Discordance in Published 30-Day Readmission Rates Following Primary Total Hip and Total Knee Arthroplasty: Centers for Medicare and Medicaid Services (CMS) Versus the National Surgical Quality Improvement Program (NSQIP).

Background: 30-day readmission is an important quality metric evaluated following primary total joint arthroplasty (TJA) that has implications for hospital performance and reimbursement. Differences in how 30-day readmissions are defined between Centers for Medicare and Medicaid Services (CMS) and other quality improvement programs (i.e., National Surgical Quality Improvement Program [NSQIP]) may create discordance in published 30-day readmission rates. The purpose of this study was to evaluate 30-day readmission rates following primary TJA using two different temporal definitions. Methods: Patients undergoing primary total hip and primary total knee arthroplasty at a single academic institution from 2015-2020 were identified via common procedural terminology (CPT) codes in the electronic medical record (EMR) and institutional NSQIP data. Readmissions that occurred within 30 days of surgery (consistent with definition of 30-day readmission in NSQIP) and readmissions that occurred within 30 days of hospital discharge (consistent with definition of 30-day readmission from CMS) were identified. Rates of 30-day readmission and the prevalence of readmission during immortal time were calculated. Results: In total, 4,202 primary TJA were included. The mean hospital length of stay (LOS) was 1.79 days. 91% of patients were discharged to home. 30-day readmission rate using the CMS definition was 3.1% (130/4,202). 30-day readmission rate using the NSQIP definition was 2.7% (113/4,202). Eight readmissions captured by the CMS definition (6.1%) occurred during immortal time. Conclusion: Differences in temporal definitions of 30-day readmission following primary TJA between CMS and NSQIP results in discordant rates of 30-day readmission. Level of Evidence: III.

Time trends in case-mix and risk of revision following hip and knee arthroplasty in public and private hospitals: a cross-sectional analysis based on 476,312 procedures from the Dutch Arthroplasty Register.

BACKGROUND AND PURPOSE: This study aims to assess time trends in case-mix and to evaluate the risk of revision and causes following primary THA, TKA, and UKA in private and public hospitals in the Netherlands. METHODS: We retrospectively analyzed 476,312 primary arthroplasties (public: n = 413,560 and private n = 62,752) implanted between 2014 and 2023 using Dutch Arthroplasty Register data. We explored patient demographics, procedure details, trends over time, and revisions per hospital type. Adjusted revision risk was calculated for comparable subgroups (ASA I/II, age ≤ 75, BMI ≤ 30, osteoarthritis diagnosis, and moderate-high socioeconomic status (SES). RESULTS: The volume of THAs and TKAs in private hospitals increased from 4% and 9% in 2014, to 18% and 21% in 2022. Patients in private hospitals were younger, had lower ASA classification, lower BMI, and higher SES compared with public hospital patients. In private hospitals, age and ASA II proportion increased over time. Multivariable Cox regression demonstrated a lower revision risk for primary THA (HR 0.7, CI 0.7-0.8), TKA (HR 0.8, CI 0.7-0.9), and UKA (HR 0.8, CI 0.7-0.9) in private hospitals. After initial arthroplasty in private hospitals, 49% of THA and 37% of TKA revisions were performed in public hospitals. CONCLUSION: Patients in private hospitals were younger, had lower ASA classification, lower BMI, and higher SES com-pared with public hospital patients. The number of arthroplasties increased in private hospitals, with a lower revision risk compared with public hospitals.

Fixation or Revision for Periprosthetic Fractures: Epidemiology, New Trends, and Projections in the United States.

BACKGROUND: Periprosthetic fractures can be devastating complications after total joint arthroplasty (TJA). The management of periprosthetic fractures is complex, spanning expertise in arthroplasty and trauma. The purpose of this study was to examine and project trends in the operative treatment of periprosthetic fractures in the United States. METHODS: A large, public and private payer database was queried to capture all International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for periprosthetic femoral and tibial fractures. Statistical models were created to assess trends in treatment for periprosthetic fractures and to predict future surgical rates. An alpha value of 0.05 was used to assess significance. A Bonferroni correction was applied where applicable to account for multiple comparisons. RESULTS: In this study, from 2016 to 2021, 121,298 patients underwent surgical treatment for periprosthetic fractures. There was a significant increase in the total number of periprosthetic fractures. The incidence of periprosthetic hip fractures rose by 38% and that for periprosthetic knee fractures rose by 73%. The number of periprosthetic fractures is predicted to rise 212% from 2016 to 2032. There was a relative increase in open reduction and internal fixation (ORIF) compared with revision arthroplasty for both periprosthetic hip fractures and periprosthetic knee fractures. CONCLUSIONS: Periprosthetic fractures are anticipated to impose a substantial health-care burden in the coming decades. Periprosthetic knee fractures are predominantly treated with ORIF rather than revision total knee arthroplasty (TKA), whereas periprosthetic hip fractures are predominantly treated with revision total hip arthroplasty (THA) rather than ORIF. Both periprosthetic knee fractures and periprosthetic hip fractures demonstrated increasing trends in this study. The proportion of periprosthetic hip fractures treated with ORIF relative to revision THA has been increasing. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association between history of cannabis use and outcomes after total hip or knee arthroplasty: a systematic review and meta-analysis.

