A time out for prayer.

Compassionate care of the surgical patient recognizes the wholeness of each individual. Patients and their caregivers come to healthcare providers with the hope of relief from pain and suffering and aspirations for the potential to feel well or be "normal" again. Many lean on their personal faith and prayer for spiritual comfort and petitions for healing. We discuss a case in which prayer is incorporated into the surgical Time Out, a scenario not uncommon in faith-based hospitals, and offer a framework to evaluate the practice that incorporates ethical principles of beneficence, non-maleficence, patient/parental autonomy, justice, and the fiduciary responsibility of the healthcare provider.

Revision Dual Mobility Constructs With Unmatched Acetabular and Femoral Components Do Not Increase Failure Rate.

BACKGROUND: Dual mobility (DM) constructs for revision total hip arthroplasty (THA) have continued to grow in popularity to mitigate instability. This benefit comes at the cost of potential unique modes of failure, and there are theoretical concerns that combining femoral and acetabular components from different manufacturers could lead to increased failure rates. We aimed to investigate rates of reoperation between matched and unmatched DM implants used in revision THA. METHODS: We retrospectively reviewed 217 revision THAs performed with DM constructs between July 2012 and September 2021 at a single institution. Dual mobility (DM) constructs were classified as "matched" if the acetabular and femoral components were manufactured by the same company. They were classified as "unmatched" if the acetabular and femoral components were manufactured by different companies. The primary outcome was reoperation for any reason. RESULTS: There were 136 matched DM constructs and 81 unmatched constructs. Average follow-up was 4.6 years (range, 2.0 to 9.6 years). There was no difference in reoperation rate between matched and unmatched groups (11.0 versus 13.6%, P = .576). The most common reasons for reoperation in both groups were instability and periprosthetic joint infection. There was 1 revision for intraprosthetic dislocation in the matched group. CONCLUSIONS: The use of unmatched DM components in revision THA was common and did not increase the risk of reoperation at an average of 4.6-year follow-up. This information can be helpful in operative planning, but further research on long-term survival will be necessary.

Racial Disparities in Treatment and Outcomes of Patients With Hepatitis C Undergoing Elective Total Joint Arthroplasty.

BACKGROUND: African Americans have the highest prevalence of chronic Hepatitis C virus (HCV) infection. Racial disparities in outcome are observed after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study sought to identify if disparities in treatments and outcomes exist between Black and White patients who have HCV prior to elective THA and TKA. METHODS: Patient demographics, comorbidities, HCV characteristics, perioperative variables, in-hospital outcomes, and postoperative complications at 1-year follow-up were collected and compared between the 2 races. Patients who have preoperative positive viral load (PVL) and undetectable viral load were identified. Chi-square and Fisher's exact tests were used to compare categorical variables, while 2-tailed Student's Kruskal-Wallis t-tests were used for continuous variables. A P value of less than .05 was statistically significant. RESULTS: The liver function parameters, including aspartate aminotransferase and model for end-stage liver disease scores, were all higher preoperatively in Black patients undergoing THA (P = .01; P < .001) and TKA (P = .03; P = .003), respectively. Black patients were more likely to undergo THA (65.8% versus 35.6%; P = .002) and TKA (72.1% versus 37.3%; 0.009) without receiving prior treatment for HCV. Consequently, Black patients had higher rates of preoperative PVL compared to White patients in both THA (66% versus 38%, P = .006) and TKA (72% versus 37%, P < .001) groups. Black patients had a longer length of stay for both THA (3.7 versus 3.3; P = .008) and TKA (4.1 versus 3.0; P = .02). CONCLUSIONS: The HCV treatment prior to THA and TKA with undetectable viral load has been shown to be a key factor in mitigating postoperative complications, including joint infection. We noted that Black patients were more likely to undergo joint arthroplasty who did not receive treatment and with a PVL. While PVL rates decreased over time for both races, a significant gap persists for Black patients.

Child-Pugh Class B or C Liver Disease Increases the Risk of Early Mortality in Patients With Hepatitis C Undergoing Elective Total Joint Arthroplasty Regardless of Treatment Status.

