The Immediate Impact of Total Knee Arthroplasty Removal From the Medicare Inpatient-Only List on Patient Derived Functional Outcomes and Hospital Satisfaction.

BACKGROUND: Total knee arthroplasty (TKA) is the standard of treatment for end-stage knee osteoarthritis. On January 1, 2018, the Centers for Medicare and Medicaid (CMS) officially removed TKA from their inpatient-only list. The clinical impact of this change is not fully understood yet. METHODS: Electronic records were retrospectively reviewed for patients who underwent TKA between January 1 to June 30, 2017, or January 1 to June 30, 2018. Patients completed Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement surveys which assessed patient reported outcomes prior to and following TKA. Hospital statistics for the 2 time points were determined and compared. This was a single institution study resulting in 351 patients in the pre-CMS change group and 350 patients in the post-CMS change group. RESULTS: Analysis of the pre-CMS and post-CMS transition cohorts indicated no significant difference in activities of daily living (ADLs), pain, or pain catastrophizing scale preoperatively or 12-months postoperatively. Additionally, there was no difference in the median change between preoperative and postoperative ADL scores (P = .866), yet pain scores approached significance with a P value of .054. The pre-CMS transition group stayed significantly longer in the hospital postoperatively and was more commonly discharged to a skilled nursing facility. No difference was seen in 30-day readmission rates (P = .253). CONCLUSIONS: Results showed that patients had similar scores for ADL, quality of life, pain, and pain catastrophizing 12-months following their TKA. Movement of TKA from the Medicare inpatient only list did not have an immediate negative impact for patient reported outcomes and 30-day readmissions at our institution in the 6-month transition period.

Mechanically stable rifampin antibiotic cement inhibits Pseudomonas aeruginosa biofilm surface growth.

Rifampin has been proven to be effective in the treatment of prosthetic infections due to its ability to intercalate into biofilms. The use of rifampin in antibiotic spacers is not well described, which would be especially important in the local periprosthetic environment where parenteral doses have poor penetration. The null hypothesis tests if rifampin use in polymethyl methacrylate (PMMA) cement will show no clinically significant impact on mechanical strength at antibiotic concentrations that remain bactericidal. Test antibiotic cement samples supplemented with 0, 30, 50, 100, 150, or 200 mg of rifampin into a standard 40 g bag were tested for compression to failure using published ASTM standards. The samples were then inoculated with Pseudomonas aeruginosa and either evaluated for lipopolysaccharide (LPS) presence as a marker of biofilm or tested by elution as the Kirby Bauer assay. Rifampin concentrations of 30 and 50 mg, showed no statistically different mechanical characteristics from control PMMA (p > 0.05). The 100-mg sample fell within the acceptable range of compressive strength and had significantly less LPS and bacterial presence compared to the control at 12 and 24 h. The ability of PMMA with 100 mg of rifampin to maintain its structural integrity and have significant bacterial inhibition at 12 and 24 h makes it a great candidate as an antibiotic bone cement additive. PMMA loaded with up to 100 mg of rifampin shows promise in the treatment and prevention of periprosthetic joint infection for total knee and total hip arthroplasty.

Chronic obstructive pulmonary disease is an independent risk factor for increased opioid use in total hip arthroplasty: A retrospective PearlDiver study.

Background: Total hip arthroplasty (THA) has become an incredibly common procedure due to its' predictability and high success rate. The success of surgery is related to strict indications and careful optimization of medical comorbidities to decrease risk and improve outcomes. Chronic obstructive pulmonary disease (COPD) has been associated with increased medical and surgical complications. A regulatory focus on opioid utilization does not usually consider COPD as a risk factor, but limited research exists on the impact of COPD on outcomes and risks after THA. Methods: Retrospective all-inclusive database analysis of Medicare patients who had undergone THA between 2007 and 2017 included in the PearlDiver Database were studied. Postoperative opioid usage was examined at 1-, 3-, 6-, and 12 months, along with surgical infection, implant complications, and revisions. Post-operative complications within 30 days, either medical or implant related, were identified. Controlling for comorbidities, age, and sex, odds ratios were calculated using multivariable logistic regression with a significant α value of 0.05. Results: COPD patients had significantly higher rates of opioid usage postoperatively. COPD patients also had an increased rate of readmissions, medical/implant complications, and revision surgeries. Discussion: This is the only study raising concern regarding opioid use in COPD patients after total hip arthroplasty, which may be critical considering the associated respiratory depression further exacerbating the COPD. Considering the evidence of poor outcomes associated with COPD in arthroplasty, appropriately screening for COPD and counseling or planning for post-operative pain control and complications is paramount.

