Decreased Risk of Readmission and Complications with Preoperative GLP-1 Analog Use in Patients Undergoing Primary Total Joint Arthroplasty.

INTRODUCTION: There has been considerable interest in the use of GLP-1 receptor analogs (GLP-1 RAs) for weight optimization in patients undergoing elective arthroplasty. As there is limited data regarding the implications of their use, our study aimed to evaluate the association between preoperative GLP-1 RA use and postoperative outcomes in patients undergoing primary total hip (THA) and total knee arthroplasty (TKA). METHODS: The TrinetX research network was queried to identify all patients undergoing primary THA or TKA between May 2005 and December 2023 across 84 healthcare organizations. Patients were stratified based on preoperative GLP-1 RA use. Propensity score matching (1:1) was performed to account for baseline differences in demographics, laboratory investigations, and comorbidities. Subsequently, risk ratios were evaluated for postoperative outcomes. RESULTS: A total of 268,504 and 386,356 patients underwent THA and TKA, of which 1,044 and 2,095 used preoperative GLP-1 RAs. After matching, GLP-1 RA use was associated with a decreased 90-day risk of periprosthetic joint infection (2.1% vs. 3.6%, RR= 0.58, P=0.042) and readmission (1.1% vs. 2.0%, RR= 0.53, P=0.017) following THA and TKA, respectively. There was no difference in the risk of all other outcomes between comparison groups. CONCLUSION: Preoperative GLP-1 RA use is associated with a 42% decreased risk of periprosthetic joint infection and 47% decreased risk of readmission in the 90-day postoperative period following THA and TKA, respectively, with no difference in other risks, including aspiration. Our findings indicate that GLP-1 RAs may be safe to use in patients undergoing elective arthroplasty; however, further studies are warranted to inform the routine use of GLP-1 RAs for weight management in THA and TKA patients.

Selective Use of Modern Cementless Total Knee Arthroplasty is Not Associated with Increased Risk of Revision in Patients Aged 65 or Greater: An Analysis from the American Joint Replacement Registry.

Modern highly porous surfaces have increased confidence and use of cementless total knee arthroplasty (TKA) in the United States. As cementless TKA use increases, there remains a paucity of literature regarding associated risk of revision in patients aged ≥65 years. We analyzed the American Joint Replacement Registry (AJRR) data from January 2012 to March 2020 identifying patients aged ≥65 years undergoing primary TKA with linked cases to supplemental centers for Medicare and Medicaid data. Patients with hybrid fixation, reverse hybrid fixation, missing component data, highly constrained implants, and stem extension/augmentation were excluded. We identified 442,745 cemented TKAs and 19,841 modern cementless TKAs with a minimum of 2-year follow-up. Cumulative incident function (CIF) curves and cause-specific Cox models evaluated the risk of all-cause revision and revision for mechanical loosening, adjusting for body mass index (BMI), sex, age, cruciate retaining (CR) versus posterior stabilized (PS) femoral design, patellar resurfacing, and Charlson's comorbidity index (CCI). Patients with cementless compared with cemented TKA were younger (mean age: 71.9 vs. 73.2 years, p < 0.001), more likely to be male sex (48.8 vs. 39.0%, p < 0.001), more likely to have a CR femoral design (81.1 vs. 45.7%, p < 0.001), less likely to have patellar resurfacing (92.7 vs. 95.0%, p < 0.001), and had a lower CCI (mean: 2.9 vs. 3.1, p < 0.001). Adjusted hazard ratios (HRs) showed no difference in associated risk for all-cause revision (HR: 1.07; 95% confidence interval [CI]: 0.92-1.24; p = 0.382) or revision for mechanical loosening (HR: 1.38; 95% CI: 0.9-2.12; p = 0.14) for cementless versus cemented TKA. Our results suggest that current selective use of cementless fixation for TKA in patients aged ≥65 years in the United States is not associated with an increased risk of revision. While encouraging, further study is necessary to establish indications for use in this age group prior to broader adoption in this patient population. LEVEL OF EVIDENCE: Therapeutic Level III.

