High Rate of Unplanned Reoperation for Interprosthetic Femur Fractures After Total Hip and Knee Arthroplasty.

BACKGROUND: Interprosthetic femur fractures (IPFFs) are a rare, but devastating complication following total joint arthroplasty. There is limited evidence to help guide their management. The purpose of this study was to describe the features, treatment, and outcomes of surgically managed IPFFs. METHODS: We retrospectively identified 75 patients who had 76 IPFFs. The mean age at the time of IPFF was 75 years (range, 29 to 94), and 78% were women. The mean body mass index was 30 (range, 19 to 51), and the mean follow-up was 3 years (range, 0 to 14). There were 16 Vancouver B1 fractures, 28 Vancouver B2 fractures, 2 Vancouver B3 fractures, and 30 Vancouver C fractures. All B1 fractures underwent open reduction internal fixation (ORIF). All Vancouver B2 and B3 fractures underwent revision arthroplasty, including 1 proximal femur replacement and 1 total femur replacement. Vancouver C fractures were treated with ORIF (n = 20), distal femoral replacement (n = 9), and in 1 case, total femur replacement (n = 1). Kaplan-Meier survivorship was used to calculate 2-year survival free from all-cause reoperation and periprosthetic joint infection (PJI). RESULTS: The 2-year survivorship-free rate from reoperation was 71%. There were 18 reoperations following initial surgical management of the IPFF, including 9 for infection, 3 for refracture, 3 for nonunion, 2 for hardware failure, and 1 for instability. An initial IPFF involving a stemmed femoral total knee arthroplasty component was associated with increased risk for reoperation (P = .007) and PJI (P = .044). There was no difference in survivorship free of reoperation between IPFFs managed with ORIF or revision arthroplasty (P = .72). CONCLUSIONS: An IPFF is a devastating complication following total joint arthroplasty with high reoperation rates, most commonly secondary to PJI. Those IPFFs that occurred between 2 stemmed components were at the highest risk for reoperation.

Femoral Component Debonding Frequently Missed on Advanced Imaging Prior to Revision of a Recalled Total Knee Arthroplasty.

BACKGROUND: Identification of femoral component debonding in the work-up of painful total knee arthroplasty (TKA) often poses a diagnostic challenge. The purpose of this study was to compare the sensitivity and specificity of radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) for identifying femoral component loosening with debonding at the time of revision of a primary TKA with a recalled polyethylene insert. METHODS: Using an institutional database, we identified all cases of revision TKA performed for this specific implant recall following a primary TKA between 2014 and 2022. Patients who had a preoperative radiograph, CT, and MRI were included (n = 77). Sensitivity, specificity, and positive and negative likelihood ratio (LR) for predicting loosening were compared among the imaging modalities, using the intraoperative evidence of implant loosening as the gold standard. RESULTS: At the time of revision surgery, the femoral component was noted to have aseptic loosening with debonding in 46 of the 77 (60%) of the TKAs. There were no significant differences in demographics in the cohort with femoral debonding compared to those with well-fixed implants. The CT demonstrated a sensitivity of 28% and a specificity of 97%, while the MRI demonstrated a sensitivity of 37% and a specificity of 94% for detecting femoral loosening due to debonding. Both CT and MRI demonstrated poor negative LRs for femoral loosening (LR 0.7). CONCLUSIONS: In this series of revision TKAs for a specific recalled component, neither CT nor MRI accurately diagnosed femoral component debonding. For patients who have this implant, it is imperative to interrogate the implant-cement interface intraoperatively and prepare for full revision surgery as well as marked bone loss secondary to osteolysis.

Cost Drivers in Two-Stage Treatment of Hip Periprosthetic Joint Infection With an Antibiotic Coated Cement Hip Spacer.

BACKGROUND: The current gold standard for treating chronic Periprosthetic Joint Infection (PJI) is a 2-stage revision arthroplasty. There has been little investigation into what specific patient and operative factors may be able to predict higher costs of this treatment. METHODS: An institutional electronic health record database was retrospectively queried for patients who developed a PJI after a total hip arthroplasty, and underwent removal of the prosthesis and implantation of an antibiotic-impregnated articulating hip cement spacer. Patient demographics, surgical variables, hospital readmissions, emergency department visits, and post-operative complications were collected. Total costs were captured through an internal accounting database through 2 years post-operatively. Negative binomial regressions were utilized for multivariable analyses. A total of 55 hips with PJI were available for cost analyses. RESULTS: A comorbidity index score was associated with a 70% increase (Odds Ratio (OR): 1.7 [1.18-2.5], P = .003) in total costs at 2-years. Illicit drug use was associated with a 70% increase in costs at 1-year post-operatively (OR 1.7 [1.18-2.5], P = .003). Metal-on-poly liners were associated with a 22% decrease in cost at 2-years post-operatively when compared to Cement-on-Bone articulating spacers, and Metal-on-poly -constrained liners accounted for 38% lower costs at 1-year (OR 0.62 [0.44-0.87], P = .004). Use of an intraoperative extended trochanteric osteotomy was associated with a 46 and 61% increase in cost at 1-year (OR 1.46 [1.14-1.89]) and 2-years (OR 1.61 [1.26-2.07], P < .001) post-operatively. CONCLUSION: Age, comorbidity index score, drug use, and extended trochanteric osteotomy were associated with increased costs of PJI treatment. This may be used to improve reimbursement models and target areas of cost savings.

