 4-part fractures while nonoperative treatment showed no change from 2016 to 2020. Additional research is needed to determine which fractures are best treated operatively while maximizing outcomes. In the setting of complex proximal humerus fractures, several options seem feasible depending on patient demographic characteristics.

An anatomic study of the morphologic characteristics of the dorsal capitolunate ligament

PURPOSE

There is consensus in favor of a description of the dorsal ligaments of the carpus as not including a direct ligament between the lunate and capitate. On the other hand, there is an anatomical formation which, according to the currently accepted description, corresponds to the dorsal midcarpal capsule, itself thickened by the dorsal intercarpal ligament. The question is whether the capsule at this point deserves to be called an individualizable ligament. In our operative experience of the dorsal carpus, we have encountered a stout structure adherent to the lunate and capitate. In this article, we present the anatomic evidence of this structure's existence.

METHODS

Seven adult fresh frozen upper extremities were dissected. Three wrists were longitudinally sectioned in line with the middle finger metacarpal. The remaining 4 were dissected dorsally. Two representative samples of the stout structure connecting the lunate to the capitate were sent to pathology for histologic analysis and staining.

RESULTS

In all 3 of the longitudinally sectioned wrists, a thick band of tissue could clearly be seen, originating on the lunate, spanning the dorsal interval between the lunate and the capitate, and inserting on the capitate. With this structure intact, dorsal dislocation of the capitate was not possible, but preliminary sectioning of the structure allowed dislocation. In the 4 dorsally dissected wrists, the same connection was observed, palmar to the dorsal intercarpal ligament, in every specimen. The average dimensions of the dorsal capitolunate were: 15.25 ± 1 mm long, 8.75 ± 1 mm wide at the midpoint, and 1.75 ± 1 mm thick. The two specimens sent to pathology after sectioning showed longitudinally oriented collagen fibers. This structure also stained positive for elastin and contained intrasubstance vascular structures.

CONCLUSION

There is a stout ligamentous structure connecting the lunate to the capitate, palmar to the dorsal intercarpal ligament. Disruption of this structure appears to be necessary for dorsal dislocation of the capitate. Clinical studies are needed to gain better understanding of the exact function and importance of this structure.

C. Difficile Infection within 6 Months before TKA Is Associated with Increased Short-Term Complications

A history of Clostridium difficile infection (CDI) before total knee arthroplasty (TKA) may be a marker for poor patient health and could be used to identify patients with higher risks for complications after TKA. We compared the frequency of 90-day postoperative CDI, complications, readmissions, and associated risk factors in (1) patients experiencing CDIs more than 6 months before TKA, (2) patients experiencing CDIs in the 6 months before TKA, and (3) patients without a history of CDI. We identified patients who underwent primary TKAs from 2010 to 2019 and had a history of CDI before TKA (n = 7,195) using a national, all-payer database. Patients were stratified into two groups: those with CDIs > 6 months before TKA (n = 6,027) and those experiencing CDIs ≤ 6 months before TKA (n = 1,168). These patients were compared with the remaining 1.4 million patients without a history of CDI before TKA. Chi-square and unadjusted odds ratios (ORs) with 95% confidence intervals (CI) were used to compare complication frequencies. Prior CDI during either timespan was associated with higher unadjusted odds for postoperative CDI (CDI > 6 months before TKA: OR 8.03 [95% CI 6.68-9.63]; p < 0.001; CDI ≤ 6 months before TKA: OR 59.05 [95% CI 49.66-70.21]; p < 0.001). Patients with a history of CDI before TKA were associated with higher unadjusted odds for 90-day complications and readmission compared with patients without a history of CDI before TKA. Other comorbidities and health metrics were not found to be associated with postoperative CDI (i.e., age, obesity, smoking, antibiotic use, etc.). CONCLUSION:  CDI before TKA was associated with higher odds of postoperative CDI compared with patients without a history of CDI. CDI ≤ 6 months before TKA was associated with the highest odds for postoperative complications and readmissions. Providers should consider delaying TKA after CDI, if possible, to allow for patient recovery and eradication of infection.

The use of preoperative continuous positive airway pressure in patients with obstructive sleep apnea following total hip arthroplasty: A propensity score matched analysis

Introduction

Obstructive sleep apnea (OSA) impacts approximately 936 million individuals globally and is known to complicate post-surgical recovery, particularly after total hip arthroplasty (THA). While continuous positive airway pressure (CPAP) is commonly recommended for managing OSA, its effect on THA recovery remains uncertain. The study aimed to assess the impact of CPAP use on post-THA outcomes in patients with OSA, focusing on medical complications and periprosthetic joint infection (PJI) at 90 days and 1 year.

Methods

A national, all-payer database was utilized to identify patients undergoing primary THA between 2010 and 2021. Patients with OSA were stratified based on CPAP use through propensity score matching. Three matched groups were formed: OSA without CPAP, OSA with CPAP, and no OSA. Medical and surgical complications were assessed at 90 days and 1 year post-THA.

Results

Patients with OSA using CPAP exhibited more baseline comorbidities than those without CPAP. CPAP use was associated with inferior outcomes, including higher odds of PJI, wound complications, and venous thromboembolism at 90 days and 1 year post-THA. These trends were consistent even after adjusting for confounders.

Conclusion

CPAP use, indicative of severe OSA, was linked to worse post-THA outcomes, emphasizing the importance of recognizing OSA severity preoperatively. The study does not advocate for or against CPAP use but underscores the heightened risk in this patient population, guiding clinicians in tailoring perioperative strategies and counseling patients about potential risks.

Staged Approach to Tibial Nail Removal Poses Increased Risk for Infection in the Setting of Total Knee Arthroplasty

BACKGROUND

While previous research has addressed conversion arthroplasty scenarios, there is limited data on outcomes of staged or concurrent removal of intramedullary (IM) nails during total knee arthroplasty (TKA). Our study aimed to explore the association between the timing of IM nail removal and the incidence of periprosthetic joint infection (PJI), surgical site infection (SSI), manipulation under anesthesia (MUA), and aseptic revision at 90 days, 1 year, and 2 years after TKA when IM nail removal is performed in either a (1) staged or (2) concurrent manner.

METHODS

We queried a national, all-payer database of all patients who underwent a primary TKA and hardware removal of an IM tibial nail. The group was separated into mutually exclusive cohorts with removal performed either (1) in a staged manner (n = 287) or (2) on the same day of TKA (n = 2,958). Surgical complications included the following: PJIs, SSIs, MUAs, and aseptic revisions. Surgical complications were collected at 90-day, 1 year, and 2-year time points.

RESULTS

Patients who had staged nail removal before TKA demonstrated the highest incidence of PJI at 90 days, 1 year, and 2 years (13.9, 16.7, and 17.1%, respectively). Adjusted multivariate regression analyses demonstrated significantly higher odds of a PJI, SSI, and MUA at 90 days, 1 year, and 2 years for all patients who had staged nail removal TKA (P < .001).

CONCLUSIONS

There was an observed association between concurrent IM nail removal and a decreased risk of PJI, SSI, and MUA when compared to patients who had nail removal in a staged fashion. However, this does not discount the utility of the staged approach, as it may be necessary for patients less tolerant to longer operative times.

Stroke History and Time Elapsed are Predictors of Complications in Total Knee Arthroplasty

BACKGROUND

A consensus has not been reached regarding the optimal timing of elective total knee arthroplasty (TKA) following a stroke. The purpose of this study was to examine the optimal period between stroke and TKA to minimize complications. Specifically, we assessed: (1) medical and surgical complications; (2) timing of stroke and TKA; (3) associated risk factors.

