Outcomes of Total Knee Arthroplasty in Patients Who Have Ehlers-Danlos syndrome: A Matched Cohort Study.

INTRODUCTION: Total knee arthroplasty is an excellent surgical option for patients who have end-stage knee osteoarthritis. While rates of major postoperative complications have steadily decreased with modern implants and operative techniques, contemporary outcome data for patients who have Ehlers-Danlos syndrome is scarce. The goal of this study was to compare complication rates after primary total knee arthroplasty in patients who have Ehlers-Danlos syndrome versus matched controls. METHODS: A large administrative database was used to identify patients who underwent primary total knee arthroplasty from 2009 to 2020. Patients who had a diagnosis of Ehlers-Danlos syndrome were identified by International Classification of Disease Coding. Propensity scores were utilized to match these patients with controls at a 1:4 ratio based on age, sex, and various comorbidities. Multivariable logistic regression analysis was used to compare the rates of medical and surgical complications at 90 days and 2 years. A total of 188 patients who had Ehlers-Danlos syndrome and 752 controls were included in this study. RESULTS: After univariate analysis, Ehlers-Danlos patients exhibited significantly higher rates of wound complications (4.8 versus 0.9%, P = 0.001) at 90 days. When adjusted for comorbidities, Ehlers-Danlos patients still exhibited significantly increased odds of developing wound complications (OR [odds ratio] 7.06, P < 0.001). CONCLUSIONS: Patients who have Ehlers-Danlos syndrome undergoing total knee arthroplasty exhibited significantly higher rates of wound complications within 90 days postoperatively, compared to matched controls. Rates of instability, manipulation under anesthesia, periprosthetic joint infection, aseptic loosening, and aseptic revision arthroplasty did not significantly differ between the cohorts. This study found generally favorable short-term outcomes of total knee arthroplasty in this population; however, the inability to control for implant type and other confounding variables may have influenced the lack of difference in complication rates at 2 years. Surgeons should monitor for the potentially increased risk of wound complications and consider the possible need for increased constraint in this population during preoperative planning.

Is Fluoroquinolone Exposure after Primary Tendon Repair Associated with Higher Rates of Reoperations? A Matched Cohort Study.

Background: The association between tendon damage and fluoroquinolone (FQ) antibiotics has been well documented. However, there is limited data evaluating the impact of postoperative FQ use on outcomes of primary tendon repairs. The purpose of this study was to compare rates of reoperation for patients with FQ exposure after primary tendon repair versus controls. Methods: A retrospective cohort study was conducted using the PearlDiver database. All patients who underwent primary repair of distal biceps ruptures, Achilles tendon ruptures, and rotator cuff tears were identified. For each tendon, patients who were prescribed FQs within 90 days postoperatively were propensity score matched at a 1:3 ratio with controls without postoperative FQ prescriptions across age, sex, and several comorbidities. Rates of reoperation were compared at two years postoperatively with multivariable logistic regression. Results: A total of 124,322 patients who underwent primary tendon procedures were identified, including 3,982 (3.2%) patients with FQ prescriptions within 90 days postoperatively: 448 with distal biceps repair, 2,538 with rotator cuff repair, and 996 with Achilles tendon repair. These cohorts were matched with 1,344, 7,614, and 2,988 controls, respectively. Patients with postoperative FQ prescriptions exhibited significantly higher rates of revision surgery after primary repair of distal biceps ruptures (3.6% vs. 1.7%; OR 2.13; 95% CI, 1.09-4.04), rotator cuff tears (7.1% vs. 4.1%; OR 1.77; 95% CI, 1.48-2.15), and Achilles tendon ruptures (3.8% vs. 1.8%; OR 2.15; 95% CI, 1.40-3.27). Conclusion: Patients with FQ prescriptions within 90 days after primary tendon repair demonstrated significantly higher rates of reoperations for distal biceps, rotator cuff, and Achilles tendon repair at two years postoperatively. To achieve optimal outcomes and avoid complications in patients following primary tendon repair procedures, physicians should consider prescribing alternative non-FQ antibiotics and counsel patients on the risk of reoperation associated with postoperative FQ use.

Concomitant Tibial Tubercle Osteotomy Reduces the Risk of Revision Surgery After Medial Patellofemoral Ligament Reconstruction for the Treatment of Patellar Instability.

