Clinical characteristics and favorable treatment responses of recurrent focal segmental glomerulosclerosis or steroid-resistant nephrotic syndrome in children after kidney transplantation.

BACKGROUND: Recurrence of focal segmental glomerulosclerosis (FSGS) or steroid-resistant nephrotic syndrome (SRNS) after kidney transplant leads to significant morbidity and potentially earlier allograft loss. To date however, reported rates, risk factors and treatment outcomes have varied widely. METHODS: We applied computational phenotypes to a multicenter aggregation of electronic health records data from 7 large pediatric health systems in the USA, to identify recurrence rates, risk factors, and treatment outcomes. We refined the data collection by chart review. RESULTS: From > 7 million patients, we compared children with primary FSGS/SRNS who received a kidney transplant between 2009 and 2020 and who either developed recurrence (n = 67/165; 40.6%) or did not (n = 98/165). Serum albumin level at time of transplant was significantly lower and recipient HLA DR7 presence was significantly higher in the recurrence group. By 36 months post-transplant, complete remission occurred in 58.2% and partial remission in 17.9%. Through 6 years post-transplant, no remission after recurrence was associated with an increased risk of allograft loss over time (p < 0.0001), but any remission showed similar allograft survival and function decline to those with no recurrence. Since treatments were used in non-random fashion, using spline curves and multivariable non-linear analyses, complete + partial remission chance was significantly higher with greater plasmapheresis sessions, CTLA4-Ig doses or LDL-apheresis sessions. Only treatment with anti-CD20, CTLA4-Ig agents, or LDL-apheresis sessions were associated with complete remission. Excluding 25 patients with mutations did not significantly change our results. CONCLUSIONS: Our contemporary high-risk cohort had higher favorable response rates than most prior reports, from combinations of agents.

Ureteral Stent Placement Prior to Definitive Stone Treatment Is Associated With Higher Postoperative Emergency Department Visits and Opioid Prescriptions for Youth Having Ureteroscopy or Shock Wave Lithotripsy.

PURPOSE: Little is known about the impact of ureteral stents on youth having stone surgery. We evaluated the association of ureteral stent placement before or concurrent with ureteroscopy and shock wave lithotripsy with emergency department visits and opioid prescriptions among pediatric patients. MATERIALS AND METHODS: We conducted a retrospective cohort study of individuals aged 0-24 years who underwent ureteroscopy or shock wave lithotripsy from 2009-2021 at 6 hospitals in PEDSnet, a research network that aggregates electronic health record data from children's health systems in the United States. The exposure, primary ureteral stent placement, was defined as a stent placed concurrent with or within 60 days before ureteroscopy or shock wave lithotripsy. Associations between primary stent placement and stone-related ED visits and opioid prescriptions within 120 days of the index procedure were evaluated with mixed-effects Poisson regression. RESULTS: Two-thousand ninety-three patients (60% female; median age 15 years, IQR 11-17) had 2,477 surgical episodes; 2,144 were ureteroscopy and 333 were shock wave lithotripsy. Primary stents were placed in 1,698 (79%) ureteroscopy episodes and 33 (10%) shock wave lithotripsy episodes. Ureteral stents were associated with a 33% higher rate of emergency department visits (IRR 1.33; 95% CI 1.02-1.73) and a 30% higher rate of opioid prescriptions (IRR 1.30; 95% CI 1.10-1.53). The magnitudes of both associations were greater for shock wave lithotripsy. Results were similar for age <18 and were lost when restricted to concurrent stent placement. CONCLUSIONS: Primary ureteral stent placement was associated with more frequent emergency department visits and opioid prescriptions, driven by pre-stenting. These results support elucidating situations where stents are not necessary for youth with nephrolithiasis.

External Validation Demonstrates Limited Clinical Utility of a Preoperative Prognostic Calculator for Periprosthetic Joint Infection.

BACKGROUND: Preoperative calculation of treatment failure risk in patients undergoing surgery for periprosthetic joint infection (PJI) is imperative to allow for medical optimization and targeted prevention. A preoperative prognostic model for PJI treatment failure was previously developed, and this study sought to externally validate the model. METHODS: A retrospective review was performed of 380 PJIs treated at two institutions. The model was used to calculate the risk of treatment failure, and receiver operating characteristic curves were generated to calculate the area under the curve (AUC) for each institution. RESULTS: When applying this model to institution 1, an AUC of 0.795 (95% confidence interval [CI]: 0.693-0.897) was found, whereas institution 2 had an AUC of 0.592 (95% CI: 0.502-0.683). Comparing all institutions in which the model had been applied to, we found institution 2 represented a significantly sicker population and different infection profile. CONCLUSION: In this cohort study, we externally validated the prior published model for institution 1. However, institution 2 had a decreased AUC using the prior model and represented a sicker and less homogenous cohort compared with institution 1. When matching for chronicity of the infection, the AUC of the model was not affected. This study highlights the impact of comorbidities and their distributions on PJI prognosis and brings to question the clinical utility of the algorithm which requires further external validation.

Effect of Machine Settings on Ultrasound Assessment of B-lines.

