Genicular Artery Embolization: A Review of Essential Anatomic Considerations.

Genicular artery embolization is increasingly recognized as a safe and effective treatment option for symptomatic knee osteoarthritis and recurrent hemarthrosis after total knee arthroplasty. Genicular arteries are an essential contributor to vascular supply for the knee joint and demonstrate considerable variability. Familiarity with the anatomy and common variations is critical for preprocedural planning, accurate target selection, and minimizing adverse events in transarterial embolization procedures. This review aimed to provide a detailed discussion of the genicular artery anatomy that is relevant to interventional radiologists performing genicular artery embolization.

Does Melatonin Improve Sleep Following Primary Total Knee Arthroplasty? A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Sleep impairment following total knee arthroplasty (TKA) is common and may decrease patient satisfaction and recovery. Standardized postoperative recommendations for sleep disturbances have not been established. We aimed to assess whether melatonin use could promote healthy sleep and reduce sleep disturbance in the acute period following TKA. METHODS: Patients undergoing primary, elective TKA between July 19, 2021 and January 4, 2024 were prospectively enrolled and randomized to receive either 5 mg of melatonin nightly or placebo for 14 days postoperatively. Participants recorded their nightly pain on the visual analog scale, the number of hours slept, and the number of night-time awakenings in a sleep diary starting the night of surgery (postoperative day [POD] 0). Sleep disturbance was assessed preoperatively and on POD 14 using the patient-reported outcome measurement information system sleep disturbance form. Epworth Sleepiness Scores were collected on POD 14 to assess sleep quality. RESULTS: Of the 138 patients enrolled, 128 patients successfully completed the study protocol, with 64 patients in each group. Melatonin patients trended toward more hours of sleep on POD 2 (placebo: 5.0 ± 2.4, melatonin: 5.8 ± 2.0, P = .084), POD 3 (placebo: 5.6 ± 2.2, melatonin: 6.3 ± 2.0, P = .075), and averaged over POD 1 to 3 (placebo: 4.9 ± 2.0, melatonin: 5.6 ± 1.8, P = .073), although no differences were observed on POD 4 or after. Fewer night-time awakenings in the melatonin group were observed on POD 1 (placebo: 4.4 ± 3.9, melatonin: 3.6 ± 2.4, P = .197), although this was not statistically significant. Preoperative and postoperative Patient-Reported Outcomes Measurement Information System Sleep Disturbance score increases were comparable for both groups (placebo: 4.0 ± 8.4, melatonin: 4.6 ± 8.2, P = .894). The melatonin (65.4%) and placebo (65%) groups demonstrated similar rates of increased sleep disturbance. CONCLUSIONS: Melatonin may promote longer sleep in the immediate postoperative period after TKA, although these benefits wane after POD 3. Disturbances in sleep should be expected for most patients, although melatonin may have an attenuating effect. Melatonin is safe and can be considered for TKA patients experiencing early sleep disturbances postoperatively.

Blood Transfusion in the Age of Tranexamic Acid: Who Needs a Type and Screen Before Total Hip Arthroplasty?

BACKGROUND: Modern surgical protocols, particularly the use of tranexamic acid (TXA), have reduced, but not eliminated, blood transfusions surrounding total hip arthroplasty (THA). Identifying patients at risk for transfusion remains important for risk reduction and to determine type and screen testing. METHODS: We reviewed 6,405 patients who underwent primary, unilateral THA between January 2014 and January 2023 at a single academic institution, received TXA, and had preoperative hemoglobin (Hgb) values. We compared demographics, baseline hemoglobin levels, and surgical details between patients who were and were not transfused. Data were analyzed utilizing multivariate regression and receiver operating characteristic (ROC) curve analysis. RESULTS: The overall perioperative and intraoperative transfusion rates were 3.4 and 1.0%, respectively. Patients who were older, women, and American Society of Anesthesiologists (ASA) class >II demonstrated an increased risk of transfusion. Risk of transfusion demonstrated an inverse correlation with preoperative Hgb levels, a bimodal association with Body Mass Index (BMI), and a direct correlation with age, surgical time, and estimated blood loss on multivariate analysis. The Receiver Operating Characteristic (ROC) analysis demonstrated a preoperative Hgb cutoff of 12 g/dL for predicting any transfusion. Above the threshold of 12 g/dL, total and intraoperative transfusions were rare, with rates of 1.7 and 0.3%, respectively. Total and intraoperative transfusion rates with Hgb between 11 and 12 g/dL were 14.3 and 4.6%, respectively. Below 11 g/dL, total and intraoperative transfusion rates were 27.5 and 10.1%, respectively. CONCLUSION: In the age of TXA, blood transfusion is rare in THA when preoperative Hgb is > 12 g/dL, challenging the need for universal type and screening. Conversely, patients who have hemoglobin < 11.0 g/dL, remain at substantial risk for transfusion. Between hemoglobin 11 and 12 g/dL, patient age, sex, BMI, ASA classification, anticipated estimated blood loss (EBL), and surgical time may help predict transfusion risk and the need for a perioperative type and screen.