PURPOSE: To compare postoperative complication rates between patients who underwent medial patellofemoral ligament reconstruction (MPFLR) and those who underwent MPFLR with tibial tubercle osteotomy (TTO) in a large-scale study. A secondary goal was to investigate demographic associations with outcomes. METHODS: Patients who underwent MPFLR (n = 3,480) or MPFLR-TTO (n = 615) for patellar instability were identified in the PearlDiver database. Rates of surgery for infection, procedures for knee stiffness, patellar fracture, and revision MPFLR within 2 years postoperatively were compared using multivariable logistic regression. Demographic associations with outcomes were also investigated. RESULTS: The MPFLR-TTO cohort exhibited a significantly lower rate of revision surgery at 2 years (0.8% vs 1.9%; odds ratio [OR], 0.33; 95% confidence interval [CI], 0.10-0.80; P = .036) when compared with the MPFLR group. Independent of index procedure, patients younger than 21 years had significantly lower rates of requiring procedures for knee stiffness (OR, 0.35; 95% CI, 0.22-0.54; P < .001) and any complication at 2 years (OR, 0.59; 95% CI, 0.45-0.78; P < .001) when compared with older patients. Male patients displayed a significantly lower rate of requiring procedures for knee stiffness at 2 years than female patients (OR, 0.46; 95% CI, 0.25-0.78; P = .007). Tobacco use was associated with a significantly higher rate of postoperative infection at 2 years (OR, 2.35; 95% CI, 1.00-5.38; P = .046). CONCLUSIONS: The MPFLR cohort exhibited higher rates of revision surgery at 2 years compared with the MPFLR-TTO cohort. Patient age under 21 years was associated with lower rates of any complication and requiring procedures for knee stiffness, male sex was associated with a lower rate of requiring procedures for knee stiffness, and tobacco use was associated with a higher rate of surgery for postoperative infection. This information can assist surgeons when counseling patients before these procedures are performed. LEVEL OF EVIDENCE: Level III, retrospective, comparative prognostic trial.

The Effects of Gout Following total Knee Arthroplasty: A Retrospective Analysis.

BACKGROUND: The prevalence of gout is increasing along with the number of total knee arthroplasties (TKA) performed annually. The purpose of this study was to evaluate the incidence of gout following TKA in patients who had a previous history of gout and to determine if it is associated with an increased rate of postoperative joint complications. METHODS: Patients who did and did not have a preoperative diagnosis of gout and underwent a primary TKA were identified from a national database. The gout patients were matched 1:1 to patients who did not have gout and rates of postoperative gout diagnoses within 2 years of surgery were compared. Complication rates at mean 1 and 2 years were then compared for both patient cohorts using multivariable logistic regressions. A total of 17,463 patients with a prior diagnosis of gout were matched with 17,463 controls. RESULTS: There were 53.8% of patients who had previous gout and had a recurrence of gout within 2 years versus 3.6% of controls (Odds Ratios [OR]: 30.86). At mean 1-year, patients who had gout were significantly more likely to experience prosthetic joint infections (PJIs) and revision procedures. At mean 2 years, gout patients were at increased risk of prosthetic loosening, PJI, revision, and incision and debridement procedures. CONCLUSION: This study suggests that patients who had a prior diagnosis of gout are significantly more likely to experience recurrent episodes of gout after TKA. Gout attacks after TKA are associated with an increase in the rate of joint complications. LEVEL OF EVIDENCE: Level III.

Sex-related differences in hip and groin injuries in adult runners: a systematic review.

OBJECTIVES: Hip/groin running-related injuries (RRIs) are relatively uncommon. It is unclear if runners of either sex are disproportionately affected. Our objective was to systematically review differences in hip/groin RRIs between males and females. DATA SOURCES: A structured and comprehensive search of four medical literature databases was performed (PubMed, Embase, Ovid Medline, and CINAHL). Terms searched were as follows: risk, epidemiology, hip injury, groin injury, overuse injury, running, sprinting, and track and field. STUDY SELECTION: Studies reporting sex-specific data on hip/groin RRIs in adult runners were included. Data was extracted and reviewed independently by two authors. STUDY APPRAISAL AND DATA SYNTHESIS: Sex-specific injury rates, risk factors, and return to sport (RTS) following hip/groin RRI were extracted. Risk of bias was assessed using the Joanna-Briggs Institute Critical Appraisal Tool. RESULTS: Ten studies with 7,353 total runners were included: 2,315 (47%) males and 2,559 (53%) females. The mean age of the included runners was 37.3 ± 8.9 years and the mean weekly running distance was 10.4 ± 8.4 km. Hip/groin injuries comprised 10.1% (491/4,874) of total RRIs, including 6.3% of RRIs sustained by males and 11.0% by females. Three studies reported significantly higher rates of hip/groin RRIs in female runners. One study reported significantly higher rates of gluteus medius and adductor RRIs for females and males, respectively. One study identified female sex as an independent risk factor for hip/groin RRIs. Three studies reported on RTS after hip/groin RRIs: the pooled RTS rate was 81.4% (57/70) at 1 to 368 days after injury. LIMITATIONS: Data was pooled when possible; however, there was considerable clinical, methodological, and statistical heterogeneity across studies. CONCLUSIONS: Hip/groin RRIs comprise a greater percentage of total injuries among injured female runners relative to males. Females may be at a higher risk for sustaining hip/groin RRIs though more research on risk factors and RTS is needed.

