High Area Deprivation Index is Associated With Not Achieving the Patient-acceptable Symptom State After TKA.

BACKGROUND: The Area Deprivation Index (ADI) approximates a patient's relative socioeconomic deprivation. The ADI has been associated with increased healthcare use after TKA, but it is unknown whether there is an association with patient-reported outcome measures (PROMs). Given that a high proportion of patients are dissatisfied with their results after TKA, and the large number of these procedures performed, knowledge of factors associated with PROMs may indicate opportunities to provide support to patients who might benefit from it. QUESTIONS/PURPOSES: (1) Is the ADI associated with achieving the minimum clinically important difference (MCID) for the Knee Injury and Osteoarthritis Outcome Score (KOOS) for pain, Joint Replacement (JR), and Physical Function (PS) short forms after TKA? (2) Is the ADI associated with achieving the patient-acceptable symptom state (PASS) thresholds for the KOOS pain, JR, and PS short forms? METHODS: This was a retrospective study of data drawn from a longitudinally maintained database. Between January 2016 and July 2021, a total of 12,239 patients underwent unilateral TKA at a tertiary healthcare center. Of these, 92% (11,213) had available baseline PROM data and were potentially eligible. An additional 21% (2400) of patients were lost before the minimum study follow-up of 1 year or had incomplete data, leaving 79% (8813) for analysis here. The MCID is the smallest change in an outcome score that a patient is likely to perceive as a clinically important improvement, and the PASS refers to the threshold beyond which patients consider their symptoms acceptable and consistent with adequate functioning and well-being. MCIDs were calculated using a distribution-based method. Multivariable logistic regression models were created to investigate the association of ADI with 1-year PROMs while controlling for patient demographic variables. ADI was stratified into quintiles based on their distribution in our sample. Achievement of MCID and PASS thresholds was determined by the improvement between preoperative and 1-year PROMs. RESULTS: After controlling for patient demographic factors, ADI was not associated with an inability to achieve the MCID for the KOOS pain, KOOS PS, or KOOS JR. A higher ADI was independently associated with an increased risk of inability to achieve the PASS for KOOS pain (for example, the odds ratio of those in the ADI category of 83 to 100 compared with those in the 1 to 32 category was 1.34 [95% confidence interval 1.13 to 1.58]) and KOOS JR (for example, the OR of those in the ADI category of 83 to 100 compared with those in the 1 the 32 category was 1.29 [95% CI 1.10 to 1.53]), but not KOOS PS (for example, the OR of those in the ADI category of 83 to 100 compared with those in the 1 the 32 category was 1.09 [95% CI 0.92 to 1.29]). CONCLUSION: Our findings suggest that social and economic factors are associated with patients' perceptions of their overall pain and function after TKA, but such factors are not associated with patients' perceptions of their improvement in symptoms. Patients from areas with higher deprivation may be an at-risk population and could benefit from targeted interventions to improve their perception of their healthcare experience, such as through referrals to nonemergent medical transportation and supporting applications to local care coordination services before proceeding with TKA. Future research should investigate the mechanisms underlying why socioeconomic disadvantage is associated with inability to achieve the PASS, but not the MCID, after TKA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Cannabis Use Following Total Joint Arthroplasty is Associated With Increased Risks? A Meta-Analysis.

BACKGROUND: With the increased legalization of cannabis, a new unknown emerges for orthopaedic surgeons and their patients. This systematic review aimed to (1) evaluate complications of cannabis use; (2) determine the effects of cannabis on pain and opioid consumption; and (3) evaluate healthcare utilizations associated with cannabis use among patients undergoing total joint arthroplasty (TJA). METHODS: A systematic review was performed. A search of the literature was performed in 5 databases. We included studies between January 2012 and July 2022 reporting cannabis use and complications, pain management, opioid consumption, length of stay, costs, or functional outcomes following TJA. A meta-analysis of odds ratios (ORs) and continuous variables was performed. A total of 19 articles were included in our final analysis. RESULTS: Cannabis use was associated with higher odds for deep vein thrombosis (DVT) (OR: 1.46, 95% Confidence Interval [CI]: 1.13 to 1.89) and revisions (OR: 1.47 [95% CI: 1.41 to 1.53]) in total knee arthroplasty (TKA). Cannabis use was associated with similar odds for DVT in total hip arthroplasty (THA) (OR: 1.30 [95% CI: 0.79 to 2.13]), pulmonary embolus in both TKA (OR: 1.29 [95% CI: 0.95 to 1.77]), THA (OR: 0.55 [95% CI: 0.09 to 3.28]), and cardiovascular complications in TKA (OR: 1.97 [95% Cl: 0.93 to 4.14]). Cannabis use did not alter pain scores, opioid consumption, or cost of care in THA (estimate: $2,550.51 [95% CI: $356.58 to $5,457.62]) but was associated with higher costs in TKA (estimate: $3,552.46 [95% CI: $1,729.71 to $5,375.22]). There was no difference in lengths of stay or functional outcomes; however, there may be a potentially increased risk for prosthetic complications, pneumonia, and cerebrovascular accidents among cannabis users. CONCLUSION: Cannabis use may be associated with an increased risk of DVTs, revisions, pneumonia, cerebrovascular accidents, and cardiac complications after TJA. Higher-level studies are needed to ascertain the impact of cannabis use for patients undergoing TJA.

