Demonstration of the pathogenicity of a common non-exomic mutation in ABCA4 using iPSC-derived retinal organoids and retrospective clinical data.

Mutations in ABCA4 are the most common cause of Mendelian retinal disease. Clinical evaluation of this gene is challenging because of its extreme allelic diversity, the large fraction of non-exomic mutations, and the wide range of associated disease. We used patient-derived retinal organoids as well as DNA samples and clinical data from a large cohort of patients with ABCA4-associated retinal disease to investigate the pathogenicity of a variant in ABCA4 (IVS30 + 1321 A > G) that occurs heterozygously in 2% of Europeans. We found that this variant causes mis-splicing of the gene in photoreceptor cells such that the resulting protein contains 36 incorrect amino acids followed by a premature stop. We also investigated the phenotype of 10 patients with compound genotypes that included this mutation. Their median age of first vision loss was 39 years, which is in the mildest quintile of a large cohort of patients with ABCA4 disease. We conclude that the IVS30 + 1321 A > G variant can cause disease when paired with a sufficiently deleterious opposing allele in a sufficiently permissive genetic background.

A Retrospective Longitudinal Study of 460 Patients with ABCA4-Associated Retinal Disease.

PURPOSE: To investigate the distribution of genotypes and natural history of ABCA4-associated retinal disease in a large cohort of patients seen at a single institution. DESIGN: Retrospective, single-institution cohort review. PARTICIPANTS: Patients seen at the University of Iowa between November 1986 and August 2022 clinically suspected to have disease caused by sequence variations in ABCA4. METHODS: DNA samples from participants were subjected to a tiered testing strategy progressing from allele-specific screening to whole genome sequencing. Charts were reviewed, and clinical data were tabulated. The pathogenic severity of the most common alleles was estimated by studying groups of patients who shared 1 allele. Groups of patients with shared genotypes were reviewed for evidence of modifying factor effects. MAIN OUTCOME MEASURES: Age at first uncorrectable vision loss, best-corrected visual acuity, and the area of the I2e isopter of the Goldmann visual field. RESULTS: A total of 460 patients from 390 families demonstrated convincing clinical features of ABCA4-associated retinal disease. Complete genotypes were identified in 399 patients, and partial genotypes were identified in 61. The median age at first vision loss was 16 years (range, 4-76 years). Two hundred sixty-five families (68%) harbored a unique genotype, and no more than 10 patients shared any single genotype. Review of the patients with shared genotypes revealed evidence of modifying factors that in several cases resulted in a > 15-year difference in age at first vision loss. Two hundred forty-one different alleles were identified among the members of this cohort, and 161 of these (67%) were found in only a single individual. CONCLUSIONS: ABCA4-associated retinal disease ranges from a very severe photoreceptor disease with an onset before 5 years of age to a late-onset retinal pigment epithelium-based condition resembling pattern dystrophy. Modifying factors frequently impact the ABCA4 disease phenotype to a degree that is similar in magnitude to the detectable ABCA4 alleles themselves. It is likely that most patients in any cohort will harbor a unique genotype. The latter observations taken together suggest that patients' clinical findings in most cases will be more useful for predicting their clinical course than their genotype. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Novel Technique for the Identification of Hip Implants Using Artificial Intelligence.