Complications Following Total Ankle Arthroplasty Versus Ankle Arthrodesis for Primary Ankle Osteoarthritis.

INTRODUCTION: There are minimal data comparing complications between ankle arthrodesis (AA) versus total ankle arthroplasty (TAR) for operative management of primary osteoarthritis (OA). This study aimed to compare outcomes following AA versus TAR for primary ankle OA using a large patient database. METHODS: Patients who received AA or TAR for primary ankle OA from 2010 to 2019 were queried from PearlDiver. Rates of common joint complications were compared at 90 days, 1 year, and 2 years postoperatively using multivariable logistic regression. RESULTS: A total of 1136 (67%) patients received AA and 584 (33%) patients underwent TAR. Patients that received AA exhibited significantly higher rates of at least one common joint complication at 90 days (19.3% vs 12.6%; odds ratio [OR] 1.69), 1 year (25.6% vs 15.0%; OR 2.00), and 2 years (26.9% vs 16.2%; OR 1.91) postoperatively. This included higher rates of adjacent fusion or osteotomy procedures, periprosthetic fractures, and hardware removal at each postoperative follow-up (all P < .05). Rates of prosthetic joint infection were comparable at 2 years postoperatively (4.3% vs 4.2%; OR 0.91). CONCLUSION: The AA cohort exhibited higher rates of postoperative joint complications in the short and medium-term, namely, subsequent fusions or osteotomies, periprosthetic fractures, and hardware removal. LEVELS OF EVIDENCE: Level III.

Reoperation Rates Following Total Ankle Arthroplasty Versus Ankle Arthrodesis for Posttraumatic Indications.

AIMS: This studied aimed to compare rates of reoperation for patients who received primary ankle arthrodesis (AA) versus total ankle replacement (TAR) for posttraumatic indications between 2010 and 2016 Q2 using a nationwide claims database. METHODS: A retrospective cohort study analyzing patients who received primary AA or TAR for posttraumatic indications was performed using PearlDiver. Reoperations assessed included prosthetic joint infection (PJI), hardware removal, adjacent joint fusion, and local open reduction internal fixation (ORIF). Multivariable logistic regression was used to compare rates of reoperations at 1 and 2 years postdischarge. RESULTS: A total of 862 (74%) patients received AA and 318 (26%) patients underwent TAR for a posttraumatic indication. At 1 year, 305 (35.4%) AA patients had at least 1 reoperation compared with 55 (17.3%) TAR patients (OR 2.32; 95% CI, 1.68-3.26). At 2 years, 364 (42.2%) AA patients and 66 (20.8%) TAR patients had at least 1 reoperation (OR 2.51; 95% CI, 1.84-3.45). ORIF, hardware removal, and adjacent joint fusions were more likely for AA patients at both time intervals (all Ps < .05). CONCLUSION: Patients who received primary AA for posttraumatic indications exhibited higher rates of major reoperations in the short to medium term compared with patients who underwent TAR. LEVELS OF EVIDENCE: Level III: Retrospective cohort study.

Trends in Surgical Approach for Single-Level Lumbar Fusion Over the Past Decade.

STUDY DESIGN: Retrospective Comparative Study. OBJECTIVE: The purpose of this study was to characterize trends in surgical approach for single-level lumbar fusion over the past decade. SUMMARY OF BACKGROUND DATA: The number of elective lumbar fusion cases performed is increasing annually. Several different surgical approaches exist for lumbar spinal fusion including novel anterior approaches developed in recent years. With ongoing innovation, trends in the utilization of common surgical approaches in recent years are unclear. MATERIALS AND METHODS: A retrospective cohort study was conducted using the PearlDiver database (Fort Wayne, IN). Patients undergoing single-level lumbar fusion between 2010 and 2019 were identified using Current Procedural Technology codes and divided into 4 mutually exclusive cohorts based on surgical approach: (1) anterior-only, (2) anterior approach with posterior instrumentation, (3) posterolateral, and (4) posterior-only interbody. Trend analyses of surgical approach utilization over the last decade were performed with the Cochran-Armitage test to evaluate the 2-tailed null hypothesis that utilization of each surgical approach for single-level lumbar fusion remained constant. RESULTS: A total of 53,234 patients met inclusion criteria and were stratified into 4 cohorts: anterior-only (n=5104), anterior with posterior instrumentation (n=23,515), posterolateral (n=5525), and posterior-only interbody (n=19,090). Trend analysis revealed the utilization of a posterior-only interbody approach significantly decreased from 36.7% to 29.2% ( P <0.001), whereas the utilization of a combined anterior and posterior approach significantly increased from 45.8% to 50.4% ( P <0.001). The utilization of an anterior-only approach also significantly increased from 7.9% to 10.5% ( P <0.001). CONCLUSIONS: Utilization of anterior-only and anterior with posterior instrumentation approaches for single-level lumbar fusion have been significantly increasing over the past decade while use of posterior-only interbody approach trended significantly downward. These data may be particularly useful for trainees and spine surgeons as new techniques and technology become available. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

How do the top 10 known offending drug classes associated with decreased bone mineral density affect total shoulder arthroplasty outcomes?

