Platelet-Rich Plasma Injections for Shoulder Adhesive Capsulitis Are at Least Equivalent to Corticosteroid or Saline Solution Injections: A Systematic Review of Prospective Cohort Studies.

PURPOSE: To evaluate the role of platelet-rich plasma (PRP) for adhesive capsulitis (AC) as compared with other injectables. METHODS: A literature search of the PubMed and Embase online databases was performed to identify articles evaluating injection therapy for the treatment of AC. The inclusion criteria included prospective studies comparing PRP against alternative injectables with a minimum of 15 patients in each treatment arm and a minimum 12-week follow-up period. Pain scores, range of motion, and function scores were the primary outcomes assessed. RESULTS: Five articles comparing PRP with corticosteroid or saline solution injections met the inclusion criteria. A total of 157 patients were treated with PRP, with a follow-up duration ranging from 3 to 6 months. All 5 studies showed statistically significant improvements in pain scores, motion, and function scores in patients receiving PRP, corticosteroid, and saline solution injections. However, PRP was consistently superior on intergroup analyses in all but 1 study. In 4 studies, pain and function scores favored PRP over control at final follow-up (range in mean difference, -2.2 to 0.69 for visual analog scale pain score [n = 5] and -50.5 to -4.0 for Shoulder Pain and Disability Index score [n = 3]), whereas 3 studies found greater improvement in shoulder motion after PRP (range in mean difference, 0.7° to 34.3° for forward flexion and -2.3° to 20.4° for external rotation [n = 4]). One study found no significant difference between PRP and corticosteroid injections but noted that the results were comparable. CONCLUSIONS: According to a limited number of prospective studies, PRP injections for AC are at least equivalent to corticosteroid or saline solution injections and often lead to improved pain, motion, and functional outcomes at 3- to 6-month follow-up. Given the small number of studies, with design heterogeneity, there is insufficient evidence to routinely recommend PRP for AC. However, the results are promising and do support considering PRP as an adjunct treatment option for AC, especially for patients refractory and/or averse to corticosteroids or alternative treatment modalities. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

Does Prednisone Dose Affect Rates of Periprosthetic Joint Infection Following Primary Total Hip and Total Knee Arthroplasty?

BACKGROUND: Prednisone use is associated with higher rates of periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). However, the relationship between prednisone dosage and infection risk is ill-defined. Therefore, this study aimed to assess the relationship between prednisone dosage and rates of PJI following TJA. METHODS: A national database was queried for all elective total hip (THA) and total knee arthroplasty (TKA) patients between 2015 and 2020. Patients who received oral prednisone following TJA were matched in a 1:2 ratio based on age and sex to patients who did not. Univariate and multivariate regression analyses were performed to assess the 90-day risk of infectious complications based on prednisone dosage as follows: 0 to 5, 6 to 10, 11 to 20, 21 to 30, and >30 milligrams. Overall, 1,322,043 patients underwent elective TJA (35.9% THA, 64.1% TKA). Of these, 14,585 (1.1%) received prednisone and were matched to 29,170 patients who did not. RESULTS: After controlling for confounders, TKA patients taking prednisone were at increased risk for sepsis (adjusted odds ratio [aOR] 2.76, P < .001), PJI (aOR 2.67, P < .001), and surgical site infection (aOR: 2.56, P = .035). THA patients taking prednisone were at increased risk for sepsis (aOR: 3.21, P < .001) and PJI (aOR: 1.73, P = .001). No dose-dependent relationship between prednisone and infectious complications was identified when TJA was assessed in aggregate. CONCLUSION: Patients receiving prednisone following TJA were at increased risk of PJI and sepsis. A dose-dependent relationship between prednisone and infectious complications was not identified. Arthroplasty surgeons should be aware of these risks and counsel TJA patients who receive prednisone therapy.

Aspirin for Venous Thromboembolic Prophylaxis Following Total Hip and Total Knee Arthroplasty: An Analysis of Safety and Efficacy Accounting for Surgeon Selection Bias.