Over the Past Decade, Preoperative Anemia Has Become a Greater Predictor of Transfusions After Total Knee Arthroplasty.

BACKGROUND: With advancements in perioperative blood management and the use of tranexamic acid, the rate of transfusions after total knee arthroplasty (TKA) has substantially decreased. As these principles are refined, other modifiable risk factors, such as preoperative anemia, may play an increasingly important role in transfusion risk for patients undergoing TKA. METHODS: A multicenter, national database was utilized to identify patients undergoing TKA from 2010 to 2021. Anemia was defined by World Health Organization definitions as < 12 g/dL for women and < 13 g/dL for men. A predictive model was created using backwards elimination logistic regression to predict transfusion risk, controlling for demographic and medical covariates. The coefficient of anemia was then analyzed for each year. The trend over time was fitted with a best-fit linear regression equation. RESULTS: There were 509,117 patients who underwent TKA, and had a mean age of 67 years (range, 18 to 89). There were 57,716 (11%) patients who were anemic preoperatively, and 15,426 (3%) of patients required a transfusion. Rate of transfusion decreased from 10.6% in 2010 to 0.6% in 2021. The odds ratio associated with anemia as a predictor of transfusion increased from 3.1 (95% confidence interval: 2.1 to 4.6) in 2010 to 14.0 (95% confidence interval: 8.9 to 24) in 2021. CONCLUSIONS: The results of this study demonstrate that the importance of preoperative anemia as a predictor of transfusion has increased over the past decade as rates of transfusion have decreased. As perioperative blood management protocols improve, preoperative anemia should be considered an important focus of intervention to reduce the risk of transfusion prior to TKA. LEVEL OF EVIDENCE: III.

Open Access Publication in Total Ankle Arthroplasty Literature Is Associated With Increased Social Media Attention, but Not Increased Citations.

Background: Open access (OA) publications are increasingly common in orthopaedic literature. However, whether OA publications are associated with increased readership or citations among total ankle arthroplasty (TAA) literature is unclear. We hypothesize that compared with non-OA status, OA status is associated with increased social media dissemination, and readership, but not with citation count. This study aimed to analyze social media attention, citations, readership, and cost of TAA OA and non-OA publications. Methods: Using a PubMed query search, there were 368 publications from 81 journals, with 25% (91/368) being OA articles and 75% (277/368) non-OA articles from 2016 to 2023. We analyzed the Altmetric Attention Score (AAS), Mendeley readership score, and citations between OA vs non-OA articles. Citations and cost of OA articles were determined using an altered timeline and publisher's website, respectively. Subgroup analysis was performed among articles published in the top 5 TAA journals (Tables 2 and 3). Negative binomial regression was used while adjusting for days since publication. Significance was considered at P <.05. Results: OA publication was associated with a larger mean AAS score (8.7 ± 37.0 vs 4.8 ± 26.3), Mendeley readership (42.4 ± 41.6 vs 34.9 ± 25.7), and Twitter mentions (4.6 ± 7.4 vs 3.3 ± 8.1), but not citations (19.7 ± 24.8 vs 20.3 ± 23.5) (Table 1). Conclusion: TAA OA publications and top 5 journals were associated with significantly increased social media attention but not Mendeley readership or citation counts.

Preoperative weight loss before total hip arthroplasty negatively impacts postoperative outcomes.