BACKGROUND: Patients with hepatitis C virus (HCV) undergoing primary elective total joint arthroplasty (TJA) are at increased risk of postoperative complications. Patients with chronic liver disease and cirrhosis, specifically Child-Pugh Class B and C, who are undergoing general surgery have high 2-year mortality risks, approaching 60% to 80%. However, the role of Child-Pugh and Model for End-Stage Liver Disease classifications of liver status in predicting survivorship among patients with HCV undergoing elective arthroplasty has not been elucidated. QUESTION/PURPOSE: What factors are independently associated with early mortality (< 2 years) in patients with HCV undergoing arthroplasty? METHODS: We performed a retrospective study at three tertiary academic medical centers and identified patients with HCV undergoing primary elective TJA between January 2005 and December 2019. Patients who underwent revision TJA and simultaneous primary TJA were excluded. A total of 226 patients were eligible for inclusion in the study. A further 25% (57) were excluded because they were lost to follow-up before the minimum study requirement of 2 years of follow-up or had incomplete datasets. After the inclusion and exclusion criteria were applied, the final cohort consisted of 75% (169 of 226) of the initial patient population eligible for analysis. The mean follow-up duration was 53 ± 29 months. We compared confounding variables for mortality between patients with early mortality (16 patients) and surviving patients (153 patients), including comorbidities, HCV and liver characteristics, HCV treatment, and postoperative medical and surgical complications. Patients with early postoperative mortality were more likely to have an associated advanced Child-Pugh classification and comorbidities including peripheral vascular disease, end-stage renal disease, heart failure, and chronic obstructive pulmonary disease. However, both groups had similar 90-day and 1-year medical complication risks including myocardial infarction, stroke, pulmonary embolism, and reoperations for periprosthetic joint infection and mechanical failure. A multivariable regression analysis was performed to identify independent factors associated with early mortality, incorporating all significant variables with p < 0.05 present in the univariate analysis. RESULTS: After accounting for significant variables in the univariate analysis such as peripheral vascular disease, end-stage renal disease, heart failure, chronic obstructive pulmonary disease, and liver fibrosis staging, Child-Pugh Class B or C classification was found to be the sole factor independently associated with increased odds of early (within 2 years) mortality in patients with HCV undergoing elective TJA (adjusted odds ratio 29 [95% confidence interval 5 to 174]; p < 0.001). The risk of early mortality in patients with Child-Pugh Class B or C was 64% (seven of 11) compared with 6% (nine of 158) in patients with Child-Pugh Class A (p < 0.001). CONCLUSION: Patients with HCV and a Child-Pugh Class B or C at the time of elective TJA had substantially increased odds of death, regardless of liver function, cirrhosis, age, Model for End-Stage Liver Disease level, HCV treatment, and viral load status. This is similar to the risk of early mortality observed in patients with chronic liver disease undergoing abdominal and cardiac surgery. Surgeons should avoid these major elective procedures in patients with Child-Pugh Class B or C whenever possible. For patients who feel their arthritic symptoms and pain are unbearable, surgeons need to be clear that the risk of death is considerably elevated. LEVEL OF EVIDENCE: Level III, therapeutic study.

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.

Unicondylar Knee Arthroplasty Has Fewer Complications but Higher Revision Rates Than Total Knee Arthroplasty in a Study of Large United States Databases.