A Permanent Articulating Spacer Versus Two-Stage Exchange for Chronic Periprosthetic Joint Infection: A Propensity Score-Matched Study.

BACKGROUND: Although 2-stage revision has been proposed as gold standard for periprosthetic joint infection treatment, limited evidence exists for the role of articulating spacers as definitive management. The purpose of this study was to compare clinical outcomes and costs associated with articulating spacers (1.5-stage) and a matched 2-stage cohort. METHODS: A retrospective review was performed for patients who had chronic periprosthetic joint infections after total knee arthroplasty defined by Musculoskeletal Infection Society criteria and were matched via propensity score matching using cumulative Musculoskeletal Infection Society scores and a comorbidity index. Patients who maintained an articulating spacer (cemented cobalt-chrome femoral component and all-poly tibia) were included in the 1.5-stage cohort. Patients who underwent a 2-stage reimplantation procedure were included in the 2-stage cohort. Outcomes included visual analog scale pain scores, 90-day emergency department visits, 90-day readmission, unplanned reoperation, reinfection, as well as cost at 1 and 2-year intervals. A total of 116 patients were included for analyses. RESULTS: The 90-day pain scores were lower in the 1.5-stage cohort compared to the 2-stage cohort (2.9 versus 4.6, P = .0001). There were no significant differences between readmission and reoperation rates. Infection clearance was equivalent at 79.3% for both groups. Two-stage exchange demonstrated an increased cost difference of $26,346 compared to 1.5-stage through 2 years (P = .0001). Regression analyses found 2 culture-positive results with the same organism decreased the risk for reinfection [odds ratio: 0.2, 95% confidence interval 0.04-0.8, P = .03]. CONCLUSION: For high-risk candidates, articulating spacers can preserve knee function, reduce morbidity from second-stage surgery, and lower the costs with similar rates of infection clearance as 2-stage exchange. LEVEL OF EVIDENCE: Level III, therapeutic study.

Appropriate patient selection for outpatient shoulder arthroplasty: a risk prediction tool.

BACKGROUND: The transition from inpatient to outpatient shoulder arthroplasty critically depends on appropriate patient selection, both to ensure safety and to counsel patients preoperatively regarding individualized risk. Cost and patient demand for same-day discharge have encouraged this transition, and a validated predictive tool may help decrease surgeon liability for complications and help select patients appropriate for same-day discharge. We hypothesized that an accurate predictive model could be created for short inpatient length of stay (discharge at least by postoperative day 1), potentially serving as a useful proxy for identifying patients appropriate for true outpatient shoulder arthroplasty. METHODS: A multicenter cohort of 5410 shoulder arthroplasties (2805 anatomic and 2605 reverse shoulder arthroplasties) from 2 geographically diverse, high-volume health systems was reviewed. Short inpatient stay was the primary outcome, defined as discharge on either postoperative day 0 or 1, and 49 patient outcomes and factors including the Elixhauser Comorbidity Index, sociodemographic factors, and intraoperative parameters were examined as candidate predictors for a short stay. Factors surviving parameter selection were incorporated into a multivariable logistic regression model, which underwent internal validation using 10,000 bootstrapped samples. RESULTS: In total, 2238 patients (41.4%) were discharged at least by postoperative day 1, with no difference in rates of 90-day readmission (3.5% vs. 3.3%, P = .774) between cohorts with a short length of stay and an extended length of stay (discharge after postoperative day 1). A multivariable logistic regression model demonstrated high accuracy (area under the receiver operator characteristic curve, 0.762) for discharge by postoperative day 1 and was composed of 13 variables: surgery duration, age, sex, electrolyte disorder, marital status, American Society of Anesthesiologists score, paralysis, diabetes, neurologic disease, peripheral vascular disease, pulmonary circulation disease, cardiac arrhythmia, and coagulation deficiency. The percentage cutoff maximizing sensitivity and specificity was calculated to be 47%. Internal validation showed minimal loss of accuracy after bias correction for overfitting, and the predictive model was incorporated into a freely available online tool to facilitate easy clinical use. CONCLUSIONS: A risk prediction tool for short inpatient length of stay after shoulder arthroplasty reaches very good accuracy despite requiring only 13 variables and was derived from an underlying database with broad geographic diversity in the largest institutional shoulder arthroplasty cohort published to date. Short inpatient length of stay may serve as a proxy for identifying patients appropriate for same-day discharge, although perioperative care decisions should always be made on an individualized and holistic basis.