BACKGROUND: Aspirin may be effective at preventing venous thromboembolism following total knee arthroplasty (TKA) or total hip arthroplasty (THA). Current evidence is limited by bias as many surgeons who use aspirin prescribe for high-risk patients alternative chemoprophylactic agents. Therefore, this study aimed to evaluate the risk of pulmonary embolism (PE) and deep vein thrombosis (DVT) in patients who received aspirin and warfarin while accounting for surgeon selection bias. METHODS: A national database was queried for patients undergoing primary elective TKA or THA from 2015 to 2020. Patients whose surgeon used aspirin in >90% of their patients were compared to patients whose surgeon used warfarin in >90% of cases. Instrumental variable analyses were performed to assess for PE, DVT, and transfusion while accounting for selection bias. Among TKA patients, 26,657 (18.8%) were in the warfarin cohort and 115,005 (81.2%) were in the aspirin cohort. Among THA patients, 13,035 (17.7%) were in the warfarin cohort and 60,726 (82.3%) were in the aspirin cohort. RESULTS: Analyses were unable to identify a difference in the risk of PE (TKA: adjusted odds ratio [aOR]: 0.98, P = .659; THA: aOR = 0.93, P = .310) and DVT (TKA: aOR = 1.05, P = .188; THA: aOR = 0.96, P = .493) between the aspirin and warfarin cohorts. However, the aspirin cohort was associated with a lower risk of transfusion (TKA: aOR = 0.58, P < .001, THA: 0.84, P < .001). DISCUSSION: After accounting for surgeon selection bias, aspirin was as effective as warfarin at preventing PE and DVT following TKA and THA. Furthermore, aspirin was associated with a lower risk of transfusion compared to warfarin.

Safety and Efficacy of Rivaroxaban in Primary Total Hip and Knee Arthroplasty.

BACKGROUND: An optimal venous thromboembolism prophylaxis agent should balance efficacy and safety. While rivaroxaban provides effective venous thromboembolism prophylaxis after total joint arthroplasty, it may be associated with higher rates of bleeding. This study aimed to compare the safety and efficacy of rivaroxaban to aspirin and enoxaparin. METHODS: A large national database was queried for patients who underwent elective primary total hip (THA) or total knee arthroplasty (TKA) from January 2015 through December 2020 who received rivaroxaban, aspirin, or enoxaparin. Multivariate analyses were performed to assess the 90-day risk of bleeding and thromboembolic complications. Among TKA patients identified, 86,721 (10.8%) received rivaroxaban, 408,038 (50.8%) received aspirin, and 108,377 (13.5%) received enoxaparin. Among THA patients, 42,469 (9.5%) received rivaroxaban, 242,876 (54.5%) received aspirin, and 59,727 (13.4%) received enoxaparin. RESULTS: After accounting for confounding factors, rivaroxaban was associated with increased risk of transfusion (TKA: adjusted odds ratio [aOR] = 2.58, P < .001; THA: aOR 1.64, P < .001), pulmonary embolism (TKA: aOR = 1.25, P = .007), and deep vein thrombosis (TKA: aOR = 1.13, P = .022) compared to aspirin. Compared to enoxaparin, rivaroxaban was associated with an increased risk of combined bleeding events (TKA: aOR = 1.07, P < .001, THA: aOR = 1.11, P < .001), but decreased risk of combined prothrombotic events (THA: aOR = 0.85, P = .036). CONCLUSION: Rivaroxaban chemoprophylaxis following TKA and THA was associated with an increased risk of bleeding and prothrombotic complications compared to aspirin and enoxaparin.

Is Intraoperative Dexamethasone Utilization Associated With Increased Rates of Periprosthetic Joint Infection Following Total Joint Arthroplasty?

BACKGROUND: Intraoperative dexamethasone can reduce postoperative pain and nausea following total knee (TKA) and total hip arthroplasty (THA). To the best of our knowledge, no study to date has been adequately powered to detect the risk of periprosthetic joint infection (PJI) from early dexamethasone exposure. This study aimed to assess PJI rates and complications in patients undergoing primary elective TKA and THA who received intraoperative dexamethasone. METHODS: A national database was used to identify adults undergoing primary elective TKA and THA between 2015 and 2020. Patients who received intraoperative dexamethasone and those who did not were identified. The primary endpoint was 90-day risk of infectious complications. Secondary end points included thromboembolic, pulmonary, renal, and wound complications. Multivariate analyses were performed to assess the risk of all endpoints between cohorts. Between 2015 and 2020, 1,322,025 patients underwent primary elective TJA, of which 857,496 (64.1%) underwent TKA and 474,707 (35.9%) underwent TKA. RESULTS: In patients who underwent TKA, dexamethasone was associated with lower risk of PJI (adjusted odds ratio: 0.87, 95% CI: 0.82-0.93, P < .001) as well as other secondary endpoints such as pulmonary embolism, deep vein thrombosis, and acute kidney injury. In patients who underwent THA, dexamethasone was associated with a lower risk of PJI (adjusted odds ratio: 0.80, 95% CI: 0.73-0.86, P < .001) as well as other secondary endpoints such as pulmonary embolism, deep vein thrombosis, acute kidney injury, and pneumonia. CONCLUSION: Intraoperative dexamethasone was not associated with increased risk of infectious complications. The data presented here provide evidence in support of intraoperative dexamethasone utilization during primary TKA or THA.