BACKGROUND: Unicondylar knee arthroplasty (UKA) has superior functional outcomes compared to total knee arthroplasty (TKA) with good mid-term and long-term survival data from high-volume institutions. We sought to quantify the risk of complications, re-operation/revision, hospital re-admission for any reason, and mortality of knee arthroplasty patients in the US patient population using 2 large databases. METHODS: UKA and TKA patients who were identified in the 2002-2011, 5% sample of Medicare data and 2004-2012 (June) MarketScan Commercial and Medicare Supplemental Databases were followed to evaluate the risk of complications, hospital re-admission for any reason, and mortality within 90 days of surgery. Survival probability defined by re-operation was calculated using the Kaplan-Meier method at 0.5, 2, 5, 7, and up to 10 years post-operatively. RESULTS: Compared to UKA, complication rates for TKA patients were significantly higher, including wound complication, pulmonary embolism, stiffness, peri-prosthetic joint infection, myocardial infarction, re-admission, and death. Age was found to be a significant risk factor (P < .05) for all complications in the Medicare cohort, except stiffness (P = .839), and all complications in the MarketScan cohort, except re-admission (P = .418), whereas gender had a variable effect on complications based on age. Survivorship of UKA was lower than TKA at all time points. Additionally, younger age adversely affected implant survival. By 7 years post-surgery, UKA survivorship in the Medicare and MarketScan cohorts was 80.9% and 74.4%, respectively. In contrast, TKA survivorship for the same cohorts was 95.7% and 91.9% by the same time point. CONCLUSION: Patients undergoing UKA have fewer post-operative complications and re-admissions than those undergoing TKA. However, patients undergoing UKA have a higher rate of re-operation and revision at up to 10 years of follow-up. It appears that age, as well as surgeon and hospital volume significantly impacts implant survivorship while gender does not have a relation. LEVEL OF EVIDENCE: Level III.

Incorporation of a Global Surgery Rotation into an Academic General Surgery Residency Program: Impact and Perceptions.

INTRODUCTION: Global surgery is increasingly recognized as a vital component of international public health. Access to basic surgical care is limited in much of the world, resulting in a global burden of treatable disease. To address the lack of surgical workforce in underserved environments and to foster ongoing interest in global health among US-trained surgeons, our institution established a residency rotation through partnership with an academic hospital in Kijabe, Kenya. This study evaluates the perceptions of residents involved in the rotation, as well as its impact on their future involvement in global health. MATERIALS AND METHODS: A retrospective review of admission applications from residents matriculating at our institution was conducted to determine stated interest in global surgery. These were compared to post-rotation evaluations and follow-up surveys to assess interest in global surgery and the effects of the rotation on the practices of the participants. RESULTS: A total of 78 residents matriculated from 2006 to 2016. Seventeen participated in the rotation with 76% of these reporting high satisfaction with the rotation. Sixty-five percent had no prior experience providing health care in an international setting. Post-rotation surveys revealed an increase in global surgery interest among participants. Long-term interest was demonstrated in 33% (n = 6) who reported ongoing activity in global health in their current practices. Participation in global rotations was also associated with increased interest in domestically underserved populations and affected economic and cost decisions within graduates' practices.

Does Intrathecal Morphine in Spinal Anesthesia Have a Role in Modern Multimodal Analgesia for Primary Total Joint Arthroplasty?

BACKGROUND: Intrathecal morphine (ITM) combined with bupivacaine spinal anesthesia can improve postoperative pain, but has potential side effects of postoperative nausea/vomiting (PONV) and pruritus. With the use of multimodal analgesia and regional anesthetic techniques, postoperative pain control has improved significantly to a point where ITM may be avoided in total joint arthroplasty (TJA). METHODS: We performed a retrospective study of primary TJA patients who underwent a standardized multimodal recovery pathway and received bupivacaine neuraxial anesthesia with ITM vs bupivacaine neuraxial anesthesia alone (control). RESULTS: In total, 598 patients were identified (131 controls, 467 ITMs) with similar demographics. On postoperative day 0 (POD 0), ITM patients had significantly lower mean visual analog scale scores (1.5 ± 1.6 vs 2.5 ± 1.9, P < .001) and consumed less oral morphine equivalents (10.5 ± 25.4 vs 16.8 ± 27.2, P = .013). ITM patients walked further compared to controls by POD 1 (133.6 ± 159.6 vs 97.3 ± 141 m, P = .028) and were less likely to develop PONV during their entire hospital stay (38.5% vs 48.6%, P = .043). No significant differences were seen for total morphine equivalents consumption, rate of discharge to care facility, length of stay, and 90-day readmission rates. CONCLUSION: ITM was associated with improved POD 0 pain scores and less initial oral/intravenous opioid consumption, which likely contributes to the subsequent improved mobilization and lower rates of PONV. In the setting of a modern regional anesthesia and multimodal analgesia recovery plan for TJA, ITM can still be considered for its benefits.