Risk Factors for Delayed Discharge and Adverse Outcomes Following Outpatient Billed Total Knee Arthroplasty.

BACKGROUND: The volume of outpatient total knee arthroplasty (TKA) has increased with advances in perioperative protocols, patient selection, and recent policy changes regarding insurance authorization. This study analyzed 30-day outcomes from a national database to better understand risk factors for delayed discharge (length of stay [LOS] ≥1), readmission, and reoperation after outpatient TKA. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was utilized to collect TKA (CPT 27447) billed as outpatient surgery performed from 2013 to 2018. Patient demographics, comorbidities, and short-term outcomes were collected and compared in LOS 0 versus LOS ≥1 cohorts. Subgroup analysis was completed for TKA performed in 2018, after the Center for Medicare Services removal of TKA from the inpatient-only list. RESULTS: A total of 13,669 patients had outpatient TKA performed from 2013 to 2018. Most patients had LOS ≥1 day (77.1%). The LOS 0 cohort demonstrated a lower 30-day readmission rate (1.8%) compared to LOS ≥1 (2.8%), P > .01. Both groups demonstrated a low 30-day reoperation rate, LOS 0 (0.7%) and LOS ≥1 (1.1%), P = .05. Regression analysis demonstrated risk factors for LOS ≥1 day included COPD, ASA ≥3, age >75, and BMI >35 kg/m2. Regression analysis demonstrated male gender, age >75, ASA ≥3, and albumin <3.5 g/dL were risk factors for readmission. Hypertension was a risk factor for 30-day reoperation. CONCLUSION: Risk factors for LOS ≥1 day include age >75, ASA ≥3, BMI >35 kg/m2. In addition, BMI >35 kg/m2 was a risk factor for readmission and reoperation. These findings reinforce appropriate patient selection when considering outpatient TKA.

Patterns and Predictors of Weight Change Before and After Total Hip Arthroplasty in Class 2 and 3 Obese Patients.

BACKGROUND: This study aimed to better understand body mass index (BMI) change patterns and factors associated with BMI change before and after total hip arthroplasty (THA) in Class 2 and 3 obese patients, and assess if preoperative or postoperative BMI change affects postoperative clinical outcomes. METHODS: We retrospectively reviewed World Health Organization Class 2 and 3 obese patients (BMI > 35.0 at surgery) who underwent THA at a tertiary medical center from 2010 to 2020. BMI was recorded at 1 year preoperatively (mean 11.6 months), and at most recent postoperative visit (mean 29.0 months). Baseline demographics and postoperative clinical outcomes were recorded. RESULTS: We reviewed 436 THAs with a mean age of 59.9 (11.5) years. Leading up to surgery 55.5% had unchanged BMI, and postoperatively 48.2% had unchanged BMI. Multivariate logistic regression revealed that those who lost BMI preoperatively were more likely to gain BMI postoperatively (odds ratio [OR] 3.28, confidence interval [CI] 1.83-5.97, P = .005), but those who gained >5% BMI preoperatively had no association with BMI change postoperatively. Those in a higher BMI class preoperatively were less likely to gain BMI preoperatively (Class 3 obese patients: OR 0.001, CI 0.0002-0.004, P < .001). African American patients were more likely to gain BMI preoperatively (OR 2.32, CI 1.16-4.66, P = .017). We did not detect an association between BMI change and postoperative clinical outcomes. CONCLUSION: In World Health Organization Class 2 or 3 obese patients, most maintained BMI between their first preoperative and final postoperative visit. Preoperatively, Class 3 obese patients were less likely to gain weight than Class 2 obese patients. The primary predictor of postoperative weight gain was preoperative weight loss. Weight change preoperatively and postoperatively were not associated with worse clinical outcomes.

Fracture Severity Based on Neer Classification Does Not Predict Short-term Complications Following Reverse Shoulder Arthroplasty.