BACKGROUND: The anticipated growth of total hip arthroplasty will result in an increased need for revision total hip arthroplasty. Preoperative planning, including identifying current implants, is critical for successful revision surgery. Artificial intelligence (AI) is promising for aiding clinical decision-making, including hip implant identification. However, previous studies have limitations such as small datasets, dissimilar stem designs, limited scalability, and the need for AI expertise. To address these limitations, we developed a novel technique to generate large datasets, tested radiographically similar stems, and demonstrated scalability utilizing a no-code machine learning solution. METHODS: We trained, validated, and tested an automated machine learning-implemented convolutional neural network to classify 9 radiographically similar femoral implants with a metaphyseal-fitting wedge taper design. Our novel technique uses computed tomography-derived projections of a 3-dimensional scanned implant model superimposed within a computed tomography pelvis volume. We employed computer-aided design modeling and MATLAB to process and manipulate the images. This generated 27,020 images for training (22,957) and validation (4,063) sets. We obtained 786 test images from various sources. The performance of the model was evaluated by calculating sensitivity, specificity, and accuracy. RESULTS: Our machine learning model discriminated the 9 implant models with a mean accuracy of 97.4%, sensitivity of 88.4%, and specificity of 98.5%. CONCLUSIONS: Our novel hip implant detection technique accurately identified 9 radiographically similar implants. The method generates large datasets, is scalable, and can include historic or obscure implants. The no-code machine learning model demonstrates the feasibility of obtaining meaningful results without AI expertise, encouraging further research in this area.

RETINITIS PIGMENTOSA ASSOCIATED WITH THE EYS C2139Y VARIANT : An Important Cause of Blindness in East Asian Populations.

PURPOSE: The study aimed to describe the phenotypic features of retinitis pigmentosa (RP) associated with the previously described EYS C2139Y variant in Singaporeans and establish the importance of this variant as a prevalent cause of RP among East Asians. METHODS: A clinical phenotyping and exome-sequencing study was conducted on consecutive patients with nonsyndromic RP. Epidemiological analysis was performed using Singaporean and global population-based genetic data. RESULTS: A study of 150 consecutive unrelated individuals with nonsyndromic RP found that 87 (58%) of cases had plausible genotypes. A previously described missense variant in the EYS gene, 6416G>A (C2139Y), occurred heterozygously or homozygously in 17 of 150 families (11.3%), all with autosomal recessive RP. Symptom onset in EYS C2139Y-related RP ranged from 6 to 45 years, with visual acuity ranging from 20/20 at 21 years to no light perception by 48 years. C2139Y-related RP had typical findings, including sectoral RP in cases with EYS E2703X in trans . The median age at presentation was 45 years and visual fields declined to less than 20° (Goldmann V4e isopter) by age 65 years. Intereye correlation for visual acuity, fields, and ellipsoid band width was high (r 2 = 0.77-0.95). Carrier prevalence was 0.66% (allele frequency of 0.33%) in Singaporean Chinese and 0.34% in East Asians, suggesting a global disease burden exceeding 10,000 individuals. CONCLUSION: The EYS C2139Y variant is common in Singaporean RP patients and other ethnic Chinese populations. Targeted molecular therapy for this single variant could potentially treat a significant proportion of RP cases worldwide.

PATTERN AND CHARACTERISTICS OF DRUSEN SUBTYPES IN CHINESE AND INDIAN POPULATIONS IN SINGAPORE.

PURPOSE: To report the pattern and characteristics of drusen subtypes in Asian populations and the association with choroidal thickness. METHODS: This is the cross-sectional analysis of the population-based cohort study. Two thousand three hundred and fifty-three eyes of 1,336 Chinese and Indian participants aged older than 50 years, eyes with best-corrected visual acuity better than 20/60, and without other retinal diseases were recruited. Pachydrusen, reticular pseudodrusen, soft and hard drusen were graded on both color fundus photographs, and optical coherence tomography imaging with automated segmentation yielding and measurements of choroidal thickness. RESULTS: Nine hundred and fifty-five Chinese and 381 Indians were included in the final analysis. The pattern of pachydrusen, soft drusen, hard drusen, and reticular pseudodrusen was 14.0%, 3.7%, 12.5%, and 0.2%, respectively. Mean choroidal thickness was the thickest in eyes with pachydrusen (298.3 µm; 95% confidence interval: 290.5-306.1), then eyes with hard (298.1 µm; 95% confidence interval: 290.6-305.5) and soft drusen (293.7 µm; 95% confidence interval: 281.9-305.4) and thinnest in eyes without drusen (284.6 µm; 95% confidence interval: 280.5-288.7). Systemic associations of the various drusen subtypes also differed. CONCLUSION: Patterns, characterization and choroidal thickness of drusen subtypes, and their associations provide insights into the Asian phenotypic spectrum of age-related macular degeneration and the underlying pathogenesis.

