The cost-effectiveness of osteoporosis medications for preventing periprosthetic fractures following femoral neck fracture indicated hip arthroplasty: a break-even analysis.

Osteoporosis treatment following arthroplasty for femoral neck fracture (FNF) is associated with lower rates of periprosthetic fracture (PPF). Our study evaluated the economic viability of treatment in patients following arthroplasty and demonstrates that treatment with oral bisphosphonates can be cost-effective in preventing PPF. INTRODUCTION: Osteoporosis treatment following arthroplasty for femoral neck fracture (FNF) is associated with lower rates of periprosthetic fracture (PPF). Although cost-effective in reducing the rate of secondary fragility fracture, the economic viability of osteoporosis treatment in preventing PPF has not been evaluated. Therefore, the purpose of this study is to use a break-even analysis to determine whether and which current osteoporosis medications are cost-effective in preventing PPF following arthroplasty for FNFs. METHODS: Three-year average cost of osteoporosis medication (oral bisphosphonates, estrogen hormonal therapy, intravenous (IV) bisphosphonates, denosumab, teriparatide, and abaloparatide), costs of PPF care, and PPF rates in patients who underwent hip arthroplasty for FNFs without osteoporosis treatment were used to perform a break-even analysis. The absolute risk reduction (ARR) related to osteoporosis treatment and sensitivity analyses were used to evaluate the cost-effectiveness of this intervention and break-even PPF rates. RESULTS: Oral bisphosphonate therapy following arthroplasty for hip fractures would be economically justified if it prevents one out of 56 PPFs (ARR, 1.8%). Given the current cost and incidence of PPF, overall treatment can only be economically viable for PPF prophylaxis if the 3-year costs of these agents are less than $1500. CONCLUSION: The utilization of lower cost osteoporosis medications such as oral bisphosphonates and estrogen hormonal therapy as PPF prophylaxis in this patient population would be economically viable if they reduce the PPF rate by 1.8% and 1.5%, respectively. For IV bisphosphonates and newer agents to be economically viable as PPF prophylaxis in the USA, their costs need to be significantly reduced.

No Difference in Revision Rates up to 10 years Following Total Hip Arthroplasty in Patients Who Had Prior Bariatric Surgery When Compared to Patients Who Had Class III Obesity: A Propensity Matched Analysis.

BACKGROUND: There is no clear research showcasing bariatric surgery's (BS's) impact on long-term surgical complications following total hip arthroplasty (THA). Therefore, this study compared the 10-year cumulative incidence and risk of revision following THA in patients who underwent BS when compared to the general population and class III obesity patients who did not undergo BS. METHODS: Patients who underwent elective THA from 2010 to 2021 were identified using an all-payer claims database. Patients who underwent BS prior to THA were separately matched to a control of the general population and those who had class III obesity (body mass index ≥40) by age, sex, Charlson Comorbidity Index, and diabetes using a 1:4 ratio. Kaplan-Meier analyses generated 10-year cumulative incidence rates, and a Cox proportional hazard ratio (HR) model generated HRs and 95% confidence intervals (CIs). RESULTS: When compared to the general control, patients who have a history of BS had an elevated 10-year risk of all-cause revision (HR 1.31, 95% CI: 1.16 to 1.47, P < .001), prosthetic joint infection (HR: 1.62, CI: 1.30 to 2.04; P < .001), mechanical loosening (HR: 1.20, CI: 1.01 to 1.44; P = .040), and dislocation/instability (HR: 1.35, CI: 1.09 to 1.68; P = .007). There was no difference in the 10-year risk of all-cause revision or other indications for revision in the BS cohort compared to the matched class III obesity cohort (P = .142). CONCLUSIONS: Those who underwent BS before THA had comparable 10-year revision rates when compared to those who had class III obesity and higher rates compared to the general population. This suggests BS may not reduce the 10-year surgical risks associated with obesity when compared to a class III obese surgical population.

Trends in anti-osteoporotic medication utilization following fragility fracture in the USA from 2011 to 2019.