Periprosthetic fracture following arthroplasty for femoral neck fracture: is a cemented stem protective?

BACKGROUND: Periprosthetic femoral fractures (PFF) carry significant morbidity following arthroplasty for femoral neck fracture (FNF). This study assessed fracture complications following arthroplasty for FNF and the effect of cement fixation of the femoral component on intraoperative and post-operative PFF. METHODS: Between February 2014 and September 2021, 740 patients with a FNF who underwent arthroplasty were analyzed for demographics, surgical management, use of cement for fixation of the femoral component, and subsequent PFF. Variables were compared with Mann-Whitney or Chi-square as appropriate. Multivariate logistic regression was used to assess independent risk factors associated with intraoperative or post-operative PFF. RESULTS: There were 163 THAs (41% cemented) and 577 HAs (95% cemented). There were 28 PFFs (3.8%): 18 post-operative and 10 intraoperative. Fewer post-operative PFFs occurred with cemented stems (1.63% vs. 6.30%, p = 0.002). Mean time from surgery to presentation with post-operative PFF was 14 months (0-45 months). Mean follow-up time was 10.3 months (range: 0-75.7 months). In multivariate regression, use of cement and THA was independently associated with decreased post-operative PFF (cement: OR 0.112, 95% CI 0.036-0.352, p < 0.001 and THA: OR 0.249, 95% CI 0.064-0.961, p = 0.044). More intraoperative fractures occurred during THA (3.68% vs. 0.69%, p = 0.004) and non-cemented procedures (5.51% vs. 0.49%, p < 0.001). In multivariate regression, use of cement was protective against intraoperative fracture (OR 0.100, CI 0.017-0.571, p = 0.010). CONCLUSIONS: In patients with a FNF treated with arthroplasty, cementing the femoral component is associated with a lower risk of intraoperative and post-operative PFF. Choice of procedure may be based on patient factors and surgeon preference.

Genicular Artery Embolization for Treatment of Knee Osteoarthritis: Interim Analysis of a Prospective Pilot Trial Including Effect on Serum Osteoarthritis-Associated Biomarkers.

PURPOSE: To characterize the safety, efficacy, and potential role of genicular artery embolization (GAE) as a disease-modifying treatment for symptomatic knee osteoarthritis (OA). MATERIALS AND METHODS: This is an interim analysis of a prospective, single-arm clinical trial of patients with symptomatic knee OA who failed conservative therapy for greater than 3 months. Sixteen patients who underwent GAE using 250-µm microspheres and had at least 1 month of follow-up were included. Six patients completed the 12-month follow-up, and 10 patients remain enrolled. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was evaluated at baseline and at 1, 3, and 12 months. Serum and plasma samples were collected for biomarker analysis. The primary end point was the percentage of patients who achieved the minimal clinically important difference (MCID) for WOMAC pain score at 12 months. Baseline and follow-up outcomes were analyzed using the Wilcoxon matched-pairs signed-rank test. RESULTS: Technical success of the procedure was 100%, with no major adverse events. The MCID was achieved in 5 of the 6 (83%) patients at 12 months. The mean WOMAC pain score decreased from 8.6 ± 2.7 at baseline to 4.9 ± 2.7 (P = .001), 4.4 ± 2.8 (P < .001), and 4.7 ± 2.7 (P = .094) at 1, 3, and 12 months, respectively. There was a statistically significant decrease in nerve growth factor (NGF) levels at 12 months. The remaining 8 biomarkers showed no significant change at 12 months. CONCLUSIONS: GAE is a safe and efficacious treatment for symptomatic knee OA. Decreased NGF levels after GAE may contribute to pain reduction and slowing of cartilage degeneration.

Patient Designation Prior to Total Knee Arthroplasty: How Can Preoperative Variables Impact Postoperative Status?