Increased Incidence of Methicillin-Resistant Staphylococcus aureus in Knee and Hip Prosthetic Joint Infection.

BACKGROUND: Periprosthetic joint infection (PJI) is a devastating complication of knee and hip arthroplasty. Past literature has shown that gram-positive bacteria are commonly responsible for these infections, although limited research exists studying the changes in the microbial profile of PJIs over time. This study sought to analyze the incidence and trends of pathogens responsible for PJI over three decades. METHODS: This is a multi-institutional retrospective review of patients who had a knee or hip PJI from 1990 to 2020. Patients with a known causative organism were included and those with insufficient culture sensitivity data were excluded. There were 731 eligible joint infections from 715 patients identified. Organisms were divided into multiple categories based on genus/species and 5-year increments were used to analyze the study period. The Cochran-Armitage trend tests were used to evaluate linear trends in microbial profile over time and a P-value <.05 was considered statistically significant. RESULTS: There was a statistically significant positive linear trend in the incidence of methicillin-resistant Staphylococcus aureus over time (P = .0088) as well as a statistically significant negative linear trend in the incidence of coagulase-negative staphylococci over time (P = .0018). There was no statistical significance between organism and affected joint (knee/hip). CONCLUSION: The incidence of methicillin-resistant Staphylococcus aureus PJI is increasing over time, whereas, coagulase-negative staphylococci PJI is decreasing, paralleling the global trend of antibiotic resistance. Identifying these trends may help with the prevention and treatment of PJI through methods such as remodeling perioperative protocols, modifying prophylactic/empiric antimicrobial approaches, or transitioning to alternative therapeutic strategies.

Associations between age-related macular degeneration and sleep dysfunction: A systematic review.

BACKGROUND: Age-related macular degeneration, a prevalent degenerative retinal disease, is associated with non-visual and psychosocial impairments that may affect sleep. In this systematic review, we evaluated associations between age-related macular degeneration (AMD) and sleep, highlighted knowledge gaps and provided evidence-based recommendations to clinicians to enable holistic management of AMD patients. METHODS: We searched PubMed, Embase and the Cochrane Central registries for papers published before May 2022. Non-English, qualitative studies and grey literature were excluded. Studies evaluating the association between AMD and sleep (including sleep disorders like insomnia and sleep apnea), and vice versa, were included. The quality of shortlisted studies was evaluated using the Newcastle Ottawa Scale. RESULTS: Six (two case-control studies, three longitudinal cohort studies and one cross-sectional study) of 551 studies were included in this review. Four studies found that AMD was associated with increased rates of sleep apnea and poorer reported sleep quality, while five studies showed that patients with sleep apnea or insomnia were at higher risk of developing AMD. Associations between self-reported sleep quantity and AMD were conflicting. No study evaluated the relationship between AMD and sleep using objective sleep assessment tools. CONCLUSION: Only a limited number of studies investigated associations between AMD and sleep. These studies suggest a bidirectional relationship between AMD and sleep dysfunction yet disagree on the relationship between sleep quantity and the likelihood of AMD. Additional studies, using objective characterisation of sleep in patients with AMD are required to confirm these findings.

Long Term Results of Two-Stage Revision for Chronic Periprosthetic Knee Infection: A Multicenter Study.