The purpose of this study was to determine whether there has been any change in osteoporosis treatment following primary fragility fractures and what agents were being given. The study found an overall low utilization rate with no difference in treatment utilization from 2011 to 2019. PURPOSE: The aim of this study is to describe trends in the utilization of anti-osteoporotic medication after fragility fracture, including changes in the specific types of medications prescribed. METHODS: Patients older than 65 with fragility fractures sustained from 2011 to 2019 were identified in the PearlDiver Patient Records Database. Osteoporosis treatment rate was defined as the rate at which patients were prescribed any of the fourteen most used anti-osteoporotic medications within 1 year of fragility fracture. Fragility fractures were subcategorized by type. Treatment of fragility fractures was further stratified by patient demographics (age and gender) and medication type. RESULTS: This study showed an overall osteoporosis treatment rate of 8.01%, with treatment rates of 6.87% following hip fractures, 6.71% following upper extremity fractures, and 14.38% following vertebral compression fractures (VCF). From 2011 to 2018, there was no change in the overall fragility fracture treatment rate (p = 0.32). Of the three fracture categories analyzed, only the treatment rate for VCFs increased (p = 0.048). Osteoporosis treatment in patients with VCF increased among patients 65-74 years old (p < 0.05) and male patients (p = 0.013). Treatment in patients with upper extremity fractures increased among patients 70-74 years old (p = 0.038). Bisphosphonates were the most frequently prescribed class of medications. Bisphosphonates and denosumab increased in utilization (p = 0.049 and p < 0.001 respectively) while calcitonin utilization decreased (p < 0.001). CONCLUSION: Besides the overall low utilization rate of osteoporosis treatment in patients following fragility fractures, there has been no change in the treatment utilization rate within the past decade. More resources and interventions need to be enforced for all providers managing these patients if we are ever to address the osteoporosis epidemic.

The impact of prior fragility fractures on long-term periprosthetic fracture risk following total knee arthroplasty.

The study found that patients undergoing total knee arthroplasty with prior fragility fracture had increased risk of subsequent fragility fracture and periprosthetic fracture within 8 years postoperatively when compared to those without a prior history. However, these patients were not at increased risk for all-cause revision within this period. PURPOSE: The aim of this study was to characterize the association of prior FFs on long-term risk of secondary fragility fracture (FF), periprosthetic fracture (PPF), and revision TKA. METHODS: Patients at least 50 years of age who underwent elective TKA were identified in the PearlDiver Database. Patients were stratified based on whether they sustained a FF within 3 years prior to TKA (7410 patients) or not (712,954 patients). Demographics and comorbidities were collected. Kaplan Meier analysis was used to observe the cumulative incidence of all-cause revision, PPF, and secondary FF within 8 years of TKA. Cox Proportional hazard ratio analysis was used to statistically compare the risk. RESULTS: In total, 1.0% of patients had a FF within three years of TKA. Of these patients, only 22.6% and 10.9% had a coded diagnosis of osteoporosis and osteopenia, respectively, at time of TKA. The 8-year cumulative incidence of secondary FF and periprosthetic fracture was significantly higher in those with a prior FF (27.5% secondary FF and 1.9% PPF) when compared to those without (9.1% secondary FF and 0.7% PPF). After adjusting for covariates, patients with a recent FF had significantly higher risks of secondary FF (HR 2.73; p < 0.001) and periprosthetic fracture (HR 1.86; p < 0.001) than those without a recent FF. CONCLUSIONS: Recent FF before TKA is associated with increased risk for additional FF and PPF within 8 years following TKA. Surgeons should ensure appropriate management of fragility fracture is undertaken prior to TKA to minimize fracture risk, and if not, be vigilant to identify patients with prior FF or other bone health risk factors who may have undocumented osteoporosis.

The Association of Postoperative Osteoporosis Therapy With Periprosthetic Fracture Risk in Patients Undergoing Arthroplasty for Femoral Neck Fractures.

BACKGROUND: Displaced femoral neck fractures in older adults are generally treated with hip arthroplasty. One concern following hip arthroplasty is the risk for periprosthetic fractures (PPFs). Most patients who have hip fractures are candidates for antiosteoporotic therapy, but the impact of this treatment on PPFs is unknown. Therefore, the primary objective of this study was to evaluate whether patients treated with antiosteoporotic medical therapy had lower odds of PPFs following arthroplasty for hip fracture. METHODS: Patients at least 65 years old who underwent hip arthroplasty for femoral neck fractures from 2010 to 2020 were identified in a national database. Patients were stratified based on whether they initiated antiosteoporotic therapy within 1 year of hip arthroplasty. Minimum follow-up was 1 year, and maximum follow-up was 10.6 years. The primary endpoint was cumulative incidence of PPF as determined using Kaplan-Meier and Cox proportional hazards regression analyses. Overall, 2,026 patients who underwent arthroplasty for femoral neck fracture received antiosteoporotic medications within 1 year following surgery (mean follow up 4.8 years; range 1.0 to 10.6 years) and 33,639 patients did not (mean follow up 4.1 years; range 1.1 to 10.3 years). RESULTS: The 10-year cumulative incidence of PPF for patients treated for osteoporosis was 3.88% compared to 5.92% for those who were untreated (P < .001). Adjusting for covariates, patients who received osteoporosis treatment had a significantly lower risk for PPF than those who were untreated (hazard ratio (HR): 0.663; 95% confidence interval (CI): 0.465-0.861; P = .038). CONCLUSION: The present study suggests that osteoporosis treatment is associated with lower incidence of PPF following hip arthroplasty for femoral neck fractures. Treatment of osteoporosis should be initiated in eligible patients who sustain a femoral neck fracture, especially those who undergo hip arthroplasty.