Background: Cannabis use may be increasing as countries legalize it and it becomes socially acceptable. A history of cannabis use may increase risk of complications after various kinds of surgery and compromise functional recovery. Here we systematically reviewed and meta-analyzed available evidence on how history of cannabis use affects recovery after hip or knee arthroplasty (THA/TKA). Methods: The PubMed, EMBASE, and Web of Science databases were comprehensively searched and studies were selected and analyzed in accordance with the PRISMA guidelines. The methodological quality of included studies was assessed based on the Newcastle-Ottawa Scale, while quality of evidence was evaluated according to the "Grading of recommendations assessment, development, and evaluation" system. Data on various outcomes were pooled when appropriate and meta-analyzed. Results: The systematic review included 16 cohort studies involving 5.91 million patients. Meta-analysis linked history of cannabis use to higher risk of the following outcomes: revision (RR 1.68, 95% CI 1.31-2.16), mechanical loosening (RR 1.77, 95% CI 1.52-2.07), periprosthetic fracture (RR 1.85, 95% CI 1.38-2.48), dislocation (RR 2.10, 95% CI 1.18-3.73), cardiovascular events (RR 2.49, 95% CI 1.22-5.08), cerebrovascular events (RR 3.15, 95% CI 2.54-3.91), pneumonia (RR 3.97, 95% CI 3.49-4.51), respiratory failure (RR 4.10, 95% CI 3.38-4.97), urinary tract infection (RR 2.46, 95% CI 1.84-3.28), acute kidney injury (RR 3.25, 95% CI 2.94-3.60), venous thromboembolism (RR 1.48, 95% CI 1.34-1.63), and deep vein thrombosis (RR 1.42, 95% CI 1.19-1.70). In addition, cannabis use was associated with significantly greater risk of postoperative transfusion (RR 2.23, 95% CI 1.83-2.71) as well as higher hospitalization costs. Conclusion: History of cannabis use significantly increases the risk of numerous complications and transfusion after THA or TKA, leading to greater healthcare costs. Clinicians should consider these factors when treating cannabis users, and pre-surgical protocols should give special consideration to patients with history of cannbis use.

Incidence of knee and hip joint replacement associated with cumulative exposure to physical factors at work.

BACKGROUND: Knee osteoarthritis (OA) has been quite consistently associated with high physical workload and specific physical factors at work, while for hip OA, fewer studies are available, which still indicate possible associations with heavy lifting and physical workload. The objective of the study was to assess the association between exposure to workplace physical factors and incidence of knee and hip arthroplasty, as markers of severe OA in these joints. METHODS: The study population was composed of employees 25-60 years who participated in the Turin 2011 census. For each job held since 1995, exposure to physical factors was assigned to individuals in the cohort through a Job-Exposure Matrix constructed from the Italian O*NET database. Using Poisson regression models, the incidence of knee and hip arthroplasty for OA, identified through hospitalizations from 2012 to 2018, was examined in relation to cumulative exposure to 7 different physical hazards and a composite indicator of physical workload constructed from 17 physical factors (Ergo-Index). RESULTS: The risk of knee OA was significantly increased in the highest cumulative exposure quartile of physical workload (incidence rate ratio = 1.98, 95% confidence interval: 1.24-3.16) and of all single hazards examined, compared to the lowest quartile, with significant trends in risk with increasing exposure. In contrast, no association was found with hip OA, whose relative risks were close to or below one in all higher-exposure quartiles of physical workload and of each single hazard. CONCLUSIONS: Our results indicate that exposure to physical hazards at work increases the likelihood of developing knee OA, but not hip OA.

[Considerable regional differences in patient injuries after primary hip and knee arthroplasty and between orthopedic departments depending on surgical volume]. / Regional skillnad i incidensen av skador efter ledprotesoperation.