Pediatric solid tumors in Africa: different biology?

PURPOSE OF REVIEW: To review the recent literature regarding biologic characteristics of pediatric solid tumors in African children. RECENT FINDINGS: Data regarding pediatric solid tumors in Africa, while increasing, remain sparse when considering the ethnic and geographic diversity of the continent. Recent work, especially regarding nephroblastoma in Kenya, has identified some biologic variability among local tribes but also when compared with North American tumors. In general, reports from across the continent reveal markedly poorer survival for pediatric patients with solid tumors when compared with high-resourced regions. SUMMARY: Multiple resource-related and infrastructure-related challenges contribute to poorer outcomes, and these require systematic, multidisciplinary, and structured solutions. Socioeconomic factors and limited access to care currently seem to drive the survival outcomes in children with solid cancers in Africa.

A Resident-led Initiative Improves Screening and Treatment for Vitamin D Deficiency in Patients with Hip Fractures.

BACKGROUND: Acute hip fractures carry a high risk of morbidity and are associated with low vitamin D levels. Improvements in screening and treating low vitamin D levels may lead to lower fall rates and a lower likelihood of additional fragility fractures. However, patients with low vitamin D levels often remain unassessed and untreated, even after they experience these fractures. QUESTIONS/PURPOSES: We wished to determine whether a resident-led initiative can improve (1) screening for and (2) treatment of vitamin D deficiency in patients with acute hip fractures. METHODS: Our department initiated a housestaff-led, quality improvement project focused on screening and treating vitamin D deficiency in patients with acute hip fractures. Screening encompassed checking serum 25-hydroxyvitamin D level during the acute hospitalization, and treating was defined as starting supplementation before discharge when the serum 25-hydroxyvitamin D level was less than 30 ng/mL. To evaluate the efficacy of this program, an administrative database identified 283 patients treated surgically for an acute hip fracture between July 2010 and June 2014. This period included 2 years before program initiation (Year 1, n = 65 patients; Year 2, n = 61 patients), the initial program year (Year 3, n = 66 patients), and the subsequent program year (Year 4, n = 91 patients). Followup was extended to 6 weeks after treatment with 9.2% (26/282) of patients lost to followup. Eight patients were excluded owing to documented intolerance of vitamin D supplementation. There were no differences regarding patient demographics, fracture type, or treatment rendered across these 4 years. The primary endpoints were the proportion of patients screened and treated for vitamin D deficiency. The secondary endpoint was the continuation of vitamin D supplementation at the patient's 6 week followup, according to the patient's medication list at that visit. This analysis included all patients, assuming those lost to followup had not continued supplementation. ANOVA and chi-square tests were used to evaluate the differences in demographic data and in screening and treating rates. RESULTS: Screening for vitamin D deficiency improved after initiation of the resident-led quality improvement program, with screening performed for 31% of patients in Year 1 (20/65; odds ratio [OR], 0.44; 95% CI, 0.26-0.75), 20% of patients in Year 2 (12/61; OR, 0.24; 95% CI, 0.13-0.46), 46% of patients in Year 3 (30/66; OR, 0.83; 95% CI, 0.51-1.35), and 88% of patients in Year 4 (80/91; OR, 7.27; 95% CI, 3.87-13.7) (p < 0.001). Vitamin D supplementation was initiated for 33% of patients in Year 1 (21/63; OR, 0.5; 95% CI, 0.30-0.84), 28% in Year 2 (17/61; OR, 0.39; 95% CI, 0.22-0.68), 50% in Year 3 (32/64; OR,1.00; 95% CI, 0.61-1.63), and 76% in Year 4 (65/86; OR, 3.10; 95% CI, 1.89-5.06) (p < 0.001). At early postoperative followup, we saw substantial improvement in the proportion of patients who continued receiving vitamin D supplementation: Year 1, 12% (8/64; OR, 0.14; 95% CI, 0.07-0.30); Year 2, 15% (9/61; OR, 0.17; 95% CI, 0.09-0.35); Year 3, 26% (16/64; OR, 0.33; 95% CI, 0.19-0.59); and Year 4, 46% (40/86; OR, 0.87; 95% CI, 0.57-1.33) (p < 0.001). CONCLUSIONS: Implementation of a resident-led quality improvement program resulted in higher rates of screening and treating vitamin D deficiency for patients with acute hip fractures. Housestaff-based initiatives may be an effective way to improve care processes that target improvements in bone health.