BACKGROUND: Many regularly prescribed classes of drugs are known to negatively impact bone health. However, it is unclear if perioperative use of these drugs impacts total shoulder arthroplasty (TSA) outcomes. The purpose of this study was to analyze the impact of perioperative use of 10 drug classes with known negative effects on bone health on prosthesis-related outcomes of TSA. METHODS: Patients who underwent primary TSA were retrospectively identified in the PearlDiver database. Within this population, patients prescribed proton pump inhibitors (PPIs), thiazolidinediones (TZDs), loop diuretics, glucocorticoids, aromatase inhibitors, calcineurin inhibitors, selective serotonin reuptake inhibitors (SSRIs), antiepileptic drugs (AEDs), first-generation antipsychotics (FGAs), and second-generation antipsychotics (SGAs) within 6 months before or 6 months after primary TSA were identified (n = 23,748). These patients were propensity score matched 1:1 with controls (n = 23,748) on age, sex, and several comorbidities. After matching, patients with perioperative drug exposure were divided into 10 subgroups (ie, 1 for each drug class). Rates of prosthesis-related complications among patients taking each medication class vs. controls were compared with multivariable logistic regression. RESULTS: Relative to controls, SGA exposure was associated with significantly higher rates of all-cause revision (odds ratio [OR] 1.68) and aseptic revision (OR 1.57). Loop diuretic exposure was associated with significantly higher rates of all-cause revision (OR 1.44) and aseptic revision (OR 1.43). Glucocorticoid exposure was associated with significantly higher rates of all-cause revision (OR 1.32) and aseptic revision (OR 1.30). SSRI exposure was associated with significantly higher rates of all-cause revision (OR 1.27) and aseptic revision (OR 1.24). Periprosthetic fracture, aseptic loosening, and septic revision was comparable for all drug cohorts compared to matched controls (all P > .05). Patients with perioperative exposure to PPIs, TZDs, FGAs, AEDs, aromatase inhibitors, and calcineurin inhibitors displayed comparable rates of all queried complications compared with controls (all P > .05). CONCLUSION: Compared with matched controls, patients with perioperative exposure to SGAs, loop diuretics, glucocorticoids and SSRIs exhibited significantly higher rates of all-cause and aseptic revisions following primary TSA. Several other medications that are risk factors for osteoporosis and fragility fractures did not demonstrate significant associations with any complications, including periprosthetic fracture. These results highlight the need for a thorough review of patients' medical history and current medication usage prior to preoperative risk counseling for patients seeking TSA.

Hepatitis C Is Associated With Higher Short-Term Complication Rates After Initial Aseptic and Septic Revision Total Hip Arthroplasty: A Matched Cohort Study.

BACKGROUND: It is unclear if hepatitis C virus (HCV) negatively impacts outcomes of revision total hip arthroplasty (rTHA). The purpose of this study is to trend recent rTHA utilization in patients who have HCV and compare postoperative complication rates versus a matched cohort. METHODS: All patients who underwent rTHA were retrospectively identified in a national database. Patients who had HCV (n = 1,746) were matched 1:3 with a matching group (n = 5,238) for age, gender, and several comorbidities. Cochran-Armitage tests were used to analyze trends in the annual proportion of rTHA performed in patients who had HCV from 2010 to 2019. Rates of 90-day medical and prosthesis-related complications within 2 years postoperatively were compared with multivariable logistic regressions. RESULTS: The annual proportion of rTHA performed in patients who had HCV significantly increased from 2010 to 2019 (P < .001). Patients who had HCV exhibited significantly higher rates of acute kidney injuries (7.6% versus 4.4%; odds ratio [OR] 1.50), transfusions (20.6% versus 14.6%; OR 1.38), and re-revisions for prosthetic joint infection (10.9% versus 6.5%; OR 1.73). In subgroup analyses, rates of re-revision for prosthetic joint infection after initial aseptic rTHA (7.1% versus 3.8%; OR 1.82) and periprosthetic fracture after initial septic rTHA (4.5% versus 1.6%; OR 2.77) were significantly higher in the HCV cohort. CONCLUSION: Similar to primary THA, patients who have HCV exhibit significantly increased complication rates after rTHA. With growing utilization in recent years, these data suggest that this population will comprise an increasingly larger proportion of rTHA procedures performed in the coming years.