Trends in Female Authorship in Orthopaedic Literature from 2002 to 2021: An Analysis of 168,451 Authors.

BACKGROUND: Significant gender disparity exists in orthopaedic surgery. While women have increasingly entered the field, we are short of the critical mass needed to drive change, including in authorship. This study aimed to characterize trends in authorship in peer-reviewed orthopaedic journals in the context of gender. METHODS: This is a cross-sectional bibliometric study of orthopaedic journals in the United States. Articles that were indexed in the orthopaedic category of the Clarivate Journal Citation Report (JCR) and the Science Citation Index Expanded (SCIE) were analyzed (n = 82). Journals not originating from the U.S. (n = 43) or not considered primarily orthopaedic journals (n = 13) were excluded. The 2020 impact factors (IFs) of the remaining 26 journals were recorded. The articles underwent automated data collection from PubMed for January 2002 to December 2021 using R software to collect the title, the journal, the publication year, the first and senior author names, and the country of origin. Gender was determined by Gender API ( https://gender-api.com ). Names with <90% accuracy were excluded. RESULTS: Overall, 168,451 names were studied, with 85,845 and 82,606 first and senior authors, respectively. Of the first and senior authors, 13.6% and 9.9%, respectively, were female. The proportion of female first authors was significantly greater than the proportion of female senior authors. The average IF was significantly higher for male authors compared with female authors (p < 0.005). Articles with female first authors were significantly more likely to have a female senior author. Orthopaedic subspecialty journals had a smaller proportion of manuscripts authored by female first and senior authors than general journals (p < 0.0001). There were 4,451 articles written by a single author, of which 92% (4,093) were written by a man and 8% (358) were written by a woman. Over the 20-year study period, the proportion of female first authorship exhibited a significant positive trend; however, there was a non-significant increase in female senior authorship. CONCLUSIONS: Female representation in orthopaedics has been growing over the past decade. Increasing publication rates of female authors reveal steps toward positive gender equity in the field and present an opportunity for female leadership visibility, illustrating the capabilities of women in orthopaedics and encouraging more women to join the field.

Chronic Obstructive Pulmonary Disease Associated with Prolonged Opiate Use, Increased Short-Term Complications, and the Need for Revision Surgery following Total Knee Arthroplasty.

Chronic obstructive pulmonary disease (COPD) is a condition which causes a substantial burden to patients, physicians, and the health care system at large. Medical comorbidities are commonly associated with adverse health outcomes in the postoperative period. Here, we present a large database review of patients undergoing total knee arthroplasty (TKA) to determine the effect of COPD on patient outcomes. The PearlDiver database was queried for all patients who underwent TKA between 2007 and the first quarter of 2017. Medical complications, surgical complications, 30-day readmission rates, revision rates, and opioid utilization were assessed at various intervals following TKA among patients with and without COPD. Multivariable regression was used to calculate adjusted odds ratios controlling for age, sex, and medical comorbidities. A total of 46,769 TKA patients with COPD and 120,177 TKA patients without COPD were studied. TKA patients with COPD experienced increased risk of 30-day readmission (40.8% vs. 32.2%, p < 0.0001), 30-day total medical complications (10.2% vs. 7.0%, p < 0.0001), prosthesis explanation at 6 months (0.4% vs. 0.2, p = 0.0130), 1 year (0.6% vs. 0.3%, p = 0.0005), and 2 years (0.8% vs. 0.5%, p = 0.0003), as well as an increased rate of revision (p < 0.0046) compared to TKA patients without COPD. Opioid utilization of TKA patients with COPD was greater significantly than that of TKA patients without COPD at 3, 6, and 12 months. Patients with COPD have an increased risk for medical and surgical complications, readmission, and prolonged opioid use following TKA.