Why and What Happens to Patients Younger Than 60 Years Who Need Revision Total Knee Arthroplasty?

BACKGROUND: With the increasing number of young patients undergoing primary total knee arthroplasty (TKA), there will be an increase in the number of patients who require revision. While the results of TKA in younger patients are well known, there is little information regarding to the outcomes of revision TKA in this population. The purpose of this study was to evaluate the clinical outcomes in patients <60 years of age undergoing aseptic revision TKA. METHODS: We retrospectively reviewed 433 patients undergoing aseptic revision TKA between 2008 and 2019. There were 189 patients <60 years compared to a group of 244 patients >60 years undergoing revision TKA for aseptic failures in terms of implant survivorships, complications, and clinical outcomes. Patients were followed for a mean of 48 months (range, 24 to 149). RESULTS: A total of 28 (14.8%) patients less than 60 years of age required repeat revision compared to 25 (10.2%) 60 years or older (odds ratio (OR) 1.94, 95% confidence interval (CI) 0.73-5.22, P = .187). There were no differences regarding postprocedural Patient-Reported Outcomes Measurement Information System (PROMIS) physical health scores (72.3 ± 13.7 versus 72.0 ± 12.0, P = .66) and PROMIS mental health scores (66.6 ± 17.4 versus 65.8. ± 14.7, P = .72), at an average of 32.9 and 30.7 months, respectively. Postoperative infection occurred in 3 (1.6%) patients <60 years of age, while 12 (4.9%) postoperative infections occurred in patients 60 years or older (OR 0.75, 95% CI 0.06-10.2, P = .83). CONCLUSION: There were no statistically significant differences in clinical outcomes between patients <60 versus > 60 years of age undergoing aseptic revision TKA.

The Association of Prior Fragility Fractures on 8-Year Periprosthetic Fracture Risk Following Total Hip Arthroplasty.

BACKGROUND: Fragility fractures are often the initial clinical presentation of osteoporosis. Patients who have a history of fragility fractures undergoing total hip arthroplasty (THA) have an increased risk of 2-year postoperative complications. However, the association of recent fragility fractures with complications beyond 2 years following THA remains unknown. The purpose of this study was to characterize the association of prior fragility fractures with 8-year risks of revision THA, periprosthetic fracture (PPF), and secondary fragility fracture. METHODS: Patients aged 50 years and more who underwent THA for osteoarthritis were identified in a large national database. Patients were stratified based on whether they sustained a fragility fracture within 3 years prior to THA. There were 18,529 patients who had a prior fragility fracture and 408,753 who did not have a prior fragility fracture. Demographics and comorbidities were collected. Kaplan-Meier and Cox Proportional Hazards analyses were used to observe the cumulative incidences of all-cause revision, PPF, and secondary fragility fracture within 8 years of index surgery. RESULTS: Patients who had recent fragility fracture had significantly higher risks of revision THA (Hazard Ratio [HR] 1.7; P < .001), PPF (HR 2.2; P < .001), and secondary fragility fracture (HR 4.9; P < .001). CONCLUSION: Prior fragility fracture was shown to be a significant risk factor for revision THA, PPF, and secondary fragility fracture within 8 years of THA. Identification of these high-risk patients with an emphasis on preoperative and postoperative bone health optimization may help minimize these complications.

10-Year Cumulative Incidence and Indications for Revision Total Knee Arthroplasty Among Patients Who Have Sickle Cell Disease.

