Lower Intraoperative and Immediate Postoperative Complications in Robotic Versus Conventional Primary Total Hip Arthroplasty: A Retrospective Cohort Analysis of Over 360,000 Patients.

PURPOSE: Although a trend of an improved alignment with robotic total hip arthroplasty (THA) over conventional methods has surfaced from recent series, it is unknown whether these results translate into meaningful enhancements in postoperative outcomes. To address this lack in the literature, we compared the perioperative morbidity and mortality with robotic and conventional THA in a large national cohort of 367,894 patients. We hypothesized that no significant differences would exist in the outcomes between the two groups. METHODS: Records were extracted from 2016-2019 from the National Inpatient Sample (NIS) database Healthcare Cost and Utilization Project which is the largest in-patient database in the United States. From 367,894 THAs, robotics were employed for 7,863 patients. The remaining 360,031 conventional THAs served as controls. The two groups were compared for demographics, admission, and hospital stay details including costs, and mortality and morbidity data including medical and surgical complications. Descriptive statistics were used for demographic data while analytical statistics including t-tests, chi-squared tests, Fischer exact test, and Pearson chi-squared tests were used for perioperative outcomes. Statistical significance was set at p<0.005. RESULTS: Demographic distributions between robotic and conventional THA groups displayed similar age and sex characteristics. Shorter mean lengths of stay (1.87 days) were seen in robotic THA versus conventional THA (2.33 days) while higher costs were noted for the former (mean $68,686.71 vs $66,840.39) (p<0.005). Low overall mortality (0.03% robotic, 0.09% conventional) was seen in both groups (p>0.005). Higher comparative incidences of anemia, acute renal failure, and pneumonia were seen in conventional THA (p<0.005) while no significant differences were noted for other complications including myocardial infarction, pulmonary embolism, deep vein thrombosis, and cardiac arrest (p>0.005). Among others, lower dislocation rates, mechanical complications, periprosthetic joint infection, and periprosthetic fractures were seen with robotic THA (p<0.005). Wound complications and superficial infection rates did not differ between the two groups (p>0.005). CONCLUSIONS: Evidence has emerged from our results to support more routine adaptation of the robotic option of performing a THA. These can be based on lower local, systemic, and mechanical complications as demonstrated by the present study. Further evaluation of these results in follow-up would help establish the foothold of robotic surgery in total hip replacement in the modern context.

The Influence of Solid Organ Transplant on Inpatient Complications, Length of Stay, and Hospital Costs in Reverse Shoulder Arthroplasty Patients.

INTRODUCTION: With innovations in transplant medicine and longer life expectancies in solid organ transplant (SOT) recipients, the incidence of shoulder arthroplasty is predictably rising in this population. Reverse shoulder arthroplasty (RSA) has become increasingly popular due to advances in prosthetic design with expanded indications. While previous studies have examined shoulder arthroplasty in SOT patients, information specifically related to RSA patients is largely unexplored. We aim to analyze the demographics and characteristics of SOT patients who have undergone RSA while assessing inpatient complication rates, length of stay (LOS), and hospital costs in these patients compared to a matched cohort of non-transplant patients. METHODS: The National Inpatient Sample (NIS) Database was utilized to identify all patients undergoing RSA from 2016 to 2019. We generated propensity-matched groups based on pre-operative variables (diabetes, tobacco use, sex, age, and obesity) to compare complications, LOS, and inpatient costs between the SOT and control groups. T-tests and Chi-squared tests were performed where appropriate and odds ratios were calculated. RESULTS: We identified 59925 patients who underwent RSA. Among those, 59769 patients (99.7%) did not have a SOT and 156 patients (0.26%) had a history of SOT. Patients in the SOT group were younger than the control group (67.0 versus 71.4 years, p<0.001). The SOT group were more likely males compared to the control group (53.8% versus 39.3%, p<0.001). Following 1:1 matching, there were 156 patients in each group. The SOT group had a higher risk of acute renal failure (ARF) compared to the control group (OR 9.41, 95% CI (2.13-41.49), p<0.001). The LOS (p<0.001) and inpatient costs (p<0.001) were higher in the SOT group. CONCLUSION: For RSA, SOT patients are younger and more likely male compared to those without SOT. Inpatient medical and surgical complications are similar between SOT and non-SOT patients, except SOT patients have a higher risk of ARF. SOT patients tend to have longer LOS and higher inpatient costs than non-SOT patients.

Racial variations in complications and costs following total knee arthroplasty: a retrospective matched cohort study.