BACKGROUND: Long-term reinfection and mortality rates and clinical outcomes with sufficient subject numbers remain limited for patients undergoing two-stage exchange arthroplasty for chronic periprosthetic knee infections. The purpose of this study was to determine the long-term reinfection, complication, and mortality following reimplantation for two-stage exchange following knee arthroplasty. METHODS: Retrospective review of 178 patients who underwent two-stage exchange knee arthroplasty for chronic PJI at three large tertiary referral institutions with an average of 6.63-year follow-up from reimplantation from 1990 to 2015. Rates of reinfection, mortality, and all-cause revision were calculated along with the cumulative incidence of reinfection with death as a competing factor. Risk factors for reinfection were determined using Cox multivariate regression analysis. RESULTS: Overall rate of infection eradication was 85.41%, with a mortality rate of 30.33%. Patients with minimum 5-year follow-up (n = 118, average 8.32 years) had an infection eradication rate of 88.98%, with a mortality rate of 33.05%. CONCLUSION: This is a large series with long-term follow-up evaluating outcomes of two-stage exchange knee arthroplasty resulting in adequate infection eradication and high mortality. Results were maintained at longer follow-up. This technique should be considered in patients with chronic PJI; however, realistic expectations regarding long-term outcomes must be discussed with patients.

Predictors of Reinfection in Prosthetic Joint Infections Following Two-Stage Reimplantation.

BACKGROUND: Two-stage reimplantation is an effective treatment for periprosthetic joint infection (PJI). Many factors are involved in the variable success of this procedure. The purpose of this study is to examine the relationship between patient risk factors, comorbidities, and the pathogen on reinfection rates following two-stage reimplantation. METHODS: We evaluated 158 patients treated for PJI from 2008-2019. Only patients who had completed a two-stage exchange were included. Patient demographics, comorbidities, laboratory values, time-to-reimplantation, pathogen, antibiotic sensitivities, host status, and reinfection rates were assessed. Multivariate analysis was performed to identify correlation between risk factors and reinfection. A P-value < .05 was considered statistically significant. RESULTS: 31 patients experienced a reinfection (19.6%). There was a statistically significant association between infection with Methicillin Sensitive Staphylococcus Aureus (MSSA) and reinfection (P = .046). Patients with a reinfection also had a significantly greater median serum C-reactive protein (CRP) level (12.65 g/dL) at the time of diagnosis compared to patients without a reinfection (5.0 g/dL) (P = .010). Median Erythrocyte Sedimentation Rate (ESR) (56 in no re-infection and 69 in re-infection) and time-to-reimplantation (101 days in no reinfection and 141 days in reinfection) demonstrated a trend toward an association with re-infection but were not statistically significant (P = .055 and P = .054 respectively). CONCLUSION: As the number of arthroplasties continue to rise, PJIs are increasing proportionately and represent a significant revision burden. Elevated C-reactive protein (CRP) levels and Methicillin Sensitive Staphylococcus aureus (MSSA) infection were strongly associated with failure of a two-stage reimplantation. While not statistically significant with our numbers, there were strong trends toward an association between elevated Erythrocyte Sedimentation Rate (ESR), longer time-to-reimplantation, and reinfection.

Creating Synergies between Citizen Science and Indigenous and Local Knowledge.

Citizen science (CS) is receiving increasing attention as a conduit for Indigenous and local knowledge (ILK) in ecosystem stewardship and conservation. Drawing on field experience and scientific literature, we explore the connection between CS and ILK and demonstrate approaches for how CS can generate useful knowledge while at the same time strengthening ILK systems. CS invites laypersons to contribute observations, perspectives, and interpretations feeding into scientific knowledge systems. In contrast, ILK can be understood as knowledge systems in its own right, with practices and institutions to craft legitimate and useful knowledge. Such fundamental differences in how knowledge is generated, interpreted, and applied need to be acknowledged and understood for successful outcomes. Engaging with complementary knowledge systems using a multiple evidence base approach can improve the legitimacy of CS initiatives, strengthen collaborations through ethical and reciprocal relationships with ILK holders, and contribute to better stewardship of ecosystems.

Inlays and the cornea.