BACKGROUND: Literature regarding total knee arthroplasty (TKA) outcomes in sickle cell disease (SCD) is limited. Moreover, 10-year survivorship of SCD implants is unknown. This study aimed to observe 10-year cumulative incidence and indications for revision TKA in patients who did and did not have SCD. METHODS: Patients who underwent primary TKA were identified using a large national database. The SCD patients were matched by age, sex, and a comorbidity index to a control cohort in a 1:4 ratio. The 10-year cumulative incidence rates were determined using Kaplan-Meier survival analyses. Multivariable analyses were conducted using Cox proportional hazard modeling. Chi-squared analyses were conducted to compare indications for revision between cohorts. In total, 1,010 SCD patients were identified, 100,000 patients included in the unmatched control, and 4,020 patients included in the matched control. RESULTS: Compared to the unmatched control cohort, SCD patients exhibited higher 10-year all-cause revision (HR: 1.86; P < .001) with higher proportions of revisions for periprosthetic joint infection (PJI) (P < .001), aseptic loosening (P < .001), and hematoma (P < .001). Compared to the matched control, SCD patients had higher 10-year all-cause revision (Hazard Ratio (HR): 1.39; P = .034) with a higher proportion of revisions for PJI (P = .044), aseptic loosening (P = .003), and hematoma (P = .019). CONCLUSION: Independent of other comorbidities, SCD patients are more likely to undergo revisions for PJI, aseptic loosening, and hematoma compared to patients who do not have SCD. Due to the high-risk of these complications, perioperative and postoperative surgical optimization should be enforced in SCD patients.

Risks of Immunosuppressive Therapy in Patients Undergoing Open Reduction Internal Fixation for Ankle Fractures.

Chronic steroid and immunosuppressant use have been shown to increase the risk for postoperative complications in orthopedic surgery. Further understanding of the risks of immunosuppression is necessary to aid in risk stratification and patient counseling. However, these risks have not yet been explored in ankle fracture patients. Thus, the purpose of this study is to determine whether patients taking immunosuppressives are at an increased risk for morbidity and mortality following open reduction and internal fixation (ORIF) of ankle fractures. Patients undergoing operative treatment for ankle fractures from 2006 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were categorized based on their use of immunosuppressive medications. Postoperative outcomes assessed included superficial surgical site infections, deep surgical site infections, organ space infections, wound dehiscence, pneumonia, unplanned intubation, pulmonary embolism, urinary tract infection, renal failure, blood transfusion requirement, deep vein thrombosis, sepsis, cardiac arrest, extended length of hospital stay, readmission, reoperation, and mortality. Univariate and multivariate analyses were performed. In total, 10,331 patients underwent operative treatment for ankle fracture. Total 10,153 patients (98.3%) were not taking immunosuppressants and 178 (1.7%) were taking these medications. In multivariate analysis, patients taking immunosuppressants were at increased risk of pulmonary embolism (odds ratio [OR] 4.382; p = .041) and hospital readmission (OR 2.131; p = .021). Use of immunosuppressive medications is an independent risk factor for pulmonary embolism and readmission following ORIF for ankle fractures. Notably, no association with wound complications, infections, or sepsis was identified.

Preoperative estimated glomerular filtration rate is a marker for postoperative complications following aseptic revision total hip arthroplasty.

INTRODUCTION: Revision total hip arthroplasty (rTHA) is increasingly performed but may carry a high rate of complication. This aim of the study was to determine if a decreased eGFR increases risks of postoperative complications following rTHA. METHODS: A retrospective cohort study using the American College of Surgeons National Quality Improvement Program Database was conducted. Patients undergoing rTHA between 2007 and 2014 were identified and stratified by glomerular filtration rates (eGFR): eGFR > 125 mL/min, eGFR 90-125 mL/min, eGFR 60-90 mL/min, eGFR 30-60 mL/min, and eGFR < 30 mL/min. The incidence of postoperative adverse events within 30 days, including cardiac, pulmonary, renal, septic, thromboembolic, urinary tract, and wound complications, blood transfusion, death, length of stay > 7 days, and unplanned return to the operating room, was assessed. The complication rates following rTHA were assessed with univariate and multivariate analysis with a significance set at p < 0.05. RESULTS: In total, 8898 revision THA procedures were included for analysis. 28.4% of patients that underwent rTHA developed a complication following surgery. Following adjustment, an eGFR of less than 30 mL/min independently increased the odds of any complication (OR 1.447; 95% C.I. 1.010-2.074; p = 0.044), cardiac complications (OR 3.344; 95% C.I. 1.040-10.752; p = 0.043), blood transfusion (O.R. 1.623; 95% C.I. 1.122-2.352; p = 0.010), and extended length of stay (O.R. 2.392; 95% C.I. 1.526-3.759; p < 0.001) when compared to normal renal function. CONCLUSIONS: Diminished eGFR of less than 30 mL/min increased the odds of total complications, cardiac complications, blood transfusions, and extended length of stay compared to normal renal function.