Factors Associated With Failure Following Proximal Femoral Replacement for Salvage Hip Surgery for Nononcologic Indications.

BACKGROUND: Proximal femoral replacement (PFR) is used when extensive proximal femoral bone loss is encountered during revision total hip arthroplasty. However, further data on 5-to-10-year survivorship and predictors of failure are needed. Our aim was to assess the survivorship of contemporary PFRs used for nononcologic indications and determine factors associated with failure. METHODS: A single-institution retrospective observational study was conducted between June 1, 2010 and August 31, 2021 for patients undergoing PFR for non-neoplastic indications. Patients were followed for a minimum of 6 months. Demographic, operative, clinical, and radiographic data were collected. Implant survivorship was determined via Kaplan-Meier analysis of 56 consecutive cemented PFRs in 50 patients. RESULTS: At a mean follow-up of 4 years, the mean Oxford Hip Score was 36.2 and patient satisfaction was rated at an average of 4.7 of 5 on the Likert scale. Radiographic evidence of femoral-sided aseptic loosening was determined in 2 PFRs at a median of 9.6 years. The 5-year survivorship with all-cause reoperation and revision as end points was 83.2% (95% Confidence Interval [CI]: 70.1% to 91.0%) and 84.9% (95% CI: 72.0% to 92.2%), respectively. The 5-year survivorship was 92.3% (95% CI: 78.0% to 97.5%) for stem length > 90 mm compared to 68.4% (95% CI: 39.5% to 85.7%) for stem length ≤ 90 mm. A construct-to-stem length ratio (CSR) ≤ 1 was associated with a 91.7% (95% CI: 76.4% to 97.2%) survival, while a CSR > 1 was associated with a 73.6% (95% CI: 47.4% to 88.1%) survival. CONCLUSION: A PFR stem length ≤ 90 mm and CSR > 1 were associated with increased rates of failure.

Positive COVID-19 Diagnosis Following Primary Elective Total Joint Arthroplasty: Increased Complication and Mortality Rates.

BACKGROUND: This study analyzed complication rates following primary elective total joint arthroplasty (TJA) in patients who subsequently contracted COVID-19. METHODS: A large national database was queried for adult patients who underwent primary elective TJA in 2020. Patients who contracted COVID-19 after total knee arthroplasty (TKA) or total hip arthroplasty (THA) underwent 1:6 matching (age [±6 years], sex, month of surgery, COVID-19-related comorbidities) to patients who did not. Differences between groups were assessed using univariate and multivariate analyses. Overall, 712 COVID-19 patients were matched to 4,272 controls (average time to diagnosis: 128-117 days [range, 0-351]). RESULTS: Of patients diagnosed <90 days postoperatively, 32.5%-33.6% required COVID-19-driven readmission. Discharge to a skilled nursing facility (adjusted odds ratio [aOR] 1.72, P = .003) or acute rehabilitation unit (aOR 4.93, P < .001) and Black race (aOR 2.28, P < .001) were associated with readmission after TKA. Similar results were associated with THA. COVID-19 patients were at increased risk of pulmonary embolism (aOR 4.09, P = .001) after TKA and also periprosthetic joint infection (aOR 4.65, P < .001) and sepsis (aOR 11.11, P < .001) after THA. The mortality rate was 3.51% in COVID-19 patients and 7.94% in readmitted COVID-19 patients compared to 0.09% in controls, representing a 38.7 OR and 91.8 OR of death, respectively. Similar results were observed for TKA and THA separately. CONCLUSION: Patients who contracted COVID-19 following TJA were at greater risk of numerous complications, including death. These patients represent a high-risk cohort who may require more aggressive medical interventions. Given the potential limitations presently, prospectively collected data may be warranted to validate these findings.

The Persistent Effects of the COVID-19 Pandemic on Total Joint Arthroplasty Changes in Practice Patterns in the United States From 2020 to 2021.