Patient satisfaction and patient-reported outcomes do not vary by BMI class in total hip arthroplasty.

PURPOSE: Obesity has been identified as a risk factor for postoperative complications in patients undergoing total hip arthroplasty (THA). This study aimed to investigate patient-reported outcomes, pain, and satisfaction as a function of body mass index (BMI) class in patients undergoing THA. METHODS: 1736 patients within a prospective observational study were categorized into BMI classes. Pre- and postoperative Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR), satisfaction, and pain scores were compared by BMI class using one-way ANOVA. RESULTS: Healthy weight patients reported the highest preoperative HOOS JR (56.66 ± 13.35) compared to 45.51 ± 14.45 in Class III subjects. Healthy weight and Class III patients reported the lowest (5.65 ± 2.01) and highest (7.06 ± 1.98, p < 0.0001) preoperative pain, respectively. Changes in HOOS JR scores from baseline suggest larger improvements with increasing BMI class, where Class III patients reported an increase of 33.7 ± 15.6 points at 90 days compared to 26.1 ± 17.1 in healthy weight individuals (p = 0.002). Fewer healthy weight patients achieved the minimal clinically important difference (87.4%) for HOOS JR compared to Class II (96.5%) and III (94.7%) obesity groups at 90 days postoperatively. Changes in satisfaction and pain scores were largest in the Class III patients. Overall, no functional outcomes varied by BMI class postoperatively. CONCLUSION: Patients of higher BMI class reported greater improvements following THA. While risk/benefit shared decision-making remains a personalized requirement of THA, this study highlights that utilization of BMI cutoff may not be warranted based on pain and functional improvement.

Preoperative Veteran RAND-12 Mental Composite Score of >60 Associated With Increased Likelihood of Patient Satisfaction After Total Hip Arthroplasty.

BACKGROUND: The present study aimed to determine the distribution of Veterans RAND 12-Item health survey (VR-12) mental component scores (MCS) of patients undergoing primary total hip arthroplasty (THA) and the thresholds of VR-12 MCS scores that predict higher health care utilizations and 1-year patient-reported outcome measures (PROMs). METHODS: A prospective cohort of 4,194 primary THA patients (January 2016 to December 2019) were included. Multivariable and cubic spline regression models were used to test for associations between preoperative VR-12 MCS and postoperative outcomes, including: 90-day hospital resource utilization (nonhome discharge, prolonged length of stay [LOS](ie, ≥3 days), all-cause readmission), attainment of patient acceptable symptom state (PASS) at 1-year postoperative and substantial clinical benefit (SCB) in the hip disability osteoarthritis outcome score (HOOS)-pain and HOOS-physical short form. RESULTS: Lower VR-12 MCS was associated with older age, obesity, Black race, women, and smokers (all P < .001). Preoperative VR-12 MCS<20 was associated with more than twice the odds of nonhome discharge (odds ratio [OR]:2.31) and prolonged LOS (OR: 3.46). VR-12 MCS >60 was associated with higher odds of achieving PASS (OR: 2.00) and SCB in HOOS-joint related (JR) (OR: 1.16). Starting VR-12 MCS ≤40, there were exponentially higher odds of worse outcomes. CONCLUSION: Low preoperative VR-12 MCS, specifically less than 40, may predict increased health care utilization. Furthermore, preoperative VR-12 MCS>60 predicts greater satisfaction at 1 year and higher odds of achieving SCB in HOOS-JR. Quantifiable thresholds for VR-12 MCS may aid in shared decision-making and patient counseling in setting expectations or may guide specific care pathway interventions to address mental health during THA. LEVEL OF EVIDENCE: II.

Blood management in total hip arthroplasty: a nationwide trend analysis from 2011 to 2018.