OBJECTIVES: B-lines are a lung ultrasound (LUS) artifact that often indicate pathology. Little is known about the optimal ultrasound machine settings to assess B-lines. We compared settings typically used to evaluate B-lines at our institution with adjusted settings based on recent studies. METHODS: In order to determine typical settings for B-line assessment, we retrospectively reviewed LUS images obtained at our institution. We then prospectively performed LUS with both typical and adjusted settings, using curvilinear and phased array probes, in 20 patients presenting to the emergency department with shortness of breath. The prospectively obtained clips were rated for quality and quantity of B-lines by 14 clinicians with experience in LUS, with 1 assigned for typical settings "much greater," 2 for typical settings "slightly greater," 3 for both settings "similar," 4 for adjusted settings "slightly greater," and 5 for adjusted settings "much greater." RESULTS: Mean ratings and 95% confidence intervals significantly exceeded the null value of 3 for both B line quality (curvilinear probe: 4.68, 4.50-4.85; phased array probe: 4.02, 3.70-4.35) and B line quantity (curvilinear probe: 4.16, 3.84-4.49; phased array probe: 3.68, 3.41-3.96). CONCLUSIONS: B-line quality and quantity were rated higher using adjusted settings based on recently published evidence than when using settings that are typically employed in our institution. Our findings suggest that B-line assessment should be performed with focal zone at the level of the pleura, harmonics off, and gain increased in the far field.

Evaluation of the PROMIS pediatric global health scale (PGH-7) in children with asthma.

OBJECTIVE: To evaluate the reliability and validity of the PROMIS Pediatric Global Health scale, a 7-item measure of perceived physical, mental, and social health, in children with asthma. METHODS: From February 2014 to February 2015, convenience samples of 8-17 year-old children (n = 182) and parents of 5-17 year-old children (n = 328) visiting an emergency department for treatment of asthma were enrolled. The Asthma Control Test was used to characterize children as controlled versus not controlled, and the PROMIS Asthma Impact Scale was used to assess asthma symptoms' impact on functional status. We conducted longitudinal analyses among 92 children and 218 parents at 3 weeks, and 74 children and 171 parents at 8 weeks after enrollment. RESULTS: The PGH-7 reliability ranged from 0.66 to 0.81 for child-report and 0.76 to 0.82 for parent-proxy. In cross-sectional analyses, children with controlled asthma had PGH-7 scores 0.40-0.95 standard deviation units higher than those who were uncontrolled. The PGH-7 was responsive to changes in overall general health between time points, with moderate effect sizes (0.5-0.6 standard deviation units). In longitudinal analyses, PGH-7 scores were no different between those who stayed uncontrolled versus became controlled at 3 weeks of follow-up; however, by 8 weeks of follow-up, the differences between these groups were 0.7-0.8 standard deviation units, indicative of large effects. CONCLUSIONS: The PGH-7 is a reliable and valid patient-reported outcome for assessing general health among children with asthma. It is a useful complement to other asthma-specific outcome measures.

Does an Elastic Compression Bandage Provide Any Benefit After Primary TKA?