Presbyopia is a growing problem in view of an aging global population and increasingly patients desire spectacle-free solutions to address this condition. Surgically implanted corneal inlays have been the topic of renewed research efforts in the past several years as a treatment option for presbyopia, with several approaches being used to modify the refractive properties of the cornea and enhance near vision. In this review we discuss historical approaches to corneal inlay surgery, critically appraise the current generation of presbyopia-correcting corneal inlays and their associated complications and consider the future prospects for emerging corneal inlay technologies that aim address the shortcomings of currently available inlays.

Two-Stage Reimplantation of a Prosthetic Hip Infection: Systematic Review of Long-Term Reinfection and Pathogen Outcomes.

BACKGROUND: Although two-stage exchange for chronic periprosthetic hip infections remains an effective option for infection eradication, long-term outcome reporting remains scarce. Compiling outcomes data for this standard of care is necessary to characterize long-term reinfection risk and identify bacteria associated with reinfection. The purpose of our study was to perform a systematic review to determine the long-term risk of reinfection after two-stage reimplantation. The second purpose was to identify the proportion of reinfections caused by the same or different organism(s) relative to the index infection. METHODS: We performed a systematic review of two-stage reimplantation randomized control trials, cohort studies, and case series for the treatment of periprosthetic joint infections, yielding 320 unique citations for abstract review, of which 138 were reviewed in full. We collected reinfection data including the timing of reinfection after successful reimplantation and the bacteria identified at reinfection. Meeting inclusion criteria were 28 studies with 2047 patients and 2055 hips that completed both reimplantation stages with just seven studies having greater than 24 month follow-up. RESULTS: Studies with longer average follow-up reported significantly higher all-time reinfection rates (P = .042). Among studies with at least 5 years of follow-up, the risk of reinfection was 10.25% (8.21-12.47). Among studies with minimum follow-up of at least 24 months, the 24-month rate of reinfection was 4.58% (2.17-7.66), which increased to 7.34% (4.44-10.82) by final follow-up. Only 12 studies reported index and recurrent pathogen data. In those studies, 3.00% (1.19-5.38) of all hips which completed both reimplantation stages were reinfected by a new pathogen, and 1.70% (0.52-3.35) of patients became reinfected by recurrent pathogens. CONCLUSION: While the majority of two stage reimplantation literature follows patients for two years, there is significant risk of reinfection into the long term. Further studies with detailed outcomes and long-term follow-up are needed to identify factors associated with late infections.

Single vs 2-Stage Revision for the Treatment of Periprosthetic Joint Infection.

Periprosthetic joint infection (PJI) is one of the most devastating complications following total joint arthroplasty, accounting for a projected 10,000 revision surgeries per year by 2030. Chronic PJI is complicated by the presence of bacterial biofilm, requiring removal of components, thorough debridement, and administration of antibiotics for effective eradication. Chronic PJI is currently managed with single-stage or 2-stage revision surgery. To date, there are no randomized, prospective studies available evaluating eradication rates and functional outcomes between the 2 techniques. In this review, both treatment options are described with the most current literature to guide effective surgical decision-making that is cost-effective while decreasing patient morbidity.

Comparison of 3D Printed Spherical Implants versus Femoral Head Allografts for Tibiotalocalcaneal Arthrodesis.

Successful tibiotalocalcaneal (TTC) arthrodesis can be difficult to achieve in patients with bulk bone defects even with the use of femoral head allograft. Retrograde intramedullary nail placement through custom 3-dimensional (3D) spherical implants is an innovative option for these patients. The purpose of this study was to compare fusion rates, graft resorption, and complication rates between patients undergoing TTC fusion with 3D sphere implants versus femoral head allografts. Patients who underwent TTC arthrodesis with an intramedullary nail along with a 3D spherical implant (n = 8) or femoral head allograft (n = 7) were included in this study. The rate of successful fusion of the tibia, calcaneus, and talar neck to the 3D sphere or femoral head allograft was compared between the groups. The rate of total fused articulations was significantly higher in the 3D sphere group (92%) than the femoral head allograft group (62%; p = .018). The number of patients achieving successful fusion of all 3 articulations was higher in the 3D sphere group (75%) than the femoral head allograft group (42.9%, p = .22). The rate of graft resorption was significantly higher in the femoral head allograft group (57.1%) than the 3D sphere group (0%, p = .016). There were no significant differences between the groups in terms of complications. These data demonstrate that the use of a custom 3D printed sphere implant is safe in patients with severe bone loss undergoing TTC arthrodesis with a retrograde intramedullary nail and may result in improved rates of successful arthrodesis.