METHODS

A national database identified 69,815 TKA patients that were separated into 6 exclusive cohorts using a stratum likelihood ratio: no stroke (n = 20,000), stroke within 6 (n = 17,764), 12 (n = 10,338), 18 (n = 8,370), 24 (n = 7,121), and 30 months (n = 6,222) prior to TKA. We analyzed 90-day, 1-year, and 2-year complications in each subgroup. Multivariate analyses were used to identify risk factors for periprosthetic joint infection (PJI).

RESULTS

The multivariate regression model identified that patients with a stroke within 6 months of TKA had increased risk of PJI at all time points (P < .001). Also, stroke 12 to 18 months before TKA elevated PJI risk at 1 and 2 years (all P < .021), while those over 18 months did not show a significant risk compared to controls (P > .067).

CONCLUSIONS

Stroke prior to TKA was associated with an increased risk of postoperative complications, specifically PJI. We recommend a minimum of 6 months between stroke and TKA, with 18 months offering the lowest risk.

Cementless medial pivot design demonstrates equal or better outcomes compared to cementless cruciate-retaining design following total knee arthroplasty

Introduction

Traditional total knee arthroplasty (TKA) designs fail to reproduce physiologic knee kinematics, which can contribute to patient dissatisfaction. In an attempt to restore more normal knee kinematics, the medial pivot (MP) design may improve knee function and stability as well as patient satisfaction. A limited number of studies have compared postoperative outcomes of exclusively cementless Cruciate-Retaining (CR) TKAs to cementless MP TKAs. We aimed to compare: (1) 90-day, 1-year, and 2-year complications and revisions, (2) preoperative and postoperative range of motion (ROM), (3) Knee Injury and Osteoarthritis Outcome (KOOS-JR), and (4) visual analog scale (VAS) pain scores at 3-month, 6-month, 1-year, and 2-years.

Methods

A retrospective analysis was performed to identify all patients who had previously undergone a TKA at our institution and compare a cementless CR system to a cementless MP design. Categorical variables, including demographics, comorbidities, and complications utilized Chi-square tests in bivariable analysis. Continuous variables, such as age, were compared using Student's t-tests. Significance was defined as p < 0.05.

Results

Cementless CR and cementless MP cohorts showed low profiles of postoperative complications and favorable patient-reported outcome measures (PROMs). The MP cohort had lower VAS pain at 1-year (1.70 vs. 3.76, p < 0.001) and 2-years (1.43 vs. 2.60, p < 0.001) and higher ROM at 3-months (118 vs. 100, p < 0.001), 6-months (113 vs. 103, p < 0.0001), and 1-year (117 vs. 110, p = 0.02), respectively.

Conclusion

This study is the first comparison of postoperative outcomes between a cementless CR TKA and cementless MP TKA designs. Implant design and fixation type are vital components influencing patient satisfaction after TKA. Pain scores and range of motion favored the cementless MP cohort in comparison to the cementless CR cohort.

Survivorship, complications, and outcomes following distal femoral replacement for neoplastic indications

Background

Distal femoral replacements (DFRs) are excellent treatment options for limb salvage procedures in patients who have bone loss secondary to neoplasm. Multiple studies report adequate survivorship and complication rates following DFR implantation, primarily for non-neoplastic indications. However, current literature regarding neoplasm-specific reports is often limited by sample size, survivorship, and patient reported outcome measurements. Therefore, we sought to examine patients who received a DFR for a neoplastic indication at multiple tertiary academic centers. Specific outcomes analyzed included: (1) revision-free survival, (2) medical/surgical complications, and (3) Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR).

Methods

All patients who underwent a DFR for a neoplastic indication were retrospectively reviewed. A total of 29 knees were included for various neoplastic indications. Outcomes of interest included: post-operative thromboses, pneumonia, dislocations, periprosthetic joint infections (PJIs), aseptic loosening, osteolysis, emergency department visits, inpatient readmissions, and revision surgeries. Patient-reported outcome measure (PROM) collected included: Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR).

Results

Revision-free survivorship was 72.4 % at 23 months with radiographic follow-up. PJI was the most common post-operative complication, affecting 3 knees (10.3 %). The mean number of emergency department visits and inpatient readmissions averaged less than one per patient (0.63 and 0.41, respectively). KOOS JR scores improved markedly among from baseline to final follow-up (44.1-57.8).

Conclusion

The use of DFR led to satisfactory medium-term clinical outcomes with an acceptable complication rate for this challenging group of patients. The marked improvement in patient satisfaction for this patient population gives a promising outlook for patients who will undergo this procedure in the future and can guide patient-provider regarding surgical expectations.

The Utility of the Area Deprivation Index in Assessing Complications After Total Joint Arthroplasty

Background

Vulnerable populations, including patients from a lower socioeconomic status, are at an increased risk for infection, revision surgery, mortality, and complications after total joint arthroplasty (TJA). An effective metric to quantify and compare these populations has not yet been established in the literature. The Area Deprivation Index (ADI) provides a composite area-based indicator of socioeconomic disadvantage consisting of 17 U.S. Census indicators, based on education, employment, housing quality, and poverty. We assessed patient risk factor profiles and performed multivariable regressions of total complications at 30 days, 90 days, and 1 year.

Methods

A prospectively collected database of 3,024 patients who underwent primary elective total knee arthroplasty or total hip arthroplasty performed by 3 fellowship-trained orthopaedic surgeons from January 1, 2015, through December 31, 2021, at a tertiary health-care center was analyzed. Patients were divided into quintiles (ADI ≤20 [n = 555], ADI 21 to 40 [n = 1,001], ADI 41 to 60 [n = 694], ADI 61 to 80 [n = 396], and ADI 81 to 100 [n = 378]) and into groups based on the national median ADI, ≤47 (n = 1,896) and >47 (n = 1,128).

Results

Higher quintiles had significantly more females (p = 0.002) and higher incidences of diabetes (p < 0.001), congestive heart failure (p < 0.001), chronic obstructive pulmonary disease (p < 0.001), hypertension (p < 0.001), substance abuse (p < 0.001), and tobacco use (p < 0.001). When accounting for several confounding variables, all ADI quintiles were not associated with increased total complications at 30 days, but age (p = 0.023), female sex (p = 0.019), congestive heart failure (p = 0.032), chronic obstructive pulmonary disease (p = 0.001), hypertension (p = 0.003), and chronic kidney disease (p = 0.010) were associated. At 90 days, ADI > 47 (p = 0.040), female sex (p = 0.035), and congestive heart failure (p = 0.001) were associated with increased total complications.

Conclusions

Balancing intrinsic factors, such as patient demographic characteristics, and extrinsic factors, such as social determinants of health, may minimize postoperative complications following TJA. The ADI is one tool that can account for several extrinsic factors, and can thus serve as a starting point to improving patient education and management in the setting of TJA.

Level of Evidence

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

Elevated risk of prosthetic infections in cannabis users after shoulder arthroplasty

INTRODUCTION

An increasing number of states are beginning to legalize recreational cannabis use, and as such, more patients using cannabis are undergoing shoulder arthroplasty procedures. The present study sought to examine the impact of cannabis use on post-operative outcomes. The primary outcomes of interest were postoperative complications, which included infection, periprosthetic fractures, periprosthetic joint infections (PJI), dislocations, and aseptic loosening as well as medical complications. Secondary outcomes were risk factors for PJI and aseptic loosening at two-years.

METHODS

A private, nationwide, all-payer database (Pearldiver Technologies) was queried to identify shoulder arthroplasty patients from 2010 to 2020. Those not using tobacco or cannabis ("control", n = 10,000), tobacco users (n = 10,000), cannabis users (n = 155), and concurrent tobacco and cannabis users (n = 9,842) were identified. Risk factors for PJI and aseptic loosening at two-years were further quantified utilizing multivariable logistic regression analysis.