INTRODUCTION: In this study, we evaluate how race corresponds to specific complications and costs following total knee arthroplasty (TKA). Our hypothesis was that minority patients, comprising Black, Asian, and Hispanic patients, would have higher complication and revision rates and costs than White patients. METHODS: Data from 2014 to 2016 were collected from a large commercial insurance database. TKA patients were assigned under Current Procedural Terminology (CPT-27447) and International Statistical Classification of Diseases (ICD-9-P-8154) codes. Minority patients were compared to White patients before and after matching for age, gender, and tobacco use, diabetes, and obesity comorbidities. Standardized complications, revisions, and total costs at 30 days, 90 days, and 1 year were compared between the groups using unequal variance t tests. RESULTS: Overall, 140,601 White (92%), 10,247 Black (6.7%), 1072 Asian (0.67%), and 1725 Hispanic (1.1%) TKA patients were included. At baseline, minority patients had 7-10% longer lengths of stay (p = 0.0001) and Black and Hispanic patients had higher Charlson and Elixhauser comorbidity indices (p = 0.0001), while Asian patients had a lower Elixhauser comorbidity index (p < 0.0001). Black patients had significantly higher complication rates and higher rates of revision (p = 0.03). Minority patients were charged 10-32% more (p < 0.0001). Following matching, all minority patients had lengths of stay 8-10% longer (p = 0.001) and Black patients had higher Charlson and Elixhauser comorbidity indices (p < 0.0001) while Asian patients had a lower Elixhauser comorbidity index (p = 0.0008). Black patients had more equal complication rates and there was no significant difference in revisions in any minority cohort. All minority cohorts had significantly higher total costs at all time points, ranging from 9 to 31% (p < 0.0001). CONCLUSION: Compared to White patients, Black patients had significantly increased rates of complications, along with greater total costs, but not revisions. Asian and Hispanic patients, however, did not have significant differences in complications or revisions yet still had higher costs. As a result, this study corroborates our hypothesis that Black patients have higher rates of complications and costs than White patients following total knee arthroplasty and recommends efforts be taken to tackle health inequities to create more fairness in healthcare. This same hypothesis, however, was not supported when evaluating Asian and Hispanic patients, probably because of the few patients included in the database and deserves further investigation.

Technical Trick: Traction Table-Assisted Lateral Decubitus Patient Positioning in Cephalomedullary Nailing of Geriatric Intertrochanteric Femur Fractures.

SUMMARY: Cephalomedullary nail fixation of geriatric intertrochanteric femur fractures is, and will continue to be, performed by most orthopaedic surgeons. The influence of technical factors on outcome is clear, and it is imperative that orthopaedic surgeons use contemporary strategies to achieve adequate reduction and fixation. The lateral patient position on a traction table potentially confers several advantages which surgeons can use to achieve quality outcomes even in patients who have challenging body morphology and/or fracture anatomy. A preferred surgical technique for lateral positioning is presented here and a case series comparing supine versus lateral nailing procedures. Lateral positioning was used more frequently in obese patients and by trauma-trained surgeons, and the results equal or exceed those in supine cases with respect to reduction and placement of fixation. Training surgeons in lateral nailing can deliver a reproducible strategy for reduction and fixation in straightforward and complex cases. By mastering the setup and technique on more simple cases, surgeons can be better prepared for the more complex where advantages of lateral nailing are even more apparent.

Hospital characteristics and perioperative complications of Hispanic patients following reverse shoulder arthroplasty-a large database study.

BACKGROUND: Hispanic patients are the youngest and fastest-growing ethnic group in the USA. Many of these patients are increasingly met with orthopedic issues, often electing to undergo corrective procedures such as reverse shoulder arthroplasty (RSA). This patient population has unique medical needs and has been reported to have higher incidences of perioperative complications following major procedures. Unfortunately, there is a lack of information on the hospitalization data and perioperative complications in Hispanic patients following procedures such as RSA. This project aimed to query the Nationwide Inpatient Sample (NIS) database to assess patient hospitalization information, demographics, and the prevalence of perioperative complications among Hispanic patients who received RSA. METHODS: Information from 2016-2019 was queried from the NIS database. Demographic information, incidences of perioperative complications, length of stay, and costs of care among Hispanic patients undergoing RSA were compared to non-Hispanic patients undergoing RSA. A subsequent propensity matching was conducted to consider preoperative comorbidities. RESULTS: The query of NIS identified 59,916 patients who underwent RSA. Of this sample, 2,656 patients (4.4%) were identified to be Hispanic, while the remaining 57,260 patients (95.6%) were found to belong to other races (control). After propensity matching, Hispanic patients had a significantly longer LOS (median = 1.4 days) than the patients in the control group (median = 1.0, P < 0.001). The Hispanic patients (89,168.5 USD) had a significantly higher cost of care than those in the control group (67,396.1 USD, P < 0.001). In looking at postoperative complications, Hispanic patients had increased incidences of acute renal failure (Hispanics: 3.1%, control group: 1.1%, P = 0.03) and blood loss anemia (Hispanics: 12.7%, control group: 10.9%, P = 0.03). CONCLUSIONS: Hispanic patients had significantly longer lengths of stay, higher costs of care, and higher rates of perioperative complications compared to the control group. For patients who are Hispanic and undergoing RSA, this information will aid doctors in making comprehensive decisions regarding patient care and resource allocation.