BACKGROUND: Compression bandages often are used after TKA to reduce swelling. However, the degree to which they are helpful has not been well characterized. QUESTIONS/PURPOSES: The purpose of this study was to determine whether use of a compression bandage after TKA was associated with (1) less leg swelling (our primary endpoint); or (2) secondary study endpoints, including improved ROM of flexion and extension, lower visual analog scale (VAS) pain scores for worst pain and pain during physical therapy just before surgery, postoperative day (POD) 1, POD 2, and POD 28, or fewer wound complications within 90 days of surgery. METHODS: A prospective, single-center, two-arm, parallel-group randomized controlled trial was conducted on 51 patients undergoing simultaneous, bilateral, primary TKA between February 2015 and August 2016. Patients were excluded if they had a body mass index > 40 kg/m, a history of a venous thromboembolic event, an allergy to the dressing or compression bandage, or lymphedema in one or both legs. Participants averaged a mean age of 62 years (range, 40-83 years). In all patients, we released the tourniquet after full wound closure, and we applied an Aquacel dressing to both limbs. Patients were randomized by opaque envelope, and the compression bandage was applied to the randomized limb. For each leg, study personnel not involved in patient care measured the patients' limb circumference (thigh, knee, and tibia), ROM, and VAS pain scores 24 hours after surgery, 48 hours after surgery, and on POD 28. The minimal clinically important difference for circumference was 2 cm with a SD of 2 cm in the circumference. For VAS, it was 2 points with a SD of 2. For ROM, it was 10° with a SD of 15. We conservatively picked an effect size of 0.5 SD and assumed a correlation between limbs of 0.3. This set the power level at 0.80 with an α error of 0.05; thus, a power analysis for paired t-tests indicated that 45 patients would be an appropriate sample size. There were 29 patients randomized to the right leg group and 22 patients randomized to the left leg group. There were no differences between the limb with and without the compression bandage preoperatively. RESULTS: Postoperatively, there were no differences between the groups in terms of leg swelling at the thigh (POD 1: mean ± SD = 51 ± 6 with compression bandage versus mean ± SD = 51 ± 6 without compression bandage, mean Δ = - 0.14, 95% confidence interval [CI], -0.65 to 0.37], p = 0.586; POD 2: mean ± SD = 53 ± 6 with compression bandage versus mean ± SD = 53 ± 7 without compression bandage, mean Δ = -0.22, 95% CI, -0.95 to 0.51, p = 0.548; POD 28: mean ± SD = 47 ± 6 with compression bandage versus mean ± SD = 47 ± 6 without compression bandage, mean Δ = -0.01, 95% CI, -0.39 to 0.38, p = 0.975), knee (POD 1: mean ± SD = 45 ± 4 with compression bandage versus mean ± SD = 45 ± 5 without compression bandage, mean Δ = -0.44, 95% CI, -1.16 to 0.28, p = 0.223; POD 2: mean ± SD = 46 ± 4 with compression bandage versus mean ± SD = 46 ± 4 without compression bandage, mean Δ = -0.30, 95% CI, -0.69 to 0.10, p = 0.137; POD 28: mean ± SD = 42 ± 5 with compression bandage versus mean ± SD = 42 ± 5 without compression bandage, mean Δ = 0.21, 95% CI, -0.34 to 0.76, p = 0.446), and shin (POD 1: mean ± SD = 40 ± 4 with compression bandage versus mean ± SD = 40 ± 4 without compression bandage, mean Δ = -0.22, 95% CI, -1.23 to 0.79, p = 0.659; POD 2: mean ± SD = 41 ± 4 with compression bandage versus mean ± SD = 41 ± 4 without compression bandage, mean Δ = -0.31, 95% CI, -0.72 to 0.09, p = 0.126; POD 28: mean ± SD = 37 ± 4 with compression bandage versus mean ± SD = 37 ± 4 without compression bandage, mean Δ = -0.34, 95% CI, -0.92 to 0.24, p = 0.246). There were no differences between the groups in terms of flexion ROM (POD 1: mean ± SD = 56 ± 25 with compression bandage versus mean ± SD = 58 ± 22 without compression bandage, mean Δ = -2.63, p = 0.234; POD 2: mean ± SD = 64 ± 20 with compression bandage versus mean ± SD = 63 ± 23 without compression bandage, mean Δ = 1.22, p = 0.534; POD 28: mean ± SD = 101 ± 20 with compression bandage versus mean ± SD = 102 ± 20 without compression bandage, mean Δ = -1.64, p = 0.103) and extension (POD 1: mean ± SD = 12 ± 7 with compression bandage versus mean ± SD = 12 ± 7 without compression bandage, mean Δ = 0.51, p = 0.328; POD 2: mean ± SD = 9 ± 5 with compression bandage versus mean ± SD = 10 ± 6 without compression bandage, mean Δ = -1.28, p = 0.061; POD 28: mean ± SD = 6 ± 14 with compression bandage versus mean ± SD = 4 ± 4 without compression bandage, mean Δ = 2.19, p = 0.252). With the numbers available, we observed greater maximal postoperative pain for the limb with the compression bandage than the control limb on POD 1 and POD 2, but not on POD 28 (POD 1: mean ± SD = 8 ± 3 with compression bandage versus mean ± SD = 7 ± 3 without compression bandage, mean Δ = 0.66, p = 0.030; POD 2: mean ± SD = 7 ± 2 with compression bandage versus mean ± SD = 7 ± 3 without compression bandage, mean Δ = 0.80, p = 0.008; POD 28: mean ± SD = 4 ± 3 with compression bandage versus mean ± SD = 3 ± 3 without compression bandage, mean Δ = 0.14, p = 0.526). Likewise, there was greater pain during physical therapy for the limb with the compression bandage than the limb without on POD 2, but not on POD 1 and POD 28 (POD 1: mean ± SD = 7 ± 3 with compression bandage versus mean ± SD = 6 ± 3 without compression bandage, mean Δ = 0.29, p = 0.460; POD 2: mean ± SD = 8 ± 2 with compression bandage versus mean ± SD = 7 ± 3 without compression bandage, mean Δ = 0.67, p = 0.018; POD 28: mean ± SD = 5 ± 2 with compression bandage versus mean ± SD = 5 ± 3 without compression bandage, mean Δ = 0.14, p = 0.600). With the numbers available, we observed no difference in 90-day wound healing complications between the limb with and the limb without the compression dressing; however, the sample size was too small to analyze this in a meaningful statistical way. Overall, there were 6% total wound complications in the compression bandage group and 12% total wound complications in the group without the compression bandage (odds ratio [OR], 0.47; p = 0.487). Drainage was not observed in the group with the compression bandage, whereas the group without the compression bandage had 6% drainage (OR, 0.00; p = 0.243). There were no deep infections or reoperations within 90 days postoperatively. CONCLUSIONS: Applying a compression bandage after TKA did not result in any clinical improvement in limb circumference, ROM, or pain. Based on this study, we believe that applying a compression bandage after TKA neither benefits nor harms the patient. Thus, we no longer use compression dressings for routine primary TKA. LEVEL OF EVIDENCE: Level I, therapeutic study.