PURPOSE: With the advent of practice changes surrounding preoperative patient optimization and postoperative protocols, a marked reduction has been reported in blood transfusion rates following total hip arthroplasty (THA). Thus, the purpose of this study was to examine differences in the prevalence of preoperative anemia, thrombocytopenia, elevated international normalized ratio (INR), bleeding disorders, and pre- and postoperative blood transfusions over the last decade. METHODS: From 2011 to 2018, the American College of Surgeons National Quality Improvement Program database was queried for all primary THA procedures (n = 208,796). The following continuous variables were examined using analysis of variance: preoperative hematocrit (HCT), platelet count, and INR. The following categorical variables were analyzed by chi-squared tests: anemia (HCT < 35.5% for females and < 38.5% for males), thrombocytopenia (platelet count < 150,000/µL), INR > 2.0, bleeding disorders, preoperative transfusions, and postoperative transfusions. RESULTS: There were decreases in preoperative anemia (2011: 16.2%; 2018: 11.4%, p < 0.001) and postoperative transfusions (2011: high = 22.2%; 2018: low = 1.3%, p < 0.001). Statistically significant but clinically irrelevant changes were observed in preoperative HCT (2011: low = 40.3, 2018: high = 41.1, p < 0.001), platelet count (2011: low = 248,700; 2018: high = 250,100, p < 0.001), thrombocytopenia (2011: high = 4.9%; 2018: low = 4.3%, p = 0.036), INR > 2.0 (2011: high = 1.1%; 2018: low = 0.7%, p = 0.001), bleeding disorders (2011: high = 2.9%; 2018: low = 2.0%, p < 0.001), and preoperative transfusions (2011: high = 0.2%; 2018: low = 0.1%, p = 0.007). CONCLUSION: Large decreases in the number of patients with preoperative anemia and those receiving postoperative blood transfusion were observed during the study period. Future investigation is needed to ascertain whether this is due to patient optimization, practice changes, "cherry-picking" of healthy patients, or a combination of these factors. LEVEL OF EVIDENCE: III.

Neighborhood Socioeconomic Disadvantage Associated With Increased Healthcare Utilization After Total Hip Arthroplasty.

BACKGROUND: The multifaceted effects of socioeconomic status on healthcare outcomes can be difficult to quantify. The Area Deprivation Index (ADI) quantifies a socioeconomic disadvantage with higher scores indicating more disadvantaged groups. The present study aimed to describe the ADI distribution for primary total hip arthroplasty (THA) patients stratified by patient demographics and to characterize the association of ADI with healthcare utilization (discharge disposition and length of stay [LOS]), 90-day emergency department (ED) visits, and 90-day all cause readmissions. METHODS: Two thousand three hundred and ninety one patients who underwent primary elective THA over a 13-month period were included. A multivariable binary logistic regression analysis with outcomes of nonhome discharge, prolonged LOS (>3 days), 90-day ED visits, and 90-day readmission were performed using predictors of ADI, gender, race, smoking status, body mass index, insurance status, and Charlson comorbidity index. Plots of restricted cubic splines were used to graph associations between ADI as a continuous variable and the outcomes of interest using odds ratios. RESULTS: In the multivariable regression model, there were statistically significant higher odds of nonhome discharge (OR, 1.82; 95% CI, 1.19-2.77, P = .005) for individuals in the 61-80 ADI quintile as compared to the reference group of 21-40. Individuals in the highest ADI quintile, 81-100, had the greatest odds of nonhome discharge (OR, 2.20; 95% CI, 1.39-3.49, P < .001) and prolonged LOS (OR, 1.91, 95% CI, 1.28-2.84, P = .001). CONCLUSIONS: Higher ADI is associated with an increased healthcare utilization within 90 days of THA.

The Potential Effects of Imposing a Body Mass Index Threshold on Patient-Reported Outcomes After Total Knee Arthroplasty.