Cruciate-Retaining Total Knee Arthroplasty: Current Concepts Review.

Posterior cruciate-retaining (CR) total knee arthroplasty for osteoarthritis of the knee is a popular implant choice. At present, there is no consensus on whether sacrifice or retention of the posterior cruciate ligament (PCL) offers superior outcomes. This review explores the current literature available on CR total knee arthroplasty (TKA). PubMed was searched by keyword to find relevant articles for inclusion. Additional sources came from article references and joint registry reports. CR design knees have distinct kinematic gait patterns from posterior-stabilizing (PS) knees and exhibit paradoxical anterior femoral movement with less femoral rollback. While CR implants offer less flexion than PS designs, the difference is not clinically detectable as clinical scores are similar in the short and long term. CR implants have better long-term survival compared to PS knees, likely due to lower risk of aseptic loosening. CR total knee arthroplasties also have shorter operating times and lower risk of peri-prosthetic fractures. Because the CR implant is unconstrained, there may be an increased risk of instability compared to PS designs, but the literature is mixed. Overall, the current literature supports the continued use of CR TKAs due to their lower risk of complications, durability, and demonstrated equivalence in function to posterior-substituting models.

Perioperative complications of legally blind patients undergoing total knee arthroplasty: A national inpatient sample database study.

Introduction: Vision impairment is a significant health concern that leads to increased morbidity and mortality globally. Significantly, legally blind (LB) patients have higher rates of hospitalization, cost, and orthopedic-related complications. Total knee arthroplasty (TKA) is commonly used to treat advanced knee osteoarthritis. However, there is limited literature reporting the demographic and hospitalization characteristics and operative outcomes of patients with LB who underwent TKA. This study addresses this gap in literature. Method: We conducted a retrospective study using a Nationwide Inpatient Sample database. We assessed perioperative complications, length of stay (LOS), and healthcare expenditure among legally blind and control cohort patients who underwent TKA. Propensity matching was conducted to identify factors associated with perioperative complications. Results: Between 2016 and 2020, there were 558,371 patients underwent TKA, with 0.1% of patients documented as legally blind. Of this cohort, the average age was significantly older than the control, 70.01 years versus 66.72 years (p < 0.001), respectively. Patients from the LB cohort had a longer length of stay (2.9 ± 1.7 days) than those from the control cohort (2.4 ± 1.3 days) (p < 0.001). Significantly, patients in the legally blind group incurred higher expenditures than those in the control group ($68,936 versus $64,808, respectively; p < 0.001). (Table 2). Propensity matching yields similar results. Analysis of TKA-associated operative complications suggested that legally blind patients had a higher proportion of blood loss anemia (20.97%, p < 0.05), required blood transfusions secondary to surgery (3.1%, p < 0.05), and periprosthetic fractures (2.6%, p < 0.05) than the control group (15.3%, 1.5%, and 0.42%, respectively). Conclusion: We report that LB patients are, on average, older and have an extended LOS, higher expenditure, and higher rates of specific TKA-associated operative complications than those without legal blindness. To date, this is the first study of its kind to provide large, population-based data on the demographics, costs, and TKA-operative complications in patients with LB and, as such, provides a purposeful basis for future research.

The effect of cocaine on patients undergoing total hip arthroplasty.