Incise Draping Reduces the Rate of Contamination of the Surgical Site During Hip Surgery: A Prospective, Randomized Trial.

BACKGROUND: Iodophor-impregnated adhesive incise drapes are widely used during surgeries for reducing surgical site contamination. There is little evidence to support the latter belief. This study evaluated the efficacy of iodophor-impregnated adhesive drapes for reducing bacterial contamination and counts at the incision site during hip surgery. METHODS: In this prospective, randomized clinical trial, we enrolled 101 patients undergoing open joint preservation procedure of the hip. Half the patients had the adhesive drape applied to the skin prior to incision, while the remainder underwent the same surgery without a drape. Culture swabs were taken from the surgical site at 5 points (preskin preparation, after skin preparation, postincision, before subcutaneous closure, prior to dressing application) and sent for culture and colony counts. Mixed-effects logistic regressions were used to estimate effects of time and drape application on contamination rate. RESULTS: At the conclusion of surgery, 12.0% of incisions with adhesive drapes and 27.4% without adhesive drapes were positive for bacterial colonization. When controlling for preoperative colonization and other factors, patients without adhesive drapes were significantly more likely to have bacteria present at the time of skin closure, and at all time points when swab cultures were taken. CONCLUSION: It appears that the iodophor-impregnated adhesive draping significantly reduces bacterial colonization of the incision. Bacterial count at the skin was extremely high in some patients in whom adhesive drapes were not used, raising the possibility that a subsequent surgical site infection or periprosthetic joint infection could arise had an implant been utilized.

How Much Pain Is Significant? Defining the Minimal Clinically Important Difference for the Visual Analog Scale for Pain After Total Joint Arthroplasty.

BACKGROUND: The ability to detect changes in patient-perceived pain after total joint arthroplasty (TJA) is critical to manage postoperative pain. The minimal clinically important difference (MCID) for visual analog scale for pain (VAS-P) has not been investigated in this population. This study investigated the MCID for VAS-P in the TJA population. METHODS: Postoperative pain scores were collected on 139 total hip arthroplasty (THA) and 165 total knee arthroplasty (TKA) patients. VAS-P was measured and Likert scores for changes in pain recorded together throughout the hospitalization per patient. Using a linear mixed model, the mean difference between preceding and current VAS-P was calculated and correlated with Likert score, when the patient reported at least slight improvement or worsening in pain, defining the MCID. Minimal detectable change was calculated using the VAS-P standard error of the means for patients reporting "no change." RESULTS: For THA, the overall mean and average highest VAS-P were 35.0 mm and 50.4 mm, respectively. For TKA, the overall mean and average highest VAS-P were 42.6 mm and 61.1 mm, respectively. The minimal detectable change in VAS-P was 14.9 mm for THA and 16.1 mm for TKA. The MCID for THA and TKA pain improvement was -18.6 mm and -22.6 mm, respectively, and for worsening was 23.6 mm and 29.1 mm, respectively. CONCLUSION: In the postoperative TJA population, VAS-P MCID changes depend on the type of surgical intervention, and whether pain is improving or worsening. Statistically significant VAS-P, improving -18.6 mm and -22.6 mm for THA and TKA patients, respectively, sets a reasonable threshold to identify clinically meaningful pain intervention with high specificity.

Operating Room Traffic Increases Aerosolized Particles and Compromises the Air Quality: A Simulated Study.

BACKGROUND: Strategies to prevent bacterial fallout and reduce particle count in the operating room (OR) are key components of preventing periprosthetic joint infection. Although OR traffic control is an important factor, a quantitative study has not been performed to investigate the influence of personnel and door opening on OR air quality. This simulated study aimed to examine the influence of these 2 factors on particle density in OR with and without the laminar air flow (LAF). METHODS: Both experiments took place within an empty OR of an arthroplasty unit equipped with an LAF system. First, the number of particles in the air was counted using a particle counting apparatus while 9 persons entered the room, one every 15 minutes. Second, the door was opened and closed starting with zero door openings per minute and increasing to 4 in 15-minute increments. Both experiments were performed once with the LAF turned on and once without. RESULTS: The number of personnel in the OR and the number of door openings per minute correlate with the density of particles. Both relationships were significantly reduced by turning the LAF on (correlation coefficients <0.4). With the LAF being turned on, the particle density per person decreased from 211.19 to 18.19 particles/ft3 (P < .001) and the particle density per rate of door openings declined from 117.80 to 1.90 particles/ft3 (P = .017). CONCLUSION: This study confirms that personnel and door opening are a major source of particles in the OR air. Controlling traffic is critical for reduction of particles and is likely to be a key preventative strategy in reducing periprosthetic joint infection. LAF is protective against the negative influence of number of people and door openings.

Computer-Assisted Total Knee Arthroplasty: Is There a Difference Between Image-Based and Imageless Techniques?