Hip and knee arthroplasties are mostly successful procedures; however, patient injuries may occur and should be reported to Löf, the Swedish patient insurance. This study investigated the incidence of patient injuries after primary total hip and knee arthroplasty in the Swedish regions, differences in incidence depending on annual surgical volume, and types of approved injuries. Approved patient injuries were related to the total number of hip and knee arthroplasties registered in the Swedish Arthroplasty Register 2012-2021. The national incidence was 11.4 and 8.1 per 1,000 hip and knee arthroplasties respectively and varied in the regions from 30.4 to 4.9 and 15.4 to 5.4 per 1,000 hip and knee arthroplasties respectively. Orthopedic departments with higher annual volumes of performed arthroplasties had a lower proportion of patient injuries. Infection was the most common patient injury, followed by nerve lesions and mechanical complications. The differences may be due to underreporting and varying quality of care in the regions. A centralization of hip and knee arthroplasties may be beneficial.

Early cartilage lesion and 5-year incident joint surgery in knee osteoarthritis patients: a retrospective cohort study.

OBJECTIVE: to investigate the association between cartilage lesion-related features observed in knee osteoarthritis (OA) patients' first MRI examination and incident knee surgery within 5 years. Additionally, to assess the predictive value of these features for the incident knee surgery. METHODS: We identified patients diagnosed with knee OA and treated at our institution between January 2015 and January 2018, and retrieved their baseline clinical data and first MRI examination films from the information system. Next, we proceeded to determine joint space narrowing grade, cartilage lesion size grade, cartilage full-thickness loss grade and cartilage lesion sum score for the medial and lateral compartments, respectively. Generalized linear regression models examined the association of these features with 5-year incident knee surgery. Positive and negative predictive values (PPVs and NPVs) were determined referring to 5-year incident knee surgery. RESULTS: Totally, 878 participants (knees) were found eligible to form the study population. Within the 5 years, surgery was performed on 61 knees. None of the cartilage-related features had been found significantly associated with incident surgery. The results were similar for medial and lateral compartments. The PPVs were low for all the features. CONCLUSIONS: Among symptomatic clinically diagnosed OA knees, cartilage lesions observed in the first MRI examinations were not found to be associated with the occurrence of joint surgery within a 5-year period. All these cartilage-related features appear to have no additional value in predicting 5-year incident joint surgery.

Association between immigration status and total knee arthroplasty outcomes in Ontario, Canada: a population-based matched cohort study.

BACKGROUND: Immigrants and refugees face unique challenges navigating the health care system to manage severe arthritis, because of unfamiliarity, lack of awareness of surgical options, or access. The purpose of this study was to assess total knee arthroplasty (TKA) uptake, surgical outcomes, and hospital utilization among immigrants and refugees compared with Canadian-born patients. METHODS: We included all adults undergoing primary TKA from January 2011 to December 2020 in Ontario. Cohorts were defined as Canadian-born or immigrants and refugees. We assessed change in yearly TKA utilization for trend. We compared differences in 1-year revision, infection rates, 30-day venous thromboembolism (VTE), presentation to emergency department, and hospital readmission between matched Canadian-born and immigrant and refugee groups. RESULTS: We included 158 031 TKA procedures. A total of 11 973 (7.6%) patients were in the immigrant and refugee group, and 146 058 (92.4%) patients were in the Canadian-born group. The proportion of TKAs in Ontario performed among immigrants and refugees nearly doubled over the 10-year study period (p < 0.001). After matching, immigrants were at relatively lower risk of 1-year revision (0.9% v. 1.6%, p < 0.001), infection (p < 0.001), death (p = 0.004), and surgical complications (p < 0.001). No differences were observed in rates of 30-day VTE or length of hospital stay. Immigrants were more likely to be discharged to rehabilitation (p < 0.001) and less likely to present to the emergency department (p < 0.001) than Canadian-born patients. CONCLUSION: Compared with Canadian-born patients, immigrants and refugees have favourable surgical outcomes and similar rates of resource utilization after TKA. We observed an underutilization of these procedures in Ontario relative to their proportion of the population. This may reflect differences in perceptions of chronic pain or barriers accessing arthroplasty.

Bilateral simultaneous hip and knee replacement: an epidemiological nationwide study from 2001 to 2016.