BACKGROUND: Obesity adversely impacts outcomes of total hip arthroplasty (THA), leading surgeons to impose body mass index cutoffs for patient eligibility and encourage preoperative weight loss. This study aimed to determine if preoperative weight loss impacts outcomes of THA in the general patient population and if it mitigates poor outcomes in obese patients. METHODS: Patients who underwent THA from 2013-2020 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified by weight loss of >10% of body weight over the preceding 6 months. We used multivariable linear and logistic regression models, adjusted for age, sex, race/ethnicity, and comorbidities, to examine the effect of significant preoperative weight loss on 30-day outcomes after THA in the general and obese patient populations. RESULTS: In the overall population, patients who lost significant weight preoperatively had significantly increased length of stay, were more likely to have a non-home discharge, return to the operating room, or be readmitted, and were more likely to experience numerous medical complications. In the obese population, patients who lost significant weight preoperatively had significantly increased length of stay and were more likely to require a transfusion or experience any medical complication. DISCUSSION: Rapid significant preoperative weight loss is not associated with improved postoperative outcomes after THA in the obese population and is associated with worse outcomes in the general population. Arthroplasty surgeons should balance these risks with the risks of obesity when advising patients about preoperative weight loss prior to THA. LEVEL OF EVIDENCE: III.

Cementless Total Knee Arthroplasty: A Resurgence-Who, When, Where, and How?

BACKGROUND: Total knee arthroplasty (TKA) is one of the most common procedures in orthopaedics, but there is still debate over the optimal fixation method for long-term durability: cement versus cementless bone ingrowth. Recent improvements in implant materials and technology have offered the possibility of cementless TKA to change clinical practice with durable, stable biological fixation of the implants, improved operative efficiency, and optimal long-term results, particularly in younger and more active patients. METHODS: This symposium evaluated the history of cementless TKA, the recent resurgence, and appropriate patient selection, as well as the historical and modern-generation outcomes of each implant (tibia, femur, and patella). Additionally, surgical technique pearls to assist in reliable, reproducible outcomes were detailed. RESULTS: Historically, cemented fixation has been the gold standard for TKA. However, cementless fixation is increasing in prevalence in the United States and globally, with equivalent or improved results demonstrated in appropriately selected patients. CONCLUSIONS: Cementless TKA provides durable biologic fixation and successful long-term results with improved operating room efficiency. Cementless TKA may be broadly utilized in appropriately selected patients, with intraoperative care taken to perform meticulous bone cuts to promote appropriate bony contact and biologic fixation.

Can You Pay Your Way to Readership? Free to Publish Open Access Formats Receive Greater Readership and Citations Than Paid Open Access Formats in Total Knee Arthroplasty Literature.

BACKGROUND: As publishing with open access is becoming increasingly popular within orthopaedics, understanding the types of publishing options available and what each may deliver is critically important. Hybrid articles require a high article processing charge. Open journal articles have a lower fee, while closed license articles are freely accessible at no charge. Open repository articles are peer-reviewed manuscripts posted freely online. The purpose of this study was to determine the relationship between article type and resulting citations, social media attention, and readership in total knee arthroplasty (TKA) literature. METHODS: Open access TKA journal articles published since 2016 were found using the Altmetric Explorer Database. Data gathered included the Altmetric Attention Score (attention), Mendeley Readership Score (readership), and citations per article. Articles were grouped by type: open journal, hybrid, closed license, and open repository. Results were analyzed using descriptive statistics and Tukey's analysis; α = 0.05. RESULTS: A total of 9,606 publications were included. The open repository had the greatest mean citations (14.40), while open journal (9.55) had fewer than all other categories (P < .001). Hybrid had the greatest mean attention (10.35), and open journal (6.16) had a lower mean attention than all other categories (P ≤ .002). Open repository had the greatest mean readership (44.68), and open journal (34.00) had a lower mean readership than all other categories (P ≤ .012). The mean publication fee for paid publication options was $1,792 United States dollars. CONCLUSIONS: In open access TKA literature, free-to-publish open repositories had the greatest mean citations and readership. Free publication options, open repositories and closed licenses, had greater readership compared to paid publication options.

Publishing on Topical Subjects in Total Joint Arthroplasty Is Associated With Increased Social Media Attention.