BACKGROUND: Image-based and imageless computer-assisted total knee arthroplasty (CATKA) has become increasingly popular. This study aims to compare outcomes, including perioperative complications and transfusion rate, between CATKA and conventional total knee arthroplasty (TKA), as well as between image-based and imageless CATKA. METHODS: Using the 9th revision of the International Classification of Diseases codes, we queried the Nationwide Inpatient Sample database from 2005 to 2011 to identify unilateral conventional TKA, image-based, and imageless CATKAs as well as in-hospital complications and transfusion rates. RESULTS: A total of 787,809 conventional TKAs and 13,246 CATKAs (1055 image-based and 12,191 imageless) were identified. The rate of CATKA increased 23.13% per year from 2005 to 2011. Transfusion rates in conventional TKA and CATKA cases were 11.73% and 8.20% respectively (P < .001) and 6.92% in image-based vs 8.27% in imageless (P = .023). Perioperative complications occurred in 4.50%, 3.47%, and 3.41% of cases after conventional, imageless, and imaged-based CATKAs, respectively. Using multivariate analysis, perioperative complications were significantly higher in conventional TKA compared to CATKA (odds ratio = 1.17, 95% confidence interval 1.03-1.33, P = .01). There was no significant difference between imageless and image-based CATKA (P = .34). Length of hospital stay and hospital charges were not significantly different between groups (P > .05). CONCLUSION: CATKA has low complication rates and may improve patient outcomes after TKA. CATKA, especially the image-based technique, may reduce in-hospital complications and transfusion without increasing hospital charges and length of hospital stay significantly. Large prospective studies with long follow-up are required to verify potential benefits of CATKA.

Development and Evaluation of a Prognostic Calculator for the Surgical Treatment of Periprosthetic Joint Infection.

BACKGROUND: Preoperative identification of patients at risk of failing surgical treatment for periprosthetic joint infection (PJI) is imperative to allow medical optimization and targeted prevention. The purpose of this study was to create a preoperative prognostic calculator for PJI treatment by assessing a patient's individual risk for treatment failure based on many preoperative variables. METHODS: A retrospective review was performed of 1438 PJIs, treated at 2 institutions from 2000 to 2014. Minimum follow-up was 1 year. A total of 63 risk factors, including patient characteristics, microbiology data, and surgical variables were evaluated using logistic regression, in which coefficients were scaled to produce weighted scores. RESULTS: The 10 significant risk factors for PJI treatment failure were in descending order of relative weight: irrigation and debridement (30 points), history of myocardial infarction (15 points), revision surgery (11 points), presence of sinus tract (10 points), resistant organisms (9 points), ever smoker (6 points), prior surgery (2.86 points per prior operation), synovial white blood cell count (8.3 × natural log of cell count), body mass index (0.66 per increment), and erythrocyte sedimentation rate (depends on both smoking and 2 stage, as these are higher order interaction factors). The area under the curve for this risk model was 0.6904 (95% confidence interval: 0.6476-0.7331). CONCLUSION: In this large cohort study, we were able to identify risk factors and their relative weight for predicting PJI treatment failure. Some of the identified factors are indeed modifiable and should be addressed before treating a patient for PJI.

Does Medicaid Insurance Confer Adequate Access to Adult Orthopaedic Care in the Era of the Patient Protection and Affordable Care Act?

BACKGROUND: A current appraisal of access to orthopaedic care for the adult patient receiving Medicaid is important, since Medicaid expansion was written into law by the Patient Protection and Affordable Care Act (PPACA). QUESTIONS/PURPOSES: (1) Do orthopaedic practices provide varying access to orthopaedic care for simulated patients with Medicaid insurance versus private insurance in a blinded survey? (2) What are the surveyed state-by-state Medicaid acceptance rates for adult orthopaedic practices in the current era of Medicaid expansion set forth by the PPACA? (3) Do surveyed rates of access to orthopaedic care in the adult patient population vary across practice setting (private vs academic) or vary with different Medicaid physician reimbursement rates? (4) Are there differences in the surveyed Medicaid acceptance rates for adult orthopaedic practices in states that have expanded Medicaid coverage versus states that have foregone expansion? METHODS: Simulated Patient Survey: We performed a telephone survey study of orthopaedic offices in four states with Medicaid expansion. In the survey, the caller assumed a fictitious identity as a 38-year-old male who experienced an ankle fracture 1 day before calling, and attempted to secure an appointment within 2 weeks. During initial contact, the fictitious patient reported Medicaid insurance status. One month later, the fictitious patient contacted the same orthopaedic practice and reported private insurance coverage status. National Orthopaedic Survey: Private and academic orthopaedic practices operating in each state in the United States were called and asked to complete a survey assessing their practice model of Medicaid insurance acceptance. State reimbursement rates for three different Current Procedural Terminology (CPT®) codes were collected from state Medicaid agencies. Results Simulated Patient Survey: Offices were less likely to accept Medicaid than commercial insurance (30 of 64 [47%] versus 62 of 64 [97%]; odds ratio [OR], 0.0145; 95% CI, 0.00088-0.23639; p < 0.001), and patients with Medicaid were less likely to be offered an appointment within 2 weeks (23 of 64 [36%] versus 59 of 64 [89%]; OR, 0.0154; 95% CI, 0.00094- 0.251; p < 0.001). The Medicaid acceptance rates observed across states sampled in the simulated patient survey were 67% (Pennsylvania), 21% (New Jersey), 58% (Delaware), and 50% (Maryland) (p = 0.04). National Orthopaedic Survey: Adult patients with Medicaid insurance had limited access to care in 109 of 342 (32%) orthopaedic practices: 37% of private and 13% of academic practices (p < 0.001). Practices that accepted Medicaid received higher reimbursement for each CPT® code relative to those that did not and acceptance of Medicaid became increasingly more likely as reimbursement rates increased (99243: OR, 1.03, 95% CI, 1.02-1.04 per dollar, p < 0.001; 99213: OR, 1.05; 95% CI, 1.03-1.07 per dollar, p < 0.001; 28876: OR, 1.01, 95% CI, 1.00-1.01 per dollar, p < 0.001). For a given reimbursement rate, private practices were less likely to take an adult patient with Medicaid relative to an academic practice (99243: OR, 0.11, 95% CI, 0.04-0.33, p < 0.001; 99213: OR, 0.11, 95% CI, 0.04-0.32, p < 0.001; 27786: OR, 0.12, 95% CI, 0.04-0.35, p < 0.001). No difference was observed when comparing Medicaid acceptance rates for all practice types between states that have expanded their Medicaid program versus those that have not (OR, 1.02; 95% CI 0.62-1.70; p = 0.934). CONCLUSIONS: In this two-part survey study, we found that a simulated patient with commercial insurance was more likely to have their insurance accepted and to gain timely access to orthopaedic care than a patient with Medicaid. Academic practice setting and increased Medicaid reimbursement rates were associated with increased access to care for the patient with Medicaid. Inequality in access to orthopaedic care based on health insurance status likely exists for the adult patient with Medicaid. Furthermore, Medicaid expansion has likely realized minimal gains in access to care for the adult orthopaedic patient. Further research is needed in delineating the patient-payer selection criteria used by orthopaedic practices to aid policymakers in reforming the Medicaid program and comprehensibly addressing this access to care disparity. LEVEL OF EVIDENCE: Level II, prognostic study.