BACKGROUND: Removal of total knee arthroplasty (TKA) from the inpatient only list has led to a greater focus on outpatient (OP) procedures. However, the impact of OP-centered models in at-risk patients is unclear. Therefore, the current analysis investigated the effect of conversion from OP to inpatient (IP) status on postoperative outcomes and determined which factors put patients at risk for status change postoperatively. METHODS: We retrospectively reviewed all patients who underwent a primary TKA at our institution between January 2, 2018, and April 26, 2022. All patients included were originally scheduled for OP surgery and were separated based on conversion to IP status postoperatively. Multiple regression analyses were used to determine the significance of all perioperative variables. Modeling via binary logistic regressions was used to determine factors predictive of status conversion. RESULTS: Of the 2,313 patients originally designated for OP TKA, 627 (27.1%) required a stay of 2 midnights or longer. Patients in the IP group had significantly higher facility discharge rates (P < .001) compared to the OP group. Factors predictive of conversion included age of 65 years and older (P < .001), women (P < .001), arriving at the postanesthesia care unit after 12 pm (P < .001), body mass index greater than 30 (P = .004), and Charlson Comorbidity Index of 4 and higher (P = .004). Being the first case of the day (P < .001) and being married (P < .001) were both protective against conversion. CONCLUSION: Certain intrinsic patient factors may predispose a patient to an IP stay, and an understanding of predisposing factors which could lead to IP conversion may improve perioperative planning moving forward.

Selective Use of Dual-Mobility Did Not Significantly Reduce 90-Day Readmissions or Reoperations After Total Hip Arthroplasty.

BACKGROUND: Selective use of dual mobility (DM) implants in total hip arthroplasty (THA) patients at high dislocation risk has been proposed. However, evidence-based utilization thresholds have not been defined. We explored whether surgeon-specific rates of DM utilization correlate with rates of readmission and reoperation for dislocation. METHODS: We retrospectively reviewed 14,818 primary THA procedures performed at a single institution between 2011 and 2021, including 14,310 fixed-bearing (FB) and 508 DM implant constructs. Outcomes including 90-day readmissions and reoperations were compared between patients who had FB and DM implants. Cases were then stratified into 3 groups based on the attending surgeon's rate of DM utilization (≤ 1, 1 to 10, or > 10%) and outcomes were compared. RESULTS: There were no differences in 90-day outcomes between FB and DM implant groups. Surgeon frequency of DM utilization ranged from 0% to 43%. There were 48 surgeons (73%) who used DM in ≤ 1% of cases, 11 (17%) in 1% to 10% of cases, and 7 (10%) in > 10% of cases. The 90-day rates of readmission (7.3% versus 7.6% versus 7.2%, P = .7) and reoperation (3.4% versus 3.9% versus 3.8%, P = .3), as well as readmission for instability (0.5% versus 0.6% versus 0.8%, P = .2) and reoperation for instability (0.5% versus 0.5% versus 0.8%, P = .6), did not statistically differ between cohorts. CONCLUSION: Selective DM utilization did not reduce 90-day readmissions or reoperations following primary THA. Other dislocation-mitigation strategies (ie, surgical approach, computer navigation, robotic assistance, and large diameter FBs) may have masked any benefits of selective DM use.

Opioid Use During Hospitalization Following Total Knee Arthroplasty: Trends in Consumption From 2016 to 2021.

BACKGROUND: In response to physician and patient concerns, many institutions have adopted protocols aimed at reducing postoperative opioid consumption after total knee arthroplasty (TKA). Thus, this study sought to examine how consumption of opioids has changed following TKA in the past 6 years. METHODS: We conducted a retrospective review of all 10,072 patients who received primary TKA at our institution from January 2016 to April 2021. We collected baseline demographic data including patient age, sex, race, body mass index (BMI), American Society of Anesthesiologist (ASA) classification, as well as dosage and type of opioid medication prescribed on each postoperative day while the patient was hospitalized following TKA. This data was converted to milligram morphine equivalents (MME) per day hospitalized to compare rates of opioid use over time. RESULTS: Our analysis found the greatest daily opioid use was in 2016 (43.2 ± 68.6 MME/day) and the least was in 2021 (15.0 ± 29.2 MME/day). Linear regression analyses found a significant linear downward trend in postoperative opioid consumption over time, with a decrease of 5.55 MME per day per year (Adjusted R-squared: 0.982, P < .001). The highest visual analog scale (VAS) score was 4.45 in 2016 and the lowest was 3.79 in 2021 (P < .001). CONCLUSION: Opioid reducing protocols have been implemented for patients recovering from primary TKA in an effort to decrease reliance on opioids for postoperative pain control. The results of this study demonstrate that such protocols have been successful in reducing overall opioid use during hospitalization following TKA. LEVEL III EVIDENCE: Retrospective Cohort.