Prior Knee Arthroscopy Is Associated With Increased Risk of Revision After Total Knee Arthroplasty.

BACKGROUND: Knee arthroscopy (KA) is frequently performed to provide improved joint function and pain relief. However, outcomes following total knee arthroplasty (TKA) after prior KA are not fully understood. The purpose of this study is to determine the relationship between prior KA within 2 years of TKA on revision rates after TKA. METHODS: Data were collected from the Humana insurance database using the PearlDiver Patient Records Database from 2006 to 2017. Subjects were identified using Current Procedural Terminology and International Classification of Diseases procedure codes to identify primary TKA. Patients were stratified into 2 groups based upon a history of prior KA. Univariate and multivariate analyses were conducted to determine association between KA and outcomes at 2-year postoperative period. RESULTS: In total, 138,019 patients were included in this study, with 3357 (2.4%) patients receiving a KA before TKA and 134,662 (97.6%) patients who did not. The most common reason for KA was osteoarthritis (40.0%), followed by medial tear of the meniscus (26.0%) and chondromalacia (21%.0). After adjustment, prior KA was associated with increased revision rate (odds ratio [OR], 1.392; P = .003), postoperative stiffness (OR, 1.251; P = .012), periprosthetic joint infection (OR, 1.326; P < .001), and aseptic loosening (OR, 1.401; P = .048). CONCLUSION: Prior KA is significantly associated with increased 2-year TKA revision rate. The most common etiology for arthroscopy was osteoarthritis. The results of the study, showing that arthroscopy before TKA substantially increases the rates of revision, PJI, aseptic loosening, and stiffness, lend further credence to the idea that patients may be better served by nonsurgical management of their degenerative pathology until they become candidates for TKA. Subjecting this population to arthroscopy appears to offer limited benefit at the cost of poorer outcomes when they require arthroplasty in the future. LEVEL OF EVIDENCE: Level III therapeutic study.

Preoperative Estimated Glomerular Filtration Rate Is a Marker for Postoperative Complications Following Revision Total Knee Arthroplasty.

BACKGROUND: Revision total knee arthroplasty (TKA) is an increasingly common procedure, but complication rates are higher than for primary TKA. A requirement for dialysis has been shown to predict postoperative complications in this patient population, but the impact of less severe, but clinically significant, renal impairment has not been addressed. METHODS: A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program Database. All patients who underwent revision TKA between 2007 and 2014 were identified and the estimated glomerular filtration rate (eGFR) was calculated for each patient. The incidence and predictors of adverse events following surgery were evaluated with univariate and multivariate analyses where appropriate. RESULTS: Patients with lower eGFRs (<60 mL/min) were found to develop more postoperative complications, including return to the operating room, postoperative pneumonia, urinary tract infection, sepsis, septic shock, and death. Decreased renal function was shown to be an independent risk factor for development of renal insufficiency, renal failure, and extended length of stay. CONCLUSION: Patients with decreased eGFRs have greater risk for many postoperative complications, but this increased risk is generally related to the greater number of comorbidities in this patient population. When controlling for these comorbidities, poor renal function is an independent risk factor for extended length of stay as well as postoperative renal injury and renal failure, and patients may benefit from perioperative measures to limit this excess renal risk.

Adult Reconstruction Hip and Knee Fellowship Program Content and Accessibility.

BACKGROUND: The objective of the study was to assess the accessibility and content of accredited adult reconstruction hip and knee fellowship program websites. METHODS: Using the online database of the American Association of Hip and Knee Surgeons (AAHKS), we compiled a list of accredited adult hip and knee/tumor reconstruction fellowship programs. A full list of adult reconstruction hip and knee fellowship programs was gathered from the AAHKS website. The program website links they provided were evaluated. A Google search was conducted to identify program websites and analyzed for accessibility and content in 3 domains: program overview, applying/recruitment, and education. RESULTS: At the time the study was conducted, there were 78 accredited adult reconstruction hip and knee fellowship programs identified through the AAHKS program directory. Three of the 78 programs identified had a functional link on the AAHKS fellowship program directory; however, Google search identified 60 websites. Eighteen programs did not have a website and were not evaluated for content. Data analysis of content in the domains of program details, application process/recruitment, and education revealed that most websites included a program description and director name with contact information. However, they were not as comprehensive in the application process/recruitment and education domains. CONCLUSIONS: AAHKS provides a reasonable method of identifying programs. Yet, most programs can readily be identified using a Google search (76.9%). Although most fellowship program websites contained program details, there is still paucity of information for fellowship candidates.