The Impact of Epilepsy on Complication Rates After Total Joint Arthroplasty: A Propensity Score-Matched Cohort Study.

BACKGROUND: It is unclear how epilepsy may affect total joint arthroplasty outcomes. The purpose of this study is to analyze the impact of epilepsy on prosthesis-related complications following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: A retrospective cohort study was conducted using a national database. Patients who have epilepsy underwent a primary THA (n = 6,981) and TKA (n = 4,987) and were matched 1:4 (THA, n = 27,924; TKA, n = 19,948). Rates of low-energy falls and prosthesis-related complications within 2 years postoperatively were compared for patients who did and did not have epilepsy with multivariable logistic regression. RESULTS: After primary TKA, patients who have epilepsy exhibited significantly higher rates of aseptic revision (4.3% versus 3.5%, odds ratio [OR] 1.21, P = .017) and revision for prosthetic joint infection (1.8% versus 1.3%, OR 1.29, P = .041). THA patients who have epilepsy exhibited significantly higher rates of prosthetic dislocation (3.2% versus 1.9%, OR 1.54, P < .001), periprosthetic fracture (2.2% versus 0.8%, OR 2.39, P < .001), and aseptic loosening (1.7% versus 1.1%, OR 1.40, P = .002). Rates of low-energy falls within 2 years after TKA (14.1% versus 6.4%, OR 2.19, P < .001) and THA (33.6% versus 7.5%, OR 5.95, P < .001) were also significantly higher for patients who have epilepsy. CONCLUSION: Epilepsy was associated with significantly higher rates of falls (P < .001) and prosthesis-related complications after primary THA (P < .05) and TKA (P < .05). Precautions should be implemented in this population during intraoperative and perioperative decision-making to reduce complication risk. LEVEL OF EVIDENCE: Level III.

Trends in Total Joint Arthroplasty Among Patients With Rheumatoid Arthritis: The Effect of Recent Disease Modifying Antirheumatic Drug Utilization Guidelines.

INTRODUCTION: The 2015 change in the American College of Rheumatology (ACR) guidelines narrowed indications for initiating treatment with biologic disease-modifying antirheumatic drugs (bDMARDs) in patients with rheumatoid arthritis (RA). This study sought to evaluate trends in total joint arthroplasty (TJA) in patients with RA and to characterize the effect of bDMARDs on arthroplasty risk in this population after the change in ACR treatment guidelines. METHODS: A retrospective review was conducted using the PearlDiver database. TJA procedures included total shoulder arthroplasty, total elbow arthroplasty, total hip arthroplasty, and total knee arthroplasty. The Cochran-Armitage Trend Test was used to evaluate trends in the volume of TJA procedures conducted in patients with RA between 2010 and 2019. Logistic regression was used to compare 2-year arthroplasty risk after an initial joint-specific RA International Classification of Diseases 10th Revision diagnosis for RA patients with versus without bDMARD exposure. RESULTS: A total of 2,942,360 patients with RA were identified, and 80,744 (2.74%) underwent TJA between 2010 and 2019. Rates of TJA procedures trended significantly upward over the decade (2.6% versus 5.1%, P < 0.001) with a sharp increase between 2015 and 2016 (2.1% versus 4.9%, P < 0.001). Among the 16,736 identified patients with an initial International Classification of Diseases 10th Revision joint-specific RA diagnosis, 3362 patients (20.09%) were treated with bDMARDs and 13,374 (79.91%) were not. Untreated patients exhibited significantly lower risk of any TJA (5.92% versus 7.73%; odds ratio [OR]: 0.72; 95% confidence interval [CI]: 0.64 to 0.82), total hip arthroplasty (OR: 0.69, 95% CI: 0.50 to 0.95), and total knee arthroplasty (OR: 0.63, 95% CI: 0.52 to 0.75) compared with treated patients. DISCUSSION: The volume of TJA procedures conducted in patients with RA has trended markedly upward over the past decade, with a sharp increase after 2015. bDMARD treatment was associated with markedly increased risk of TJA, likely because of initiation of bDMARDs in only those patients with advanced disease per ACR guidelines.

The Impact of Hepatitis C on Complication Rates After Revision Total Knee Arthroplasty: A Matched Cohort Study.