BACKGROUND: Several studies have compared the pros and cons of simultaneous bilateral versus staged bilateral hip and knee replacement but the outcomes of these two surgical options remains a matter of controversy. This study aimed to evaluate demographic features, incidence and hospitalization rates of bilateral one stage total hip and knee arthroplasty in Italy. METHODS: The Italian Ministry of Health's National Hospital Discharge Reports (SDO) were used to gather data. This study referred to the adult population (+ 20 years of age) from 2001 to 2015 for hip arthroplasty and from 2001 to 2016 for knee arthroplasty. RESULTS: Overall, 1,544 bilateral simultaneous hip replacement were carried out. The incidence rate was 0.21 cases per 100,000 adult Italian residents. Male/female ratio was 1.1. The average days of hospital stay was 11.7 ± 11.8 days. The main primary codified diagnosis was: osteoarthrosis, localized, primary, pelvic region and thigh (ICD code: 715.15). 2,851 bilateral simultaneous knee replacement were carried out. The incidence rate was 0.37 cases per 100,000 adult Italian residents. Male/female ratio was 0.6. The average days of hospital stay was 7.7 ± 5.8 days. The main primary codified diagnosis was: osteoarthrosis, localized, primary, lower leg (ICD code: 715.16). CONCLUSIONS: The burden of hip and knee osteoarthrosis as a leading cause of bilateral joint replacement is significant in Italy. The national registers' longitudinal analysis may provide data for establishing international guidelines regarding the appropriate indications for one stage bilateral simultaneous hip or knee replacement versus two stage.

Comparison of revision rates and epidemiological data of a single total knee arthroplasty system of different designs (cruciate retaining, posterior stabilized, mobile bearing, and fixed bearing): a meta-analysis and systematic review of clinical trials and national arthroplasty registries.

BACKGROUND: This study aimed to meta-analyze epidemiological data, revision rates, and incidences of different designs of a single Total Knee Arthroplasty System and compare these factors across different countries. METHODS: A systematic review was conducted on clinical studies and arthroplasty registries of ATTUNE TKA from 1999 to 2020. The main endpoints analyzed were revision rates and epidemiological data. RESULTS: The average age of patients was 67.8 years, with a gender distribution of 60% female and 40% male. The pooled average BMI was 29.4 kg/m2. Eight clinical studies showed a pooled revision rate per 100 observed CY of 0.5 (n = 1343 cases). Cumulative revision rates after 1, 3, and 5 years varied among registries, with the Swiss registry having the highest revision data (after 5 years: 6.3%) and the American registry having the lowest revision data (after 5 years: 1.7%). A comparison of the revision rates of mobile bearing and fixed bearing (41,200 cases) as well as cruciate retaining and posterior stabilized (n = 123,361 cases) showed no significant advantage in the first 5 years after implantation. CONCLUSION: In conclusion, pooled data from 41,200 cases of TKA with a single Total Knee Arthroplasty System in two arthroplasty registries revealed that there was no significant difference in revision rates between the mobile bearing and fixed bearing design within the first 5 years after implantation. In addition, a comparison of the revision rates in n = 123,361 cases showed no significant advantage for cruciate retaining or posterior stabilized in the first 5 years after implantation.

Factors influencing patient selection of orthopaedic surgeons for total hip (THA) and total knee arthroplasty (TKA).

INTRODUCTION: The importance of identifying how patients choose their healthcare providers has grown with the prevalence of consumer-centric health insurance plans. There is currently a lack of studies exploring the factors associated with how patients select their hip and knee joint arthroplasty surgeons. The purpose of this study was to determine how patients find their arthroplasty providers and the relative importance of various arthroplasty surgeon characteristics. METHODS: An electronic mail survey was sent to 3522 patients who had visited our institution for an arthroplasty surgeon office visit between August 2022 and January 2023. The survey consisted of multiple-choice questions, which aimed to inquire about the patients' referral sources for their current arthroplasty surgeon. In addition, patients were requested to rate the significance of 22 surgeon-related factors, on a scale of 1 (Not Important At All) to 5 (Very Important), in choosing their arthroplasty surgeon. RESULTS: Of the 3522 patients that received the survey, 538 patients responded (15.3%). The most common referral sources were physician referral (50.2%), family/friend referral (27.7%), and self-guided research (24.5%). Of those that were referred by a physician, 54.4% of respondents were referred by another orthopaedic provider. Patients rated board certification (4.72 ± 0.65), in-network insurance status (4.66 ± 0.71), fellowship training (4.50 ± 0.81), bedside manner/personality (4.32 ± 0.86), and facility appearance (4.26 ± 0.81) as the five most important factors in picking an arthroplasty surgeon. Television (1.42 ± 0.83), print (1.50 ± 0.88), and online (1.58 ± 0.93) advertisements, along with social media presence (1.83 ± 1.08), and practice group size (2.97 ± 1.13) were rated as the five least important factors. CONCLUSION: Patients are most likely to select an arthroplasty surgeon based on referral from other physicians, namely orthopedic surgeons, in addition to board certification status, in-network insurance, and fellowship training. Overall, these findings highlight the importance of physician credentials and reputation within the orthopaedic community in order to attract and retain patients.