Background: Cocaine use has surged in the past decade, with 4.8 million Americans (1.7% of the population greater than 12) reporting use in 2021, leading to a healthcare burden of 1.3 billion dollars. Cocaine users experience prolonged hospital stays, higher costs, worse surgical outcomes, increased risk of medical conditions, and inflammation-related osteoarthritis. The study aims to identify factors influencing length of stay, costs, and perioperative complications in cocaine users undergoing total hip arthroplasty (THA) to reduce these risks. Methods: This study utilized the NIS database, providing comprehensive information on patient demographics, length of stay, hospital costs, and complications. Statistical analyses were conducted using SPSS software, including propensity matching and significance testing, to compare outcomes between cocaine users (CU) and non-cocaine users (NCU) undergoing total hip arthroplasty. Results: After propensity matching, cocaine users had a significantly longer LOS (4.8 days) in comparison to non-cocaine users (2.6 days) (p < 0.001). Similarly, the CU group had a larger of care (87984.9) than the NCU group (69149.2) (p < 0.001). Cocaine users had significantly higher rates of blood loss anemia (OR: 3.24, 95% CI: 2.21, 4.73), blood loss anemia (OR: 1.59, 95% CI: 1.12, 2.24), blood transfusion (OR: 2.23, 95% CI: 1.04, 4.78), periprosthetic dislocation (OR: 6.57, 95% CI: 1.47, 29.32), and periprosthetic infection (OR: 4.59, 95% CI: 1.54, 13.68) than patients in the non-cocaine user's group. Conclusion: Cocaine users had a significantly longer length of stay, higher costs of care, and an increased number of post-operative complications compared to non-cocaine users. These data contribute to understanding the potential ramifications of cocaine users undergoing THA.

Complications and Costs Associated With Ethnicity Following Total Hip Arthroplasty: A Retrospective Matched Cohort Study.

BACKGROUND: Minority patients often have greater numbers of complications, revisions, and costs after total hip arthroplasty (THA). This study investigates how race correlates with specific surgical complications, revisions, and total costs following THA both before and after propensity matching. METHODS: Data from 2014-2016 were collected from a large commercial insurance database known as PearlDiver. THA patients were assigned under Current Procedural Terminology (CPT-27130) and International Statistical Classification of Diseases (ICD-9-P-8151) codes and then divided into groups based on racial status in the database. Patients of different ethnicities including White, Black, Asian, and Hispanic patients were compared in regard to age, gender, comorbidities, lengths of stay, and surgical complications and costs at thirty days, ninety days, and one year using unequal variance t-tests. Black, Asian, and Hispanic patients are collectively referred to as minority patients. Patient comparisons were done both before and after matching for age, gender, tobacco use, diabetes, and obesity comorbidities. RESULTS: A total of 73,688 White (93%), 4,822 Black (6%), 268 Asian (0.3%), and 420 Hispanic (0.5%) THA patients were included. Significantly more minority patients underwent THA under the age of 65 and had higher comorbidity indices and lengths of stay. Black patients had significantly higher complication rates, but there was no significant difference in rates of revision in any minority group. Minority patients were charged 9%-83% more. After matching, Black and Hispanic patients maintained higher comorbidity indices and lengths of stay. Black patients had a spectrum of complication rates but significantly decreased revision rates. Furthermore, after matching, minority patients were charged 5%-65% more. CONCLUSIONS: Black patients experienced significantly greater rates of complications and higher total costs; whereas, Asian and Hispanic patients did not have significant differences in complications but did have higher costs. Therefore, this study aligns with previous studies and supports our hypothesis that Black ethnicity patients have worse outcomes than White ethnicity patients after THA, advocating for reducing health disparities and establishing more equitable healthcare, but does not support our hypothesis for Asian and Hispanic patients, likely due to a small study population size, warranting further research into the topic.

Perioperative complications of legally blind patients undergoing total hip arthroplasty - A national in-patient sample database study.

Background: Legally blind patients are more prone to injury-related falls, which may lead to hip fractures, often necessitating total hip arthroplasty (THA), as a corrective procedure. Many of these patients have unique medical needs and have increased rates of perioperative complications following surgical procedures. However, there is limited information on the hospitalization data and perioperative complications in this population following guidelines such as THA. The purpose of this study was to evaluate the patient characteristics, demographics, and prevalence of perioperative issues among THA patients who were legally blind. Methods: Using 2016-2019 data from the Nationwide Inpatient Sample (NIS), the incidence of perioperative complications, length of stay (LOS), and the cost of care (COC) among patients undergoing THA who were categorized as legally blind patients, compared to those who were not were analyzed. Propensity matching was conducted to consider associated factors that may influence perioperative complications. Results: From 2016 to 2019, 367,856 patients underwent THA, according to the NIS. Of those, 322 (0.1%) patients were categorized as legally blind, and the remaining 367,534 (99.9%) patients were not identified as legally blind (control). Legally blind patients were significantly younger than the control group (65.4 years vs. 66.7 years, p < 0.001). After propensity matching, legally blind patients had longer LOS (3.9 days vs. 2.8, p = 0.04), increased discharges to another facility (45.9% vs. 29.3%, p < 0.001), and fewer discharges to home (21.4% vs. 32.2%, p = 0.02) than control patients. Conclusions: The legally blind group had significantly longer LOS, higher rates of discharge to another facility, and lower rates of discharge to home compared to the control group. This data will help providers make informed decisions about patient care and resource allocation for legally blind patients undergoing THA.