RESULTS

Compared to non-users, cannabis users experienced the highest odds for PJI and aseptic revisions, which were followed by concurrent cannabis and tobacco users and tobacco-only users. Concurrent users, as well as tobacco users were at higher risk for dislocation. Cannabis use was the most significant risk factor for PJI, followed by concurrent use and male sex.

CONCLUSIONS

Our study found cannabis use to cause greater risk for superficial and deep infection. More research involving randomized trials are needed to fully elucidate the impact of cannabis use on shoulder arthroplasty procedures. Clinically, these findings can appropriately guide surgeons and patients alike regarding expectations prior to undergoing TSA.

Use and Application of Large Language Models for Patient Questions Following Total Knee Arthroplasty

BACKGROUND

A consumer-focused health care model not only allows unprecedented access to information, but equally warrants consideration of the appropriateness of providing accurate patient health information. Nurses play a large role in influencing patient satisfaction following total knee arthroplasty (TKA), but they come at a cost. A specific natural language artificial intelligence (AI) model, ChatGPT (Chat Generative Pre-trained Transformer), has accumulated over 100 million users within months of launching. As such, we aimed to compare: (1) orthopaedic surgeons' evaluation of the appropriateness of the answers to the most frequently asked patient questions after TKA; and (2) patients' comfort level in answering their postoperative questions by using answers provided by arthroplasty-trained nurses and ChatGPT.

METHODS

We prospectively created 60 questions based on the most commonly asked patient questions following TKA. There were 3 fellowship-trained surgeons who assessed the answers provided by arthroplasty-trained nurses and ChatGPT-4 to each of the questions. The surgeons graded each set of responses based on clinical judgment as: (1) "appropriate," (2) "inappropriate" if the response contained inappropriate information, or (3) "unreliable," if the responses provided inconsistent content. Patients' comfort level and trust in AI were assessed using Research Electronic Data Capture (REDCap) hosted at our local hospital.

RESULTS

The surgeons graded 44 out of 60 (73.3%) responses for the arthroplasty-trained nurses and 44 out of 60 (73.3%) for ChatGPT to be "appropriate." There were 4 responses graded "inappropriate" and one response graded "unreliable" provided by the nurses. For the ChatGPT response, there were 5 responses graded "inappropriate" and no responses graded "unreliable." There were 136 patients (53.8%) who were more comfortable with the answers provided by ChatGPT compared to 86 patients (34.0%) who preferred the answers from arthroplasty-trained nurses. Of the 253 patients, 233 (92.1%) were uncertain if they would trust AI to answer their postoperative questions. There were 127 patients (50.2%) who answered that if they knew the previous answer was provided by ChatGPT, their comfort level in trusting the answer would change.

CONCLUSIONS

One potential use of ChatGPT can be found in providing appropriate answers to patient questions after TKA. At our institution, cost expenditures can potentially be minimized while maintaining patient satisfaction. Inevitably, successful implementation is dependent on the ability to provide information that is credible and in accordance with the objectives of both physicians and patients.

LEVEL OF EVIDENCE

III.

Addition of vancomycin to cefazolin is often unnecessary for preoperative antibiotic prophylaxis during total joint arthroplasties

PURPOSE

The gold standard to decrease total joint arthroplasty (TJA) periprosthetic joint infection (PJI) is preoperative antibiotic prophylaxis. Despite substantial prevention efforts, rates of PJIs are increasing. While cefazolin is the drug of choice for preoperative prophylaxis, adjunctive vancomycin therapy has been used in methicillin-resistant Staphylococcus aureus (MRSA) endemic areas. However, studies examining these combinations are lacking. Therefore, we sought to examine complications among vancomycin plus cefazolin and cefazolin-only recipients prior to primary TJA in a single institutional sample and specifically assessed: (1) microbiological aspects, including periprosthetic joint and surgical site infections, microbes cultured from the infection, and frequency of microbes cultured from nasal swab screening; (2) 30-day emergency department (ED) visits and re-admissions; as well as (3) associated risk factors for infection.

METHODS

A total of 2,907 patients (1,437 receiving both cefazolin and vancomycin and 1,470 given cefazolin only) who underwent primary TJA between 1 January 2014 and 31 May 2021 were identified. SSI and PJI as well as rates of cultured microbes rates were obtained through one year, those with prior nasal swab screening and 30-day re-admission were identified. Subsequently, multiple regression analyses were performed to investigate potential independent risk factors for PJIs.

RESULTS

There was no significant difference in the rates of SSI (P = 0.089) and PJI (P = 0.279) between the groups at one year after operation. Commonly identified organisms included Staphylococcus and Streptococcus species. The VC cohort did have a greater reduction of MRSA in the previously nasal swab-screened subset of patients. Multiple regression analyses demonstrated emergency as well as inpatient admissions as risk factors for PJI.

CONCLUSIONS

Adjunctive vancomycin therapy offers increased protection against MRSA in previously screened individuals. However, those negative for MRSA screening do not require vancomycin and have similar protection to infection compared to recipients of cefazolin only in a high-powered single institution analysis in an MRSA endemic area.

The Impact of Preoperative Weight Loss Timing on Surgical Outcomes in Total Hip Arthroplasty

BACKGROUND

Elevated body mass index (BMI) increases surgical complications post-total hip arthroplasty (THA). However, the effects of rapid weight loss pre-THA remain unclear. This study evaluated patients who had initial BMIs between 40 and 50, and then achieved a BMI under 35 at various intervals before their THA. Comparisons were made with consistent obese and nonobese groups to understand potential complications.

METHODS

Using a national database, we categorized THA patients based on initial BMI and weight loss timing before the surgery. These were contrasted with those maintaining a steady BMI of 20 to 30 or 40 to 50. We monitored outcomes like periprosthetic joint infections (PJI), surgical site infections (SSI), and noninfectious revisions for 2 years postsurgery, incorporating demographic considerations. Statistical analyses utilized Chi-square tests for categorical outcomes and Student's t-tests for continuous variables.

RESULTS

Among patients who had a BMI of 45 to 50, weight loss 3 to 9 months presurgery increased PJI risks at 90 days (Odds Ratios [OR]: 2.15 to 5.22, P < .001). However, weight loss a year before the surgery lowered the PJI risk (OR: 0.14 to 0.27, P < .005). Constantly obese patients faced heightened PJI risks 1 to 2 years postsurgery (OR: 1.64 to 1.95, P < .015). Regarding SSI, risks increased with weight loss 3 to 9 months before surgery, but decreased when weight loss occurred a year earlier. In the BMI 40 to 45 group, weight loss 3 to 6 months presurgery showed higher PJI and SSI at 90 days (P < .001), with obese participants consistently at greater risk.

CONCLUSIONS

While high BMI poses THA risks, weight loss timing plays a crucial role in postoperative complications. Weight loss closer to the surgery (0 to 9 months) can heighten risks, but shedding weight a year in advance seems beneficial. Conversely, initiating weight loss approximately a year before surgery offers potential protective effects against postoperative issues. This highlights the importance of strategic weight management guidance for patients considering THA, ensuring optimal surgical results and reducing potential adverse outcomes.

The Current Epidemiology of Revision Total Knee Arthroplasty in the United States From 2016 to 2022

BACKGROUND

The number of revision total knee arthroplasties (TKAs) is projected to reach 268,200 cases annually by 2030 in the United States. The growing demand for revision TKA can be attributed to the successes of primary TKAs combined with an aging population, patient desires to remain active, as well as expanded indications for younger patients. Given the evolving nature of revision TKAs, an epidemiological analysis of: (1) etiologies; (2) demographics, including age and region; as well as (3) lengths of stay (LOS) offers a way to minimize the gap between appropriate understanding and effective intervention.

METHODS

From 2016 to 2022, a national, all-payer database was queried. Incidences and indications were analyzed for a total of 135,983 patients who had revision TKA procedures.