Proximal humerus fractures (PHF) are common in elderly and osteoporotic patients, and these fractures are often described using the Neer classification. As reverse shoulder arthroplasty (RSA) for PHF becomes more common, it is helpful to identify the utility of Neer classification in predicting postoperative outcomes for patients undergoing RSA. The medical records of patients undergoing primary RSA for PHF at a single academic institution from 2013-2019 were identified using medical billing codes. A multivariable logistic regression analysis identified independent factors associated with all cause 90-day readmissions, reoperation, and length of stay (LOS) greater than three days. Fifty-five patients (average age of 72.3 ± 8.6 years) were included. No statistically significant differences among two-, three-, and four-part fractures with regard to LOS, discharge location, 90-day readmission, revision surgery, postoperative dislocation, or deep infection were detected. These findings suggest that Neer classification for PHF is not predictive of short-term complications after RSA. (Journal of Surgical Orthopaedic Advances 31(2):104-108, 2022).

Intravenous tranexamic acid vs. topical thrombin in total shoulder arthroplasty: a comparative study.

BACKGROUND: Blood loss and transfusions have been highlighted as a significant predictor of postoperative morbidity. Tranexamic acid (TXA) has been shown to decrease blood loss and transfusion in shoulder arthroplasty. However, the utility of topical thrombin in total shoulder arthroplasty (TSA) is unknown. The purpose of this study was to assess the utility of topical thrombin in TSA and compare the effectiveness of topical thrombin to intravenous (IV) TXA. METHODS: An institutional database was used to query shoulder arthroplasty patients from January 2017 to July 2019. Patients undergoing TSA were identified with CPT (Current Procedural Terminology) code (23742). After excluding reverse shoulder arthroplasty, arthroplasty for fracture or revision, the study groups were stratified based on intervention with IV TXA, topical thrombin, or neither. Patient demographics, American Society of Anesthesiologists (ASA) class, baseline coagulopathy, preoperative and postoperative hemoglobin levels, operative time, transfusion, length of stay, and 90-day readmission for each treatment group was obtained. RESULTS: A total of 283 TSA cases were included for final analysis. There was no statistically significant difference in the baseline characteristics with age, body mass index, or ASA class. The postoperative hemoglobin level (mg/dL) was higher in the group that received either IV TXA or thrombin compared with no hemostatic agents (P = .001). Calculated blood loss in TSA was significantly higher in the group without hemostatic agents, 369.8 mL (standard deviation [SD] 59.5), compared with IV TXA or topical thrombin, 344.3 mL (SD 67.1) and 342.9 mL (SD 65.6) (P = .03). Operative time was highest in the group that received no hemostatic agents, 2.3 hours (SD 0.6) (P = .01). The transfusion rate for TSA treated with IV TXA or topical thrombin was equivalent (2.2%) but significantly lower than the no intervention group (12%) (P = .01). The odds ratio for transfusion with IV TXA was 0.16 (95% confidence interval [CI] 0.07-0.40, P = .001) and for topical thrombin, 0.1 (95% CI 0.02-0.42, P = .02). CONCLUSION: Topical thrombin is an effective adjunct to reduce blood loss and transfusion risk after TSA and a reasonable intraoperative alternative for TXA for patients with contraindication to IV TXA.

Trends in reimbursement for primary and revision total elbow arthroplasty.

BACKGROUND: Relative value units (RVUs) are an essential component of reimbursement calculations from the Centers for Medicare & Medicaid Services. RVUs are calculated based on physician work, practice expense, and professional liability insurance. Procedures that are more complex, such as revision arthroplasty, require greater levels of physician work and should therefore be assigned a greater RVU. The purpose of this study is to compare RVUs assigned for primary and revision total elbow arthroplasty (TEA). METHODS: The National Surgical Quality Improvement Program database was used to collect all primary and revision total elbow arthroplasties performed between January 2015 and December 2017. Variables collected included age at time of surgery, RVUs assigned for the procedure, and operative time. RESULTS: A total of 359 cases (282 primary TEA, 77 revision TEA) were included in this study. Mean RVUs for primary TEA was 21.4 (2.0 standard deviation [SD]) vs. 24.4 (1.7 SD) for revision arthroplasty (P < .001). Mean operative time for primary TEA was 137.9 minutes (24.4 SD) vs. 185.5 minutes (99.7 SD) for revision TEA (P < .001). The RVU per minute for primary TEA was 0.16 and revision TEA was 0.13 (P < .001). This amounts to a yearly reimbursement difference of $71,024 in favor of primary TEA over revision TEA. CONCLUSION: The current reimbursement model does not adequately account for increased operative time, technical demand, and pre- and postoperative care associated with revision elbow arthroplasty compared with primary TEA. This leads to a financial advantage on performing primary TEA.

Malnutrition in elective shoulder arthroplasty: a multi-institutional retrospective study of preoperative albumin and adverse outcomes.