Length of Endoprosthetic Reconstruction in Revision Knee Arthroplasty Is Associated With Complications and Reoperations.

BACKGROUND: Complex revision total knee arthroplasty (TKA) often calls for endoprosthetic reconstruction to address bone loss, poor bone quality, and soft tissue insufficiency. Larger amounts of segmental bone loss in the setting of joint replacement may be associated with greater areas of devascularized tissue, which could increase the risk of complications and worsen functional results. QUESTIONS/PURPOSES: Are longer endoprosthetic reconstructions associated with (1) higher risk of deep infection; (2) increased risk of reoperation and decreased implant survivorship; or (3) poorer ambulatory status? METHODS: This is a single-institution retrospective case series of nononcologic femoral endoprosthetic reconstructions for revision TKA from 1995 to 2013 (n = 32). Cases were categorized as distal (n = 17) or diaphyseal (n = 15) femoral reconstructions based on extension to or above the supracondylar metaphyseal-diaphyseal junction, respectively. Five patients from each group were lost to followup before 2 years (distal mean 4 years [range, 2-8 years]; diaphyseal mean = 6 years [range, 2-16 years]), and one of the 12 distal reconstructions and two of the 10 diaphyseal reconstructions had not been evaluated within the past 5 years. Clinical outcomes and ambulatory status (able to walk or not) were assessed through chart review by authors not involved in any cases. Prior incidence of periprosthetic joint infection was high in both groups (distal = seven of 12 versus diaphyseal = four of 10; p = 0.670). RESULTS: Patients with diaphyseal femoral replacements were more likely to develop postoperative deep infections than patients with distal femoral replacements (distal = three of 12 versus diaphyseal = nine of 10; p = 0.004). Implant survivorship (revision-free) for diaphyseal reconstructions was worse at 2 years (distal = 100%, 95% confidence interval [CI], 100%-100% versus diaphyseal = 40%, 95% CI, 19%-86%; p = 0.001) and 5 years (distal = 90%, 95% CI, 75%-100% versus diaphyseal = 30%, 95% CI, 12%-73%; p = 0.001). Infection-free, revision-free survival (retention AND no infection) was worse for diaphyseal femoral replacing reconstructions than for distal femoral replacements at 2 years (distal = 70%, 95% CI, 48%-100% versus diaphyseal = 20%, 95% CI, 6%-69%; p = 0.037) and 5 years (distal = 70%, 95% CI, 48%-100% versus diaphyseal = 10%, 95% CI, 2%-64%; p = 0.012). There was no difference with the small numbers available in proportion of patients able to walk (distal reconstruction = eight of 11 versus diaphyseal = seven of 10; p = 1.000), although all but one patient in each group required walking aids. CONCLUSIONS: Endoprosthetic femoral reconstruction is a viable salvage alternative to amputation for treatment of failed TKA with segmental distal femoral bone loss. In our small series even with substantial loss to followup and likely best-case estimates of success, extension proximal to the supracondylar metaphyseal-diaphyseal junction results in higher infection and revision risk. In infection, limb salvage remains possible with chronic antibiotic suppression, which we now use routinely for all femoral replacement extending into the diaphysis. LEVEL OF EVIDENCE: Level III, therapeutic study.