BACKGROUND: The SARS-CoV-2 (COVID-19) pandemic has dramatically disrupted orthopaedic surgery practice patterns. This study aimed to examine differences between patients who underwent total joint arthroplasty (TJA) before the pandemic compared to 2020 and 2021. METHODS: A retrospective cohort study was performed on all patients who underwent elective inpatient TJA from January 2017 to December 2021 using a national large database. Descriptive statistics were utilized to trend length of stay (LOS) and patient age. Patient demographics, discharge destinations, and rates of medical comorbidities were assessed for patients undergoing TJA in 2020 and 2021 compared to patients from prepandemic years (2017 to 2019). Overall, 1,173,366 TJAs were identified (2017 to 2019: 810,268 TJAs, average 270,089 cases/year; 2020: 175,185 TJAs; 2021: 187,627 TJAs). There was a 35.3% and 30.5% decrease in 2020 and 2021, respectively, when compared to the prepandemic annual average. RESULTS: Average LOS decreased from 1.6 days in January 2020 to 0.9 days by December 2021. Same-day discharges increased from 6.2% of cases in 2019 to 30.5% in 2021. Discharge to skilled nursing facilities (SNF) reduced from 11.3% in 2017 to 2019 to 4.3% and 4.5% in 2020 and 2021, respectively. Patients ≥70 years old undergoing elective TJA decreased from 39.6% in 2017 to 2019 to 29.2% in April 2020. CONCLUSION: In response to the COVID-19 pandemic, same-day discharges following primary elective TJA increased markedly, the average LOS decreased, discharges to SNFs decreased, and a preferential shift toward younger patients was observed. LEVEL OF EVIDENCE: Therapeutic Level III.

Tranexamic Acid and Prothrombotic Complications Following Total Hip and Total Knee Arthroplasty: A Population-Wide Safety Analysis Accounting for Surgeon Selection Bias.

BACKGROUND: Tranexamic acid (TXA) utilization during total joint arthroplasty (TJA) has become ubiquitous. However, concerns remain regarding the risk of thrombotic complications. The goal of this study was to examine the risk of prothrombotic complications in patients who received TXA during total knee (TKA) and total hip arthroplasty (THA). METHODS: The Premier Healthcare Database was queried for patients who underwent elective TJA. TXA utilization trends were described from 2008 to 2020. Two analyses were performed using ICD-10 codes from 2016 to 2020: (1) patients who received TXA compared to patients who did not receive TXA and, (2) to account for surgeon selection bias, patients whose surgeon utilized TXA consistently (≥90% of cases) compared to patients whose surgeons used TXA infrequently (≤30% of cases). Multivariate and instrumental variable analyses (IVA) were performed to assess outcomes while accounting for confounding factors. TXA utilization increased from 0.1% of cases in 2008 to 89.2% in 2020. From 2016 to 2020, 1,120,858 TJAs were identified (62.1% TKA, 27.9% THA), of which 874,627 (78.0%) received TXA. RESULTS: Patients who received TXA were at lower risk of prothrombotic (adjusted Odds Ratio (aOR) 0.82, P < .001), bleeding (aOR 0.75, P < .001), and infectious complications (aOR 0.91, P < 0.001). Furthermore, patients who underwent surgery from surgeons who utilized TXA consistently were at lower risk for prothrombotic (aOR 0.90, P < .001) and bleeding (aOR 0.72, P < .001) complications. CONCLUSION: The widespread utilization of TXA during elective TJA was not associated with increased rates of prothrombotic complications. These findings persisted after accounting for surgeon selection bias. LEVEL OF EVIDENCE: Level III.

Standard versus low-dose computed tomography for assessment of acetabular fracture reduction using novel step and gap measurement technique.

PURPOSE: Quality of reduction is of paramount importance after acetabular fracture and is best assessed on computed tomography (CT). A recently proposed measurement technique for assessment of step and gap displacement is reproducible but has not been validated. The purpose of this study is to validate a well-established measurement technique against known displacements and to determine if it can be used with low dose CT. METHODS: Posterior wall acetabular fractures were created in 8 cadaveric hips and fixed at known step and gap displacements. CT was performed at multiple radiation doses for each hip. Four surgeons measured step and gap displacement for each hip at all doses, and the measurements were compared to known values. RESULTS: There were no significant differences in measurements across surgeons, and all measurements were found to have positive agreement. Measurement error < 1.5 mm was present in 58% of gap measurements and 46% of step measurements. Only for step measurements at a dose of 120 kVp did we observe a statistically significant measurement error. There was a significant difference in step measurements made by those with greater and those with fewer years in practice. CONCLUSION: Our study suggests this technique is valid and accurate across all doses. This is important as it may reduce the amount of radiation exposure for patients with acetabular fractures.