Atypical Shoulder Instability Patterns in Adolescents Following Traumatic Anterior Shoulder Dislocation.

BACKGROUND: Traumatic anterior shoulder instability is common in the adolescent athlete, and when it is untreated, the recurrence rate is high. Atypical lesions-such as anterior glenoid periosteal sleeve, humeral glenohumeral ligament, and insertional tendon avulsions-may occur within this population, and accurate diagnosis and appropriate lesion management are key to treatment success. PURPOSE: To evaluate the age, skeletal immaturity, bone loss, and uncommon soft tissue lesions as correlates of posttraumatic anterior shoulder instability lesion patterns in an adolescent population. STUDY DESIGN: Cross-sectional study, Level of evidence, 3. METHODS: Consecutive patients ≤18 years of age (160 shoulders) treated within a single institution for traumatic anterior shoulder instability between June 2013 and June 2021 were reviewed. Demographics, injury mechanism, radiographic and magnetic resonance imaging of lesions, the presence of any bone loss, operative findings, and physeal status were recorded. An overall 131 shoulders met the inclusion criteria. Instability lesion type was analyzed categorically by age <15 or ≥15 years; individual age was assessed for correlation with any bone loss present. Atypical lesions-anterior labral periosteal sleeve avulsion, humeral avulsion of the glenohumeral ligament, subscapularis avulsion-were assessed for correlations with age, open physeal status, and the presence of any bone loss. RESULTS: An overall 131 shoulders (mean, 15.3 years; range, 10.5-18.3) were identified for this study: 55 in patients <15 years old and 76 in patients ≥15 years old. Bony injuries such as Bankart and Hill-Sachs lesions were more common in the ≥15-year-old group (P = .044 and P = .024, respectively). Bony Bankart injuries were found at a rate of 18.2% in the <15-year-old group, as compared with 34.2% in the ≥15-year-old group (P < .05). Anterior labral periosteal sleeve avulsions were more common in the <15-year-old group (n = 13 [23.6%] vs n = 8 [10.5%]; P < .044), as were all atypical lesions combined (n = 23 [41.8%] vs n = 13 [17.1%]; P < .0018]. CONCLUSION: In this series of anterior shoulder instability in children and adolescents, instability lesions varied significantly by age. Bone loss was associated with older age at presentation, and atypical lesions were more common in patients <15 years of age. Treatment teams should be aware of less common soft tissue injuries in this young age group and ensure careful review of adequate imaging for proper diagnosis and treatment in these younger patients.

Socio-demographic factors impact time to discharge following total knee arthroplasty.

AIM: To determine social, logistical and demographic factors that influence time to discharge in a short stay pathway (SSP) by following total knee arthroplasty (TKA). METHODS: The study included primary TKA's performed in a high-volume arthroplasty center from January 2016 through December 2016. Potential variables associated with increased hospital length of stay (LOS) were obtained from patient medical records. These included age, gender, race, zip code, body mass index (BMI), number of pre-operative medications used, number of narcotic medications used, number of patient reported allergies (PRA), simultaneous bilateral surgery, tobacco use, marital status, living arrangements, distance traveled for surgery, employment history, surgical day of the week, procedure end time and whether the surgery was performed during a major holiday week. Multivariate step-wise regression determined the impact of social, logistical and demographic factors on LOS. RESULTS: Eight hundred and six consecutive primary SSP TKA's were included in this study. Patients were discharged at a median of 49 h (post-operative day two). The following factors increased LOS: Simultaneous bilateral TKA [46.1 h longer (P < 0.001)], female gender [4.3 h longer (P = 0.012)], age [3.5 h longer per ten-year increase in age (P < 0.001)], patient-reported allergies [1.1 h longer per allergy reported (P = 0.005)], later procedure end-times [0.8 h longer per hour increase in end-time (P = 0.004)] and Black or African American patients [6.1 h longer (P = 0.047)]. Decreased LOS was found in married patients [4.8 h shorter (P = 0.011)] and TKA's performed during holiday weeks [9.4 h shorter (P = 0.011)]. Non-significant factors included: BMI, median income, patient's living arrangement, smoking status, number of medications taken, use of pre-operative pain medications, distance traveled to hospital, and the day of surgery. CONCLUSION: The cost of TKA is dependent upon LOS, which is affected by multiple factors. The clinical care team should acknowledge socio-demographic factors to optimize LOS.