BACKGROUND: Malnutrition is associated with poor postoperative outcomes after knee, hip, and spine surgery. However, whether albumin labs should be part of the routine preoperative workup for shoulder arthroplasty remains understudied. This study investigated the role of preoperative albumin levels in predicting common postoperative adverse outcomes in patients undergoing shoulder arthroplasty. METHODS: All shoulder arthroplasty cases performed at 2 tertiary referral centers between July 2013 and May 2019 (institution 1) and between June 2007 and Feb 2020 (institution 2) were reviewed. A total of 421 primary and 71 revision elective shoulder arthroplasty cases had preoperative albumin levels recorded. Common demographic variables and relevant Elixhauser comorbidities were pulled. Outcomes gathered included extended (>3 days) postoperative inpatient length of stay (eLOS), 90-day readmission, and discharge to rehab or skilled nursing facility (SNF). RESULTS: The prevalence of malnutrition (albumin <3.5 g/dL) was higher in the revision group compared with the primary group (36.6% vs. 19.5%, P = .001). Reverse shoulder arthroplasty (P = .013) and increasing American Society of Anesthesiologists score (P = .016) were identified as independent risk factors for malnutrition in the primary group. In the revision group, liver disease was associated with malnutrition (P = .046). Malnourished primary shoulder arthroplasty patients had an increased incidence of eLOS (26.8% vs. 13.6%, P = .003) and discharge to rehab/SNF (18.3% vs. 10.3%, P = .045). On univariable analysis, low albumin had an odds ratio (OR) of 2.34 for eLOS (P = .004), which retained significance in a multivariable model including age, American Society of Anesthesiologists score, sex, and body mass index (OR 2.11, P = .03). On univariable analysis, low albumin had an OR of 1.94 for discharge to SNF/rehab (P = .048), but this did not reach significance in the multivariable model. Among revisions, malnourished patients had an increased incidence of eLOS (30.8% vs. 6.7%, P = .014) and discharge to rehab/SNF (26.9% vs. 4.4%, P = .010). In both the primary and revision groups, there was no difference in 90-day readmission rate between patients with low or normal albumin. CONCLUSION: Malnutrition is more prevalent among revision shoulder arthroplasty patients compared with those undergoing a primary procedure. Primary shoulder arthroplasty patients with low preoperative albumin levels have an increased risk of eLOS and may have an increased need for postacute care. Low albumin was not associated with a risk of 90-day readmissions. Albumin level merits further investigation in large, prospective cohorts to clearly define its role in preoperative risk stratification.

Single-stage versus two-stage revision for shoulder periprosthetic joint infection: a systematic review and meta-analysis.

BACKGROUND: Shoulder periprosthetic joint infection (PJI) is a significant complication after arthroplasty with high morbidity. An evidence-based algorithm for the treatment of shoulder PJI is lacking in current practice. The purpose of this systematic review and meta-analysis was to understand and compare the role of single- and 2-stage shoulder arthroplasty revision for PJI. METHODS: A comprehensive literature review was performed to identify all studies related to shoulder arthroplasty for PJI in PubMed, Scopus, and EMBASE. Inclusion criteria for this systematic review were studies that reported on single- or 2-stage revision, with infection eradication and a minimum follow-up of 12 months and a minimum of 5 patients for analysis. A random-effects meta-analysis was performed, and heterogeneity was assessed with Cochrane Q and I2. RESULTS: A total of 13 studies reporting on single-stage revision and 30 studies reporting on 2-stage revision were included in final analysis. The majority of positive cultures from single-stage revision for PJI resulted in Cutibacterium acnes with 113 of 232 (48.7%) reported cases compared with 190 of 566 (33.7%) reported cases for 2-stage revision. However, there was a lower percentage of methicillin-resistant Staphylococcus aureus positive cultures, with 2.5% for single-stage compared with 9.7% for 2-stage revision. The overall pooled random-effect reinfection incidence was 0.05 (95% confidence interval: 0.02-0.08), with moderate heterogeneity (I2 = 34%, P = .02). The reinfection rate was 6.3% for single-stage and 10.1% for 2-stage revision, but this was not significant (Q = 0.9 and P = .40). CONCLUSION: Based on a systematic review with meta-analysis, single-stage revision for shoulder PJI is an effective treatment. Indeed, our analysis showed single-stage to be more effective than 2-stage, but this is likely confounded by a treatment bias given the higher propensity of virulent and drug-resistant bacteria treated with 2-stage in the published literature. This implies that shoulder surgeons treating PJI can be reassured of a low recurrence rate (6.3%) when using single-stage treatment for C acnes or other sensitive, low-virulence organisms.