RESULTS

The most common etiologies for revision TKA procedures were infection (19.3%) and aseptic loosening (12.8%), followed by mechanical complications (7.9%). The largest age group was 65 to 74 years (34.9%) followed by 55 to 64 years (32.2%), then age >75 years (20.5%). The South had the largest total procedure cohort (39.8%), followed by the Midwest (28.6%), then the Northeast (18.6%), and the West (13.0%). The mean length of stay was 3.86 days (range, 1.0 to 15.0).

CONCLUSIONS

Our study details the current status of revision TKA through 2022. While infection and aseptic loosening remain leading causes, we found a low aseptic loosening rate of 12.8%.

Operative Versus Nonoperative Treatment for Closed Displaced Midshaft Clavicle Fractures

BACKGROUND

Nonoperative treatment for clavicle fractures has historically been standard of care, but with a concomitant rise in recent operative fixation for displaced midshaft clavicle fractures (MCF), a re-evaluation of treatment modalities is necessary. The purpose of this study was to compare nonunion rates among operative and nonoperative treatment of closed displaced MCF. Specifically, we assessed the following between operative and nonoperative management: (1) 90-day to 1-year nonunion and malunion incidence; (2) 90-day medical complications; and (3) 90-day to 1-year total costs of care.

METHODS

An all-payer national database was retrospectively reviewed for closed displaced MCF from 2010 to 2020 (n = 173 188). Of these, patients undergoing operative fixation within 30 days of a displaced MCF were identified (n = 17 452). Nonoperative displaced MCF patients were matched with operative patients at a 3:1 ratio. Outcomes at 90 days and 1 year included: nonunion, total cost, and complications.

RESULTS

Closed displaced MCF with operative fixation resulted in significantly increased nonunion rates at 1 year compared with nonoperative treatment (3.97% vs 1.63%, odds ratio = 2.50 [2.26-2.77], P < .001). Kaplan-Meier survivorship and log-rank score demonstrated the same for a 1-year nonunion endpoint (P < .001). As expected, the operative cohort incurred higher median total costs of care at 90 days ($3255.00 vs $1024.00, P < .001) and 1 year ($1978.00 vs $4799.50, P < .001) compared with nonoperative treatment.

CONCLUSION

Our study found higher nonunion incidence after operative fixation of displaced MCF. These results may serve as a catalyst for future high-quality prospective studies comparing treatment options for closed displaced MCF.

Risk Factors Portending a Total Hip Arthroplasty for Patients Who Have Osteonecrosis of the Femoral Head

INTRODUCTION

Osteonecrosis of the femoral head (ONFH) poses a substantial burden to orthopaedic surgeons. However, the exact risk attributed by each specific patient factor for those who end up receiving a total hip arthroplasty (THA) are not well known. We assessed: (1) patient demographics (age and sex); (2) blood cell dyscrasias (sickle-cell disease and hypercoagulable states); and (3) substance use (oral corticosteroid use, tobacco use, and alcohol abuse).

MATERIALS AND METHODS

A retrospective search examined all patients who had a primary THA (n=715,100) between January 1, 2010 and April 30, 2020 using a national, all-payer database. Risk factors studied included age, sex, sickle-cell, hypercoagulable state, oral corticosteroid use, tobacco use, and alcohol abuse.

RESULTS

Several risk factors were found to be significantly predictive for ONFH requiring THA: age <55 years (odds ratio [OR] 1.02, 95% confidence interval [CI] of 1.01 to 1.02, p<0.001), men (OR 1.07, 95% CI of 1.04 to 1.10, p<0.001), oral corticosteroid use (OR 1.21, 95% CI of 1.17 to 1.25, p<0.001), tobacco use (OR 1.15, 95% CI of 1.11 to 1.18, p<0.001), and alcohol abuse (OR 1.05, 95% CI of 1.01 to 1.08, p=0.009).

CONCLUSIONS

Based on the results of this study, young age, men, oral corticosteroid use, tobacco use, and alcohol abuse are risk factors for patients who have ONFH and had a THA. The degree of risk from greatest to least were: oral corticosteroid use, tobacco use, men, alcohol abuse, and age <55 years old.

The Utility of the Social Vulnerability Index as a Proxy for Social Disparities Following Total Knee Arthroplasty

BACKGROUND

In 2021, alternative payment models accounted for 40% of traditional Medicare reimbursements. As such, we sought to examine health disparities through a standardized categorization of social disparity using the social vulnerability index (SVI). We examined (1) risk factors for SVI ≥ 0.50, (2) incidences of complications, and (3) risk factors for total complications between patients who have SVI < 0.50 and SVI ≥ 0.50 who had a total knee arthroplasty (TKA).

METHODS

Patients who underwent TKA between January 1, 2022 and December 31, 2022 were identified in the state of Maryland. A total of 4,952 patients who had complete social determinants of health data were included. Patients were divided into 2 cohorts according to SVI: < 0.50 (n = 2,431) and ≥ 0.50 (n = 2,521) based on the national mean SVI of 0.50. The SVI identifies communities that may need support caused by external stresses on human health based on 4 themed scores: socioeconomic status, household composition and disability, minority status and language, and housing and transportation. The SVI theme of household composition and disability encompassed patients aged 65 years and more, patients aged 17 years and less, civilians who have a disability, single-parent households, and English language deficiencies. The higher the SVI, the more social vulnerability or resources are needed to thrive in a geographic area.

RESULTS

When controlling for risk factors and patient comorbidities, the theme of household composition and disability (odds ratio 2.0, 95% confidence interval 1.1 to 5.0, P = .03) was the only independent risk factor for total complications. Patients who had an SVI ≥0.50 were more likely to be women (65.8% versus 61.0%, P < .001), Black (34.4% versus 12.9%, P < .001), and have a median household income < $87,999 (21.3% versus 10.2%, P < .001) in comparison to the patients who had an SVI < 0.50, respectively.

CONCLUSIONS

The SVI theme of household composition and disability, encompassing patients aged 65 years and more, patients aged 17 years and less, civilians who have a disability, single-parent households, and English language deficiencies, were independent risk factors for total complications following TKA. Together, these findings offer opportunities for interventions with selected patients to address social disparities.

Trends in Deep Vein Thrombosis Prophylaxis After Total Knee Arthroplasty: 2016 to 2021

BACKGROUND

In 2011, the American Academy of Orthopaedic Surgeons released a consensus recommending venous thromboembolism (VTE) prophylaxis after total knee arthroplasty (TKA). The purpose of our study was to examine (1) incidences of postoperative complications, including pulmonary embolism (PE), deep vein thrombosis (DVT), and transfusion rates; (2) trends from 2016 to 2021 in VTE prophylaxis; and (3) independent risk factors for 90-day total complications following TKA between aspirin, enoxaparin, rivaroxaban, and warfarin.

METHODS

Using a national, all-payer database from 2016 to 2021, we identified all patients who underwent primary TKA. Exclusions included all patients who had prescribed anticoagulants within 1 year prior to TKA, hypercoagulable states, and cancer. Data were collected on baseline demographics, including age, sex, diabetes, and a comorbidity index, in each of the VTE prophylaxis cohorts. Postoperative outcomes included rates of PE, DVT, and transfusion. Multivariable regressions were performed to determine independent risk factors for total complications at 90 days following TKA.

RESULTS

From 2016 to 2021, aspirin was the most used anticoagulant (n = 62,054), followed by rivaroxaban (n = 26,426), enoxaparin (n = 20,980), and warfarin (n = 13,305). The cohort using warfarin had the highest incidences of PE (1.8%) and DVT (5.7%), while the cohort using aspirin had the lowest incidences of PE (0.6%) and DVT (1.6%). The rates of aspirin use increased the most from 2016 to 2021 (32.1% to 70.8%), while the rates of warfarin decreased the most (19.3% to 3.0%). Enoxaparin, rivaroxaban, and warfarin were independent risk factors for total complications at 90 days.