Background: It is unclear if hepatitis C (HCV) negatively impacts outcomes of revision total knee arthroplasty (rTKA). The purpose of this study was to compare complication rates after rTKA for patients with HCV vs matched controls. Methods: A retrospective cohort study was conducted using the PearlDiver database (PearlDiver Inc., Colorado Springs, CO). Patients with HCV who underwent rTKA (n = 1448) were matched 1:4 with controls (n = 5792) on age, sex, and several comorbidities. Rates of medical complications within 90 days and prothesis-related complications within 2 years postoperatively were compared with logistic regression for (1) patients with vs without HCV and (2) HCV patients who underwent aseptic vs septic rTKA. Results: Relative to controls, patients with HCV exhibited significantly higher rates of medical complications (27.7% vs 20.9%; odds ratio [OR] 1.47), periprosthetic fractures (2.3% vs 1.1%; OR 2.20), all-cause repeat rTKA (11.7% vs 9.4%; OR 1.29), and repeat rTKA for prosthetic joint infection (PJI) (6.7% vs 3.6%; OR 1.92). Within the HCV cohort, HCV patients with initial septic rTKA exhibited significantly higher rates of medical complications (41.7% vs 22.7%; OR 2.39), all-cause subsequent rTKA (15.9% vs 10.2%; OR 1.67), and repeat rTKA for PJI (15.9% vs 3.4%; OR 5.39). Conversely, HCV patients with initial aseptic rTKA exhibited significantly higher rates of aseptic loosening (2.6% vs 7.4%; OR 0.33). Conclusions: Patients with HCV exhibited significantly higher rates of medical and prosthesis-related complications after rTKA than controls. Among patients with HCV, initial septic rTKA was associated with significantly higher rates of medical complications, repeat rTKA, and PJI.

Does pre-arthroplasty antiviral treatment for hepatitis C reduce complication rates after total shoulder arthroplasty? A matched cohort study.

Background: Hepatitis C virus (HCV) is associated with increased complications of risk after arthroplasty. The purpose of this study was to examine the impact of HCV and a pre-arthroplasty antiviral treatment on complications following total shoulder arthroplasty (TSA). Methods: A retrospective matched cohort study was conducted using an administrative claims database. Patients who underwent TSA were identified with Current Procedural Terminology -23472 and International Classification of Diseases procedural codes. A total of 1244 HCV patients were matched 1:3 with 3732 noninfected controls across age, sex, diabetes mellitus, tobacco use, and obesity. The HCV patients with treatment before TSA were identified by claims containing antiviral drug codes. Multivariable logistic regression was used to compare rates of 90-day medical complications and prosthesis-related complications within 2 years postoperatively for (1) HCV patients vs. controls, (2) antiviral-treated HCV patients vs. controls, and (3) antiviral-treated HCV patients vs. untreated HCV patients. Results: Patients with HCV exhibited significantly higher rates of blood transfusion (OR 2.12), acute kidney injuries (OR 1.86), inpatient readmission (OR 2.06), revision TSA (OR 1.48), dislocation (OR 1.92), mechanical complications (OR 1.39), and prosthetic joint infection (OR 1.53) compared to controls. Antiviral-treated HCV patients exhibited a significantly lower rate of myocardial infarction (OR 0.27) and comparable rates of all other complications relative to controls (all P > .05). Compared to untreated HCV patients, antiviral-treated HCV patients exhibited significantly lower rates of 90-day medical complications (OR 0.57) and prosthetic joint infection (OR 0.36). Conclusions: HCV is associated with significantly increased complication rates after TSA. Antiviral treatment before TSA may reduce the risk of postoperative complications.

Is Prior Hip Arthroscopy Associated With Higher Complication Rates or Prolonged Opioid Claims After Total Hip Arthroplasty? A Matched Cohort Study.

Background: Hip arthroscopy (HA) procedures have increased exponentially in recent years. Their effect on outcomes after subsequent total hip arthroplasty (THA) remains unclear. Purpose: To compare rates of complications and opioid claims after elective THA among patients with prior HA versus controls. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent THA were identified in the PearlDiver database. Arthroplasty performed for hip fractures and hip avascular necrosis were excluded. Within this population, patients with HA before arthroplasty (n = 3156) were propensity score matched 1:1 with controls on age, sex, US region, and several comorbidities. Rates of medical complications within 90 days and prosthesis-related complications within 2 years were queried. The number of patients with an opioid claim within 0 to 30 days and subsequent opioid claim(s) during the 90-day global period were obtained to assess rates of prolonged opioid use after arthroplasty. Rates of postoperative complications and opioid claims were compared using logistic regression. Results: Patients with prior HA exhibited significantly lower rates of readmission (5.6% vs 7.3%; odds ratio [OR], 0.72), pulmonary embolism (0.2% vs 0.6%; OR, 0.45), urinary tract infection (3.1% vs 4.0%; OR, 0.75), and blood transfusion (3.6% vs 6.1%; OR, 0.55). The prior HA cohort also exhibited a significantly lower rate of prosthetic joint infection at 1 year postoperatively (0.6% vs 1.3%; OR, 0.50). Rates of dislocation, periprosthetic fracture, mechanical complications, and aseptic revision arthroplasty were statistically comparable between the cohorts within 2 years. The prior HA cohort was significantly less likely to file persistent opioid claims after 30 days postoperatively, including between 31 and 60 days (27.2% vs 33.1%; OR, 0.74) and 61 to 90 days (16.2% vs 20.9%; OR, 0.71). Conclusion: After elective THA, patients with prior HA exhibited significantly lower rates of medical complications and prolonged opioid claims within 90 days and prosthetic joint infection at 1 year. Rates of all other prosthesis-related complications within 2 years were statistically comparable.