Hospital Revenue, Cost, and Contribution Margin in Inpatient Versus Outpatient Primary Total Joint Arthroplasty.

BACKGROUND: Removal of primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA) from the inpatient-only list has financial implications for both patients and institutions. The aim of this study was to evaluate and compare financial parameters between patients designated for inpatient versus outpatient total joint arthroplasty. METHODS: We reviewed all patients who underwent TKA or THA after these procedures were removed from the inpatient-only list. Patients were statistical significance into cohorts based on inpatient or outpatient status, procedure type, and insurance type. This included 5,284 patients, of which 4,279 were designated inpatient while 1,005 were designated outpatient. Patient demographic, perioperative, and financial data including per patient revenues, total and direct costs, and contribution margins (CMs) were collected. Data were compared using t-tests and Chi-squared tests. RESULTS: Among Medicare patients receiving THA, CM was 89.1% lower for the inpatient cohort when compared to outpatient (P < .001), although there was no statistical significance difference between cohorts for TKA (P = .501). Among patients covered by Medicaid or Government-managed plans, CM was 120.8% higher for inpatients receiving THA (P < .001) when compared to outpatients and 136.3% higher for inpatients receiving TKA (P < .001). CONCLUSION: Our analyses showed that recent costs associated with inpatient stay inconsistently match or outpace additional revenue, causing CM to vary drastically depending on insurance and procedure type. For Medicare patients receiving THA, inpatient surgery is financially disincentivized leaving this vulnerable patient population at a risk of losing access to care. LEVEL III EVIDENCE: Retrospective Cohort Study.

Comparison of Operating Room Air Quality in Primary Versus Revision Total Knee Arthroplasty.

BACKGROUND: Airborne biologic particles (ABPs) can be measured intraoperatively to evaluate operating room (OR) sterility. Particulate matter (PM) up to 2.5 microns can contain microbial species which may increase infection risk. Our study examines the differences in air quality and ABP count in primary total knee arthroplasty (TKA) and revision TKA (rTKA). METHODS: We analyzed primary and rTKAs in a single OR at an academic institution from January 2020 to December 2020. Procedures from March 15, 2020, to May 4, 2020, were excluded to avoid COVID-related confounding. Temperature, humidity, and ABP count per minute were recorded with a particle counter intraoperatively and cross-referenced with surgical data from the electronic health records using procedure start and end times. Descriptive statistics were used to evaluate the differences in variables. P values were calculated using t-test and chi-square test. RESULTS: A total of 107 TKA cases were included: 79 (73.8%) primary TKAs and 28 (26.2%) rTKAs. Time spent in an OR was significantly higher for rTKAs (primary: 176 ± 46.7 minutes vs revision: 220 ± 47.1 minutes, P < .0001). Compared to primary TKAs, rTKAs had significant percent increases in ABP rates for particles measuring 0.3 µm (+70.4%, P < .001), 0.5 µm (+97.2%, P < .0001), 1.0 µm (+53.2%, P = .001), and 2.5 µm (+30.3%, P = .017) and for PM 2.5 (+108.3%, P < .001) and PM 5.0 (+105.6%, P < .001). CONCLUSION: rTKAs had significantly longer time spent in an OR and significant percent increases in ABP rates for particles measuring 0.3 µm, 0.5 µm, and 1.0 µm compared to primary TKAs. Measurements of PM 2.5 and 5.0 (which can contain large numbers of microbes) were also significantly greater in rTKAs. Further research is needed to determine whether the size and quantity of ABPs translate to higher infection rates after rTKA.

Evaluation of Emergency Department Visits Following Total Joint Arthroplasty: Same-Day Discharge vs Non-Same-Day Discharge.