BACKGROUND: Operative eligibility thresholds based on body mass index (BMI) alone may risk restricting access to improved pain control, function, and quality of life. This study evaluated the use of BMI-cutoffs to offering TKA in avoiding: 1) 90-day readmission, 2) one-year mortality, and 3) failure to achieve clinically important one-year PROMS improvement (MCID). METHODS: A total of 4126 primary elective unilateral TKA patients from 2015 to 2018 were prospectively collected. For specific BMI(kg/m2) cutoffs: 30, 35, 40, 45, and 50, the positive predictive value (PPV) for 90-day readmission, one-year mortality, and failure to achieve one-year MCID were calculated. The number of patients denied complication-free postoperative courses per averted adverse outcome/failed improvement was estimated. RESULTS: Rates of 90-day readmission and one-year mortality were similar across BMI categories (P > .05, each). PPVs for preventing 90-day readmission and one-year mortality were low across all models of BMI cutoffs. The highest PPV for 90-day readmission and one-year mortality was detected at cutoffs of 45 (6.4%) and 40 (0.87%), respectively. BMI cutoff of 40 would deny 18 patients 90-day readmission-free, and 194 patients one-year mortality-free postoperative courses for each averted 90-day readmission/one-year mortality. Such cutoff would also deny 11 patients an MCID per avoided failure. Implementing BMI thresholds alone did not influence the rate of improvements in KOOS-PS, KRQOL, or VR-12. CONCLUSION: Utilizing BMI cutoffs as the sole determinants of TKA ineligibility may deny patients complication-free postoperative courses and clinically important improvements. Shared decision-making supported by predictive tools may aid in balancing the potential benefit TKA offers to obese patients with the potentially increased complication risk and cost of care provision.

The accelerating anuran: evolution of locomotor performance in cane toads (Rhinella marina, Bufonidae) at an invasion front.

As is common in biological invasions, the rate at which cane toads (Rhinella marina) have spread across tropical Australia has accelerated through time. Individuals at the invasion front travel further than range-core conspecifics and exhibit distinctive morphologies that may facilitate rapid dispersal. However, the links between these morphological changes and locomotor performance have not been clearly documented. We used raceway trials and high-speed videography to document locomotor traits (e.g. hop distances, heights, velocities, and angles of take-off and landing) of toads from range-core and invasion-front populations. Locomotor performance varied geographically, and this variation in performance was linked to morphological features that have evolved during the toads' Australian invasion. Geographical variation in morphology and locomotor ability was evident not only in wild-caught animals, but also in individuals that had been raised under standardized conditions in captivity. Our data thus support the hypothesis that the cane toad's invasion across Australia has generated rapid evolutionary shifts in dispersal-relevant performance traits, and that these differences in performance are linked to concurrent shifts in morphological traits.

Total Joint Arthroplasty Outcomes in Patients With a Previously Failed Toxicology Screen: A Propensity Score-Matched Analysis.

BACKGROUND: The purpose of this study is to review the outcomes of a consecutive series of arthroplasty patients who had previously failed a urine toxicology test. Specifically, we assessed (1) mortality at last follow-up; (2) 90-day readmission and reoperation; (3) rate of complications; and (4) hospital length of stay (LOS) and rates of nonhome discharge. METHODS: A single-institution, electronic medical record database was queried for primary arthroplasty patients from 2006 to 2017 who had previously failed a day-of-arthroplasty urine toxicology screen. Patients were matched in a 2:1 ratio with toxicology-negative controls. RESULTS: The mortality rate among toxicology-positive THA patients was 1 of 20 (5%) compared to 0 of 40 among controls (P = .333); the rate of readmission was 3 of 20 (15%) vs 0 of 40 (P = .033); the rate of reoperation was 1 of 20 vs 0 of 40 (P = .333); the rate of surgical complications was 6 of 20 (30%) vs 1 of 40 (2.5%) (P = .004); the rate of medical complication was 4 of 20 (20%) vs 1 of 40 (2.5%) (P = .038); the average LOS was 4 days (range, 1-8 days) vs 2 days (range, 1-10) (P = .002); and the rate of nonhome discharge was 5 of 20 (25%) vs 2 of 40 (5%) patients in the control group (P = .013). The mortality rate among toxicology-positive TKA patients was 1 of 19 (5.3%) compared to 0 of 38 among controls (P = .333); the rate of readmission was 5 of 19 (26.3%) vs 2 of 39 (5.3%) (P = .033); the rate of reoperation was 3 of 19 (15.8%) vs zero (P = .033); the rate of surgical complications was 4 of 21 (21.1%) vs 1 of 38 (2.6%) (P = .038); the rate of medical complications was 5 of 19 (26.3%) vs 2 of 38 (5.3%) (P = .035); the average LOS was 4 days (range, 2-6 days) vs 2 days (range, 1-8 days) (P = .001), the rate of nonhome discharge was 7 of 19 (36.8%) compared to 2 of 38 (5.3%) in the control group (P = .004). CONCLUSION: These results suggest that toxicology-positive patients require a careful discussion of goals of care before undertaking total hip arthroplasty or total knee arthroplasty.