The Impact of a Non-Compete Clause on Patient Care and Orthopaedic Surgeons in the State of Louisiana: Afraid of a Little Competition?

Background: Non-compete clauses (NCC) are commonly required for physicians practicing in an employed model. With growing pressures driving surgeons to practice in an employed model instead of physician-led practices, the purpose of this survey was to determine the impact of NCCs on orthopaedic surgeons and their patients in Louisiana. Methods: A voluntary, single-mode online survey containing 23 questions was created using the Qualtrics XM Platform (Qualtrics, Provo, UT) and distributed to 259 orthopaedic surgeons who are members of the Louisiana Orthopaedic Association. Survey questions assessed the prevalence and details of existing NCCs and perceptions of their impact on surgeons' practice, patients, and personal life. Results: 117 members responded (response rate: 45.2%), of which 91 (77.8%) finished the survey. Nearly half (44%) of respondents had an expired or active NCC in their contract. Most (84.3%) believed NCCs give employers unfair leverage during contract negotiations. NCCs have deterred or would deter 71.4% of respondents from accepting another job offer. Respondents believed NCCs negatively impact patients, including forcing patients to drive long distances to maintain continuity of care (64.4%) and forcing surgeons to abandon their patients if they seek new employment (76.7%). Many respondents reported NCCs also exert significant detrimental effects on their personal life, including mandatory relocation of their family (67.0%). Nearly all (97.8%) believed such clauses have become unreasonable over the last decade with the rise of large hospital conglomerates. Most surgeons (83.7%) believed that removal of NCCs from all orthopaedic surgeons' contracts would improve the overall healthcare of orthopaedic patients in Louisiana. Conclusion: Perceptions of NCCs were overwhelmingly negative among orthopaedic surgeons in Louisiana. Such clauses give employers an unfair advantage during contract negotiations and exert a significant detrimental impact on surgeons and their patients. While NCCs may be reasonable in the business sector and other professions, it is unclear how such clauses benefit surgeons or improve patient care and may be detrimental to both. Study Design: Cross-sectional Survey.

The Impact of Celiac Disease on Complication Rates After Total Joint Arthroplasty: A Matched Cohort Study.

Background: While many studies have demonstrated increased complication risk after total joint arthroplasty in patients with inflammatory bowel disease, it is unclear if celiac disease is associated with similarly increased risk. The purpose of this study was to analyze if celiac disease is associated with increased postoperative complications following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods: A retrospective cohort study was conducted using the PearlDiver database. Patients with celiac disease who underwent THA (n = 1701) and TKA (n = 3515) were matched 1:3 with controls (THA, n = 5103; TKA, n = 10,545) on age, sex, year of arthroplasty, diabetes mellitus, tobacco use, and obesity. Rates of medical complications within 90 days and joint complications including revision arthroplasty, prosthetic joint infection, periprosthetic fracture, and aseptic loosening within 2 years postoperatively were queried. Complication rates were compared for patients with celiac disease vs controls with multivariable logistic regression. Results: After primary THA, patients with celiac disease exhibited significantly higher rates of acute myocardial infarction within 90 days (2.7% vs 1.9%; odds ratio 1.45; 95% confidence interval 1.01-2.07) and periprosthetic fractures at 2 years postoperatively (1.1% vs 0.5%; odds ratio 2.09; 95% confidence interval 1.14-3.79) than controls. Following primary TKA, patients with celiac disease exhibited higher but statistically comparable complication rates than controls (all P > .05). Conclusions: Celiac disease was associated with significantly higher rates of acute myocardial infarction and periprosthetic fracture after primary THA. Complication rates after primary TKA were similar between the cohorts. Level of Evidence: Level III.

Osteoporosis management and secondary fragility fracture rates in patients with multiple sclerosis: a matched cohort study.