Is There a Difference in Infection Risk Between Single and Multiple Doses of Prophylactic Antibiotics? A Meta-analysis.

BACKGROUND: The prevention of surgical site infection guidelines issued by the Centers for Disease Control and Prevention (CDC) recently recommended that only a single dose of preoperative antibiotics be administered to patients undergoing clean-contaminated procedures based on data from a variety of surgical disciplines. For orthopaedic procedures, where postoperative infections can have significant consequences, the existing evidence for this recommendation is widely debated. QUESTIONS/PURPOSES: Is there a difference in postoperative infection risk when utilizing a single dose of preoperative antibiotics compared with multiple doses of perioperative antibiotics for orthopaedic procedures where implants are placed? METHODS: MEDLINE, EMBASE, Google Scholar, and Cochrane were systematically reviewed for randomized controlled trials (RCTs) of a single dose of preoperative antibiotics compared with pre- and postoperative prophylaxis from 1980 to 2017 for all orthopaedic procedures where implants were being placed. Infection (both superficial and deep) as a primary outcome through all available followup was required for inclusion. Fourteen RCTs detailing 9691 orthopaedic procedures were included for analysis, including seven arthroplasty, one spine, and six general orthopaedic trials (two specific to hip fracture fixation). Pooled infection outcomes were analyzed with random-effects modeling in light of study heterogeneity. Bias was evaluated using the Cochrane risk of bias tool as well as a funnel plot for publication bias, and quality of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Bias was largely uncertain; however, a high risk of bias was noted in four studies. No significant overall publication bias was noted. The quality of evidence was determined to be very low based on the GRADE tool, downgraded based on risk of bias, inconsistency, and imprecision. Despite the quality of evidence, the data were pooled in light of the current recommendations from the CDC to critically evaluate the recommendation that a single dose of antibiotics be utilized. RESULTS: There were no differences in infection risk between single- versus multiple-dose groups (single: 83 of 4263 [2%], multiple: 101 of 5428 [2%]; odds ratio, 0.92 [95% confidence interval, 0.56-1.51]; p = 0.740, I = 36% for statistical heterogeneity). CONCLUSIONS: There is no difference in infection risk between a single dose and multiple doses of perioperative antibiotics for orthopaedic procedures where implants are utilized, consistent with recent recommendations. However, the quality of evidence for orthopaedic procedures is low, and a randomized study with a sufficient sample size is needed to examine the issue before universal adoption of a single antibiotic dose. LEVEL OF EVIDENCE: Level I, therapeutic study.

Traditional Laboratory Markers Hold Low Diagnostic Utility for Immunosuppressed Patients With Periprosthetic Joint Infections.