Biceps tenotomy has earlier pain relief compared to biceps tenodesis: a randomized prospective study.

PURPOSE:  Surgical management for long head of the biceps (LHB) tendinopathy with either biceps tenotomy or tenodesis is a reliable, but debated treatment option. The aim of this prospective, randomized, single-blinded study is to evaluate differences in pain relief and subjective outcomes between biceps tenotomy versus tenodesis for LHB tendinopathy. METHODS:  Subjects were randomized and blinded to biceps tenotomy versus arthroscopic tenodesis intra-operatively. Outcomes evaluated included subjective patient outcome scores, pain, and cosmetic deformity. Subjective outcomes scores and pain were analyzed using a two-way ANOVA, controlling for concomitant rotator cuff repair. Binary outcomes were compared using Chi-square tests. RESULTS:  Thirty-four subjects (31 male, 3 female) with a median age of 56 (range 30-77) were enrolled. Twenty subjects were randomized to tenotomy and 14 to tenodesis. Fifty-six percent had concomitant rotator cuff repairs. The mean VAS pain score at 3 months was lower with tenotomy versus tenodesis. 2-year follow-up demonstrated no statistically significant differences for VAS, ASES, or SANE. 15/20 (75%) subjects with biceps tenotomy reported no pain medication use at the 2-week postoperative visit versus 5/14 (33%) for biceps tenodesis. Popeye deformity was found in 5/20 (25%) of tenotomy subjects versus 1/14 (7%) in tenodesis subjects. CONCLUSION: Outcomes appear similar between biceps tenotomy versus tenodesis; however, the tenotomy group demonstrated greater incidence of cosmetic deformity but an earlier improvement in postoperative pain. LEVEL OF EVIDENCE: Treatment Studies, Level II.

Perioperative Selective Serotonin Reuptake Inhibitor Use Is Associated With an Increased Risk of Transfusion in Total Hip and Knee Arthroplasty.

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) have been shown in both orthopedic and general surgery literature to be associated with an increased risk of blood loss, and this is thought to occur via diminished platelet serotonin reuptake and subsequent decline in platelet aggregation potential. In this study, we aim at quantifying the effect of treatment with SSRIs on blood loss and transfusion rates following total hip (THA) or total knee arthroplasty (TKA). METHODS: THA (4485) and TKA (5584) cases from January 2013 to December 2017 at the investigating institution were queried and analyzed separately from an institutional database. Patients were stratified by utilization of an SSRI at the time of surgery. Patient demographics, baseline coagulopathy, preoperative and postoperative hemoglobin, transfusion, and length of stay were obtained to compare the 2 cohorts. RESULTS: The transfusion rate for SSRI users was 3.9% in the TKA group and 8.5% in the THA group. After controlling for age, gender, body mass index, presence of coagulopathy, procedure (THA vs TKA), and SSRI status, SSRI utilization was significantly associated with increased blood loss (P < .004), and logistic regression controlling for the same variables showed SSRI utilization to be predictive of transfusion (odds ratio, 1.476; P < .001). CONCLUSION: SSRI utilization was associated with increased perioperative blood loss and predictive of transfusion risk, particularly with THA. This represents an important factor that may be modified in the setting of total joint arthroplasty but further work will be necessary to study potential alternative medications for depression in the perioperative phase.

Risk Factors for Early Readmission and Reoperation After Outpatient Total Hip Arthroplasty.

Outpatient total hip arthroplasty (THA) is a safe option for select patients. The purpose of this study was to analyze a national database and understand risk factors that lead to unplanned early readmission and reoperation after outpatient THA. The National Surgical Quality Improvement Program database was used to collect outpatient THAs performed from 2013 to 2020. The outpatient setting was defined as a reported hospital length of stay of 23 hours or less. Data variables collected included patient demographics, medical comorbidities, American Society of Anesthesiologists classification, functional status, preoperative laboratory values, National Surgical Quality Improvement Program morbidity probability, and 30-day readmissions and reoperations. A total of 15,055 patients underwent outpatient THA. Mean age was 62.6 years, and 52.1% of patients were men. Mean body mass index was 29.3 kg/m2. The overall rate of readmission was 1.8%, and the reoperation rate was 1.0%. Patients with a 30-day readmission were older (P<.01), with a higher incidence of hypertension (P<.01), steroid use (P<.01), and bleeding disorders (P=.01). Patients with a 30-day reoperation had higher body mass index (P<.01), hypertension (P<.01), and steroid use (P<.01). Regression analysis demonstrated that independent risk factors for readmission were age (P<.01) and steroid use (P<.01). Risk factors for 30-day reoperation were hypertension (P<.01) and steroid use (P<.01). There is a higher risk of early readmission after outpatient THA for older patients with hypertension, bleeding disorders, and steroid use. Patients with hypertension and steroid use have a higher risk for reoperation after outpatient THA. Modifiable risk factors should be addressed preoperatively, with proper patient selection for outpatient THA. [Orthopedics. 2024;47(1):e38-e44.].