Efficacy of Manipulation Under Anesthesia for Stiffness Following Total Knee Arthroplasty: A Systematic Review.

BACKGROUND: Knee stiffness following primary total knee arthroplasty can lead to unsatisfactory patient outcomes secondary to persistent pain and loss of function. Manipulation under anesthesia (MUA) remains a viable option for treatment of post-operative stiffness. However, the optimal timing and clinical efficacy of manipulation of anesthesia remains unknown. METHODS: A systematic review of the literature was performed to identify studies that reported clinical outcomes for patients who underwent MUA for post-operative stiffness treatment. Repeat MUA procedures were included in the study but were analyzed separately. RESULTS: Twenty-two studies (1488 patients) reported on range of motion (ROM) after MUA, and 4 studies (81 patients) reported ROM after repeat MUA. All studies reported pre-MUA motion of less than 90°, while mean ROM at last follow-up exceeded 90° in all studies except 2. For studies reporting ROM improvement following repeat MUA, the mean pre-manipulation ROM was 80° and the mean post-manipulation ROM was 100.6°. CONCLUSION: MUA remains an efficacious, minimally invasive treatment option for post-operative stiffness following TKA. MUA provides clinically significant improvement in ROM for most patients, with the best outcomes occurring in patients treated within 12 weeks post-operatively. PROSPERO REGISTRATION NUMBER: CRD42016052215.

Efficacy of Revision Surgery for the Treatment of Stiffness After Total Knee Arthroplasty: A Systematic Review.

BACKGROUND: Knee stiffness following total knee arthroplasty (TKA) may cause pain and reduced functionality, contributing to unsatisfactory surgical outcomes. Revision surgery remains a possible treatment for refractory postoperative stiffness. However, the efficacy of the procedure has not been systematically evaluated. METHODS: A systematic review of the literature was performed to identify studies that reported on outcomes for patients who underwent revision surgery for postoperative stiffness after TKA. RESULTS: Ten studies (including 485 knees) were reviewed. The most common etiologies of stiffness requiring revision TKA were component malposition, malalignment, overstuffing, aseptic loosening, arthrofibrosis, patella baja, and heterotopic ossification. Of 9 studies reviewing range of motion outcomes after revision TKA, 7 studies documented significant improvement and 2 found trends toward improvement. Seven of 8 studies documenting Knee Society knee scores and 7 of 9 studies documenting functional scores found improvement after revision TKA. All studies reporting on pain found improvement at final follow-up after revision TKA. CONCLUSION: Revision TKA results in increased range of motion, improved functionality, and reduced pain in most patients who require surgery for stiffness. The present literature is inadequate to predict which patients will achieve adequate outcomes from revision TKA based on the specific etiology of their stiffness, although identification of the etiology may help in surgical planning. Surgeons performing revision TKA should counsel patients on the risks and benefits of undergoing revision surgery, with the understanding that outcomes for well-selected patients are generally favorable.

Progression of Authorship of Scientific Articles in The Journal of Hand Surgery, 1985-2015.