Preoperative Anemia Independently Predicts 30-Day Complications After Aseptic and Septic Revision Total Joint Arthroplasty.

BACKGROUND: Preoperative anemia is a common, important risk factor for adverse events after joint arthroplasty surgery. It affects 21%-35% patients undergoing total joint arthroplasty. To date, few studies have investigated the effect of preoperative anemia, specifically in revision total joint arthroplasty surgery. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent revision total joint arthroplasty from 2006 to 2014. We matched 6830 patients undergoing aseptic revision (3415 anemic vs 3415 not anemic) and 2650 patients undergoing septic revision (1325 anemic vs 1325 not anemic). In each cohort, patients were propensity score-matched 1:1 by the presence of preoperative anemia. The inpatient hospitalization data, postoperative complications, as well as demographics and comorbidities were compared between patients with or without anemia who underwent revision total joint arthroplasty. RESULTS: After adjusting for comorbidities via multivariate regression, anemia was associated with an increased risk of overall complications (aseptic: odds ratio [OR], 1.45; 95% confidence interval [CI], 1.24-1.70; P < .001; septic: OR, 2.16; 95% CI, 1.83-2.56; P < .001), deep infection (aseptic: OR, 1.68; 95% CI, 1.19-2.38; P = .003; septic: OR, 1.44; 95% CI, 1.06-1.94; P = .018), mortality (aseptic: OR, 2.18; 95% CI, 1.09-4.36; P = .028; septic: OR, 3.16; 95% CI, 1.03-9.74; P = .045), and increased hospital length of stay (aseptic: adjusted coefficient, 1.02 days; 95% CI, 0.73-1.31; P < .001; septic: adjusted coefficient, 2.04 days; 95% CI, 1.53-2.55; P < .001). CONCLUSION: Preoperative anemia is independently associated with postoperative complications, mortality, and increased length of stay in revision total joint arthroplasty. Further studies are needed to evaluate if preoperative treatment of anemia may modify this risk.

Early Outcomes of Primary Total Hip Arthroplasty After Prior Lumbar Spinal Fusion.

BACKGROUND: The coexistence of degenerative hip disease and spinal pathology is not uncommon with the number of surgical treatments performed for each condition increasing annually. The limited research available suggests spinal pathology portends less pain relief and worse outcomes after total hip arthroplasty (THA). We hypothesize that primary THA patients with preexisting lumbar spinal fusions (LSF) experience worse early postoperative outcomes. METHODS: This study is a retrospective matched cohort study. Primary THA patients at 1 institution who had undergone prior LSF (spine arthrodesis-hip arthroplasty [SAHA]) were identified and matched to controls of primary THA without LSF. Early outcomes (<90 days) were compared. RESULTS: From 2012 to 2014, 35 SAHA patients were compared to 70 matched controls. Patients were similar in age, sex, American Society of Anesthesiologist score, body mass index, and Charlson Comorbidity Index. SAHA patients had higher rates of complications (31.4% vs 8.6%, P = .008), reoperation (14.3% vs 2.9%, P = .040), and general anesthesia (54.3% vs 5.7%, P = .0001). Bivariate analysis demonstrated SAHA to predict reoperation (odds ratio, 5.67; P = .045) and complications (odds ratio, 4.89; P = .005). With the numbers available, dislocations (0% vs 2.8%), infections (0% vs 8.6%), readmissions, postoperative walking distance, and disposition only trended to favor controls (P > .05). Comparing controls to SAHA patients with <3 or ≥3 levels fused, longer fusions had increased cumulative postoperative narcotic consumption (mean morphine equivalents, 44.3 vs 46.9 vs 169.4; P = .001). CONCLUSION: Patients with preexisting LSF experience worse early outcomes after primary THA including higher rates of complications and reoperation. Lower rates of neuraxial anesthesia and increased narcotic usage represent potential contributors. The complex interplay between the lumbar spine and hip warrants attention and further investigation.

The James A. Rand Young Investigator's Award: Administrative Claims vs Surgical Registry: Capturing Outcomes in Total Joint Arthroplasty.