BACKGROUND: Social media platforms are often used for research dissemination and collaboration. Given the increased prevalence of online-only publications, understanding what drives research dissemination is important. Here, we analyzed factors associated with increased social media attention among peer-reviewed publications in total knee arthroplasty, total hip arthroplasty, and unicompartmental knee arthroplasty. METHODS: We analyzed publications about total knee arthroplasty, total hip arthroplasty, or unicompartmental knee arthroplasty from 2010 to 2022 using a national database. We analyzed a weighted count of social media mentions, using negative binomial regressions adjusting for days since publication. Publications on "hot topics" in arthroplasty were examined including navigation/robotics, COVID-19, race/ethnicity, body mass index, and reimbursement. There were 9,542 publications included, 4,216 (44%) were open access (OA), 338 (3.5%) included navigation, 32 (0.34%) discussed race/ethnicity, 20 (0.2%) discussed COVID-19, 3,840 (40%) were randomized studies, 30 (0.3%) discussed reimbursement, and 2,867 (30%) were in top-10 orthopaedic journals. RESULTS: Factors associated with higher weighted score included studies about COVID-19 (50 versus 6.0, P < .001), race/ethnicity (15.8 versus 6.0, P < .001), OA status (6.3 versus 5.8, P = .001), and randomized studies (6.5 versus 5.7, P < .001). Studies from top-10 journals had a lower score (5.8 versus 6.2, P = .025), as did studies about body mass index (3.4 versus 6.1, P = .001). Studies about navigation and reimbursement did not have significantly different scores. CONCLUSIONS: Studies on COVID-19, race/ethnicity, randomized studies, and OA publication were associated with increased social media while those in top-10 orthopaedic journals had lower scores. LEVEL OF EVIDENCE: Level IV, Prognostic Study.

Open Access Publication in Total Knee Arthroplasty Is Associated With Increased Social Media Attention, but Is Not Associated With Increased Citations.

BACKGROUND: Open access (OA) publication is growing in total joint arthroplasty literature. While OA manuscripts are free to view, these publications require a fee from authors. This study aimed to compare social media attention and citation rates between OA and non-OA publications in the total knee arthroplasty (TKA) literature. METHODS: There were 9,606 publications included, with 4,669 (48.61%) as OA articles. The TKA articles were identified from 2016 to 2022. Articles were grouped as OA or non-OA and Altmetric Attention Score (AAS), a weighted count of social media attention, and the Mendeley readership were analyzed using negative binomial regressions while adjusting for days since publication. RESULTS: The OA articles had greater mean AAS (13.45 versus 8.42, P = .012) and Mendeley readership (43.91 versus 36.72, P < .001). OA was not an independent predictor of number of citations when compared to non-OA articles (13.98 versus 13.63, P = .914). Subgroup analysis of studies in the top 10 arthroplasty journals showed OA was not an independent predictor of AAS (13.51 versus 9.53, P = .084) or number of citations (19.51 versus 18.74, P = .495) but was an independent predictor of Mendeley readership (49.05 versus 40.25, P < .003). CONCLUSION: The OA publications in the TKA literature were associated with increased social media attention, but not overall citations. This association was not observed among the top 10 journals. Authors may use these results to weigh the relative importance of readership, citations, and online engagement to the cost of OA publication.

The Definition of Anemia Matters When Using Preoperative Hemoglobin as a Screening Tool Prior to Total Hip and Knee Arthroplasty.