CONCLUSIONS

An epidemiological analysis of VTE prophylaxis use from 2016 to 2021 shows an increase in aspirin following TKA compared to other anticoagulant cohorts in a nationally representative population. This approach provides more insight and a better understanding of anticoagulation trends over this time period in a nationally representative sample.

Comparative analysis of open versus endoscopic carpal tunnel release in a comprehensive national database

PURPOSE

Carpal tunnel syndrome is the most common compressive neuropathy. There is limited evidence to support endoscopic compared to open carpal tunnel release according to the 2016 American Academy of Orthopaedic Surgeons Clinical Practice Guideline on carpal tunnel syndrome. The purpose of the present study was to assess differences between the two procedures by comparing 30- and 90-day complications and mean hospital costs in a large patient population.

METHODS

Using the national Mariner15 Database by PearlDiver Technologies, we retrospectively studied 27,192 carpal tunnel syndrome patients who received carpal tunnel release using an endoscopic or open surgical approach from 2010 to 2019. Patients who met the inclusion criteria were grouped and case-matched at a 1:1 ratio through the corresponding International Classification of Diseases codes (n = 13,596) and assessed for 30- and 90-day complications such as median nerve injury, superficial palmar arch injury, and revision carpal tunnel release surgery. Univariate analysis was used to compare outcomes and a multivariate regression was performed to identify risk factors associated with each outcome.

RESULTS

Endoscopic carpal tunnel release was associated with a higher rate of median nerve injury than open release at 30 days (0.3% vs. 0.1% odds ratio, 2.21; 95% confidence interval, 1.29-3.81; p < 0.05) and 90 days (0.4% vs. 0.3%; odds ratio, 1.77; 95% confidence interval, 1.16-2.70; p < 0.05). Endoscopic release was also associated with a higher rate of superficial palmar arch injury (0.1% vs. 0%; odds ratio, 25.02; 95% confidence interval, 1.48-423.0; p < 0.05).

CONCLUSIONS

In the present study, risk of median nerve injury and vascular injury was higher after endoscopic than open carpal tunnel release. At 90 days, all-cause revision rates were similar between techniques. Surgeons should understand these differences, to optimize surgical decision-making.

LEVEL OF EVIDENCE

Therapeutic, IIIa.

Preoperative Corticosteroid Injections Within 4 Weeks of Arthroscopic Shoulder Procedures Are Associated With Increased Postoperative Infection Rates

PURPOSE

To refine the understanding of the effect of timing of corticosteroid injections (CSIs) and shoulder arthroscopy on postoperative infection.

METHODS

An insurance database was used to determine all patients who underwent shoulder arthroscopy for a 5-year period with an associated preoperative ipsilateral corticosteroid injection. Patients were stratified into cohorts based on timing of preoperative CSI: (1) 0-<2 weeks, (2) 2-<4 weeks, (3) 4-<6 weeks, and (4) 6-<8 weeks. Patients were pooled to include all patients who had a CSI less than 4 weeks and those longer than 4 weeks. A cohort of patients who never had a corticosteroid injection before undergoing arthroscopy were used as a control. All patients had a follow-up of 2 years. Multivariable regression analyses were performed using R Studio with significance defined as P < .05.

RESULTS

Multivariate logistic regression showed a greater odds ratio (OR) for postoperative infection in patients who received CSI 0-<2 weeks before shoulder arthroscopy at 90 days (3.10, 95% confidence interval [CI] 1.62-5.57, P < .001), 1 year (2.51, 95% CI 1.46-4.12, P < .001), and 2 years (2.08, 95% CI 1.27-3.28, P = .002) compared with the control group. Patients who received CSI 2-<4 weeks before shoulder arthroscopy had greater OR for infection at 90 days (2.26, 95% CI 1.28-3.83, P = .03), 1 year (1.82, 95% CI 1.13-2,82, P = .01), and 2 years (1.62, 95% CI 1.10-2.47, P = .012). Patients who received CSI after 4 weeks had similar ORs of infection at 90 days (OR 1.15, 95% CI 0.78-1.69, P = .48) 1 year (OR 1.18, 95% CI 0.85-1.63 P = .33), and 2 years (OR 1.09, 95% CI 0.83-1.42, P = .54), compared with the control cohort.

CONCLUSIONS

The present study shows the postoperative infection risk is greatest when CSIs are given within 2 weeks of shoulder arthroscopy, whereas CSIs given within 2-<4 weeks also portend increased risk, albeit to a lesser degree. The risk of postoperative infection is not significantly increased when CSIs are given more than 1 month before surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative, prognosis study.

Optimal Method of Skin Wound Management for Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Skin closure for total knee arthroplasty (TKA) typically focuses on promoting optimal healing, while preventing wound complications and infection, allowing for functionality and immediate ambulation, and providing for excellent cosmesis. In this systematic review and meta-analysis of the literature, we will focus on closure of the skin. Specifically, we assessed: (1) wound complication risk of different techniques and (2) closing time of different sutures/techniques. There were 20 reports on infection risk and closing time. Meta-analyses focused on the qualifying studies for closing time and wound complication risk reports were also performed. These studies (378 patients) demonstrated overall lower wound complication risks with the use of barbed compared with traditional sutures (3% vs. 6%, p < 0.05). The subsequent meta-analysis included 749 patients demonstrating overall significant closing time reductions of a mean of 7 minutes with the use of barbed sutures (p < 0.05). Therefore, multiple recent reports suggest superior outcomes and faster results when using barbed sutures for TKA skin closure.

Trends in deep vein thrombosis prophylaxis after total hip arthroplasty: 2016 to 2021

Introduction

Venous thromboembolism (VTE) has long been acknowledged as a potential complication of total hip arthroplasty (THA) contributing to heightened patient morbidity, mortality, and substantial healthcare costs. We aimed to: 1) assess trends in VTE prophylaxis utilization between 2016 and 2021; 2) determine the incidence of postoperative VTE and transfusions; and 3) identify independent risk factors for 90-day VTE and transfusion risks following THA in relation to the use of aspirin, dabigatran, enoxaparin, rivaroxaban, and warfarin.

Methods

A national, all-payer database was queried from January 1, 2016 and December 31, 2022. Use trends for aspirin, enoxaparin, rivaroxaban, dabigatran, and warfarin as thromboprophylaxis following THA was assessed. Incidence of ninety-day postoperative outcomes assessed included rates of 90-day postoperative VTE and transfusion.

Results

From 2016 to 2021, aspirin (n = 36,346) was the most used agent for VTE prophylaxis after THA, followed by dabigatran (n = 13,065), rivaroxaban (n = 11,790), enoxaparin (n = 11,380), and warfarin (n = 6326). Independent risk factors for 90-day VTE included CKD, COPD, CHF, obesity, dabigatran, enoxaparin, rivaroxaban, and warfarin (all p < 0.05).

Conclusion

Aspirin was used with increasing frequency and demonstrated lower rates of VTE and transfusion following THA, compared to dabigatran, enoxaparin, rivaroxaban, and warfarin. These findings seem to indicate that the increasing use of aspirin in VTE prophylaxis has been accomplished in appropriately selected patients.

Cemented Versus Cementless Femoral Fixation for Total Hip Arthroplasty Following Femoral Neck Fracture in Patients Aged 65 and Older

BACKGROUND

Femoral neck fractures are common in individuals over 65, necessitating quick mobilization for the best outcomes. There's ongoing debate about the optimal femoral component fixation method in total hip arthroplasty (THA) for these fractures. Recent U.S. data shows a preference for cementless techniques in over 93% of primary THAs. Nonetheless, cemented fixation might offer advantages like fewer revisions, reduced periprosthetic fractures, lesser thigh pain, and enhanced long-term implant survival for those above 65. This study compares cementless and cemented fixation methods in THA, focusing on postoperative complications in patients aged 65 and older.