The Effect of Early versus Late Manipulation Under Anesthesia on Opioid Use, Surgical Complications, and Revision Following Total Knee Arthroplasty.

Previous studies of early versus late manipulation under anesthesia (MUA) do not report on postoperative opioid utilization or revisions and focused on small single-institution retrospective cohorts. The PearlDiver Research Program (www.pearldiverinc.com), which uses an all-inclusive insurance database, was used to identify patients undergoing primary total knee arthroplasty (TKA) who received (1) late MUA (>12 weeks), (2) early MUA (≤12 weeks), or (3) TKA only. To develop the control group cohort of TKA-only patients, 3:1 matching was conducted using 11 risk factor variables deemed significant by chi-squared analysis. Complications and opioid utilization were compared through multivariate regression analysis, controlling for age, gender, and Charlson Comorbidity Index. The risk of TKA revision was assessed through Cox-proportional hazards modeling and Kaplan-Meier survival analysis with log-rank test. Between 2011 and 2017, 2,062 TKA patients with early MUA, 1,112 TKA patients with late MUA, and a control cohort of 8,327 TKA-only patients were identified in the database. The percent of patients registering opioid use decreased from 54.6% 1 month pre-MUA to 4.6% (p < 0.0001) 1 month post-MUA following early MUA, whereas only from 32.6 to 10.4% (p < 0.0001) following late MUA. Late MUA was associated with higher risk of repeat MUA at 6 months (adjusted odds ratio [aOR] = 2.74, p < 0.0001), 1 year (aOR = 2.66, p < 0.0001), and 2 years (aOR = 2.63, p < 0.0001) following index MUA. Hazards modeling and survival analysis showed increased risk of TKA revision following late MUA (adjusted hazard ratio [aHR] = 3.50, 95% confidence interval [CI]: 2.77-4.43, p < 0.0001) compared to early MUA (aHR = 2.15, 95% CI: 1.72-2.70, p < 0.0001), with significant differences in survival to revision curves (p < 0.0001). When compared to early MUA at 1 year, late MUA was associated with a significantly increased risk of prosthesis explantation (aOR = 2.89, p = 0.0026 vs. aOR = 0.93, p = 0.8563). MUA within 12 weeks after index TKA had improved pain resolution and significant curtailing of opioid use. Furthermore, late MUA was associated with prolonged opioid use, increased risks of revision, as well as prosthesis explantation, supporting screening and early intervention in cases of slow progression and stiffness. The level of evidence of this study is III.

Comparison of periprosthetic joint infection rates in the direct anterior approach and non-anterior approaches to primary total hip arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Periprosthetic joint infection is a serious complication and devastating mode of failure of total hip arthroplasty. Various surgical approaches exist for total hip arthroplasty, including the increasingly popularised direct anterior approach. There is no clear consensus on which approach is least associated with periprosthetic joint infection. The objective of this meta-analysis was to compare the rate of periprosthetic joint infection between surgical approaches to primary total hip arthroplasty for osteoarthritis. METHODS: A search of 3 electronic databases (PubMed/MEDLINE, Embase, and Cochrane Library) was conducted for relevant studies up to June 2020 with a defined list of inclusion and exclusion criteria. Randomised controlled trials and longitudinal studies reporting periprosthetic joint infection rates after primary total hip arthroplasty for osteoarthritis were included based on surgical approach. Data extraction was completed, and a meta-analysis was then performed using OpenMeta[Analyst] software. RESULTS: A total of 24,407 hips were included for meta-analysis with an overall PJI incidence of 0.57%. The incidence rate for periprosthetic joint infection was 0.77% in the direct anterior approach group and 0.44% in the non-anterior approach group. The use of an anterior approach for a total hip arthroplasty was associated with an increased risk for periprosthetic joint infection (odds ratio = 1.404; 95% confidence interval, 0.711-2.771; p = 0.03). CONCLUSIONS: The direct anterior approach to total hip arthroplasty may be associated with a significantly increased risk for periprosthetic joint infection compared to non-anterior approaches, even though the overall rate was still small. This should be considered by orthopedic surgeons when choosing the surgical approach.