This study highlights the persistent osteoporosis treatment gap following fragility fractures. Patients with multiple sclerosis sustained more primary hip fractures than controls and exhibited significantly higher rates of falls within three years post-fracture. However, multiple sclerosis (MS) patients were significantly more likely to be diagnosed with osteoporosis and treated with medications. INTRODUCTION: The purpose of this study was to compare rates of osteoporosis management, falls, and secondary fractures following primary fragility fractures among patients with MS versus matched controls. MATERIALS AND METHODS: A retrospective matched cohort study was conducted using the PearlDiver database. Patients aged ≥ 50 years with primary fragility fractures were identified (n = 120,368). Within this population, patients with MS were matched 1:10 with controls across age, sex, and US region. Rates of osteoporosis diagnoses and pharmacologic treatment, low-energy falls, and secondary fragility fractures were compared at three years post-fracture via logistic regression. RESULTS: A total of 1,232 patients with MS (mean age, 65.7 years) with primary fragility fractures were matched with 12,320 controls (mean age, 65.8 years). Primary hip fractures were significantly more common in the MS cohort (47.4% vs. 34.2%, p < 0.001). After the initial fracture, patients with MS were significantly more likely to receive a formal osteoporosis diagnosis (12.9% vs. 9.7%; OR 1.35; 95% CI, 1.13-1.61) and osteoporosis pharmacotherapy (14.4% vs. 11.9%; OR 1.24; 95% CI, 1.04-1.46). The MS cohort also exhibited significantly higher rates of falls (27.8% vs 22.7%; OR 1.15; 95% CI, 1.01-1.32). Rates of secondary fractures were comparable (6.3% vs. 5.0%; OR 1.10; 95% CI, 0.85-1.40). CONCLUSION: Primary hip fragility fractures were significantly more common in patients with MS compared to matched controls. Following an initial fracture, patients with MS exhibited a significantly higher rate of falls but were more likely to be diagnosed with osteoporosis and treated with medications.

Femur Strength is Similar Before and After Iatrogenic Fracture During Total Hip Arthroplasty: A Biomechanical Analysis.

Background: The purpose of this study was to compare the biomechanical strength of femurs before an iatrogenic periprosthetic fracture vs after an initial fracture with supporting cerclage fixation during cementless total hip arthroplasty. Material and methods: Nineteen composite femurs and 5 matched pairs of cadaveric femurs were implanted with a single-wedge or dual-wedge tapered femoral stem and tested for ultimate load to failure producing a periprosthetic fracture. Following initial fracture, each femur was cerclaged with Vitallium cables and retested for ultimate load to failure. The mean force eliciting iatrogenic fracture before cabling and that after cabling were compared with a two-sided paired Student's t-test. Results: All composite femurs developed periprosthetic fractures with an average length extension from the calcar of 75.17 mm. For the 19 composite femurs, the mean ultimate load to failure before cabling and that after cabling were not significantly different (2422.95 N vs 2505.14 N, P = .678). For the 10 cadaveric femurs, the mean ultimate load to failure for the initial fracture vs that after cabling was statistically comparable (5828.62 N vs 7002.63 N, P = .126). Subanalysis of the 5 cadaveric femurs with a double-wedge stem revealed a significantly higher mean load to failure following cabling (5007.38 N vs 7811.17 N, P = .011). Conclusion: Biomechanical strength was similar for femurs that sustained an initial iatrogenic periprosthetic fracture and the same femurs cabled with cerclage wires after being fractured. These data may assist in operative decision-making for treating iatrogenic fractures during total hip arthroplasty.

Latex Allergy as an Independent Risk Factor for Prosthetic Joint Infection.

In response to increasing rates of self-reported latex allergies, changes have been made to prevent anaphylaxis in the operating room, including the use of latex-free gloves. However, the impact of these changes on the risk of prosthetic joint infection (PJI) after arthroplasty is unclear. This study evaluated whether documented latex allergy is an independent risk factor for PJI and aseptic revision surgery after total hip arthroplasty (THA) and total knee arthroplasty (TKA). A retrospective matched cohort study was conducted with an administrative claims database. A total of 17,501 patients who underwent TKA and had documented latex allergy were matched 1:4 with 70,004 control subjects, and 8221 patients who underwent THA and had documented latex allergy were matched 1:4 with 32,884 control subjects. Multivariable logistic regression showed that patients who had TKA and had a latex allergy showed significantly higher risk of PJI at both 90 days (odds ratio [OR], 1.26) and 1 year (OR, 1.22) and significantly higher risk of aseptic revision TKA at 1 year (OR, 1.21) after surgery compared with control subjects. Patients who had THA and had a latex allergy had significantly higher risk of PJI at 1 year (OR, 1.19) compared with control subjects. Rates of aseptic revision THA were higher in the latex allergy cohort but statistically comparable (P>.05). Latex allergy was associated with significantly increased risk of PJI and aseptic revision after TKA and significantly increased risk of PJI after THA. More work is needed to determine whether these risks can be mitigated or if latex allergy is an inherent, nonmodifiable risk factor requiring modification to typical arthroplasty pathways. [Orthopedics. 2022;45(4):244-250.].