Utilization of Total Joint Arthroplasty in Physician-Owned Specialty Hospitals vs Acute Care Facilities.

BACKGROUND: The recent emergence of physician-owned specialty hospitals has sparked controversy about overutilization. Thus, the purpose of this study was to compare utilization patterns of total joint arthroplasty (TJA) between physician-specialty hospitals (PSHs) and acute care hospitals (ACHs). METHODS: A retrospective study was conducted from January 2010 to August 2014 comparing primary TJA patients between a PSH and an ACH; 103 PSH patients were matched to 103 ACH patients by age, gender, BMI, and ASA classification with similar case distribution between facilities. All surgeons in the study operated at both hospitals and were shareholders of the PSH. Information on nonoperative treatments, and timing to the initial appointment, consent, and surgery were analyzed using univariate analysis. RESULTS: Nonoperative treatments before surgery were similar between hospitals (P = 1.00). The time from the initial appointment to consent was longer for PSH (P = .0001). However, the time from consent to the date of surgery (P = .04) and the timing from symptoms to initial appointment (P = .006) was shorter for PSH. The time from initial appointment to the day of surgery was similar between groups (P = .20). Patients were more likely to be consented for surgery on their first clinic visit when undergoing surgery at ACH (87 of 103, 84.4%) compared to PSH (61 of 103; 59.2%; P < .001). Length of stay was significantly shorter for both total knee arthroplasty (P = .001) and total hip arthroplasty patients (P = .001) at PSH. CONCLUSION: Facility ownership in PSH resulted in similar conservative treatment before TJA. The time to surgical consent after the initial appointment was longer PSH, whereas the time from consent to the date of surgery was shorter at the PSH.

Optimizing Mechanical Alignment With Modular Stems in Revision TKA.

BACKGROUND: Although mechanical alignment is critical for optimal function and long-term implant durability, the role of modular stems in achieving ideal alignment is unclear. METHODS: We identified 319 revision total knee arthroplasty from 2003-2013, for which stem length, stem diameter, and stem fixation method were recorded prospectively. Three-dimensional canal-filling ratio, the product of canal-filling ratio at the stem tip in both the anteroposterior and lateral planes, and alignment were measured radiographically. RESULTS: Ideal alignment of the femur was considered to be 95° in the anteroposterior (AP) plane and from 1° of extension to 4° of flexion in the lateral plane, and ideal tibial alignment was considered to be 90° in the AP plane. Even after accounting for difference in stem size and canal-fill, ideal AP alignment was more reliably achieved with press-fit stems. CONCLUSION: Furthermore, increased engagement of the diaphysis and its anatomical axis with canal-filling stems facilitates accurate alignment.

In-Hospital Mortality in Patients With Periprosthetic Joint Infection.