PURPOSE: For scientists, authorship is academic currency. Authorship characteristics have been studied in a subset of the surgical and medical literature, but trends in the specialty of hand surgery have not yet been investigated. Specifically, a longitudinal analysis of number, educational training, sex, and geographical origin of authors has not been conducted. We explored the progression of authorship of scientific articles in a leading hand surgery journal. METHODS: We recorded number of authors, number of references, degrees, and sex of the first and senior authors as well as geographical origin of the corresponding author in The Journal of Hand Surgery in 1985, 1995, 2005, and 2015. All original work was analyzed. RESULTS: A total of 892 articles were reviewed. The mean number of authors per article increased significantly from 2.6 in 1985 to 3.9 in 2015 and the number of references increased significantly from 13.7 in 1985 to 22.6 in 2015. There was a significant increase in the proportion of first authors with an MD/PhD, PhD, master's or bachelor's degree since 1985. During that same time period, a decrease in the proportion of first authors who held solely an MD was seen. There was a significant increase in proportion of the number of last authors with an MD/PhD, PhD or Master's degree in that same time period. There has been significant growth in publications originating from the "Far East" and "Other" regions, with 4.2% and 5.0% of publications, respectively, in 1985 having increased to 10.3% and 7.4% of publications, respectively, in 2015. Female first authorship significantly increased over the study period from 7.9% in 1985 to 22.1% of publications in 2015. CONCLUSIONS: There has been a significant increase in number of authors per article in The Journal of Hand Surgery. Similar to other studies, we noted shifts in the degrees most commonly held by authors, an increase in references per article, and a greater representation of international authors in the hand surgery. In addition, the proportion of manuscripts written by female authors has increased in the past 30 years, with the largest increase occurring between 2005 and 2015. CLINICAL RELEVANCE: This manuscript strives to provide further insight into the changing characteristics of authors contributing to the hand surgery literature. With increased pressure to publish in academia, it is important to understand how publishing author characteristics have evolved over time. In addition, the published literature of a field could be considered one repository of the insights and advancements of the field. One would hope that the authors contributing to that literature are a deep and wide reflection of the people working in that field. Analyzing authorship is one way to assess the breadth and depth of contributions from the profession.

AIDS but not asymptomatic HIV is associated with lower 2-10-year implant survivorship following total knee arthroplasty.

INTRODUCTION: Prior studies have demonstrated HIV does not increase the risk of 2-year complications following TKA; however, the literature is sparse regarding the impact of HIV and AIDS on long-term implant survivorship. The purpose of this study was to compare the 10-year cumulative incidence and risk of revision TKA in patients with and without asymptomatic HIV, and with and without AIDS. METHODS: Patients with HIV who underwent elective TKA were identified using a national database and divided into subgroups of asymptomatic HIV (AHIV) and acquired immunodeficiency syndrome (AIDS). These patients with HIV were propensity matched based on age, sex, and Charlson Comorbidity Index (CCI) to a control group of elective TKA patients without HIV in a 1:2 ratio. Patients were also compared to an unmatched control group. RESULTS: The 10-year risk for all-cause revision TKA was higher in the HIV group compared to unmatched controls (HR 1.40, 95% CI 1.02-1.93, p = 0.038) but not matched controls (HR 1.13, 95% CI 0.77-1.63, p = 0.594). When compared to both control groups (unmatched; matched), the AIDS group had a higher risk of 10-year all-cause revision (HR 2.74, 95% CI 1.51-4.99, p < 0.001; HR 2.19, 95% CI 1.17-4.11, p = 0.014), dislocation/instability (HR 4.89, 95% CI 1.54-15.51, p = 0.007; HR 3.86, 95% CI 1.12-13.34, p = 0.033), and periprosthetic fracture [PPF] (HR 0.67, 95% CI 0.16-2.74, p = 0.002; HR 3.82, 95% CI 1.08-13.45, p = 0.037). However, patients with AIDS were not at increased risk of PJI or mechanical loosening compared to unmatched controls or matched controls. DISCUSSION: This study expands on current literature by following a nationwide cohort of HIV/AIDS patients for 10 years after TKA. Although a diagnosis of asymptomatic HIV was not associated with increased risk of 10-year revision rates following TKA, a diagnosis of AIDS was. Surgeons should ensure patients' serum CD4 level is sufficient, ideally in the normal range of 500-1500 cells per mm3, before undergoing TKA.

Risk of revision total knee arthroplasty for patients with prior bariatric surgery or class III obesity.

BACKGROUND: Bariatric surgery (BS) is indicated for select class III obesity patients undergoing total knee arthroplasty (TKA) to reduce obesity-related complications. This study assessed the effect of BS on TKA revision rates compared to the general population and class III obesity patients without a history of BS. METHODS: A national database identified patients who had primary TKA. They were divided into two groups: those with BS prior to TKA and those without. Patients without BS formed two control groups, a matched general population, and a matched class III obese cohort. The BS group was matched with controls based on age, Charlson Comorbidity Index (CCI), gender, and diabetes mellitus. Revision rates were analyzed using Kaplan-Meier survival analysis and hazard ratios (HR), calculated using Cox proportional hazard modeling. RESULTS: 14,292 BS patients were compared to 57,006 matched general population controls, and 19,504 BS patients were compared to 77,846 matched class III obesity control patients. BS patients had a higher risk of 5-year all-cause revision (HR: 1.13; P = 0.014) and revision due to periprosthetic fracture (HR: 1.39; P < 0.001) compared to the general population. Compared to class III obesity controls, BS patients had a lower risk of 5-year revision due to prosthetic joint infection (HR: 0.77; P = 0.001), with no difference in all-cause revision (P = 0.362). CONCLUSION: BS does not reduce all-cause TKA revision risk compared to the general or matched class III obesity population. However, it lowers the risk of revision due to prosthetic joint infection when compared to patients with class III obesity. LEVEL OF EVIDENCE: IV.