Computer-Navigated and Robotic-Assisted Total Knee Arthroplasty: Increasing in Popularity Without Increasing Complications.

BACKGROUND: Data on the clinical impact of computer navigation (CN) and robotic assistance (RA) in total knee arthroplasty (TKA) are mixed. This study aims to describe modern utilization trends in CN-TKA, RA-TKA, and traditionally-instrumented (TD) TKA and to assess for differences in postoperative complications and opioid consumption by procedure type. METHODS: A national database was queried to identify primary, elective TKA patients from 2015 to 2020. Trends in procedural utilization rates were assessed. Differences in 90-day postoperative complications and inpatient opioid consumption were assessed. Multivariate regression analyses were performed to account for potential confounders. RESULTS: Of the 847,496 patients included, 49,317 (5.82%) and 24,460 (2.89%) underwent CN-TKA and RA-TKA, respectively. CN-TKA utilization increased from 5.64% (2015) to 6.41% (2020) and RA-TKA utilization increased from 0.84% (2015) to 5.89% (2020). After adjusting for confounders, CN-TKA was associated with lower periprosthetic joint infection (P = .001), pulmonary embolism (P < .001), and acute respiratory failure (P = .015) risk compared to traditional (TD) TKA. RA-TKA was associated with lower deep vein thrombosis (P < .001), myocardial infarction (P = .013), and pulmonary embolism (P = .001) risk than TD-TKA. Lower postoperative day 1 opioid usage was seen with CN-TKA and RA-TKA than TD-TKA (P < .001). Lower postoperative day 0 opioid consumption was also seen in RA-TKA (P < .001). CONCLUSION: From 2015 to 2020, there was a relative 13.7% and 601.2% increase in CN-TKAs and RA-TKAs, respectively. This trend was associated with reductions in hospitalization duration, postoperative complications, and opioid consumption. These data support the safety of RA-TKA and CN-TKA compared to TD-TKA. Further investigation into the specific indications for these technology-assisted TKAs is warranted.

Midterm Survivorship of Robotic-Assisted Lateral Unicompartmental Knee Arthroplasty.

BACKGROUND: Lateral unicompartmental knee arthroplasty (UKA) is a popular alternative to total knee arthroplasty (TKA) for patients with isolated lateral compartment osteoarthritis. Few studies have investigated outcomes following robotic-assisted lateral UKA. The purpose of this study is to evaluate mid-term survivorship and patient-reported outcomes of robotic-assisted lateral UKA. METHODS: A retrospective case series was conducted on all robotic-assisted lateral UKAs performed by a single surgeon between 2013 and 2019. Patient demographics, surgical variables, and Kozinn and Scott criteria were collected. Implant survivorship was estimated using the Kaplan-Meier method with all-cause reoperation and conversion to TKA as endpoints. Participating patients were assessed for patient satisfaction and the Forgotten Joint Score-12. Correlations between patient demographics and patient outcome scores were investigated. RESULTS: In total, 120 lateral UKAs were identified, 84 of which met inclusion criteria, with a mean follow-up of 4.0 years (range 2.0-7.0). Five-year survivorship was 92.9% (95% confidence interval [CI] 84.5-96.7) with all-cause reoperation as the endpoint, and 100% (95% CI 95.0-100) with conversion to TKA as the endpoint. One patient was converted to TKA after the 5-year mark, resulting in a 6-year survival for conversion to TKA of 88.9% (95% CI 44.9-98.5). Average Forgotten Joint Score-12 score was 82.7/100, and patient satisfaction 4.7/5. Mean coronal plane correction was 2.5° ± 1.9° toward the mechanical axis. Neither final postoperative alignment nor failure to meet classic Kozinn and Scott criteria for UKA resulted in differences in patient-reported outcomes. CONCLUSION: The current study demonstrates high mid-term survivorship and excellent patient-reported outcomes with robotic-assisted lateral UKA. Robotic-assisted lateral UKA is a viable treatment option for isolated lateral compartment arthritis even in patients who do not meet classic indications.

Limb Length Discrepancy in Total Hip Arthroplasty: Is the Lesser Trochanter a Reliable Measure of Leg Length?