BACKGROUND: Preoperative anemia is common in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). Several definitions of anemia have been described, with no clear consensus on the optimal one for preoperative screening. We hypothesized that depending on the definition used preoperatively, the proportion of anemic patients identified who would require a postoperative allogeneic blood transfusion would vary significantly. METHODS: A total of 681,141 patients were identified in a national database who underwent either THA or TKA. Preoperative anemia was classified according to the World Health Organization (WHO) definition, Cleveland Clinic (CC) definition, or race, age, and sex-specific definition described by Beutler et al in 2006. The optimal preoperative (OP) hemoglobin thresholds to predict perioperative transfusions were also calculated using receiver operating characteristic curves. RESULTS: When using the WHO definition, 18% of anemic patients required a transfusion versus 14% (OP definition), 12% (CC definition), and 16% (Beutler definition). Similarly, 0.69% of anemic patients sustained a periprosthetic joint infection within 30 days using the WHO definition versus 0.59% (OP definition), 0.60% (CC definition), or 0.66% (Beutler definition). Using the WHO definition, 5.3% of patients would have sustained a major complication versus 4.5% (OP definition), 4.4% (CC definition), and 5.0% (Beutler definition). CONCLUSIONS: Variation in the definition of anemia for preoperative screening in THA and TKA results in substantial differences in discriminative ability to predict perioperative transfusions. The WHO definition identified the largest proportion of patients who ultimately received a perioperative transfusion.

Preoperative COVID-19 infection status negatively impacts postoperative outcomes of geriatric hip fracture surgery.

OBJECTIVES: Compare outcomes for patients with recently diagnosed COVID-19 infection to those without COVID-19 infection undergoing operative treatment of hip fractures using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. DESIGN: Retrospective propensity score matched cohort. METHODS: Patients who received surgery for an acute hip fracture (intramedullary nail (IMN), open reduction internal fixation (ORIF) or hemiarthroplasty) in 2021 were identified from the NSQIP database. Propensity score matching was implemented using patient demographics and preoperative medical conditions to compare outcomes for COVID-19-positive and COVID-19-negative cohorts. RESULTS: After matching, COVID-19-positive patients exhibited a higher risk of 30-day mortality (Odds ratio (OR) 1.48, 95 % confidence interval (CI) 1.01 - 2.04), pneumonia (OR 2.90, 95 % CI: 1.91 - 4.33), unplanned intubation (OR 2.53, 95 % CI: 1.39 - 4.39), and septic shock (OR 2.51, 95 % CI: 1.10 - 4.67). COVID-19-positive patients were also more likely to have a longer length of hospital stay (Hazard Ratio 1.3, 95 % CI: 1.20 - 1.41) and were more likely to be discharged to an acute care hospital (OR 1.90, 95 % CI: 1.03 - 3.06). CONCLUSIONS: Active COVID-19 infection is an independent risk factor for complications as well as increased resource utilization in patients undergoing surgical treatment of acute hip fracture. Using the results of this multicenter study, quantification of these risks can help inform practice and treatment protocols for this population. LEVEL OF EVIDENCE: III.

Mapping the course to recovery: a prospective study on the anatomic distribution of early postoperative pain after total knee arthroplasty.

INTRODUCTION: Early postoperative pain following total knee arthroplasty significantly impacts outcomes and patient satisfaction. However, the characteristics and sources of early pain after total knee arthroplasty remain unclear. Therefore, the purpose of this study was to determine the anatomic distribution and course of postoperative pain in the acute and subacute period following total knee arthroplasty. METHODS: A prospective observational study of primary, elective unilateral total knee arthroplasty cases was conducted at our academic tertiary care medical center from January 2021 to September 2021. Preoperative variables were extracted from institutional electronic medical records. Postoperatively, patients utilized a knee pain map to identify the two locations with the most significant pain and rated it using the visual analog scale (VAS). The data were collected on day 0, at 2 weeks, 2 months, and 6 months after operation. RESULTS: This study included 112 patients, with 6% of patients having no pain at postoperative day 0, 22% at 2 weeks, 46% at 2 months, and 86% at 6 months after operation. In those who reported pain, the VAS score (mean ± standard deviation) was 5.8 ± 2.4 on postoperative day 0 and decreased at each follow-up time point (5.4 ± 2.3 at 2 weeks, 3.9 ± 2.2 at 2 months, and 3.8 ± 2.7 at 6 months). The majority of patients were able to identify distinct loci of pain. The most common early pain loci were patellae, thigh, and medial joint line, and this distribution dissipated by 6 months. CONCLUSION: At 2 postoperative weeks, pain was primarily at the medial joint, and at 6 months postoperatively, pain was more likely to be at the lateral joint. No relationship was found between pain at six months and pain scores or location at postoperative day 0 or 2 weeks. Understanding the distribution and progression of knee pain following total knee arthroplasty may benefit patient education and targeted interventions. LEVEL OF EVIDENCE: Level II, prospective observational study.