Direct Costs Vary by Outcome in Two-Stage Revision Arthroplasty for the Treatment of Hip Periprosthetic Joint Infection.

Background: Two-stage revision arthroplasty is the gold standard for treating chronic prosthetic joint infection (PJI), but there has been limited analysis of the costs incurred beyond the index procedure and how additional complications and/or surgeries impact the cost of care. Methods: The electronic health record was queried for patients who underwent a total hip arthroplasty complicated by PJI and then underwent removal of the prosthesis with implantation of an antibiotic-impregnated articulating cement spacer. Patient demographics, surgical variables, hospital readmissions, emergency department (ED) visits, and postoperative complications were recorded. Data on total costs were collected with an internal accounting database. The average follow-up duration was 3.35 years. Results: Univariate analyses showed statistically significant differences between outcome groups (reimplantation, reimplantation requiring later revision, retained spacer, and Girdlestone resection arthroplasty) in total overall costs, ED visit costs, and postoperative costs at 1 and 2 years after the initial spacer placement. The median total cost at 2 years for each group was $38,865 ($29,144-49,471) (reimplantation), $79,223 ($53,442-100,152) (reimplantation with revision), $54,096 ($20,872-73,903) (retained spacer), $62,134 ($52,135-101,546) (Girdlestone). Patients who underwent successful reimplantation requiring no further surgery had significantly lower total costs than patients who needed revision surgeries after reimplantation ($38,865 [$29,144-49,471] vs $79,223 [$53,442-100,152], P = .007). Patients with a Girdlestone resection arthroplasty had higher total costs at 1 year ($59,708 [$41,781-80,916] vs $33,093 [$27,237-40,429], P = .043) and higher costs attributable to ED visits at 2 years than the reimplantation group ($23,581 [$14,029-41,519] vs $15,307 [$6291-29,119], P = .009). Conclusions: A significant variation exists among total costs for the 2-stage treatment of hip PJI when stratified by the final outcome.

Relative Value Units Underestimate Reimbursement for Revision Shoulder Arthroplasty.

INTRODUCTION: Relative value units (RVUs) have been fundamental to reimbursement calculations in payment models for arthroplasty surgeons. RVUs are based on various factors, including physician work, and have been higher for increased complexity, such as revision arthroplasty. The purpose of this study was to compare RVUs and estimated reimbursement differences between primary and revision shoulder arthroplasty. METHODS: The National Surgical Quality Improvement Program database was used to collect primary and revision shoulder arthroplasty cases in 2017. Data variables collected included age at the time of surgery, surgical time, and RVU for each shoulder arthroplasty. RESULTS: A total of 4,948 shoulder arthroplasty patients (4,657 primary and 291 revision) were included in this study. The mean age was 69.1 years (9.6 SD) for primary shoulder arthroplasty and 67.8 years (10.4 SD) for revision shoulder arthroplasty, P = 0.02. RVU for primary shoulder arthroplasty was 22.1 (0 SD) compared with 26.4 (1.1 SD) for revision shoulder arthroplasty (P = 0.0001). Surgical time was significantly higher in revision versus primary cases, 131.5 minutes (89.0 SD) versus 109.3 minutes (42.5 SD) (P = 0.0001). RVUs per minute were near equivalent for primary and revision arthroplasty at 0.20 (0.1 SD) and 0.20 (01 SD), respectively. However, owing to the difference in surgical time and cases per day, this translates to an estimated reimbursement difference of $174,554.4 per year more for primary shoulder arthroplasty over revision cases. CONCLUSION: The current RVU model does not adequately factor surgical time for revision shoulder arthroplasty and translates to a notable yearly reimbursement difference that favors primary shoulder arthroplasty.

Physician burnout and professional satisfaction in orthopedic surgeons during the COVID-19 Pandemic.