The Case of Disappearing Tibia in Rheumatoid Knee Tenosynovitis.

Introduction: Knee pain and osteoarthritis are frequent patient complaints, with a rapidly increasing prevalence. By comparison, the prevalence of rheumatoid arthritis (RA) is significantly lower at around 1%. Inflammatory arthropathies, like RA, are difficult to differentiate from infection, crystal arthropathies, or malignancy. In addition, radiography and roentgenograms are often inconclusive or non-specific, making it much more difficult to evaluate, diagnose, and manage this condition. The current case is unique due to its location in the knee joint, rather than more common presentations in the upper extremities, and use of MRI imaging for diagnosis of RA with tenosynovitis. Case Report: In a Caucasian 70-year-old female with sudden debilitating knee pain and a large atraumatic defect over tibial plateau, MRI showed a large fluid collection within the left gracilis muscle. Gram stain and culture of the aspirate remained negative. The only significant history involved a possible diagnosis of RA. Conclusion: While rheumatoid tenosynovitis is common in the upper extremities, lower extremity features have not been well reported before. We diagnosed the patient with progressive RA and rheumatoid tenosynovitis. This unique presentation and rare usage of MRI imaging may be contributing to an underreporting of this diagnosis in the lower extremities.

Understanding Health Economics in Joint Replacement Surgery.

The number of arthroplasty procedures has been rising at a significant rate, contributing to a notable portion of the nation's health care spending. This growth has contributed to an increase in the number of health care economic studies in the field of adult reconstruction surgery. Although these articles are filled with important information, they can be difficult to understand without a background in business or economics. The goal of this review is to define the common terminology used in health care economic studies, assess their value and benefit in the context of total joint arthroplasty, and highlight shortcomings in the current literature. [Orthopedics. 2022;45(4):e174-e182.].

Silver carboxylate-doped titanium dioxide-polydimethylsiloxane coating decreases Cutibacterium acnes adherence and biofilm formation on polyether ether ketone.

BACKGROUND CONTEXT: Cutibacterium acnes (C. acnes) is a gram-positive facultative anaerobe found in the deep sebaceous follicles of the skin on the shoulder and back. C. acnes has been increasingly recognized as a pathogen in spinal surgical site infection (SSI) especially in the presence of instrumentation. PURPOSE: This study assesses whether a silver carboxylate-doped titanium dioxide-polydimethylsiloxane (TiO2-PDMS) coating can decrease C. acnes adherence and biofilm formation on PEEK and four other commonly used spinal implant materials, stainless steel, cobalt chromium, titanium, and titanium alloy. STUDY DESIGN: We compared the adherence of C. acnes over 24 hours between uncoated, 95:5 TiO2 to PDMS ratio with 10× silver carboxylate coating and a 100% silver carboxylate coating on each implant material, which were uniformly saw cut and sterilized. Implants were then subjected to scanning electron microscopy (SEM) and confocal scanning laser microscopy (CSLM). METHODS: Samples were coated using 95:5 TiO2-PDMS 10× silver carboxylate, 100% silver carboxylate, or left uncoated. C. acnes was applied onto the samples and allowed to adhere for periods of 4, 8, 12, 16, or 20 hours. Nonadherent bacteria were then washed from the samples. These samples were then allowed to continue incubating for a total of 24 hours. SEM and confocal laser scanning microscope were used to visualize all samples for the presence of biofilm and quantification of C. acnes adherence at each time point. RESULTS: The 95:5 TiO2-PDMS 10× silver carboxylate coating was able to significantly decrease C. acnes adherence on PEEK after 8, 12, 16, and 20 hours of adherence. No statistical difference was found between the 95:5 TiO2-PDMS 10× silver carboxylate coating and the 100% silver carboxylate positive control. We previously observed extensive C. acnes biofilm formation on uncoated PEEK, but none on PEEK coated with either the 95:5 TiO2-PDMS 10× silver carboxylate or 100% Ag coating . Furthermore, no biofilm formation was observed on stainless steel, cobalt chromium, titanium, and titanium alloy coated with 95:5 TiO2-PDMS 10× silver carboxylate or 100% Ag coating. CONCLUSION: A 95:5 TiO2-PDMS 10× silver carboxylate coating decreases C. acnes adhesion and prevents biofilm formation on PEEK and other common orthopedic implant materials. CLINICAL SIGNIFICANCE: A 95:5 TiO2-PDMS 10× silver carboxylate coating may help decrease spinal SSI due to C. acnes, especially in procedures with instrumentation.