Effects of a Total Knee Arthroplasty Care Pathway on Cost, Quality, and Patient Experience: Toward Measuring the Triple Aim.

BACKGROUND: Care pathways are increasingly important as the shift toward value-based care continues; however, there is an inconsistent literature regarding their efficacy. The authors hypothesized that a total knee arthroplasty (TKA) care pathway, at a multihospital health system, would decrease cost, length of stay (LOS), discharges to inpatient facilities, postoperative complications at 90 days, and improve patient experience. METHODS: A historical control study with multivariable regression was used to determine the association of an evidence-based care pathway with episode of care cost, LOS, discharge disposition, 90-day postoperative complications, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. RESULTS: In total, 6760 primary TKA surgeries were analyzed. Multivariable regression demonstrated that the full protocol period was associated with a decrease in episode of care costs (-8.501%, 95% confidence interval [CI] -9.639 to -7.350), a decrease in LOS (-26.966%, 95% CI -28.516 to -25.382), and an increase in discharges to home (odds ratio [OR] 3.838, 95% CI 3.318-4.446). The full protocol was not associated with a change in 90-day complications (OR 1.067, 95% CI 0.905-1.258) or patient willingness to recommend (OR 1.06, 95% CI 0.72-1.55). Adjusted episode of care cost savings, normalized to average national Medicare reimbursement, were $2360 per patient. CONCLUSION: TKA care pathways are an effective tool for standardizing care and reducing costs across a large health system. Further investigations are needed to develop interventions to consistently reduce complications. National scale implementation of care pathways in TKA could lead to estimated cost reductions of approximately $1.6 billion annually.

Quantifying Blood Loss and Transfusion Risk After Primary vs Conversion Total Hip Arthroplasty.

BACKGROUND: Primary total hip arthroplasty (THA) and conversion THA may result in substantial blood loss, sometimes necessitating transfusion. Despite the complexities of the latter, both are grouped in the same category for quality assessment and reimbursement. This study's purpose was to compare both blood loss and transfusion risk in primary and conversion THA and identify their associated predictors. METHODS: A total of 1616 patients who underwent primary and conversion THA at a single hospital from 2009-2013 were reviewed (primary THA = 1575; conversion THA = 41). Demographics, comorbidities, and perioperative data were collected from electronic records. Blood loss was calculated using a validated method. Transfusion triggers were based on standardized criteria. Separate multivariable regression models for blood loss and transfusion were performed. RESULTS: Conversion THA patients were younger (P = .002), had lower age-adjusted Charlson scores (P = .006), longer surgeries (P < .001), higher blood loss (P < .001), and more transfusions (P < .001). Primary and conversion THA groups were different in terms of surgical approach (P < .001), anesthesia type (P = .002), and venous thromboembolism prophylaxis (P = .01). Compared to primary THA, conversion THA had an average 478.9 mL higher blood loss (P = .003) and increased adjusted odds ratio of 3.2 (P = .019) for transfusion. CONCLUSION: Conversion THA leads to higher blood loss and transfusion compared with primary THA. These differences were quantified in the present study and showed consistent results between the 2 metrics. The differences between these procedures should be addressed during quality assurance because conversion THA is associated with higher resource utilization, which is important in the allocation of resources and tiered reimbursement strategies.

Day of Surgery Affects Length of Stay and Charges in Primary Total Hip and Knee Arthroplasty.

BACKGROUND: Length of hospital stay (LOS) is a large driver of cost after primary total joint arthroplasty (TJA). Strategies to decrease LOS may help reduce the economic burden of TJA. This study's aim was to investigate the effect of day of the week of surgery on mean LOS and total charges following primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: An administrative clinical database at a large US health care system was reviewed for all primary THA and TKA admissions performed between 2010 and 2012 (n = 15,237). Of these, 14,800 cases met our inclusion criteria and were analyzed. Furthermore, the cohort was divided into early (Monday/Tuesday) and late week (Thursday/Friday) surgeries, excluding Wednesday surgeries (n = 2835). Univariate and multiple regression analyses examined the effect of each variable on LOS. RESULTS: Mean LOS for THA and TKA on Monday was 3.54 and 3.35 days and increased to 4.12 and 3.66 days on Friday (P < .0001), respectively. Late vs early week admissions had 0.358 (95% confidence interval: 0.29-0.425, P < .001) additional hospital days. Increased age (0.003 days per unit increase in age, P = .02) and severity of illness score (0.781 days per level increase, P < .001) were associated with increased LOS. Late week surgery had a greater effect on LOS for TKA than for THA. TKAs were associated with higher charges for late week surgery vs early week surgery (P < .001). CONCLUSION: Late week TJA cases, older age, and increasing severity of illness score were associated with increased LOS. Furthermore, late week TKA was associated with increased total charges.