Examining racial disparities in utilization rate and perioperative outcomes following knee and hip arthroplasty.

BACKGROUND: Previous arthroplasty utilization research predominantly examined Black and White populations within the US. This is the first known study to examine utilization and complications in poorly studied minority racial groups such as Asians and Native Hawaiian/Pacific-Islanders (NHPI) as compared to Whites. RESULTS: Data from 3304 primary total hip and knee arthroplasty patients (2011 to 2019) were retrospectively collected, involving 1789 Asians (52.2%), 1164 Whites (34%) and 320 Native Hawaiians/Pacific Islanders (NHPI) (9.3%). The 2012 arthroplasty utilization rates for Asian, White, and NHPI increased by 32.5%, 11.2%, and 86.5%, respectively, by 2019. Compared to Asians, Whites more often underwent hip arthroplasty compared to knee arthroplasty (odds ratio (OR) 1.755; p < 0.001). Compared to Asians, Whites and NHPI more often received total knee compared to unicompartmental knee arthroplasty (White: OR 1.499; NHPI: OR 2.013; p < 0.001). White patients had longer hospitalizations (2.66 days) compared to Asians (2.19 days) (p = 0.005) following bilateral procedures. Medicare was the most common insurance for Asians (66.2%) and Whites (54.2%) while private insurance was most common for NHPI (49.4%). Compared to Asians, economic status was higher for Whites (White OR 0.695; p < 0.001) but lower for NHPI (OR 1.456; p < 0.001). After controlling for bilateral procedures, NHPI had a lower risk of transfusion compared to Asians (OR 0.478; p < 0.001) and Whites had increased risk of wound or systemic complications compared to Asians (OR 2.086; p = 0.045). CONCLUSIONS: Despite NHPI demonstrating a significantly poorer health profile and lower socioeconomic status, contrary to previous literature involving minority racial groups, no significant overall differences in arthroplasty utilization rates or perioperative complications could be demonstrated amongst the racial groups examined.

General anesthesia is not associated with dementia in older adults with osteoarthritis for hip/knee replacements, a national population-based nested case-control study.

BACKGROUND: Dementia is a prevalent neurological condition, yet the relationship between dementia and general anesthesia remains uncertain. The study aimed to explore the association between general anesthesia and dementia using a nationwide population-based database. METHODS: The study extracted data from Taiwan's national health insurance, which encompassed the records of one million insured residents. A total of 59,817 patients aged 65 years and above, diagnosed with osteoarthritis between 2002 and 2010, were included. Among these patients, 3277 individuals with an initial diagnosis of dementia between 2004 and 2013 were matched with non-dementia patients based on age, gender, and the date of osteoarthritis diagnosis. Following a 1:2 random matching, the case group included 2171 patients with dementia, while the control group consisted of 4342 patients without dementia. The data was analyzed using conditional and unconditional logistic regressions. RESULTS: No significant differences in the odds of dementia were found between individuals exposed to general and regional anesthesia during hip/knee replacement surgeries (OR = 1.11; 95%CI: 0.73-1.70), after adjusting for age, sex, and co-morbidities. Similarly, there were no significant differences in the odds of dementia based on different durations of anesthesia exposure (General: <2 h: OR = 0.91, 95%CI = 0.43-1.92; 2-4 h: OR = 1.21, 95%CI = 0.82-1.79; >4 h: OR = 0.39, 95%CI = 0.15-1.01; compared to no exposure. Regional: <2 h: OR = 1.18, 95%CI = 0.85-1.62; 2-4 h: OR = 0.9, 95%CI = 0.64-1.27; >4 h: OR = 0.55, 95%CI = 0.15-1.96; compared to no exposure). Likewise, no significant differences were observed in the odds of dementia based on the number of replacement surgeries (twice: OR = 0.74, 95%CI = 0.44-1.23, compared to once). CONCLUSION: Neither general anesthesia nor regional anesthesia in hip/knee surgery was associated with dementia. Different numbers and durations of anesthesia exposure showed no significant differences in the odds for dementia.

Site of Service Disparities Exist for Total Joint Arthroplasty.