BACKGROUND: Administrative claims in total joint arthroplasty are used for observational studies and payment adjustments under the Comprehensive Care for Joint Replacement (CJR) legislation. Claims data have not been validated against prospective surgical outcome registries for primary total hip (THA) or knee arthroplasty (TKA). We hypothesized that significant differences in reported comorbidity and adverse event measures exist between administrative claims and prospective registry data relevant to payment adjudication under the CJR reimbursement model. METHODS: Comorbidities and outcomes in primary TKA and THA in the United Healthcare and Medicare Standard Analytical File 5% Sample insurance claims datasets (PearlDiver Technologies, Inc) were compared to age-matched cohorts from the National Surgical Quality Improvement Program (ACS-NSQIP) surgical outcomes data from 2007 to 2011 using comparable International Classification of Diseases, Ninth Revision, Clinical Modification and Current Procedural Terminology codes at 30, 90, and 360 days from index arthroplasty. Pearson's chi-square test was used for statistical analyses. RESULTS: The total study population included 93,953 primary THA and 176,944 TKA patients. Primary TKA and THA patients in insurance claims cohorts had significantly fewer reported comorbidities, higher rates of surgical site infection, pulmonary embolism, wound dehiscence, thromboembolic events, and neurologic deficits, and lower reported rates of revision surgery than ACS-NSQIP cohorts within 30 days of primary TKA and THA. Cumulative incidence of adverse events increased significantly from 30 to 360 days after primary arthroplasty. CONCLUSION: We report significant discordance in the prevalence of patient comorbidities and incidence of adverse events in primary THA and TKA between ACS-NSQIP and the administrative claims data of Medicare and United Healthcare. These disparities have implications for observational outcome studies as well as payment adjudication under the CJR reimbursement model in total joint arthroplasty.

Methylene Blue-Guided Debridement as an Intraoperative Adjunct for the Surgical Treatment of Periprosthetic Joint Infection.

BACKGROUND: Current methods to identify infected tissue in periprosthetic joint infection (PJI) are inadequate. The purpose of this study was (1) to assess methylene blue-guided surgical debridement as a novel technique in PJI using quantitative microbiology and (2) to evaluate clinical success based on eradication of infection and infection-free survival. METHODS: Sixteen total knee arthroplasty patients meeting Musculoskeletal Infection Society criteria for PJI undergoing the first stage of 2-stage exchange arthroplasty were included in this prospective study. Dilute methylene blue (0.1%) was instilled in the knee before debridement, residual dye was removed, and stained tissue was debrided. Paired tissue samples, stained and unstained, were collected from the femur, tibia, and capsule during debridement. Samples were analyzed by neutrophil count, semiquantitative culture, and quantitative polymerase chain reaction (PCR). Clinical success was a secondary outcome. RESULTS: The mean age was 64.0 ± 6.0 years, and follow-up was 24.4 ± 3.5 months. More bacteria were found in methylene blue-stained vs unstained tissue-based on semiquantitative culture (P = .001). PCR for staphylococcal species showed 9-fold greater bioburden in methylene blue-stained vs unstained tissue (P = .02). Tissue pathology found 53 ± 46 polymorphonuclear leukocytes per high-power field in methylene blue-stained vs 4 ± 13 in unstained tissue (P = .0001). All subjects cleared their primary infection and underwent reimplantation. At mean 2-year follow-up, 25% of patients failed secondary to new infection with a different organism. CONCLUSION: These results suggest a role for methylene blue in providing a visual index of surgical debridement in the treatment of PJI.

Long-Acting Opioid Use Independently Predicts Perioperative Complication in Total Joint Arthroplasty.