Rivaroxaban Use for Thrombosis Prophylaxis Is Associated With Early Periprosthetic Joint Infection.

BACKGROUND: Periprosthetic joint infection is a disastrous complication after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The use of certain agents to prevent deep vein thrombosis after arthroplasty has been linked to an increased risk of adverse effects including wound drainage and infection. Adverse effects of one alternative, rivaroxaban, was studied in a single community hospital. METHODS: International Classification of Diseases, Clinical Modification 9 codes were used to identify primary THAs and TKAs in an administrative database at one large-volume community hospital performed in 2012. Patients were divided into 2 groups: the study group received rivaroxaban, whereas the control group received another form of chemical thromboprophylaxis for at least 2 weeks postoperative. Demographics, risk factors, and illness severity scores were collected for each group. The primary measured outcome was the incidence of deep surgical site infection (SSI) within 30 days postoperative. RESULTS: A total of 639 TKA or THA patients were included, with 159 patients who received rivaroxaban and 480 who received another form of chemical thromboprophylaxis. There were no significant differences between groups regarding demographics, risk factors, or illness severity scores. Incidence of early deep SSI in the rivaroxaban group was higher than in the control group (2.5% vs 0.2%; P < .015). CONCLUSION: The use of rivaroxaban for thromboprophylaxis led to a significantly increased incidence of deep SSI in a continuous series of patients undergoing primary THA and TKA in a single institution.

Trends in prevalence and complications for smokers who underwent total hip arthroplasty from 2011 to 2019: an analysis of 243,163 patients.

BACKGROUND: Smoking is an established risk factor for postoperative complications after total hip arthroplasty (THA). It is unknown if the decreasing prevalence of adult smoking in the United States is reflected in the elective THA patient population. We aimed to investigate recent trends in: (1) the prevalence of smoking pre-THA, stratified by patient demographics; and (2) rates of 30-day complications and increased healthcare utilisation post-THA in smokers versus non-smokers. METHODS: Patients who underwent primary elective THA (2011-2019) were identified using the National Surgical Quality Improvement Program database. A total of 243,163 cases (Smokers: n = 30,536; Non-smokers: n = 212,627) were included. Trends analyses were performed for smoking prevalence across the study period. Smokers were propensity score-matched (1:1) to a cohort of non-smokers (n = 29,628, each), and rates of 30-day complications, readmission, and non-home discharge were compared. RESULTS: The rate of preoperative smoking significantly decreased from 14.0% in 2011 to 11.6% in 2019 (p-trend = 0.0286). When stratified, a significant decreasing trend in smoking was found for males and all races; within races, American-Indian/Alaska-Native race had the sharpest decline (2011:36.3% vs. 2019:23.2%). No significant change in 30-day complication rates among smokers or non-smokers was observed (p-trend > 0.05), but non-home discharge significantly decreased for both smokers (p-trend = 0.001) and non-smokers (p-trend < 0.001). After matching, higher rates of superficial surgical site infections (SSI) (0.9% vs. 0.5%; p < 0.001), deep SSI (0.5% vs. 0.3%; p < 0.001), wound disruption (0.2% vs. 0.1%; p = 0.006), and readmission (4.2% vs. 3.1%; p = <0.001) were found in smokers versus non-smokers. CONCLUSIONS: The present study is encouraging that national efforts to reduce the prevalence of smoking may be successful within the THA population, but there is a persistently elevated risk of postoperative complications in smokers after THA.

Establishing patient-centered metrics for the knee injury and osteoarthritis outcome score following medial unicompartmental knee arthropalsty.