BACKGROUND: The rate of outpatient total joint arthroplasty procedures, including those performed at ambulatory surgical centers (ASCs) and hospital outpatient departments, is increasing. The purpose of this study was to analyze if type of insurance is associated with site of service (in-patient vs outpatient) for total joint arthroplasty and adverse outcomes. MATERIALS AND METHODS: We identified patients undergoing unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), or total hip arthroplasty (THA) using Current Procedural Terminology codes in a national administrative claims database. Eligible patients were stratified by type of insurance (Medicaid, Medicare, private). The primary outcome was site of service. Secondary outcomes included general complications, procedural complications, and revision procedures. We evaluated the associations using adjusted multivariable logistic regression models. RESULTS: We identified 951,568 patients for analysis; 46,703 (4.9%) patients underwent UKA, 607,221 (63.8%) underwent TKA, and 297,644 (31.3%) underwent THA. Overall, 9.6% of procedures were outpatient. Patients with Medicaid were less likely than privately insured patients to receive outpatient UKA or THA (UKA: odds ratio [OR], 0.729 [95% CI, 0.640-0.829]; THA: OR, 0.625 [95% CI, 0.557-0.702]) but more likely than patients with Medicare to receive outpatient TKA or THA (TKA: OR, 1.391 [95% CI, 1.315-1.472]; THA: OR, 1.327 [95% CI, 1.166-1.506]). Patients with Medicaid were more likely to experience complications and revision procedures. CONCLUSION: Differences in site of service and complication rates following hip and knee arthroplasty exist based on type of insurance, suggesting a disparity in care. Further exploration of drivers of this disparity is warranted and can inform interventions (eg, progressive value-based payments) to support equity in orthopedic services. [Orthopedics. 2024;47(3):179-184.].

The Utilization of Press-Fit Total Knee Arthroplasty is Not Evenly Distributed: A National Registry Review.

BACKGROUND: This study evaluates trends of cemented versus press-fit total knee arthroplasty (TKA). We hypothesized that press-fit TKA is more common in younger and obese patients. There may also be racial, geographic, and institutional variation. METHODS: The American Joint Replacement Registry was used to conduct a retrospective review of primary TKA procedures for osteoarthritis in the United States between January 2019 and March 2022. The objective was to identify differences in incidence, demographics, body mass index (BMI), Charlson Comorbidity Index (CCI), and institutional teaching status (teaching vs. non-teaching) between press-fit and cemented TKAs. RESULTS: Two hundred ninety-seven thousand four hundred two patients (61% female, average age 68 years, 88.3% White) underwent cemented TKA versus 50,880 patients (52% female, average age 65 years, 89% White) underwent press-fit TKA. Overall, 20.8% of press-fit versus 19.9% of cemented TKA had a BMI of 35 to 39.9 and 15.2% of press-fit versus 12.5% of cemented TKA had BMI >40 ( P < 0.001). Patients undergoing press-fit TKA were less likely Black (OR = 0.727; P < 0.0001), Asian (OR = 0.651, P < 0.0001), and Native Hawaiian/other Pacific Islander (OR = 0.705, P < 0.02) with White as the reference group. Northeastern and Southern United States were more likely to use press-fit TKA than the Midwest (OR = 1.89 and OR = 1.87, P < 0.0001) and West (OR = 1.67; and OR = 1.65; P < 0.0001). Press-fit TKA incidence in 2019 was 9.9% versus 20.6% in 2022 ( P < 0.001). CONCLUSION: Press-fit TKA is increasingly more common in Northeastern and Southern United States, and patients are older than expected. Patients with BMI >35 had a slightly higher rate of undergoing press-fit than cemented TKA. Notable racial differences also exist. Additional research addressing racial disparities and evaluating longevity of press-fit designs is needed.

Postoperative Bisphosphonates Use is Associated with Reduced Adverse Outcomes After Primary Total Joint Arthroplasty of Hip and Knee: A Nationwide Population-Based Cohort Study.