BACKGROUND: Traditionally, most efforts have focused on readmission rates while little has been reported on emergency department (ED) presentation. This study aims to analyze the difference between same-day discharge (SDD) and non-SDD primary total hip and knee arthroplasty cases to determine the rate and reasons associated with 90-day ED presentations. METHODS: We retrospectively reviewed all patients who underwent primary total hip arthroplasty and total knee arthroplasty between 2011 and 2021. The patients were separated into 2 cohorts: (1) SDD and (2) required a longer length of stay. The primary outcome was an ED visit within 90 days of the index operation. Secondary outcomes included reasons for ED visits and readmission rates. Multivariable logistic regressions were performed to compare the 2 groups while accounting for significant demographic variables. RESULTS: Of the 24,933 patients included, 1,725 (7%) were SDD and 23,208 (93%) required a longer length of stay. The overall rate of 90-day ED visits was significantly lower for patients who were SDD compared to non-SDD (1.6% vs 4.0%, P = .004). However, when stratified based on the reason for ED visit, no single cause was significant between the 2 cohorts. The most commonly reported reasons were pain (32.1% vs 26.7%, P = .064) and other non-orthopedic-related medical issues (25.0% vs 29.5%, P = .206). Among those who presented to the ED, the readmission rate did not statistically differ (25.0% vs 23.4%, P = .131). CONCLUSION: Patients who underwent SDD were less likely to present to the ED within 90 days following their surgery compared to non-SDD. Approximately three fourths of the patients in both cohorts that visited the ED did not require readmission. Future efforts should focus on developing interventions to reduce the burden of these visits on the healthcare system. LEVEL III EVIDENCE: Retrospective Cohort Study.

The Effect of Femoral Head Size on Groin Pain in Total Hip Arthroplasty.

BACKGROUND: Although increased femoral head size reduces the risk of instability in total hip arthroplasty (THA), it may lead to iliopsoas irritation and increased anterior groin pain. The purpose of this study is to compare outcomes between non-modular dual-mobility (NDM) implants and small (≤32 mm) and large (≥36 mm) fixed-bearing (FB) constructs. METHODS: A retrospective review of all primary total hip arthroplasties from 2011 to 2021 was conducted at a single, urban academic institution. Patients were separated into 3 cohorts: NDM implant ≤32 mm and FB implant ≥36 mm. Demographics and outcomes such as length of stay, dislocation, and anterior groin pain were assessed. Patients were deemed as having groin pain if they received an iliopsoas injection or had extended physical therapy ordered beyond 3 months postoperatively. RESULTS: There were 178 NDM implants, 936 ≤32-mm FB, and 2,454 ≥36-mm FB implants included. Length of stay significantly differed between the groups (48.4 ± 43.3 vs 63.2 ± 40.6 vs 57.2 ± 38.1 hours; P = .001). Although not statistically significant, the ≥36-mm FB cohort had the highest rate of dislocations (0.6% vs 0.7% vs 0.9%; P = .84). Although no patients with an NDM implant received an iliopsoas injection, 9 patients (0.9%) with a ≤32-mm FB implant and 9 patients (0.4%) with a ≥36-mm implant received an injection (P = .06). However, 18 (10.1%) patients with an NDM implant, 304 (32.5%) patients with a ≤32-mm FB implant, and 355 (14.5%) patients with a ≥36-mm FB implant received extended physical therapy 3 months after surgery (P < .001). CONCLUSION: NDM implants, as well as FB implants with both small and large head sizes are effective at preventing dislocation. NDM implants did not result in an increase in anterior groin pain compared to ≤32-mm and ≥36-mm FB constructs. LEVEL III EVIDENCE: Retrospective cohort study.

Failure to Meet Same-Day Discharge is Not a Predictor of Adverse Outcomes.

INTRODUCTION: As more centers introduce same-day discharge (SDD) total joint arthroplasty (TJA) programs, it is vital to understand the factors associated with successful outpatient TJA and whether outcomes vary for those that failed SDD. The purpose of this study is to compare outcomes of patients that are successfully discharged home the day of surgery to those that fail-to-launch (FTL) and require a longer in-hospital stay. MATERIALS AND METHODS: We retrospectively reviewed all patients who enrolled in our institution's SDD TJA program from 2015 to 2020. Patients were stratified into two cohorts based on whether they were successfully SDD or FTL. Outcomes of interest included discharge disposition, 90-day readmissions, 90-day revisions, surgical time, and patient-reported outcome measures (PROMs) as assessed by the FJS-12 (3 months, 1 year, and 2 years), HOOS, JR, and KOOS, JR (preoperatively, 3 months, and 1 year). Demographic differences were assessed with chi-square and Mann-Whitney U tests. Outcomes were compared using multilinear regressions, controlling for demographic differences. RESULTS: A total of 1491 patients were included. Of these, 1384 (93%) were successfully SDD while 107 (7%) FTL and required a longer length-of-stay. Patients who FTL were more likely to be non-married (p = 0.007) and ASA class III (p = 0.017) compared to those who were successfully SDD. Surgical time was significantly longer for those who FTL compared to those who were successfully SDD (100.86 vs. 83.42 min; p < 0.001). Discharge disposition (p = 0.100), 90-day readmissions (p = 0.897), 90-day revisions (p = 0.997), and all PROM scores both preoperatively and postoperatively did not significantly differ between the two cohorts. CONCLUSION: Our results support the notion that FTL is not a predictor of adverse outcomes as patients who FTL achieved similar outcomes as those who were successfully SDD. The findings of this study can aid orthopedic surgeons to educate their patients who wish to participate in a similar program, as well as patients that have concerns after they failed to go home on the day of surgery. LEVEL III EVIDENCE: Retrospective Cohort Study.