In vitro visualization and quantitative characterization of Pseudomonas aeruginosa biofilm growth dynamics on polyether ether ketone.

Prevention and treatment of orthopedic device-related infection (ODRI) is complicated by the formation of bacterial biofilms. Biofilm formation involves dynamic production of macromolecules that contribute to the structure of the biofilm over time. Limitations to clinically relevant and translational biofilm visualization and measurement hamper advances in this area of research. In this paper, we present a multimodal methodology for improved characterization of Pseudomonas aeruginosa grown on polyether ether ketone (PEEK) as a model for ODRI. PEEK discs were inoculated with P. aeruginosa, incubated for 4-48 h time intervals, and fixed with 10% neutral-buffered formalin. Samples were stained with fluorescent dyes to measure biofilm components, imaged with confocal laser scanning microscopy (CLSM) and scanning electron microscopy (SEM), and quantified. We were able to visualize and quantify P. aeruginosa biofilm growth on PEEK implants over 48 h. Based on imaging data, we propose a generalized growth cycle that can inform orthopedic diagnostic and treatment for this pathogen on PEEK. These results demonstrate the potential of using a combined CLSM and SEM approach for determining biofilm structure, composition, post-adherence development on orthopedic materials. This model may be used for quantitative biofilm analysis for other pathogens and other materials of orthopedic relevance for translational study of ODRI.

Review of Pre-Operative Skin Preparation Options Based on Surgical Site in Orthopedic Surgery.

Background: Surgical site infections (SSIs) are a primary contributor to surgical morbidity and mortality, causing a substantial financial burden on the healthcare system. Specifically, Cutibacterium acnes contributes greatly to infections in the shoulder and spine regions. Prevention of infection is crucial to improve patient outcomes and reduce costs. This article reviews current surgical skin preparation solutions, the unique distribution of organisms at common orthopedic surgical sites, and recommends solutions based on surgical location. Methods: A search of electronic databases (PubMed, MEDLINE, and Embase) was conducted for relevant literature until December 2020. Sources were compiled based on title and abstract, then full texts were read for possible inclusion. This review summarizes the most recent publications in the field of SSIs and preparation solutions. Results: The mechanism and efficacy of alcohol-, iodine-, and chlorhexidine-based preparations were reviewed, along with experimental preparations. This article identifies common colonization patterns for the shoulder, elbow, hip, knee, spine, foot, and ankle, and discusses recommendations for preparations based on current evidence. Recommendations: For shoulder and elbow operations, we recommend ChloraPrep™ (CareFusion, BD, El Paso, TX), DuraPrep™ (3M Health Care, St. Paul, MN), or Betadine® applied with 4 × 4 gauze sponge, three-day pre-operative benzyl peroxide, and application of 3% hydrogen peroxide before skin preparation. For the hip and knee, we recommend application of 2% chlorhexidine gluconate (CHG) cloth the night before and morning of surgery and either DuraPrep or iodine-alcohol skin prep prior to surgery. For spine surgeries, we recommended ChloraPrep. For foot and ankle, our recommendations are: ChloraPrep or DuraPrep, submersion of foot in 70% ethanol/10% isopropyl alcohol for five minutes prior to procedure, application with a bristled brush, and a second vigorous scrub with 4 × 4 soaked gauze. Conclusions: The current surgical skin preparations have both benefits and drawbacks. We recommend that orthopedic surgeons choose a skin preparation based on surgical site and prevalence of unique skin flora there.