A Study of Physical Resilience and Aging (SPRING): Conceptual framework, rationale, and study design.

Understanding the physiological basis of physical resilience to clinical stressors is crucial for the well-being of older adults. This article presents a novel framework to discover the biological underpinnings of physical resilience in older adults as part of the "Characterizing Resiliencies to Physical Stressors in Older Adults: A Dynamical Physiological Systems Approach" study, also known as The Study of Physical Resilience and Aging (SPRING). Physical resilience, defined as the capacity of a person to withstand clinical stressors and quickly recover or improve upon a baseline functional level, is examined in adults aged 55 years and older by studying the dynamics of stress response systems. The hypothesis is that well-regulated stress response systems promote physical resilience. The study employs dynamic stimulation tests to assess energy metabolism, the hypothalamic-pituitary-adrenal axis, the autonomic nervous system, and the innate immune system. Baseline characteristics influencing resilience outcomes are identified through deep phenotyping of physical and cognitive function, as well as of biological, environmental, and psychosocial characteristics. SPRING aims to study participants undergoing knee replacement surgery (n = 100), bone and marrow transplantation (n = 100), or anticipating dialysis initiation (n = 60). Phenotypic and functional measures are collected pre-stressor and at multiple times after stressor for up to 12 months to examine resilience trajectories. By improving our understanding of physical resilience in older adults, SPRING has the potential to enhance resilient outcomes to major clinical stressors. The article provides an overview of the study's background, rationale, design, pilot phase, implementation, and implications for improving the health and well-being of older adults.

Body Mass Index and Revision Total Knee Arthroplasty: Does Cause for Revision Vary by Underweight or Obese Status?

BACKGROUND: Body mass index (BMI) impacts risk for revision total knee arthroplasty (rTKA), but the relationship between BMI and cause for revision remains unclear. We hypothesized that patients in different BMI classes would have disparate risk for causes of rTKA. METHODS: There were 171,856 patients who underwent rTKA from 2006 to 2020 from a national database. Patients were classified as underweight (BMI < 19), normal-weight, overweight/obese (BMI 25 to 39.9), or morbidly obese (BMI > 40). Multivariable logistic regressions adjusted for age, sex, race/ethnicity, socioeconomic status, payer status, hospital geographic setting, and comorbidities were used to examine the effect of BMI on risk for different rTKA causes. RESULTS: Compared to normal-weight controls, underweight patients were 62% less likely to undergo revision due to aseptic loosening, 40% less likely due to mechanical complications, 187% more likely due to periprosthetic fracture, 135% more likely due to periprosthetic joint infection (PJI). Overweight/obese patients were 25% more likely to undergo revision due to aseptic loosening, 9% more likely due to mechanical complications, 17% less likely due to periprosthetic fracture, and 24% less likely due to PJI. Morbidly obese patients were 20% more likely to undergo revision due to aseptic loosening, 5% more likely due to mechanical complications, and 6% less likely due to PJI. CONCLUSION: Mechanical reasons were more likely to be the cause of rTKA in overweight/obese and morbidly obese patients, compared to underweight patients, for whom revision was more likely to be infection or fracture related. Increased awareness of these differences may promote patient-specific management to reduce complications. LEVEL OF EVIDENCE: III.

Racial and Socioeconomic Disparities in Risk and Reason for Revision in Total Joint Arthroplasty.