BACKGROUND: While periprosthetic joint infection (PJI) has a huge impact on patient function and health, only a few studies have investigated its impact on mortality. The purpose of this large-scale study was to (1) determine the rate and trends of in-hospital mortality for PJI and (2) compare the in-hospital mortality rate of patients with PJI and those undergoing revision arthroplasty for aseptic failure and patients undergoing other nonorthopedic major surgical procedures. METHODS: Data from the Nationwide Inpatient Sample from 2002 to 2010 were analyzed to determine the risk of in-hospital mortality for PJI patients compared with aseptic revision arthroplasty. The Elixhauser comorbidity index was used to obtain patient comorbidities. Multiple logistic regression analyses were used to examine whether PJI and other patient-related factors were associated with mortality. RESULTS: PJI was associated with an increased risk (odds ratio, 2.05; P < .0001) of in-hospital mortality (0.77%) compared with aseptic revisions (0.38%). The in-hospital mortality rate of revision total hip arthroplasties with PJI was higher than those for interventional coronary procedures (1.22%; 95% confidence interval [CI], 1.20-1.24), cholecystectomy (1.13%; 95% CI, 1.11-1.15), kidney transplant (0.70%; 95% CI, 0.61-0.79), and carotid surgery (0.89%; 95% CI, 0.86-0.93). CONCLUSION: Patients undergoing treatment for PJI have a 2-fold increase in in-hospital mortality for each surgical admission compared to aseptic revisions. Considering that PJI cases often have multiple admissions and that this analysis is by surgical admission, the risk of mortality will accumulate for every additional surgery. Surgeons should be cognizant of the potentially fatal outcome of PJI and the importance of infection control to reduce the risk of mortality.

Perioperative Complications in Patients With Sleep Apnea Undergoing Total Joint Arthroplasty.

BACKGROUND: This study aims to evaluate the effect of sleep apnea (SA) on perioperative complications after total joint arthroplasty (TJA) and whether the type of anesthesia influences these complications. METHODS: Using the ninth and tenth revisions of the International Classification of Diseases, coding systems, we queried our institutional TJA database from January 2005 to June 2016 to identify patients with SA who underwent TJA. These patients were matched in a 1:3 ratio based on age, gender, type of surgery, and comorbidities to patients who underwent TJA but were not coded for SA. Perioperative complications were identified using the same coding systems. Multivariate analysis was used to test if SA is an independent predictor of perioperative complications and if type of anesthesia can affect these complications. RESULTS: A total of 1246 patients with SA were matched to 3738 patients without SA. Pulmonary complications occurred more frequently in patients with SA (1.7% vs 0.6%; P < .001), confirmed using multivariate analysis (odds ratio = 2.91; 95% confidence interval, 1.58-5.36; P = .001). Use of general anesthesia increased risk of all but central nervous system complications and mortality (odds ratio = 15.88; 95% confidence interval, 3.93-64.07; P < .001) regardless of SA status compared with regional anesthesia. Rates of pulmonary and gastrointestinal complications, acute anemia, and mortality were lower in SA patients when regional anesthesia was used (P < .05). CONCLUSION: SA increases risk of postoperative pulmonary complications. The use of regional anesthesia may reduce risk of pulmonary complications and mortality in SA patients undergoing TJA.

Should Preoperative Antibiotics Be Tailored According to Patient's Comorbidities and Susceptibility to Organisms?

BACKGROUND: Preoperative antibiotic prophylaxis remains one of the most important strategies for preventing periprosthetic joint infection (PJI). Current guidelines recommend giving universal antibiotic prophylaxis to all total joint arthroplasty patients regardless of their medical conditions or immune status; however, no studies have evaluated the individualizing of antibiotics. The aims of this study were (1) to determine if comorbidities influence the organism profile of PJIs, and (2) to investigate if the efficacy of two different perioperative antibiotics (cefazolin or vancomycin) for preventing PJI is affected by patient's comorbidities. METHODS: Using an institutional database of 1022 PJIs, the influence of different patient's comorbidities on the organism profile was evaluated. To investigate the influence of perioperative antibiotics (cefazolin or vancomycin monotherapy) on PJI rate, 8575 primary total joint arthroplasties were identified, crossmatched for PJI, and analyzed based on the comorbidities of the cohort. The PJI rate of each antibiotic within each comorbidity was compared. RESULTS: Although no comorbidities were associated with an increased rate of Gram-positive infections or Gram-negative infections, metastatic disease (odds ratio [OR] 5.71, P = .018), congestive heart failure (OR 2.2, P = .010), chronic pulmonary disease (OR 1.76, P = .015), and diabetes mellitus (OR 1.66, P = .019) were associated with antibiotic resistant organisms. However, there was no difference in the PJI rate between cefazolin and vancomycin monotherapy when stratifying for diabetes mellitus, rheumatoid arthritis, liver disease, and hypothyroidism. CONCLUSION: The results of the present study support the current recommendations of a universal antibiotic prophylaxis protocol rather than an antibiotic regimen individualized to a patient's comorbidities.

Povidone-Iodine-Based Solutions for Decolonization of Nasal Staphylococcus aureus: A Randomized, Prospective, Placebo-Controlled Study.