Silver carboxylate and titanium dioxide-polydimethylsiloxane coating decreases adherence of multi-drug resistant Serratia marcescens on spinal implant materials.

PURPOSE: The opportunistic multi-drug resistant nosocomial gram negative bacilli Serratia marcescens (S. marcescens) is a rising contributor to spinal implant infections (Iguchi et al., Genome Biol Evol 6:2096-2110, 2014; Teresa et al., J Clin Microbiol 55:2334-2347; Dante et al., J Clin Microbiol 54:120-126). This study investigates the most effective matrix ratio of an antibiotic-independent, silver carboxylate-doped titanium dioxide (TiO2)-polydimethylsiloxane (PDMS) coating in preventing adherence of multidrug resistant pathogen S. marcescens to spinal implant materials. METHODS: This project examined an antibiotic-independent, silver carboxylate-doped titanium dioxide (TiO2)-polydimethylsiloxane (PDMS) coating on three common spinal implant materials, polyetheretherketone (PEEK), stainless steel (SS), and titanium (Ti), which previously were found to be prone to bacterial adhesion (Garcia et al., Spine Deform 8:351-359). After generation of dose response curves to find the optimal silver carboxylate concentration, 95% TiO2-5% PDMS was combined with 10× silver carboxylate and compared to 100% silver carboxylate and uncoated implants. Implants were imaged using scanning electron microscopy and confocal laser scanning microscopy to detect adherent S. marcescens. RESULTS: Ninety-five percent TiO2-5% PDMS and 10× silver carboxylate coating decreased adherence of S. marcescens on PEEK by 99.61% (p = 0.001), on titanium by 98.77% (p = 0.001), and on stainless steel by 88.10% (p = 0.001) after 24 h. The average decrease in bacterial adherence was 95.49% compared to uncoated implants. CONCLUSION: A coating composition comprised of 95% TiO2-5% PDMS matrix and 10× silver carboxylate most effectively decreases adherence of S. marcescens on spinal implants. These results suggest that the application of a non-antibiotic, bactericidal coating prior to spinal surgery may prevent the adherence and proliferation of MDR S. marcescens and decrease the incidence of spinal SSI.

Distal femoral valgus cut angles unreliable in total knee arthroplasty.

We hypothesized that valgus distal femoral cut angle made using a conventional cutting guide would be reproducible in a Sawbone model, regardless of training level. 3°, 5°, or 7° valgus cuts were made on lower extremity Sawbone specimens and were measured with radiographic imaging. 66 patient radiographs were also analyzed to compare pre and post-operative femoral cut angles, and VR12 measurements from each patient were collected. All femoral cuts deviated significantly from target cuts. Also, pre-TKA valgus angles showed no correlation with the angles post-TKA, and final cut angle did not correlate with functional outcomes at 1 year post-surgery.

Comparing patient reported outcomes in depuy sigma curved versus curved plus polyethylene inserts in cruciate retaining total knee arthroplasty.

Total knee designs have evolved to allow more motion with compromising stability. The purpose of this study is to compare standard congruency and anterior lipped liners' effects on patient reported outcomes after TKA. 68 patients were retrospectively reviewed, and their SF-12 and KOOS scores were assessed preoperatively and one year post-operatively. Two-sample t-tests were used to compare differences between groups. The CVD design had a statistically significant greater improvement in KOOS-Pain compared to CVD+. No statistical difference was observed in the outcomes. The results may suggest that higher congruency designs lead to less physiological joint kinematics and pain.