Discontinuation of Intraoperative Liposomal Bupivacaine in Primary THA Does Not Clinically Change Postoperative Subjective Pain, Opioid Consumption, or Objective Functional Status.

BACKGROUND: There is debate regarding the benefit of liposomal bupivacaine (LB) as part of a periarticular injection (PAI) in total hip arthroplasty (THA). Here, we evaluate the effect of discontinuing intraoperative LB PAI on immediate postoperative subjective pain, opioid consumption, and objective functional outcomes. METHODS: On July 1, 2019, an institutional policy discontinued the use of intraoperative LB PAI. A consecutive cohort that received LB PAI and a subsequent cohort that did not were compared. All patients received the same opioid-sparing protocol. Nursing documented verbal rating scale pain scores were averaged per patient per 12-hour interval. Opiate administration events were converted into morphine milligram equivalences per patient per 24-hour interval. The validated Activity Measure for Postacute Care (AM-PAC) tool was used to evaluate functional outcomes. RESULTS: Six hundred thirty eight primary THAs received LB followed by 939 that did not. In the non-LB THAs, BMI was higher (30.06 vs 29.43; P < .05). Besides marital status, the remaining baseline demographics were similar between the two cohorts (P > .05). The non-LB THA cohort demonstrated a marginal increase in verbal rating scale pain scores between 12 to 24 hours (4.42 ± 1.70 vs 4.20 ± 1.87; P < .05) and 36 to 48 hours (4.49 ± 1.72 vs 4.21 ± 1.83; P < .05). There was no difference in inpatient opioid administration up to 96 hours postoperatively (P > .05) or AM-PAC functional scores within the first 24 hours (P > .05). CONCLUSION: A small statistical, but not clinically meaningful, difference was observed in subjective pain scores with LB PAI discontinuation. Opioid consumption and postoperative AM-PAC functional scores were unchanged after LB PAI discontinuation.

Adductor Canal Blocks Reduce Inpatient Opioid Consumption While Maintaining Noninferior Pain Control and Functional Outcomes After Total Knee Arthroplasty.

BACKGROUND: The use of perioperative adductor canal blocks (PABs) continues to be a highly debated topic for total knee arthroplasty (TKA). Here, we evaluate the effect of PABs on immediate postoperative subjective pain scores, opioid consumption, and objective functional outcomes. METHODS: On December 1, 2019, an institution-wide policy change was begun to use PABs in primary elective TKAs. Patient demographics, immediate postoperative nursing documented pain scores, opioid administration events, and validated physical therapy functional scores were prospectively collected as part of the standard of care and retrospectively queried through our electronic data warehouse. A historical comparison cohort was derived from consecutive patients undergoing TKA between July 1, 2019 and November 30, 2019. RESULTS: 405 primary TKAs received PABs, while 789 patients were in the control cohort. Compared with controls, average verbal rating scale pain scores were lower among PAB recipients from 0-12 hours (2.42 ± 1.60 vs 2.05 ± 1.60; <.001) and 24-36 hours (4.92 ± 2.00 vs 4.47 ± 2.27; <.01). PAB recipients demonstrated significantly lower opioid consumption within the first 24 hours (44.34 ± 40.98 vs 36.83 ± 48.13; P < .01) and during their total inpatient stay (92.27 ± 109.81 vs 77.52 ± 123.11; <.05). AM-PAC scores within the first 24 hours were also higher for PABs (total scores: 20.28 ± 3.06 vs 20.71 ± 3.12; <.05). CONCLUSION: While the minimal clinically important differences in pain scores and functional status were comparable between both cohorts, patients demonstrated a significant reduction in overall inpatient opiate consumption after the introduction of PABs. Surgeons should consider these findings when evaluating for perioperative pain management, opioid-sparing, and rapid discharge protocols.

Femoral Neck Notching in Dual Mobility Implants: Is This a Reason for Concern?