METHODS

We analyzed a national database to identify patients aged 65+ who underwent primary THA for femoral neck fractures between 2016 and 2021, using either cementless (n = 2,842) or cemented (n = 1,124) techniques. A 1:1 propensity-matched analysis was conducted to balance variables such as age, sex, and comorbidities, resulting in two equally sized groups (n = 1,124 each). We evaluated outcomes like infection, venous thromboembolism (VTE), wound issues, dislocation, periprosthetic fracture, etc., at 90 days, 1 year, and 2 years post-surgery. A P-value < 05 indicated statistical significance.

RESULTS

The cemented group initially consisted of older individuals, more females, and higher comorbidity rates. Both groups had similar infection and wound complication rates, and aseptic loosening. The cemented group, however, had lower periprosthetic fracture rates (2.5 versus 4.4%, P = .02) and higher VTE rates (2.9 versus 1.2%, P = .01) at 90 days. After 1 and 2 years, the cementless group experienced more aseptic revision surgeries.

CONCLUSIONS

This study, using a large, national database and propensity-matched cohorts, indicates that cemented femoral component fixation in THA leads to fewer periprosthetic fractures and aseptic revisions, but a higher VTE risk. Fixation type choice should consider various factors, including age, sex, comorbidities, bone quality, and surgical expertise. This data can inform surgeons in their decision-making process.

Biologic Disease-Modifying Antirheumatic Drugs Do Not Increase Risk for Prosthetic Joint Infection in Setting of Total Knee Arthroplasty

Over 25% of patients with rheumatoid arthritis (RA) are expected to undergo a joint replacement during their lifetime. Current practice guidelines recommend withholding biologic therapy 1 week prior to total hip arthroplasty, given its immunosuppressive effects. Most patients are on a regimen including biologic and nonbiologic therapy; however, the individual influences of these therapies are not well understood in the setting of total knee arthroplasty (TKA). Therefore, we sought to compare biologic, nonbiologic, and recipients of both types of therapy in patients with RA undergoing TKA. We specifically assessed (1) medical complications at 90 days; (2) surgical complications up to 1 year; and (3) independent risk factors for prosthetic joint infections (PJIs).A retrospective review was conducted using a national, all-payer database for patients undergoing primary TKA from January 2010 to April 2020 (n = 1.97 million). Patients diagnosed with RA were then separated into at least 1-year users of biologic (n = 3,092), nonbiologic (28,299), or dual (n = 10,949) therapy. Bivariate analyses were utilized to assess for 90-day medical and up to 1-year surgical outcomes. Additionally, multivariate regression models were utilized to assess for independent risk factors.The incidence and odds ratio for medical/surgical outcomes were equivocal among the biologic, nonbiologic, and recipients receiving both types of therapy (p > 0.061). No differences were observed between the type of therapy as additional risk factors for infection (p > 0.505). However, glucocorticoids at 90 days and alcohol abuse, diabetes mellitus, obesity, as well as tobacco use were identified as additional risk factors for PJI(p < 0.036).No appreciable differences in medical or surgical outcomes were associated with the independent use of biologic, nonbiologic, or recipients of both types of therapy in patients with RA. Additionally, alcohol abuse, diabetes mellitus, glucocorticoids, obesity, and tobacco use conferred an increased risk of PJI. These results can serve as an adjunct to current practice guidelines.

Effect of Various Ancillary Operating Room Techniques on Wound Healing Outcomes After Total Hip Arthroplasty

INTRODUCTION

The successful management of wound healing following total hip arthroplasty (THA) is multifaceted, relying on various intraoperative techniques and surgical variables. Recent reviews have evaluated many of these factors, including the comparison between mesh-adhesive dressings and other skin closure methods, the closing time of different suture techniques, and the four aspects of closure for THA (deep fascial layer; subdermal layer; intradermal layer). However, previous articles did not cover certain topics that can be directly influenced by the surgeon. Specifically, these include the use of deep vein thrombosis (DVT) prophylaxis, the management of intraoperative drains, and the selection of surgical approaches. Therefore, in this comprehensive systematic review of the literature, we have focused on three factors that may influence wound healing. We evaluated the following: (1) the impact of different DVT prophylaxis methods on wound healing and infection rates; (2) the effects of intraoperative drain use on wound healing; (3) the influence of various surgical approaches on wound closure, and postoperative infection rates. By concentrating on these areas, this review aims to provide a more complete understanding of the factors that contribute to successful wound management after THA.

MATERIALS AND METHODS

A systematic search of electronic databases, including PubMed, Cochrane Library, Medline, and Embase, was conducted to identify studies assessing surgical variables and techniques, specifically focusing on DVT prophylaxis, intraoperative drain use, and surgical approaches and their impact on wound healing in THA. Relevant terms like "hip," "arthroplasty," "wound healing," "DVT prophylaxis," and "surgical approaches" refined the search, which included English language publications until May 1, 2023. Independent screening by two authors and a third mediator facilitated the selection process, with 13 studies meeting the criteria. Assessment of these studies involved evaluating their evidence level and methodological quality using the Modified Coleman Methodology Score (MCMS). A comparison was made on wound healing outcomes in THA, specifically focusing on the three factors outlined in the introduction: (1) the impact of different DVT prophylaxis methods on wound healing and infection rates; (2) the effects of intraoperative drain use on wound healing; and (3) the influence of various surgical approaches on wound closure and postoperative infection rates. Data synthesis for the studies provided a comprehensive summary, categorizing them by evidence level, and aimed to contribute to a more complete understanding of the factors that influence successful wound management after THA.

RESULTS

In studies examining DVT prophylaxis for total knee arthroplasties (TKA), three reports found that both rivaroxaban and enoxaparin had similar wound infection rates at 0.36%. However, one study segment suggested a slightly higher infection rate for rivaroxaban at 0.71% compared to enoxaparin's 0.49%. Despite this difference, it was not statistically significant (odds ratio [OR] 1.34, 95% confidence interval [CI] 0.46 to 3.86). In recent research, a low dose of aspirin has been observed to yield fewer wound complications when contrasted with other techniques. Five studies on intraoperative drain use revealed mixed outcomes. A total of five studies were identified that evaluated wound complications with drains following THA, comprising two randomized controlled trials (RCTs) and three observational cohort studies, with a combined sample size of 765. Among these, four studies specifically compared the use of closed suction drains to no drains. Half of these studies (two out of four) reported no significant differences in wound complications between the two groups, while the other half presented mixed findings. In surgical approach comparisons by Jin et al., meta-analysis between the direct anterior approach (DAA) and posterolateral approach (PLA) showed no significant difference in complications (OR 0.57, p=0.952). Two studies analyzed bikini incision DAA versus PLA or conventional DAA, indicating comparable outcomes with no significant differences in wound complications between the approaches and no major variations in healing, acute PJI, or dysesthesia when comparing bikini incision DAA to conventional DAA.

CONCLUSION

Wound healing post THA is a complex process, influenced by various surgical techniques and intraoperative decisions. This systematic review meticulously examined three critical factors: the role of DVT prophylaxis, the implications of intraoperative drain usage, and the impact of different surgical approaches. Our analysis revealed that rivaroxaban and enoxaparin exhibit similar wound infection rates in THA. The decision to use intraoperative drains in the current literature indicates no definite advantage or disadvantage regarding wound problems with the use of closed-suction drainage in THA. In exploring surgical methodologies, the DAA and the PLA showed comparable complication rates. Yet, specific techniques within the DAA category demonstrated variations in delayed wound healing, particularly among obese patients. These findings emphasize the nuanced role of surgical choices in determining wound healing outcomes. As the field of THA continues to evolve, it becomes important for surgeons to be well-informed, ensuring optimal patient outcomes.