Increased Medical and Implant-Related Complications in Total Hip Arthroplasty Patients With Underlying Chronic Obstructive Pulmonary Disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) has been associated with impaired bone metabolism. The purpose of this study is to investigate rates of readmission, respiratory complications, implant-related complications, and revision after total hip arthroplasty (THA) in patients with and without underlying COPD. METHODS: The PearlDiver Mariners database was used to divide patients undergoing primary THA (CPT-27130) into two cohorts: 1) THA with COPD (including asthma) or 2) THA without COPD. The incidence of 30-day readmission, COPD exacerbation, pneumonia, other respiratory complications as well as dislocations, mechanical loosening, and joint prosthetic infection was calculated through logistic regression. The risk of THA revision was also assessed through Cox-proportional hazards regression. All regression controlled for age, gender, and medical comorbidities found to be associated with COPD. RESULTS: Between 2010 and 2018, 97,784 THA patients with COPD and 338,243 THA patient without COPD were studied. THA patients with COPD had higher risk of 30-day readmission (aOR = 1.17, 95% CI 1.11-1.23, P < .0001). There was higher risk of 30-day pneumonia (aOR = 2.07, 95% CI 1.76-2.44, P < .0001). THA patients with COPD also faced higher risk of 30-day dislocations (aOR = 1.31, 95% CI 1.19-1.45, P < .0001), joint prosthetic infections (aOR = 1.25, 95% CI 1.14-1.37, P < .0001), and periprosthetic fracture (aOR = 1.19, 95% CI 1.07-1.32, P = .0015). Regarding revisions, 3.3% of THA patients with COPD underwent THA revision at 1 year, a higher risk than THA patients without COPD (aOR = 1.11, 95% CI 1.06-1.16, P < .0001). CONCLUSION: Patients undergoing THA with underlying COPD face a higher rate of comorbidities, respiratory complications, implant complications, and revision surgeries, than patients without COPD. LEVEL OF EVIDENCE: III.

Applicant Ranking Criteria in Adult Reconstruction Fellowship: Your Interview Counts When Applying for Fellowship.

Background The criteria for successful ranking in the fellowship match remains unclear. Although some data are available regarding the qualities sought after in medical students for the residency match, little information is available regarding the fellowship match. In this study, for arthroplasty applications to our institution, the interview was hypothesized to be the most important factor for ranking, with little impact from other commonly assessed variables. Methodology All 40 applicants who applied for fellowship were selected to interview for the 2017 Brown University Comprehensive Adult Reconstruction Fellowship and were evaluated on the interview, United States Medical Licensing Examination (USMLE) scores, letters of recommendation, personal statement, extracurricular activities, research, and caliber of undergraduate institution, medical school, and residency program. The interview score was based on a combined score of individual components of personality, program fit, and research. Results Of the 40 applicants who were interviewed, eight did not match. The interview score was the only statistically significant variable and had the highest correlation with ranking (r = 0.92). Moreover, extracurricular activities correlated with a higher ranking whereas USMLE Step 1/Step 2 scores had a relatively low correlation (r = 0.32 and 0.29, respectively). Recommendation letters and caliber of medical school, undergraduate education, and residency demonstrated low correlations. The personal statement and research components had the lowest correlations. Conclusions The combined interview score, in particular the personality and program fit components, was the most important determinant of successful ranking at our institution. Because all 40 applicants who applied for an arthroplasty fellowship at our institution were selected for an interview, there was no pre-interview selection bias that would confound these results. However, the ranking does not correlate with an applicant's success in fellowship, and further research is required to determine the qualifications of a successful surgeon.

Fluorescent-conjugated antibodies as rapid ex vivo markers for bacterial presence on orthopedic surgical explants and synovium: A pilot study.