BACKGROUND: Nasal Staphylococcus aureus decolonization reduces the risk of surgical site infections after orthopedic procedures. Povidone-iodine (PI)-based solutions have shown promising results in bacteria decolonization. The unique physiology of the nose may pose challenges for the bioactivity profiles of PI solutions. This study compared the antibacterial efficacy of an off-the-shelf PI product with a specifically manufactured PI-based skin and nasal antiseptic (SNA). METHODS: This randomized, placebo-controlled study was conducted at a single institution between April 2014 and July 2015. Four hundred and twenty-nine patients undergoing primary or revision total joint arthroplasty, femoroacetabular osteoplasty, pelvic osteotomy, or total shoulder arthroplasty were included. 10% off-the-shelf PI, 5% PI-based SNA, or saline (placebo) were used for nasal decolonization. Baseline cultures were taken immediately preoperatively, followed by treatment of both nares twice for 2 minutes with 4 applicators. Reculturing of the right nostril occurred at 4 hours and the left at 24 hours. RESULTS: Ninety-five of the 429 patients (22.1%) had a positive culture result for S. aureus; 13 (3.03%) were methicillin-resistant S. aureus. Of these 95, 29 were treated with off-the-shelf PI, 34 with SNA, and 32 with saline swabs. At 4 hours post-treatment, S. aureus culture was positive in 52% off-the-shelf PI patients, 21% SNA patients, and 59% saline patients. After 24 hours posttreatment, S. aureus culture was positive in 72% off-the-shelf PI patients, 59% SNA patients, and 69% saline group. SNA was significantly more effective at decolonizing S. aureus over the 4-hour time interval (P = .003); no significant difference was observed over the 24-hour time interval between the 3 groups. CONCLUSION: A single application of PI-based SNA before surgery may be effective in eliminating nasal S. aureus in over two-thirds of patients. Off-the-shelf PI swabs were not as effective at 4 hours as the specifically manufactured product for S. aureus decolonization.

The Incidence and Economic Burden of In-Hospital Venous Thromboembolism in the United States.

BACKGROUND: Venous thromboembolism (VTE) is a potentially preventable and costly complication after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The in-hospital incidence and economic burden of VTE following total joint arthroplasty (TJA) in the United States is unknown. The aim of this study was to examine this issue. METHODS: The Nationwide Inpatient Sample was used to estimate the total number of THA, TKA, and VTE events using International Classification of Diseases, Ninth Revision procedure codes from years 2002 to 2011. The rate of in-hospital deep vein thrombosis (DVT) and pulmonary embolism (PE), associated length of hospitalization, and current and projected in-hospital charges were obtained. RESULTS: Revision arthroplasties had higher rates of in-hospital VTE compared to primary TJAs (2.5% vs 1.6%, P < .0001). Among primary TJAs, the median rate of in-hospital VTE was 0.59% (0.55%-0.63%) for primary THA and 1.01% (0.94%-1.08%) for primary TKA. Revision THAs developed more VTE events compared to revision TKAs (1.35% [1.25%-1.46%] vs 1.16% [1.07%-1.26%]). Patients with a VTE have longer hospitalizations (median primary TKA: 7 vs 3; median primary THA: 6 vs 3, P < .0001). The overall rate of VTE decreased over the last decade; however, the PE rates have remained relatively constant. Moreover, the associated costs with VTE events have increased significantly over the last decade. CONCLUSION: Based on the analysis of the Nationwide Inpatient Sample database, the rate of in-hospital DVT following TJA appears to have declined over the last decade while the incidence of PE has remained constant. This may indicate that the current recommendations by the American Academy of Orthopaedic Surgeons for VTE prophylaxis are adequate for preventing DVT without increasing the rate of PE or that institutional screening and reporting of DVT has been reduced because DVTs became a "never" event.

A Current Procedural Terminology Code for "Knee Conversion" Is Needed to Account for the Additional Surgical Time Required Compared to Total Knee Arthroplasty.

BACKGROUND: Previous knee injury requiring surgical intervention increases the rate of future arthroplasty. Coding modifiers for removal of previous hardware or increased complexity offer inconsistent results. A Current Procedural Terminology code for knee conversion does not currently exist as it does for conversion hip arthroplasty. We investigate the extra time associated with conversion knee arthroplasty. METHODS: Sixty-three total knee arthroplasty (TKA) cases in the setting of previous knee hardware were identified from our institution between 2008 and 2015. Knee conversions were matched to primary TKA by age, gender, body mass index, Charlson Comorbidity Index, and surgeon, in a 3:1 ratio. Patients who underwent knee conversions were compared to matched TKA with regard to operative time, length of stay, discharge destination, readmission, and repeat procedures within 90 days from index procedure. RESULTS: The mean operating room time for primary TKA was 71.7 minutes (range 36-138). The mean operating room time for knee conversion was significantly greater by an additional 31 minutes; mean 102.1 minutes (range 56-256 minutes, P < .0001). Rates of readmission, 0.5% vs 3.2%, and repeat procedures, 5.3% vs 12.7%, within 90 days were greater for knee conversions. There was no difference in length of stay or discharge destination. CONCLUSION: Total knee conversion results in a 43% increase in operative time and more than twice the rate of readmission and repeat procedures within 90 days compared to TKA. This suggests the need for an additional Current Procedural Terminology code for knee conversion arthroplasty to compensate surgeons for the extra time required for conversions.