Curtailing infection risks in hepatitis C patients: the effect of antiviral treatment in revision shoulder arthroplasty

BACKGROUND

Revision shoulder arthroplasty (RevSA) is a complex procedure that can result in various postoperative complications. However, the impact of hepatitis C virus (HCV) on postoperative complications after RevSA remains unclear because of limited and inconsistent evidence. This study aims (1) to investigate the incidence of postoperative complications in patients with HCV undergoing RevSA and (2) to evaluate the impact of HCV treatment on complication rates at different time points after the revision procedure, specifically at 90 days, 1 year, and 2 years.

METHODS

We queried a national, all-payer database to investigate recent trends in the use of RevSA among HCV patients to assess postoperative complication rates, including venous thromboembolism (VTE), wound complication, transfusion, and periprosthetic joint infection (PJI). Statistical analyses involved propensity score matching to create balanced cohorts and logistic regression to determine the relative risk of postoperative complications. Data were analyzed with SPSS software (version 24.0 for Windows). The study included patients who underwent partial or total RevSA procedures between January 1, 2010, and December 31, 2020. Patients were identified based on medical claims that included procedural codes for RevSA and associated diagnosis codes for PJI or insertion/removal of an antibiotic spacer. A Bonferroni correction was used because many tests were performed and statistical significance was set at P = .0125.

RESULTS

The HCV cohort demonstrated higher PJI rates at 1-year (5.5% vs. 3.9%, P = .006) and 2-year follow-ups (6.7% vs. 4.6%, P = .006). However, no significant differences emerged in VTE and wound complication rates between the HCV and non-HCV cohorts. Comparing untreated and treated HCV patients, the former showed significantly higher PJI rates at 2 years (P = .010), whereas the treated group had significantly lower odds ratios for PJI. When comparing treated HCV patients with the non-HCV cohort, minimal differences were found in postoperative outcomes, indicating no significant difference in the risk of complications between the groups.

CONCLUSION

Our study observed an association between HCV patients who received antiviral treatment prior to RevSA and a reduced incidence of PJI compared to untreated HCV patients. When comparing this group to the non-HCV controls, there was no significant difference in the incidence of PJI, suggesting a potential association between antiviral treatment and the observed risk patterns in HCV patients. Proper management of HCV-positive patients during RevSA is crucial for improving outcomes and reducing complications.

Effect of Various Ancillary Operating Room Techniques on Wound Healing Outcomes After Total Knee Arthroplasty

INTRODUCTION

The successful management of wound healing after total knee arthroplasty (TKA) depends on several aspects of ancillary intraoperative techniques and surgical variables. Many of these have been evaluated in a few recent reports. The prior reviews studied many aspects of wound healing and, for example, found lower risks of wound complications with barbed sutures compared with interrupted closure with non-barbed sutures, no differences in wound complications between adhesives, subcuticular sutures, staples, glue, or mesh adhesives for the closure of the skin layer, and that mesh adhesives may be associated with faster closing times compared to subcuticular sutures or staples in TKA. However, some topics that can be influenced by the surgeon were not covered in these previous reviews. Namely, the use of deep vein thrombosis (DVT) prophylaxis, tourniquet application, management of intraoperative drains, surgical approach selection, and patellar handling techniques can all potentially influence wound healing. Therefore, in this comprehensive systematic review of the literature, we focused on these five factors that may influence wound healing. Specifically, we evaluated: (1) the impact of different DVT prophylaxis methods on wound healing and infection rates; (2) the role of tourniquet application on wound closure and potential infection risks; (3) the effects of intraoperative drain usage on wound healing; (4) the influence of different surgical approaches on wound closure and postoperative infection rates; and (5) the effects of varying patellar handling strategies on wound healing and infection rates.

MATERIALS AND METHODS

A systematic search of electronic databases, including PubMed, Cochrane Library, Medline, and Embase, was conducted to identify studies assessing auxiliary surgical techniques and their impact on wound healing in total knee arthroplasty (TKA). Relevant terms like "knee," "arthroplasty," and "wound healing" refined the search, which included English language publications until May 1, 2023. Independent screening by two authors and a third mediator facilitated the selection process, with 24 studies meeting the criteria. Assessment of these studies involved evaluating their evidence level and methodological quality using the Modified Coleman Methodology Score (MCMS). A comparison was made on wound healing outcomes in TKA, which included evaluating methodological quality parameters like sample sizes, follow-up durations, and clinical effect measurements. Data synthesis for the studies provided a comprehensive summary, categorizing them by evidence level.

RESULTS

There were seven reports on DVT prophylaxis that showed no statistically significant differences in wound complications among various treatment methods and medications in patients undergoing total knee arthroplasty (TKA), with wound complication rates ranging from 0.25 to 1%, except that aspirin appeared to have lower wound complications rates in three recent studies than other methods. There were five reports on tourniquet application that showed a generally increased rate of wound complications, but no increase in deep infections. The five reports on intraoperative drain use showed that while there is an increase in total blood loss in the group with drains, ranging from 568ml to 1,856ml, compared to 119ml to 535ml in the no-drain group, there are no significant differences in wound complications, infection rates, or other postoperative outcomes such as swelling, deep vein thrombosis, and range of motion between the drain and no-drain groups. There were three studies on surgical approaches revealing no differences in wound complication rates between the mini-subvastus and medial parapatellar incisions. Also, the surgical variables of patella eversion and anterior tibial translation were only studied in one report.

CONCLUSION

The current literature highlights the importance of using aspirin when possible for DVT prophylaxis and the possibility that tourniquets may lead to increased superficial wound complications. Drains or surgical approach do not appear to lead to wound problems. Surgical variables, such as patella eversion and anterior tibial translation, need more study.

Is Tomorrow's Health Care Today: A Look at Current Payment Models for the Future?

The promise of controlling spending and improving the quality of care incentivizes health care providers to prioritize value through alternative payment models. Findings regarding improved value and cost savings of the Comprehensive Care for Joint Replacement (CJR) redesign are consistent throughout selected metropolitan hospitals. Before refinement can take place, reporting on baseline financial status is a necessity to ensure the starting point of hospitals before CJR takes effect. Evidence-based protocols, outcomes-based measures to evaluate results, and cooperation across specialties to deliver high quality care will be necessary to insure improved care throughout the episode. This commentary reviews the CJR program and provides recommendations for the near future in order to best serve the needs of patients as we move forward in the bundled payments direction.

Assessment of the AAOS guidelines using the AGREE II instrument: An update

Background

The American Academy of Orthopaedic Surgeons (AAOS) provides clinical guidelines and frequently updates and expands on the recommendations. High quality, up-to-date, and applicable clinical guidelines are increasingly important tools for physicians to have. Assessing these continuously updating guidelines' overall quality has most recently been done in 2013 when there were 14 guidelines. Since then, nearly all guidelines have been updated and now 28 guidelines are provided. Our goal was to evaluate the updated 2023 AAOS guidelines using the well-established Advancing Guideline Development, Reporting and Evaluation in Health Care (AGREE II) tool.

Methods

On April 23, 2023, all 28 guidelines set forth by AAOS were compiled. Using the AGREE II tool, a well-recognized and established tool for evaluation of guideline quality used across all disciplines, three independent reviewers appraised the current guidelines. These data were used to run descriptive statistics and assessed accordingly.

Results

Across the 28 guidelines, the average AGREE II domain scores were as follows: Scope and Purpose (median score, 85%), Stakeholder Involvement (median score, 87%), Rigor of Development (median score, 87%), Clarity of Presentation (median score, 87%), Applicability (median score, 48%), Editorial Independence (median score, 87%), and Overall Assessment (median score, 80s%).

Conclusions

Five of the six AGREE II domains, including the overall assessment, tested achieved a median score above the 50% mark. These results indicate that the AAOS guidelines met many criteria for high quality based on a critical appraisal.