BACKGROUND: Although predictive laboratory markers and cutoffs for immunocompetent patients are well-studied, similar reference ranges and decision thresholds for immunosuppressed patients are less understood. We investigated the utility of typical laboratory markers in immunosuppressed patients undergoing aspiration of a prosthetic hip or knee joint. METHODS: A retrospective review of adult patients with an immunosuppressed state that underwent primary and revision total joint arthroplasty with a subsequent infection at our tertiary, academic institution was conducted. Infection was defined by Musculoskeletal Infection Society criteria. A multivariable analysis was used to identify independent factors associated with acute (<90 days) and chronic (>90 days) infection. Area under the receiver-operator curve (AUC) was used to determine the best supported laboratory cut points for identifying infection. RESULTS: We identified 90 patients with immunosuppression states totaling 172 aspirations. Mean follow-up from aspiration was 33 months. In a multivariate analysis, only synovial fluid cell count and synovial percent neutrophils were found to be independently correlated with both acute and chronic infection. A synovial fluid cell count cutoff value of 5679 nucleated cells/mm3 maximized the AUC (0.839) for predicting acute infection, while a synovial fluid cell count cutoff value of 1293 nucleated cells/mm3 maximized the AUC (0.931) for predicting chronic infection. CONCLUSION: Physicians should be aware of lower levels of synovial nucleated cell count and percentage of neutrophils in prosthetic joint infections of the hip or knee in patients with immunosuppression. Further investigation is necessary to identify the best means of diagnosing periprosthetic joint infection in this patient population.

Prior Hip Arthroscopy Increases Risk for Perioperative Total Hip Arthroplasty Complications: A Matched-Controlled Study.

BACKGROUND: Arthroscopic hip surgery is becoming increasingly popular for the treatment of femoroacetabular impingement and labral tears. Reports of outcomes of hip arthroscopy converted to total hip arthroplasty (THA) have been limited by small sample sizes. The purpose of this study was to investigate the impact of prior hip arthroscopy on THA complications. METHODS: We queried our institutional database from January 2005 and December 2017 and identified 95 hip arthroscopy conversion THAs. A control cohort of 95 primary THA patients was matched by age, gender, and American Society of Anesthesiologists score. Patients were excluded if they had undergone open surgery on the ipsilateral hip. Intraoperative complications, estimated blood loss, operative time, postoperative complications, and need for revision were analyzed. Two separate analyses were performed. The first being intraoperative and immediate postoperative complications through 90-day follow-up and a second separate subanalysis of long-term outcomes on patients with minimum 2-year follow-up. RESULTS: Average time from hip arthroscopy to THA was 29 months (range 2-153). Compared with primary THA controls, conversion patients had longer OR times (122 vs 103 minutes, P = .003). Conversion patients had a higher risk of any intraoperative complication (P = .043) and any postoperative complication (P = .007), with a higher rate of wound complications seen in conversion patients. There was not an increased risk of transfusion (P = .360), infection (P = 1.000), or periprosthetic fracture between groups (P = .150). When comparing THA approaches independent of primary or conversion surgery, there was no difference in intraoperative or postoperative complications (P = .500 and P = .790, respectively). CONCLUSION: Conversion of prior hip arthroscopy to THA, compared with primary THA, resulted in increased surgical times and increased intraoperative and postoperative complications. Patients should be counseled about the potential increased risks associated with conversion THA after prior hip arthroscopy.

Clinical Impact of Routine Complete Blood Counts Following Total Knee Arthroplasty.

BACKGROUND: Routine laboratory studies are generally obtained following total knee arthroplasty (TKA), and often continued daily until discharge. This study aims to investigate the utility and cost-effectiveness of complete blood count (CBC) tests following TKA. METHODS: Retrospective review identified 484 patients who underwent primary TKA under a tourniquet at a single institution. Preoperative and postoperative CBC values were collected along with demographic data, use of tranexamic acid (TXA), and transfusion rates. Logistic regression models were calculated for all variables. RESULTS: Twenty-five patients required transfusion following TKA (5.2%). Patients requiring transfusion had significantly lower preoperative hemoglobin compared to patients who did not require transfusion (11.47 vs 13.58 g/dL, P = .005). Risk of transfusion was 5.2 times higher in patients with preoperative anemia (95% confidence interval 2.90-9.35, P < .001). Without TXA, patients were 2.75 times more likely to receive transfusion (95% confidence interval 1.43-5.30, P < .001). An average of 2.9 CBC tests were collected per patient who did not receive medical intervention, costing a total of $144,773.80 in associated hospital charges ($316.10 per patient). CONCLUSION: Ensuring quality, cost-effective patient care following total joint arthroplasty is essential in the era of bundled payments. Routine postoperative CBCs do not add value for patients with normal preoperative hemoglobin who receive TXA during TKA performed under tourniquet. Patients who are anemic preoperatively or do not receive TXA should obtain a postoperative CBC test. Daily CBCs are unnecessary if the first postoperative CBC does not prompt intervention.