INTRODUCTION: Data regarding racial/ethnic and socioeconomic differences in revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) have been inconsistent. This study examined racial/ethnic and socioeconomic disparities in comorbidity-adjusted risk and reason for rTHA and rTKA. METHODS: Patients who underwent rTHA or rTKA between 2006 and 2014 in the National Inpatient Sample were identified. Multivariable logistic regression models adjusted for payer status, hospital geographic setting, and patient characteristics (age, sex, and Elixhauser Comorbidity Index) were used to examine the effect of race/ethnicity and socioeconomic status on trends in annual risk of rTHA/rTKA and causes of rTHA/rTKA. RESULTS: Black patients were less likely to undergo rTHA and more likely to undergo rTKA while Hispanic patients were more likely to undergo rTHA and less likely to undergo rTKA ( P < 0.001 for all) compared with White patients. Patients residing in areas of lower income quartiles were more likely to undergo rTHA and rTKA compared with those in the highest quartile ( P < 0.001), and these disparities persisted and widened over time. Black, Hispanic, and Asian patients were less likely to undergo rTHA/rTKA because of dislocation compared with White patients ( P < 0.001 for all). Patients from areas of lower income quartiles were more likely to undergo rTHA because of septic complications and less likely to require both rTHA and rTKA because of mechanical complications ( P < 0.001 for all). DISCUSSION: Racial/ethnic and socioeconomic disparities exist in risk and cause of rTHA and rTKA. Increasing awareness and a focus on minimizing variability in hospital quality may help mitigate these disparities.

Ultracongruent Designs Compared to Posterior-Stabilized and Cruciate-Retaining Tibial Inserts - What Does the Evidence Tell Us? A Systematic Review and Meta-Analysis.

BACKGROUND: Posterior-stabilized (PS) and cruciate-retaining (CR) have been the most common tibial designs used in total knee arthroplasty. Ultra-congruent (UC) inserts are becoming popular because they preserve bone without relying on the posterior cruciate ligament balance and integrity. Despite increasing use, there is no consensus on how UC inserts perform versus PS and CR designs. METHODS: A comprehensive literature search of 5 online databases was performed for articles from January 2000 to July 2022 comparing the kinematic and clinical outcomes of PS or CR tibial inserts to UC inserts. There were nineteen studies included. There were 5 studies comparing UC to CR and 14 comparing UC to PS. Only one randomized controlled trial (RCT) was rated "good quality". RESULTS: For CR studies, pooled analyses showed no difference in knee flexion (n = 3, P = .33) or Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores (n = 2, P = .58). For PS studies, meta-analyses showed better anteroposterior stability (n = 4, P < .001) and more femoral rollback (n = 2, P < .001) for PS but no difference in knee flexion (n = 9, P = .55) or medio-lateral stability (n = 2, P = .50). There was no difference with WOMAC (n = 5, P = .26), Knee Society Score (n = 3, P = .58), Knee Society Knee Score (n = 4, P = .76), or Knee Society Function Score (n = 5, P = .51). CONCLUSION: Available data demonstrates there are no clinical differences between CR or PS and UC inserts in small short-term studies ending around 2 years after surgery. More importantly, high-quality research comparing all inserts is lacking, demonstrating a need for more uniform and longer-term studies beyond 5 years after surgery to justify increased UC usage.

Trends in Racial, Ethnic, and Gender Diversity in Orthopaedic Surgery Adult Reconstruction Fellowships From 2007 to 2021.