Patient-reported and radiographic outcomes of a porous-coated acetabular cup in robotic assisted total hip arthroplasty at 2-year follow up

Introduction

Several implant manufacturers have developed ultra-porous metal substrate acetabular components recently. Despite this, data on clinical and radiographic outcomes remain limited. Our study evaluated postoperative patient-reported outcome measures (PROMs) and radiographic analyses in patients fitted with a novel acetabular porous-coated component.

Methods

A total of 152 consecutive patients underwent a total hip arthroplasty by a single orthopaedic surgeon. All patients underwent surgery utilizing the same CT-scan based robotic-assisted device with the same porous cementless acetabular shell. They received standardized postoperative physical therapy, rehabilitation, and pain protocols. Preoperatively, first postoperative visit, 6-months, 1-year, and 2-years, patients were evaluated based on Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain, physical function, and total scores; 2) Patient-Reported Outcomes Measurement Information System (PROMIS)-10 physical and mental scores; 3) Hip Disability and Osteoarthritis Outcome Score (HOOS)-Jr scores; as well as 4) acetabular component positions and 5) evidence of acetabular component loosening.

Results

Significant improvements were observed by 6 months in WOMAC pain, physical function, and total scores (p < 0.05), maintained at 1 and 2 years. PROMIS-10 physical scores also improved significantly from preoperative to 6 months postoperative and remained so at 1 and 2 years postoperative (p < 0.05). No significant changes were found in PROMIS-10 mental scores. HOOS-Jr scores significantly improved from preoperative to 6 months postoperative and remained so through 2 years (p < 0.05). At 6 months, slight changes were noted in abduction angle and horizontal and vertical offset. Radiolucencies, initially found in 3 shells, reduced to 1 shell with 2 new radiolucencies by 6 months, and remained stable with no subsequent operative interventions. At 1 year and 2 years, no radiographic abnormalities were noted, including complete resolution of prior radiolucencies as well as stable components.

Conclusion

This porous cementless acetabular shell, implanted with CT-scan-based robotic-assisted techniques, demonstrated excellent postoperative PROMs at 2 years. Stable radiolucencies suggest good component stability. The early stable clinical and radiographic results suggest promising long-term outcomes with this device.

Level of evidence

III (retrospective cohort study).

Postoperative Opioid Dependence in Patients Undergoing Either Total or Reverse Shoulder Arthroplasty for Proximal Humerus Fracture Fixation

INTRODUCTION

In elderly patients who have proximal humerus fractures, treatment commonly involves total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA). Following these procedures, patients often require opioids for postoperative analgesia. This common scenario is of clinical and societal importance, as increased postoperative opioid usage has been shown to worsen outcomes and increase the likelihood for dependence. We aimed to compare postoperative opioid use in patients undergoing either TSA or RSA for fixation of their proximal humerus fracture. Specifically, we assessed: (1) postoperative opioid use at two, four, six, eight, and greater than eight weeks postoperatively; (2) aseptic revision rates at 90-days, one year, and two years postoperatively; and (3) periprosthetic joint infection (PJI) rates at 90-days, one year, and two years postoperatively between patients undergoing TSA or RSA for the surgical management of their proximal humerus fractures.

MATERIALS AND METHODS

For this review, we queried a national all-payer database from October 1, 2015 to October 31, 2020 (n=1.5 million) for all patients who had a "proximal humerus fracture" diagnosis who underwent either TSA or RSA. There were two cohorts: patients undergoing TSA (n=731) and patients undergoing RSA (n=731). Bivariate Chi-square analyses.

RESULTS

We found no differences (p>0.05) in opioid use postoperatively in patients undergoing RSA for proximal humerus management compared to patients undergoing TSA after two weeks. There was not a significant difference in aseptic revision or PJI rates between the two cohorts (all p>0.05).

CONCLUSION

The evidence comparing opioid use in patients undergoing either TSA or RSA for proximal humerus fracture fixation is lacking. Our study specifically showed no differences in opioid use postoperatively in patients undergoing RSA for proximal humerus management compared to patients undergoing TSA.

Bariatric surgery prior to total hip arthroplasty: does timing or type matter?

INTRODUCTION

Morbid obesity is a known risk-factor for increased complications following total hip arthroplasty (THA). Thus, many orthopaedic surgeons recommend bariatric surgery (BS). However, there is no consensus on the type (commonly either a Roux-en-Y gastric bypass [RYGB] or sleeve gastrectomy [SG]) and timing of BS prior to THA. Therefore, the purpose of this study is to compare BS recipients prior to THA to assess differences in 90-day to 2-year medical/surgical complications as well as revisions for: (1) type of BS (RYGB and SG); and (2) timing of BS. Additionally, we aim to assess risk factors for postoperative prosthetic joint infections (PJIs), dislocations, and revisions.

METHODS

We queried a national, all-payer database to identify patients undergoing primary THA from January 2010 to October 2020 (n = 715,100). Patients were then divided into 6 cohorts: 2 cohorts without history of BS (body mass index [BMI] kg/m2 20-35 [n = 59,995]) and BMI > 40 [n = 36,799]); 2 cohorts with previous RYGB (n = 1278) or SG (n = 1051); and 2 cohorts that underwent BS either 6-12 months (n = 412) and >12 months (n = 1655) prior to the THA. Bivariate chi-square analyses of medical and surgical outcomes at 90 days-2 years were conducted. Multivariate logistic regressions identified independent risk factors for PJIs, dislocations, and revisions.

RESULTS

At 90 days-2 years, no differences in postoperative medical/surgical complications or revisions were seen among timing or type of BS. The BMI > 40 kg/m2 cohort had the highest complication profile among all other cohorts. Timing and type of BS has similar odds of PJIs, dislocations, and revisions.

CONCLUSIONS

Patients undergoing RYGB or SG 6-12 months and >1 year prior to THA showed similar complications profiles. These results suggest, bariatric patients do not need to wait 1 year before undergoing a THA.

Race Associated With Increased Complication Rates After Total Knee Arthroplasty

BACKGROUND

Racial and ethnic disparities have been suggested to be associated with poor outcomes after total knee arthroplasty (TKA). While socioeconomic disadvantage has been studied, analyses of race as the primary variable are lacking. Therefore, we examined the potential differences between Black and White TKA recipients. Specifically, we assessed 30-day and 90-day, as well as 1 year: (1) emergency department visits and readmissions; (2) total complications; (3) as well as risk factors for total complications.

METHODS

A consecutive series of 1,641 primary TKAs from January 2015 to December 2021 at a tertiary health care system were reviewed. Patients were stratified according to race, Black (n = 1,003) and White (n = 638). Outcomes of interest were analyzed using bivariate Chi-square and multivariate regressions. Demographic variables such as sex, American Society of Anesthesiologists classification, diabetes, congestive heart failure, chronic pulmonary disease, and socioeconomic status based on Area Deprivation Index were controlled for across all patients.

RESULTS

The unadjusted analyses found that Black patients had an increased likelihood of 30-day emergency department visits and readmissions (P < .001). However, in the adjusted analyses, Black race was demonstrated to be a risk factor for increased total complications at all-time points (P ≤ .0279). Area Deprivation Index was not a risk for cumulative complications at these time points (P ≥ .2455).

CONCLUSION

Black patients undergoing TKA may be at increased risk for complications with more risk factors including higher body mass index, tobacco use, substance abuse, chronic obstructive pulmonary disease, congestive heart failure, hypertension, chronic kidney disease, and diabetes and were thus, "sicker" initially than the White cohort. Surgeons are often treating these patients at the later stages of their diseases when risk factors are less modifiable, which necessitates a shift to early, preventable public health measures. While higher socioeconomic disadvantage has been associated with higher rates of complications, the results of this study suggest that race may play a greater role than previously thought.