BACKGROUND: Dual mobility (DM) total hip arthroplasty (THA) implants have been advocated for patients at risk for impingement due to abnormal spinopelvic mobility. Impingement against cobalt-chromium acetabular bearings, however, can result in notching of titanium femoral stems. This study investigated the incidence of femoral stem notching associated with DM implants and sought to identify risk factors. METHODS: A multicenter retrospective study reviewed 256 modular and 32 monoblock DM components with minimum 1-year clinical and radiographic follow-up, including 112 revisions, 4 conversion THAs, and 172 primary THAs. Radiographs were inspected for evidence of femoral notching and to calculate acetabular inclination and anteversion. Revisions and dislocations were recorded. RESULTS: Ten cases of femoral notching were discovered (3.5%), all associated with modular cylindrospheric cobalt-chromium DM implants (P = .049). Notches were first observed radiographically at mean 1.3 years after surgery (range 0.5-2.7 years). Notch location was anterior (20%), superior (60%), or posterior (20%) on the prosthetic femoral neck. Notch depth ranged from 1.7% to 20% of the prosthetic neck diameter. Eight cases with notching had lumbar pathology that can affect spinopelvic mobility. None of these notches resulted in stem fracture, at mean 2.7-year follow-up (range 1-7.6 years). There were no dislocations or revisions in patients with notching. CONCLUSION: Femoral notching was identified in 3.5% of DM cases, slightly surpassing the dislocation rate in a cohort selected for risk of impingement and instability. Although these cases of notching have not resulted in catastrophic failures thus far, further study of clinical sequelae is warranted. Component position, spinopelvic mobility, and implant design may influence risk.

Patient Satisfaction After Total Hip Arthroplasty Is Not Influenced by Reductions in Opioid Prescribing.

BACKGROUND: Opioids have played an important part in post-operative analgesia, but concerns with associated morbidity and the fate of leftover pills have prompted the creation of opioid-sparing protocols. The purpose of this study is to investigate the impact of the implementation of an opioid-sparing protocol on survey-based patient satisfaction scores following total hip arthroplasty (THA). METHODS: This study is a retrospective review of prospectively collected data on patients who underwent primary THA between November 2014 and July 2019. Inclusion criteria consisted of primary elective THA with complete Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey information. Cohorts were separated based on their date of surgery relative to the start of an institutional opioid-sparing-protocol in October 2018. Discharge prescriptions and refills were recorded on chart review and converted to milligram morphine equivalents (MME) for comparison between different opioids. HCAHPS results were analyzed for percentage of "top box" ratings for comparison between the 2 groups. RESULTS: In total, 1003 patients met inclusion criteria: 804 pre-protocol and 199 post-protocol. Mean length of stay decreased from 1.74 ± 1.03 to 1.50 ± 1.11 days (P < .001). Pre-operative Visual Analog Scale pain decreased from 7.00 ± 2.30 to 6.41 ± 2.66 (P = .011) as did the rate of opioid refills (15.6%-9.1%; P = .019). Quantity of opioid medication prescribed upon discharge also decreased from 432 ± 298 to 114 ± 156 MME (P < .001). There was no change in "top box percentages" for satisfaction with pain control (79.7% pre-protocol, 82.1% post-protocol; P = .767). There was a significant increase in proportion of patients reporting top box satisfaction with their overall surgical experience after protocol implementation (88.2%-94.0%; P = .018). CONCLUSION: A reduction in opioids prescribed after THA is not associated with a decrease in patient satisfaction with regard to pain control, as measured by the HCAHPS survey, nor is it associated with an increase in post-operative opioid refills. LOE: III. CLINICAL RELEVANCE: This study suggests that HCAHP scores are not negatively impacted by a reduction in post-operative opioid analgesics.

Incomplete Administration of Intravenous Vancomycin Prophylaxis is Common and Associated With Increased Infectious Complications After Primary Total Hip and Knee Arthroplasty.