Short and Long-Term Postoperative Complications Following Total Joint Arthroplasty in Patients With Human Immunodeficiency Virus, Hepatitis B, or Hepatitis C.

INTRODUCTION: Due to advancement in treatment against human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), the prevalence of this patient population electing to undergo total joint arthroplasty (TJA) is increasing. Current literature is scarce and conflicting especially when evaluating long-term surgical complications. The purpose of this study is to assess the postoperative medical and surgical complications following TJA in these patient populations. METHODS: Using a nationwide database between 2005 and 2012, 4 cohorts were created: patients with HIV, HCV, HBV, and HIV and HBV or HCV who underwent TJA. Cohorts were matched to a control group by age, gender, and Charlson Comorbidity Index. Thirty-day and 90-day medical complications and 90-day and 2-year surgical complications were evaluated using odds ratios with 95% confidence intervals. RESULTS: Following TJA, patients with HCV or HBV had increased risk of pneumonia, sepsis, joint infection, and revision surgery at 90 days and 2 years. Patients with HIV did not have increased risk of infection at 90 days and 2 years but did have increased risk of revision at 90 days (odds ratio 3.21, 95% confidence interval 1.31-7.84) following total hip arthroplasty. CONCLUSIONS: Patients with HIV, HBV, or HCV have an overall increased risk of postoperative medical and surgical complications following TJA. Patients with HBV or HCV are at risk of more complications than patients with HIV especially for infection within 90 days after TJA. Patients with HIV are at risk of mechanical complications but do not appear to be at significant risk for infection following total hip arthroplasty.

Trends in Opioid Utilization Before and After Total Knee Arthroplasty.

BACKGROUND: Opioids are a mainstay in perioperative pain management among patients undergoing total knee arthroplasty (TKA). However, patterns in opioid use before and after TKA have not been well-studied. The objectives of this study are to characterize prescribing trends preoperatively and postoperatively and identify risk factors for chronic postoperative opioid use. METHODS: A review of the prescription-tracking database of a large private payer from 2007 to 2013 was performed using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes. Chronic opioid use was defined as opioid prescriptions over 6 contiguous months postoperatively. RESULTS: We identified 66,950 patients who underwent TKA with minimum 2-year follow-up and medication codes. Of those taking opioids preoperatively (n = 36,668), 34.8% became chronic users postoperatively compared to only 5.0% of the opioid-naïve cohort (n = 30,282). Major risk factors for chronic postoperative opioid use included preoperative opioid use (relative risk [RR] 3.75, 95% confidence interval [CI] 3.59-3.93), female gender (RR 1.23, 95% CI 1.20-1.25), and younger age (≤44 vs ≥60: RR 1.41, 95% CI 1.32-1.49; 45-59 vs ≥60: RR 1.42, 95% CI 1.40-1.46). From 2007 to 2013, there was a significant linear increase in opioid use preoperatively (odds ratio [OR] 1.04, 95% CI 1.03-1.05, P < .001) and postoperatively (OR 1.20, 95% CI 1.18-1.21, P < .001), but chronic postoperative opioid use increased only marginally (OR 1.01, 95% CI 1.00-1.02, P = .021). CONCLUSION: The greatest risk factors for chronic postoperative opioid use were preoperative use, younger age, female gender, greater length of stay, and worse health status. Although the use of opioids continues to grow significantly preoperatively and postoperatively, chronic opioid use post-TKA has remained clinically unchanged.