Bisphosphonates have been associated with a decreased risk of revision surgery after total joint arthroplasty of the hip or knee (TJA) because of their effects on decreased periprosthetic bone loss and prosthetic migration. However, the results in the early literature are inconsistent, and the influence of bisphosphonates on associated complications and subsequent TJA remains unknown. This study investigated the association between the use of bisphosphonates and the risk of adverse outcomes after primary TJA. This matched cohort study utilized the National Health Insurance Research Database in Taiwan to identify patients who underwent primary TJA over a 15-year period (January 2000-December 2015 inclusive). Study participants were further categorized into two groups, bisphosphonate users and nonusers, using propensity score matching. The Kaplan-Meier curve analysis and adjusted hazard ratios (aHRs) of revision surgery, adverse outcomes of primary surgery and subsequent TJA were calculated using Cox regression analysis. This study analyzed data from 6485 patients who underwent total hip arthroplasty (THA) and 20,920 patients who underwent total knee arthroplasty (TKA). The risk of revision hip and knee arthroplasty was significantly lower in the bisphosphonate users than in the nonusers (aHR, 0.54 and 0.53, respectively). Furthermore, the risk of a subsequent total joint arthroplasty, adverse events and all-cause mortality were also significantly reduced in the bisphosphonate users. This study, involving a large cohort of patients who underwent primary arthroplasties, revealed that bisphosphonate treatment may potentially reduce the risk of revision surgery and associated adverse outcomes. Furthermore, the use of bisphosphonates after TJA is also associated with a reduced need for subsequent arthroplasty.Research Registration Unique Identifying Number (UIN): ClinicalTrials.gov Identifier-NCT05623540 ( https://clinicaltrials.gov/show/NCT05623540 ).

Prevalence of anemia and association with outcome in joint arthroplasty - is there a difference between primary and revision cases?

PURPOSE: Anemia has been shown to be a modifiable pre-operative, patient factor associated with outcome following arthroplasty. The aims of this retrospective study were to (1) ascertain the prevalence of preoperative anemia in patients undergoing primary and revision hip and knee arthroplasty at a tertiary referral center and (2) to test the association with outcome and whether it differs between primary and revision cases. METHODS: All hip and knee primary and revision arthroplasties performed at a Canadian academic, tertiary-care, arthroplasty center between 2012 and 2017 were included in this study. The study group consisted of 5944 patients, of which 5251 were primary Total Hip and Knee Arthroplasties or Hip Resurfacings and 693 were revision arthroplasties (65% hip revisions/35% knee revisions). Anemia was classified as per WHO definition (hemoglobin < 130 g/L for men and < 120 g/L for women). All anemic patients were grouped into mild, moderate or severe anemia. Length-of-stay, perioperative transfusion-rate, 90-day readmission, overall complication rate and reoperation rates were recorded. The effect of preoperative anemia and the effect of severity of the anemia was evaluated through multivariable regression analysis controlling for relevant covariates. RESULTS: Preoperatively, 15% (786/5251) of the primary patients and 47% (322/693) of the revision arthroplasty patients were anemic preoperatively. Anemic revision patients were 3.1 times more likely (95% CI: 1.47-6.33) to obtain blood transfusions during the hospital stay, compared to a 4.9 times higher risk in primary patients. The odds ratio to sustain any postoperative complication if anemic was 1.5 times higher (95% CI: 0.73-3.16) in revision patients and 1.7 in primary cases. In addition, the 90-day readmission rate among both groups was 1.6 times higher in anemic patients. Furthermore, anemic revision patients had a 5.3 days longer length of stay (95% CI: 2.63-7.91), compared to only 1 additional day in anemic primary patients (95% CI: 0.69-1.34). CONCLUSION: In this study cohort, the prevalence of anemia in patients awaiting revision arthroplasty was 3 times higher (46.6%) than in primary arthroplasty patients (18.7%). Preoperative anemia was associated with similarly, inferior outcomes in both groups. To reduce postoperative complications and the "burden" associated with anemia, these findings strongly recommend optimizing the preoperative hemoglobin in all arthroplasty patients. However, revision patients are affected more frequently, and particular attention must therefore be taken to this growing group in the future. LEVEL OF EVIDENCE: Level III.

Cardiac interventions on total knee arthroplasty: a national inpatient sample-based analysis.