BACKGROUND: This study aimed to determine the minimal clinically important difference (MCID) and the patient acceptable symptoms state (PASS) threshold for the knee injury and osteoarthritis outcome score (KOOS) pain subscore, KOOS physical short form (PS), and KOOS joint replacement (JR) following medial unicompartmental knee arthroplasty (mUKA). METHODS: Prospectively collected data from 743 patients undergoing mUKA from a single academic institution from April 2015 through March 2020 were analyzed. Patient-reported outcome measures (PROMs) were collected both pre-operatively and 1-year post-operatively. Distribution-based and anchored-based approaches were used to estimate MCIDs and PASS, respectively. The optimal cut-off point and the percentage of patients who achieved PASS were also calculated. RESULTS: MCID for KOOS-pain, KOOS-PS, and KOOS-JR following mUKA were calculated to be 7.6, 7.3, and 6.2, respectively. The PASS threshold for KOOS pain, PS, and JR were 77.8, 70.3, and 70.7, with 68%, 66%, and 64% of patients achieving satisfactory outcomes, respectively. Cut-off values for delta KOOS pain, PS, and JR were found to be 25.7, 14.3, and 20.7 with 73%, 69%, and 68% of patients achieving satisfactory outcomes, respectively. CONCLUSION: The current study identified useful values for the MCID and PASS thresholds at 1 year following medial UKA of KOOS pain, KOOS PS, and KOOS JR scores. These values may be used as targets for surgeons when evaluating PROMS using KOOS to determine whether patients have achieved successful outcomes after their surgical intervention. Potential uses include the integration of these values into predictive models to enhance shared decision-making and guide more informed decisions to optimize patient outcomes. LEVEL OF EVIDENCE: III.

Medicare's Post-Acute Care Reimbursement Models as of 2023: Past, Present, and Future.

The Centers for Medicare & Medicaid Services is continually working to mitigate unnecessary expenditures, particularly in post-acute care (PAC). Medicare reimburses for orthopaedic surgeon services in varied models, including fee-for-service, bundled payments, and merit-based incentive payment systems. The goal of these models is to improve the quality of care, reduce health-care costs, and encourage providers to adopt innovative and efficient health-care practices. This article delves into the implications of each payment model for the field of orthopaedic surgery, highlighting their unique features, incentives, and potential impact in the PAC setting. By considering the historical, current, and future Medicare reimbursement models, we hope to provide an understanding of the optimal payment model based on the specific needs of patients and providers in the PAC setting.

A Longitudinal Analysis of Weight Changes before and after Total Knee Arthroplasty: Weight Trends, Patterns, and Predictors.

Longitudinal data on patient trends in body mass index (BMI) and the proportion that gains or loses significant weight before and after total knee arthroplasty (TKA) are scarce. This study aimed to observe patients longitudinally for a 2-year period and determine (1) clinically significant BMI changes during the 1 year before and 1 year after TKA and (2) identify factors associated with clinically significant weight changes.A prospective cohort of 5,388 patients who underwent primary TKA at a tertiary health care institution between January 2016 and December 2019 was analyzed. The outcome of interests was clinically significant weight changes, defined as a ≥5% change in BMI, during the 1-year preoperative and postoperative periods, respectively. Patient-specific variables and demographics were assessed as potential predictors of weight change using multinomial logistic regression.Overall, 47% had a stable weight throughout the study period (preoperative: 17% gained, 15% lost weight; postoperative: 19% gained, 16% lost weight). Patients who were older (odds ratio [OR] = 0.95), men (OR = 0.47), overweight (OR = 0.36), and Obese Class III (OR = 0.06) were less likely to gain weight preoperatively. Preoperative weight loss was associated with postoperative weight gain 1 year after TKA (OR = 3.03). Preoperative weight gain was associated with postoperative weight loss 1 year after TKA (OR = 3.16).Most patients maintained a stable weight before and after TKA. Weight changes during the 1 year before TKA were strongly associated with reciprocal rebounds in BMI postoperatively, emphasizing the importance of ongoing weight management during TKA and the recognition of patients at higher risk for weight gain.Level of evidence II (prospective cohort study).

Stepping Up Recovery: Integrating Patient-reported Outcome Measures and Wearable Technology for Rehabilitation Following Knee Arthroplasty.

Improvement after knee arthroplasty (KA) is often measured using patient-reported outcome measures (PROMs). However, PROMs are limited due to their subjectivity. Therefore, wearable technology is becoming commonly utilized to objectively assess physical activity and function. We assessed the correlation between PROMs and step/stair flight counts in total (TKA) and partial knee arthroplasty (PKA) patients.Analysis of a multicenter, prospective, longitudinal cohort study investigating the collection of average daily step and stair flight counts, was performed. Subjects (N = 1,844 TKA patients and N = 489 PKA patients) completed the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and provided numerical rating scale pain scores pre- and postoperatively. Only patients who reported living in a multilevel home environment (N = 896 TKA patients and N = 258 PKA patients) were included in analysis of stair flight counts. Pearson correlation coefficients were calculated to determine correlations between variables.Among TKA patients, pain scores demonstrated a negative correlation to mean step counts at preoperative (r = -0.14, p < 0.0001) and 1-month follow-up (r = -0.14, p < 0.0001). Similar negative correlations were true for pain and stair flight counts at preoperative (r = -0.16, p < 0.0001) and 1-month follow-up (r = -0.11, p = 0.006). KOOS JR scores demonstrated weak positive correlations with mean step counts at preoperative (r = 0.19, p < 0.0001) and 1-month postoperative (r = 0.17, p < 0.0001). Similar positive correlations were true for KOOS JR scores and stair flight counts preoperatively (r = 0.13, p = 0.0002) and at 1-month postoperatively (r = 0.10, p = 0.0048). For PKA patients, correlations between pain and KOOS JR with step/stair counts demonstrated similar directionality.Given the correlation between wearable-generated data and PROMs, wearable technology may be beneficial in evaluating patient outcomes following KA. By combining subjective feedback with the objective data, health care providers can gain a holistic view of patients' progress and tailor treatment plans accordingly.