BACKGROUND: Vancomycin is often used as antimicrobial prophylaxis in patients undergoing total hip or knee arthroplasty. Vancomycin requires longer infusion times to avoid associated side effects. We hypothesized that vancomycin infusion is often started too late and that delayed infusion may predispose patients to increased rates of surgical site infections and prosthetic joint infections. METHODS: We reviewed clinical data for all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients at our institution between 2013 and 2020 who received intravenous vancomycin as primary perioperative gram-positive antibiotic prophylaxis. We calculated duration of infusion before incision or tourniquet inflation, with a cutoff of 30 minutes defining adequate administration. Patients were divided into two groups: 1) appropriate administration and 2) incomplete administration. Surgical factors and quality outcomes were compared between groups. RESULTS: We reviewed 1047 primary THA and TKA patients (524 THAs and 523 TKAs). The indication for intravenous vancomycin usage was allergy (61%), methicillin-resistant staphylococcus aureus colonization (17%), both allergy and colonization (14%), and other (8%). 50.4% of patients began infusion >30 minutes preoperatively (group A), and 49.6% began infusion <30 minutes preoperatively (group B). Group B had significantly higher rates of readmissions for infectious causes (3.6 vs 1.3%, P = .017). This included a statistically significant increase in confirmed prosthetic joint infections (2.2% vs 0.6%, P = .023). Regression analysis confirmed <30 minutes of vancomycin infusion as an independent risk factor for PJI when controlling for comorbidities (OR 5.22, P = .012). CONCLUSION: Late infusion of vancomycin is common and associated with increased rates of infectious causes for readmission and PJI. Preoperative protocols should be created to ensure appropriate vancomycin administration when indicated.

Utilization of a Novel Opioid-Sparing Protocol in Primary Total Hip Arthroplasty Results in Reduced Opiate Consumption and Improved Functional Status.

BACKGROUND: Total hip arthroplasty (THA) candidates have historically received high doses of opioids within the perioperative period; however, the amounts are being continually reduced as awareness of opioid abuse spreads. Here we seek to evaluate the effectiveness of a novel opiate-sparing protocol (OSP) for primary THAs in reducing opiate administrations, while maintaining similar levels of pain control and postoperative function. METHODS: All patients undergoing primary THA between January 1, 2019 and June 30, 2019 were placed under a novel OSP. Data were prospectively collected as part of standard of care. To assess the primary outcome of opiate consumption, nursing documented opiate administration events were converted into morphine milligram equivalences (MMEs) per patient encounter per 24-hour interval. Postoperative pain and functional status were assessed as secondary outcomes using the Verbal Rating Scale for pain and the Activity Measure for Post-Acute Care scores, respectively. RESULTS: One thousand fifty primary THAs had received our institution's OSP, and 953 patients were utilized as our historical control. OSP patients demonstrated significantly lower 0-24, 24-48, and 48-72 hours with less opiate administration variance (total MME: Control 75.55 ± 121.07 MME vs OSP 57.10 ± 87.48 MME; 24.42% decrease, P < .001). Although pain scores reached statistical significance between 0 and 12 (Control 2.09 vs OSP 2.36, P < .001), their differences were not clinically significant. Finally, OSP patients demonstrated a trend toward higher Activity Measure for Post-Acute Care scores across all 6 domains (total scores: Control 20.53 ± 3.67 vs OSP 20.76 ± 3.64, P = .18). CONCLUSION: Implementation of an OSP can significantly decrease the utilization of opioids in the immediate postoperative period. Inpatient opioid administration can be significantly reduced while maintaining a comparable and non-inferior level of pain and function.

Virtual Reality Simulation Facilitates Resident Training in Total Hip Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: No study has yet assessed the efficacy of virtual reality (VR) simulation for teaching orthopedic surgery residents. In this blinded, randomized, and controlled trial, we asked if the use of VR simulation improved postgraduate year (PGY)-1 orthopedic residents' performance in cadaver total hip arthroplasty and if the use of VR simulation had a preferentially beneficial effect on specific aspects of surgical skills or knowledge. METHODS: Fourteen PGY-1 orthopedic residents completed a written pretest and a single cadaver total hip arthroplasty (THA) to establish baseline levels of knowledge and surgical ability before 7 were randomized to VR-THA simulation. All participants then completed a second cadaver THA and retook the test to assess for score improvements. The primary outcomes were improvement in test and cadaver THA scores. RESULTS: There was no significant difference in the improvement in test scores between the VR and control groups (P = .078). In multivariate regression analysis, the VR cohort demonstrated a significant improvement in overall cadaver THA scores (P = .048). The VR cohort demonstrated greater improvement in each specific score category compared with the control group, but this trend was only statistically significant for technical performance (P = .009). CONCLUSIONS: VR-simulation improves PGY-1 resident surgical skills but has no significant effect on medical knowledge. The most significant improvement was seen in technical skills. We anticipate that VR simulation will become an indispensable part of orthopedic surgical education, but further study is needed to determine how best to use VR simulation within a comprehensive curriculum. LEVEL OF EVIDENCE: Level 1.