BACKGROUND: Burnout and professional satisfaction is an often an overlooked component for healthcare outcomes; the COVID-19 pandemic represents an unprecedented stressor that could contribute to higher levels of burnout. OBJECTIVES: Our primary objective was to evaluate the association of a battery of fulfillment, job satisfaction change, COVID-19 concerns, and coping measures. Our secondary objective was to determine whether the fulfillment and coping measures differed by gender and by experience levels among a battery of physician specialties. METHODS: The study was a purposive sample of convenience. Study participants included all trainees and attending orthopedic surgeons from our academic institution; all participants were invited to complete a survey built around a validated measure of professional fulfillment aimed at assessing response to acute change and stressors. We performed univariate statistics and a matrix correlational analysis to correlate different survey domains with variables of interest. RESULTS: The survey was sent electronically to 138 individuals; 63 surveys were completed (response rate = 45.7%). Twenty-seven (42.8%) individuals met the threshold criteria for fulfillment whereas 10 (15.9%) met the threshold for burnout. We found that surgeon perspectives on COVID-19 were not associated with burnout or professional fulfillment. Burnout was inversely associated with professional fulfillment (R = -0.35). Support seeking was noted to be correlated with professional fulfillment (R = 0.37). CONCLUSIONS: Stressors related to COVID-19 pandemic were not correlated with physician burnout and fulfillment. This held true even when stratifying by gender and by attending vs. trainee. Continued efforts should be implemented to protect against physician burnout and ensure professional fulfillment for Orthopedic surgeons.

Utility of postoperative hemoglobin testing following total shoulder arthroplasty.

BACKGROUND: Identifying areas of excess cost for shoulder arthroplasty patients can play a role in effective health care spending. The purpose of this study was to assess the utility of postoperative complete blood count (CBC) testing after total shoulder arthroplasty (TSA) and identify which patients benefit from routine CBC testing. METHODS: We performed a retrospective review of a cohort of patients who underwent primary TSA from January 2018 through January 2019. All patients in this cohort received tranexamic acid. Patient demographic characteristics and patient-specific risk factors such as American Society of Anesthesiologists score, Elixhauser index, body mass index, smoking status, and coagulopathy history were obtained. Perioperative values including length of surgery, preoperative and postoperative hemoglobin (Hgb) levels, and need for transfusion were also obtained. RESULTS: This study included 387 TSA patients in the final analysis. Comparison between the cohort requiring transfusion and the cohort undergoing no intervention revealed no statistically significant differences in age, sex, body mass index, American Society of Anesthesiologists score, or Elixhauser index. The group receiving transfusions was found to have significantly lower levels of preoperative Hgb (11.3 g/dL) and postoperative Hgb (8.1 g/dL) (P < .0001). Additionally, the percentages of patients with abnormal preoperative Hgb levels (<12 g/dL) (72.3%) and postoperative day 1 Hgb levels < 9 g/dL (81.8%) were significantly higher in the group receiving transfusions (P < .0001). A multivariate regression model identified an abnormal preoperative Hgb level (<12 g/dL), with an odds ratio of 3.8 (95% confidence interval, 1.5-6.2; P < .001), and postoperative day 1 Hgb level < 9 g/dL, with an odds ratio of 3.3 (95% confidence interval, 0.4-6.1; P < .03), as significant predictors of the risk of transfusion with a sensitivity of 64% and specificity of 96.2% with an area under the curve of 0.87. CONCLUSION: Routine CBC testing may not be necessary for patients who receive tranexamic acid and have preoperative Hgb levels > 12 mg/dL and first postoperative Hgb levels > 9 mg/dL. This translates to potential health care cost savings and improves current evidence-based perioperative management in shoulder arthroplasty.

Are Weightbearing Restrictions Required After Microfracture for Isolated Chondral Lesions of the Knee? A Review of the Basic Science and Clinical Literature.

CONTEXT: A strict rehabilitation protocol is traditionally followed after microfracture, including weightbearing restrictions for 2 to 6 weeks. However, such restrictions pose significant disability, especially in a patient population that is younger and more active. EVIDENCE ACQUISITION: An extensive literature review was performed through PubMed and Google Scholar of all studies through December 2018 related to microfracture, including biomechanical, basic science, and clinical studies. For inclusion, clinical studies had to report weightbearing status and outcomes with a minimum 12-month follow-up. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 3. RESULTS: Review of biomechanical and biology studies suggest new forming repair tissue is protected from shear forces of knee joint loading by the cartilaginous margins of the defect. This margin acts as a shoulder to maintain axial height and allow for tissue remodeling up to at least 12 months after surgery, well beyond current weight bearing restriction trends. A retrospective case-control study showed that weightbearing status postoperatively had no effect on clinical outcomes in patients who underwent microfracture for small chondral (<2 mm2) defects. In fact, 1 survey showed that many orthopaedic surgeons currently do not restrict weightbearing after microfracture. CONCLUSION: This clinical literature review suggests that weightbearing restrictions may not be required after microfracture for isolated tibiofemoral chondral lesions of the knee. STRENGTH OF RECOMMENDATION TAXONOMY: C.