Analysis of revision rates and complication rates among patients undergoing unicompartmental and bicompartmental knee Arthroplasties when compared to Total knee arthroplasty.

BACKGROUND: With recent advances in partial knee arthroplasty, there is conflicting data regarding the outcomes and revision rates for bicompartmental knee arthroplasty (BKA) and unicompartamental knee arthroplasty (UKA) compared to total knee arthroplasty (TKA). This study uses national data to compare surgical and medical complications of UKA, BKA, and TKA to aid surgical decision-making. METHODS: A retrospective cohort analysis was done using the Mariner dataset of the PearlDiver patient records database from 2010-2019. Current Procedural Terminology (CPT) codes were used to identify patients who underwent UKA, BKA, and TKA for a primary indication of osteoarthritis (OA). Univariate and multivariable analyses were performed to determine 1-year and 2-year revision, prosthetic joint infection (PJI), and loosening, 1-year manipulation under anesthesia (MUA), and 90-day postoperative medical complications. RESULTS: The BKA cohort was found to have higher odds of one and two-year revision compared to UKA and TKA cohorts. Additionally, the UKA cohort had higher odds of one and two-year revision but lower odds of 1-year MUA than the TKA cohort. However, both the BKA and UKA cohorts had lower odds of any 90-day postoperative complications when compared to the TKA cohort. CONCLUSIONS: Even with modern implants and approaches, our study found that revision rates are highest for BKA followed by UKA and TKA at two years postoperatively. Notably, medical complications were much less common after all partial knee replacement types when compared to TKA. These findings may be used to guide patients in selecting the appropriate surgery to meet their goals and expectations.

Reduced Early Revision Surgery and Medical Complications in Computer-assisted Knee Arthroplasty Compared With Non-computer-assisted Arthroplasty.

BACKGROUND: Computer assistance can help surgeons achieve mechanical accurate alignment, but the clinical effect of this technology in different arthroplasty types remains controversial because of conflicting functional outcomes, revision rates, and complication rates. The goal of this study was to compare 90-day medical complications and 1 and 2-year revision surgeries after computer-assisted patellofemoral arthroplasty, unicompartmental knee arthroplasty (CA-UKA), bicompartmental knee arthroplasty (CA-BKA), and total knee arthroplasty (CA-TKA) with non-computer-assisted procedures. METHODS: A retrospective cohort analysis was conducted using the Mariner data set of the PearlDiver Patient Records Database from 2010 to 2018. Current Procedural Terminology codes were used to identify patients who underwent patellofemoral arthroplasty, unicompartmental knee arthroplasty, bicompartmental knee arthroplasty, and total knee arthroplasty with or without computer assistance for osteoarthritis. All included patients were followed up for 2 years. Univariate and multivariable analyses were conducted. RESULTS: On multivariable analysis, revision within 1 year was decreased in patients who underwent computer-assisted patellofemoral arthroplasty (odds ratio [OR]: 0.541, P = 0.031), CA-UKA (OR: 0.798, P = 0.019), and computer-assisted bicompartmental knee arthroplasty (OR: 0.186, P = 0.025) compared with the same surgeries without technology assistance. CA-TKA had decreased odds of revision for aseptic loosening at 2 years (OR: 0.789, P < 0.001). CA-UKA and CA-TKA had decreased risk of overall 90-day medical complications (OR: 0.838, P < 0.001; OR: 0.903, P < 0.001, respectively) and major complications (OR: 0.750, P = 0.004; OR: 0.822, P < 0.001, respectively). DISCUSSION: Complication rates and revision surgeries for all arthroplasty types were equivalent or more favorable when computer assistance was used during surgery. Our results quantify some early benefits to using computer assistance in total and partial knee arthroplasties.