BACKGROUND: Orthopaedic surgery has seen improvement in its representation of women, whereas the representation of racial/ethnic minorities has remained stagnant over the past decade. Overall, the surgical field lags behind other specialties in sex and racial/ethnic parity. Although demographic disparities within orthopaedics have been analyzed for both residents and faculty members, information for adult reconstruction fellows remains limited. METHODS: Sex and race/ethnicity demographics for adult reconstruction orthopaedic fellowship matriculants were collected via a database published by the Accreditation Council for Graduate Medical Education (ACGME) from 2007 to 2021. Statistical analyses, including descriptive statistics and significance testing, were performed. RESULTS: During the 14-year time frame, men trainees remained high with an overall average percentage of 88% and demonstrated increasing representation (P trend = .012). White non-Hispanics, Asians, Blacks, and Hispanics represented on average 54%, 11%, 3%, and 4%, respectively. White non-Hispanics (P trend = .039) and Asians (P trend = .030) saw increasing and decreasing representation, respectively. Women, Blacks, and Hispanics remained relatively stagnant throughout the observation period as no trends were appreciable (P trend >.05, each). CONCLUSION: Using publicly available demographic data from the Accreditation Council for Graduate Medical Education (ACGME) from 2007 to 2021, we found relatively limited progress in the representation of women and those from traditionally marginalized groups seeking additional training in adult reconstruction. Our findings mark an initial step in measuring the demographic diversity among adult reconstruction fellows. Further research is needed to ascertain specific factors likely to attract and retain members from minoritized groups into orthopaedics.

Racial Disparities in Short-Stay and Outpatient Total Hip and Knee Arthroplasty: 13-year Trend in Utilization Rates and Perioperative Morbidity Using a National Database.

BACKGROUND: The objective of this study was to assess racial and ethnic disparities in short-stay (< 2-midnight length of stay) and outpatient (same-day discharge) total joint arthroplasties (TJAs). We aimed to determine (1) whether there are differences in postoperative outcomes between short-stay Black, Hispanic, and White patients and (2) the trend in utilization rates of short-stay and outpatient TJA across these racial groups. METHODS: This was a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Short-stay TJAs done between 2008 and 2020 were identified. Patient demographics, comorbidities, and 30-day postoperative outcomes were assessed. Multivariate regression analysis was used to assess differences between racial groups in minor and major complication rates, as well as readmission and revision surgery rates. RESULTS: Of a total of 191,315 patients, 88% were White, 8.3% were Black, and 3.9% were Hispanic. Minority patients were younger and had greater comorbidity burden when compared with Whites. Black patients had greater rates of transfusions and wound dehiscence when compared with White and Hispanic patients ( P < 0.001, P = 0.019, respectively). Black patients had lower adjusted odds of minor complications (odds ratio [OR], 0.87; confidence interval [CI], 0.78 to 0.98), and minorities had lower revision surgery rates in comparison with Whites (OR, 0.70; CI, 0.53 to 0.92, and OR, 0.84; CI, 0.71 to 0.99, respectively). The utilization rate for short-stay TJA was most pronounced for Whites. CONCLUSION: There continues to persist marked racial disparities in demographic characteristics and comorbidity burden in minority patients undergoing short-stay and outpatient TJA procedures. As outpatient-based TJA becomes more routine, opportunities to address these racial disparities will become increasingly more important to optimize social determinants of health. LEVEL OF EVIDENCE: III, retrospective cohort study.

A Surgical Robotic System for Osteoporotic Hip Augmentation: System Development and Experimental Evaluation.

Minimally-invasive Osteoporotic Hip Augmentation (OHA) by injecting bone cement is a potential treatment option to reduce the risk of hip fracture. This treatment can significantly benefit from computer-assisted planning and execution system to optimize the pattern of cement injection. We present a novel robotic system for the execution of OHA that consists of a 6-DOF robotic arm and integrated drilling and injection component. The minimally-invasive procedure is performed by registering the robot and preoperative images to the surgical scene using multiview image-based 2D/3D registration with no external fiducial attached to the body. The performance of the system is evaluated through experimental sawbone studies as well as cadaveric experiments with intact soft tissues. In the cadaver experiments, distance errors of 3.28mm and 2.64mm for entry and target points and orientation error of 2.30° are calculated. Moreover, the mean surface distance error of 2.13mm with translational error of 4.47mm is reported between injected and planned cement profiles. The experimental results demonstrate the first application of the proposed Robot-Assisted combined Drilling and Injection System (RADIS), incorporating biomechanical planning and intraoperative fiducial-less 2D/3D registration on human cadavers with intact soft tissues.