BACKGROUND: Comorbid cardiovascular diseases have been associated with poor outcomes in total knee arthroplasty (TKA); however, our understanding of TKA with prior cardiac treatment procedures has largely been undocumented. In this study, we examined TKA patients who had undergone different cardiac interventions that addressed their condition. The purpose was to characterize and compare outcomes for a growing patient population not yet analyzed. MATERIALS AND METHODS: The 2016-2019 Nationwide Inpatient Sample database was queried for 558,256 patients who had TKA (ICD-10CM). Backgrounds significant for pacemaker [PM] (n = 8025), coronary artery bypass [CABG] (n = 12,683), heart valve surgery [HV] (n = 4125), or coronary stent [CS] (n = 19,483) were compared against those without, across demographics, admission information, and various complications. RESULTS: Cardiac interventions were associated with increased age, male gender, length of stay, and cost of care. CABG, and Stent groups had more diabetics, but HV had significantly fewer (p = 0.008). PM and HV had significantly less tobacco use and, in addition to CABG, less obesity. Postoperatively, mortality was elevated in the PM [Odds ratio (OR) 2.89, p = 0.008], CABG (OR 2.53, p = 0.006) and CS group (OR 1.94, p = 0.018), but not HV. Myocardial infarctions were elevated in the CABG (OR 3.874) and CS group (OR 5.11) (p < 0.001). PM, HV, and CS had increased odds of periprosthetic fracture by 2.15-fold (p < 0.001), 2.09-fold (p < 0.001), 1.29-fold (p = 0.011) respectively. HV saw increased periprosthetic mechanical complications (OR 1.48, p = 0.006). CABG increased the odds of deep surgical site infection 14.23-fold and CS 9.22-fold (p < 0.001). Postoperative pneumonia was increased in PM, CABG, and CS groups (OR 2.15,), (OR 2.21,), (OR 1.64,) (p < 0.001). CONCLUSIONS: Patients who have undergone cardiac intervention are generally at risk for adverse stays. Furthermore, risk factors and complications vary between the groups. Our analysis emphasizes the importance of individualized medical care and as a basis for electing and informing patients for TKA.

Racial Disparities in Treatment and Outcomes of Patients With Hepatitis C Undergoing Elective Total Joint Arthroplasty.

BACKGROUND: African Americans have the highest prevalence of chronic Hepatitis C virus (HCV) infection. Racial disparities in outcome are observed after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study sought to identify if disparities in treatments and outcomes exist between Black and White patients who have HCV prior to elective THA and TKA. METHODS: Patient demographics, comorbidities, HCV characteristics, perioperative variables, in-hospital outcomes, and postoperative complications at 1-year follow-up were collected and compared between the 2 races. Patients who have preoperative positive viral load (PVL) and undetectable viral load were identified. Chi-square and Fisher's exact tests were used to compare categorical variables, while 2-tailed Student's Kruskal-Wallis t-tests were used for continuous variables. A P value of less than .05 was statistically significant. RESULTS: The liver function parameters, including aspartate aminotransferase and model for end-stage liver disease scores, were all higher preoperatively in Black patients undergoing THA (P = .01; P < .001) and TKA (P = .03; P = .003), respectively. Black patients were more likely to undergo THA (65.8% versus 35.6%; P = .002) and TKA (72.1% versus 37.3%; 0.009) without receiving prior treatment for HCV. Consequently, Black patients had higher rates of preoperative PVL compared to White patients in both THA (66% versus 38%, P = .006) and TKA (72% versus 37%, P < .001) groups. Black patients had a longer length of stay for both THA (3.7 versus 3.3; P = .008) and TKA (4.1 versus 3.0; P = .02). CONCLUSIONS: The HCV treatment prior to THA and TKA with undetectable viral load has been shown to be a key factor in mitigating postoperative complications, including joint infection. We noted that Black patients were more likely to undergo joint arthroplasty who did not receive treatment and with a PVL. While PVL rates decreased over time for both races, a significant gap persists for Black patients.

Total Hip and Total Knee Arthroplasty Outpatient Case Volume During the 2020 COVID-19 Pandemic in New York and California.

BACKGROUND: Inpatient total hip and total knee arthroplasty were substantially impacted by the SARS-CoV-2 (COVID-19) pandemic. We sought to characterize the transition of total joint arthroplasty (TJA) to the outpatient setting in 2 large state health systems during this pandemic. METHODS: Adult patients who underwent primary elective TJA between January 1, 2016 and December 31, 2020 were retrospectively reviewed using the New York Statewide Planning and Research Cooperative System and California Department of Health Care Access and Information datasets. Yearly inpatient and outpatient case volumes and patient demographics, including age, sex, race, and payer coverage, were recorded. Continuous and categorical variables were compared using descriptive statistics. Significance was set at P < .05. RESULTS: In New York during 2020, TJA volume decreased 16% because 22,742 fewer inpatient TJAs were performed. Much of this lost volume (46.6%) was offset by a 166% increase in outpatient TJA. In California during 2020, TJA volume decreased 20% because 34,114 fewer inpatient TJAs were performed. Much of this lost volume (37%) was offset by a 47% increase in outpatient TJA. CONCLUSIONS: This present study demonstrates a marked increase in the proportion of TJA being performed on an outpatient basis in both California and New York. In both states, despite a decrease in overall TJA volume in 2020, outpatient TJA volume increased markedly. LEVEL OF EVIDENCE: Therapeutic Level IV, Retrospective Cohort Study.