BACKGROUND: Opioid therapy is an increasingly used modality for treatment of musculoskeletal pain despite multiple associated risks. The purpose of this study was to evaluate how preoperative opioid use affects early outcomes after total joint arthroplasty. METHODS: A total of 174 patients undergoing total joint arthroplasty were matched by age, gender, and procedure into 3 groups stratified by preoperative opioid use (nonuser, short acting [eg, Vicodin], long acting [eg, Oxycontin]). RESULTS: Compared to nonusers, preoperative long-acting use was associated with increased postoperative mean opioid consumption (46 mg vs 366 mg mean morphine equivalents, P < .001) and independently predicted complications within 90 days (odds ratio: 6.15, confidence interval: [1.46, 25.95], P = .013). CONCLUSION: Preoperative opioid use should be disclosed as a risk factor for complication to patients and taken into consideration by physicians before initiating opioid management.

Significant Functional Improvement at 2 Years After Isolated Patellofemoral Arthroplasty With an Onlay Trochlear Implant, But Low Mental Health Scores Predispose to Dissatisfaction.

INTRODUCTION: We reviewed the clinical and radiographic outcomes of a consecutive series of patients who underwent patellofemoral arthroplasty (PFA) using a modern onlay-style trochlear design and all-polyethylene patellar component. An additional goal of the study was to elucidate, for the first time, the extent to which patients were satisfied with their implant and whether expectations were met after undergoing PFA. METHODS AND MATERIALS: We identified a consecutive series of 70 knees (53 patients) treated with primary isolated PFA between October 2007 and May 2012. For our clinical outcomes analysis, we included patients with a minimum follow-up of 2 years and available preoperative original Knee Society scores. RESULTS: At an average 4.9 years of follow-up, the mean range of motion and Knee Society Knee and Function scores improved significantly, and less than 4% of patients required revision arthroplasty. There was no radiographic evidence of component loosening or wear. Despite these improvements, new Knee Society scores indicated that fewer than two-thirds of patients were satisfied or had their expectations met. Dissatisfied patients and those whose expectations were not met had significantly lower Mental Health scores according to the Short Form-36 following PFA. CONCLUSIONS: Despite the clinical and radiographic success of this implant, patient satisfaction remained low, which may be partially explained by poor mental health.

Prior Lumbar Spinal Arthrodesis Increases Risk of Prosthetic-Related Complication in Total Hip Arthroplasty.

BACKGROUND: Degenerative hip disorders often coexist with degenerative changes of the lumbar spine. Limited data on this patient population suggest inferior functional improvement and pain relief after surgical management. The purpose of this study is to compare the rates of prosthetic-related complication after primary total hip arthroplasty (THA) in patients with and without prior lumbar spine arthrodesis (SA). METHODS: Medicare patients (n = 811,601) undergoing primary THA were identified and grouped by length of prior SA (no fusion, 1-2 levels fused [S-SAHA], and ≥3 levels fused [L-SAHA]). RESULTS: Compared with controls, patients with prior SA had significantly higher rates of complications including dislocation (control: 2.36%; S-SAHA: 4.26%; and L-SAHA: 7.51%), revision (control: 3.43%, S-SAHA: 5.55%, and L-SAHA: 7.77%), loosening (control: 1.33%, S-SAHA: 2.10%, and L-SAHA: 3.04%), and any prosthetic-related complication (control: 7.33%, S-SAHA: 11.15% [relative risk: 1.52], and L-SAHA: 14.16% [relative risk: 1.93]) within 24 months (P < .001). CONCLUSION: The interplay of coexisting degenerative hip and spine disease deserves further attention of both arthroplasty and spine surgeons.

Evaluating online information regarding the direct anterior approach for total hip arthroplasty.

We evaluated the quality of information available on the Internet regarding the direct anterior approach (DAA). The top 50 Web sites from three major search engines (Google, Yahoo!, and Bing) were tabulated utilizing the search term direct anterior hip replacement. Of these, only 22% were authored by a hospital/university, while 60% were by a private physician/clinic. Most Web sites presented the DAA as "better" than other surgical approaches describing benefits, such as accelerated recovery though only 35% described risks of the approach. While only 39% of sites presented patient eligibility criteria, greater than 75% had the ability to make an appointment. Web sites regarding the DAA provide patients with a limited perspective and may be focused on attracting new patients, as opposed to accurately educating them.