Risk factors for dislocation after revision total hip arthroplasty.

BACKGROUND: Despite dislocation being the most frequent complication after revision THA, risk factors for its occurrence are not completely understood. QUESTIONS/PURPOSES: We therefore (1) determined the overall risk of dislocation after revision THA in a large series of revision THAs using contemporary revision techniques, (2) identified patient-related risk factors predicting dislocation, and (3) identified surgical variables predicting dislocation. METHODS: We performed 1211 revision THAs between June 2004 and October 2010 in 576 women and 415 men who had a mean age of 64.7 years (range, 25-95 years) at time of surgery. Forty-six (4%) were lost to followup and 13 died (1%), leaving 1152 hips followed for a minimum of 90 days (mean, 2 years; range, 90 days to 7.1 years). Multivariate logistic regression was performed to identify risk factors for dislocation. The model was also tested on patients followed for a minimum 1 year to assess any difference in longer followup. RESULTS: One hundred thirteen patients dislocated over the followup period (9.8%). Factors that were different between patients who dislocated and those who remained stable included a history of at least one previous dislocation (odds ratio [OR] = 2.673), abductor deficiency (OR = 2.672), and Paprosky acetabulum class (OR = 1.522). Use of a constrained liner (OR = 0.503) and increased femoral head size (OR = 0.942) were protective against dislocation, while with longer followup a constrained liner was no longer significant. CONCLUSIONS: Dislocation remains a common problem after revision THA. Identifying these risk factors can assist in patient education and surgical planning. Recognition of these risk factors in both patient type and surgical strategy is important for the surgeon performing revision THA and for minimizing these risks. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Return to Sports and Return to Work After Total Hip Arthroplasty: A Systematic Review and Meta-analysis.

BACKGROUND: Return to work (RTW) and sports (RTS) are critical gauges to improvement among patients after total hip arthroplasty (THA). This study aimed to determine rates, timelines, and prognostic factors associated with RTW and RTS outcomes after primary THA. METHODS: A systematic review was conducted on MEDLINE, EMBASE, and CENTRAL databases with 57 studies meeting inclusion/exclusion criteria. The risk of bias was assessed using the Risk of Bias in Non-randomized Studies of Interventions and risk of bias in randomized trials (RoB2) tools. Meta-analysis and pooled analysis were conducted, with forest plots to summarize odds ratios and 95% confidence interval (CI). RESULTS: The pooled RTW rate across all studies was 70% (95% CI, 68%-80%), with rates varying significantly from 11% to 100%. The mean time to RTW was 11.2 weeks (range 1-27). A time point analysis showed increasing RTW rates with a maximum rate at 2 years of 90%. Increased age (p < 0.001) and preoperative heavy labor (p = 0.005) were associated with lower RTW rates. The RTS rate ranged from 42% to 100%, with a pooled rate of 85% (95% CI, 74%-92%). The mean time to RTS was 16.1 weeks (range 8-26). The RTS ranged from 20% to 80% with a pooled proportion of 56% (95% CI, 42%-70%, I2 = 90%) for high-intensity sports and from 75% to 100% for low-intensity sports with a pooled proportion of 97% (95% CI, 83-99, I2 = 93%). CONCLUSION: Most patients RTW and RTS after THA in an increasing manner as time passes with rates more than 85% after 1 year. These rates may be greatly affected by various factors, most notably age, the intensity of the sport, and the type of work performed. In general, young patients, low-demand work or sports can be resumed as soon as 4 to 6 weeks after surgery, but with increased restrictions as the intensity increases. This information should be used by practitioners to manage postoperative expectations and provide appropriate recommendations to patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.