Surgical infection is one of the most pressing problems in the field of orthopedic surgery; however, current detection methods are plagued by high costs and long wait times. This study seeks to demonstrate the ability of a novel assay using fluorescently conjugated antibodies and confocal laser scanning microscopy (CLSM) to accurately detect bacterial presence on orthopedic surgical explants, tissue, and synovial fluid in 30 min. Explanted hardware, tissue, and synovial fluid samples suspected to be infected were collected from human subjects with institutional review board consent. Samples were prepared using a 30-min protocol, consisting of rinsing, nonspecific blocking and staining steps, and imaged using CLSM. Images were analyzed using ImageJ (National Institute of Health) to determine the percent area of Gram positive and Gram negative bacteria. Results of the assay were compared to the hospital's microbiological laboratory and Gram staining results. Ninety three samples were collected and tested using the 30-min testing protocol; 75 samples were synovial fluid and 18 were tissue and explants. Seventy four of 75 (98.6%) synovial fluid samples correlated with the hospital laboratory's microbiological findings. Of the 18 explant and tissue samples, our assay found bacterial presence in 14 of 18 samples, while the hospital microbiology laboratory found bacterial presence in 13 of 18 samples. This assay reliably stained and rapidly identified the presence of Gram negative and Gram positive bacteria on surgical explants, tissue and synovial fluid in 30 min. This methodology may serve as a point of service tool for the determination of bacterial presence during surgical procedures.

Wound Irrigation in Orthopedic Open Fractures: A Review.

Background: Management of open fractures remains a major clinical challenge because of the higher energy involved in the injury, the greater local trauma, tissue necrosis, and extensive contamination. Even though early surgical debridement was thought to be critical, limited available operative techniques have minimized surgery in favor of early antibiotic administration. No clear agreement on the surgical approach, debridement, or irrigation technique exists. Surgeons continue to argue about the use of various fluids, the appropriate pressure of irrigation, antiseptics, and other factors. The current work reviews the available data and summarizes the capabilities of modern orthopedic irrigation solutions. Methods: To delineate available research on the topic, the PubMed database was queried for the most common techniques, fluid variables, and chemical adjuvants utilized in current open fracture and wound irrigation methodologies. Modes of delivery, volume, pressure, temperature, timing, solution type, and additives are evaluated in the context of known outcomes to determine which solutions may be preferable. Results: Various methods have been described with their own advantages as well as limitations. Particular solutions may apply to specific clinical scenarios, presence of implants, and degree of tissue contamination. Desired irrigation solutions are isotonic, non-toxic, non-hemolytic, transparent, sterilizable, efficient in removing debris and pathogens, as well as affordable; however, no current irrigant achieves all these desired characteristics. Conclusions: Despite being crucial for the healing of open fractures, there is no clear gold standard for irrigation. Although there are some novel irrigation solutions, there has been a paucity of research on finding new, safer, and more effective irrigation solutions that will promote wound healing and reduce infection.

Analysis of growth and biofilm formation of bacterial pathogens on frequently used spinal implant materials.

STUDY DESIGN: A microscopy-based investigation of the permissive factors leading towards bacterial adherence on commonly utilized spinal implants. OBJECTIVE: The adherence and subsequent colonization and biofilm formation of bacteria on orthopaedic implants represents one of the most serious problems facing orthopaedic surgeons. Once a biofilm is formed, surgeons may have to resort to implant removal, a strategy that may cause substantial patient morbidity and lead to additional cost to the healthcare system. This problem has been further compounded by the rise of antibiotic-resistant strains of bacterial pathogens. In this study, two commonly encountered bacterial pathogens in surgical site infections (SSI) were characterized for adherence pattern, density, and propagation on five commonly used spinal implant materials via scanning electron microscopy (SEM) and confocal laser scanning microscopy (CLSM). The results show that bacterial adherence is largely dependent on the microtopographical features observed on the surface of the materials tested. METHODS: Five commonly utilized spinal implant materials were inoculated with two of the most common nosocomial pathogens and visualized via scanning electron microscopy and confocal laser scanning microscopy. RESULTS: Analysis of 90 spinal implant pieces showed that even though no material showed the ability to prevent adherence of both pathogens tested, the presence of surface imperfections and rougher microtopography was found to harbor the most bacterial presence. CONCLUSION: Our data suggests that implants materials with uniform surface and minimal imperfections may reduce the ability of bacterial to adhere to implants. LEVEL OF EVIDENCE: Level I evidence: "Investigation of a diagnostic test".