BACKGROUND: Limb length discrepancy (LLD) after total hip arthroplasty may affect clinical outcomes and patient satisfaction. Preoperative LLD estimates on anteroposterior pelvic radiographs fail to account for anatomical limb variation distal to the femoral reference points. The objective of this study is to determine how variations in lower limb skeletal lengths contribute to true LLD. METHODS: Full-length standing anteroposterior radiographs were used to measure bilateral leg length, femoral length, and tibial length. Leg length was evaluated using 2 different proximal reference points: the center of the femoral head (COH) and the lesser trochanter (LT). Mean side-to-side discrepancy (MD) and percentage asymmetry (%AS) for each measurement were evaluated in the overall cohort and when stratified by patient demographic variables. RESULTS: One hundred patients were included with an average age of 62.9 ± 11.2 years. Average femoral length was 434.0 ± 39.8 mm (MD 4.3 ± 3.5 mm) and tibial length was 379.9 ± 34.6 mm (MD 5.9 ± 12.7 mm). Average COH-talus was 817.5 ± 73.2 mm (MD 6.4 ± 5.1 mm). Average LT-talus was 760.5 ± 77.6 mm (MD 5.8 ± 5.1 mm). Absolute asymmetry >10 mm was detected in 16% of patients for COH-talus and 15% for LT-talus, while %AS >1.5% was detected in 13% of patients for COH-talus and 18% for LT-talus. Female gender was associated with increased femoral length %AS (P = .037). CONCLUSION: Approximately 1 in 6 patients have an LLD of >10 mm when measured from either the LT or COH. Surgeons using either of these common femoral reference points to estimate LLD on pelvic radiographs should consider these findings when planning for hip reconstruction. LEVEL OF EVIDENCE: Level III.

Laminoplasty in Motion: Evolving Techniques and Complications.

Cervical laminoplasty is an increasingly popular surgical option for the treatment of cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament (OPLL). Over the past few decades, there have been substantial developments in both surgical technique and hardware options. As the field of cervical surgery rapidly evolves, there is a timely need to reassess the evolving complications associated with newer techniques. This review aims to synthesize the available literature on cervical laminoplasty and associated mechanical complications pertaining to different laminoplasty hinge fixation options.

Are all Cages Created Equal? Analysis of Cervical Cage Malfunctions Using FDA MAUDE Database.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To characterize failure rates of cervical cages based on manufacturer and design characteristics using the nationwide database of reported malfunctions. BACKGROUND: The Food and Drug Administration (FDA) aims to ensure the safety and efficacy of cervical interbody implants postimplantation; however, intraoperative malfunctions may be overlooked. MATERIALS AND METHODS: The FDA's Manufacturer and User Facility Device Experience database was queried for reports of cervical cage device malfunctions from 2012 to 2021. Each report was categorized based on the failure type, implant design, and manufacturer. Two market analyses were performed. First, "failure-to-market share indices" were generated by dividing the number of failures per year for each implant material by its yearly US market share in cervical spine fusion. Second, "failure-to-revenue indices" were calculated by dividing the total number of failures per year for each manufacturer by their approximate yearly revenue from spinal implants in the US. Outlier analysis was performed to generate a threshold value above which failure rates were defined as greater than the normal index. RESULTS: In total, 1336 entries were identified, and 1225 met the inclusion criteria. Of these, 354 (28.9%) were cage breakages, 54 (4.4%) were cage migrations, 321 (26.2%) were instrumentation-related failures, 301 (24.6%) were assembly failures, and 195 (15.9%) were screw failures. Poly-ether-ether-ketone implants had higher failure by market share indices for both migration and breakage compared with titanium. Upon manufacturer market analysis, Seaspine, Zimmer-Biomet, K2M, and LDR exceeded the failure threshold. CONCLUSION: The most common cause of implant malfunction was breakage. Poly-ether-ether-ketone cages were more likely to break and migrate compared with titanium ones. Many of these implant failures occurred intraoperatively during instrumentation, which underscores the need for FDA evaluation of these implants and their accompanying instrumentation under the appropriate loading conditions before commercial approval.

Characteristics of Very Young Patients Undergoing Total Hip Arthroplasty: A Contemporary Assessment.

Background: This study aims to compare indications, patient characteristics, hospital factors, and complication rates between total hip arthroplasty (THA) patients aged 30 years or younger and those older than 30 years using a large national database. Methods: The Premier Healthcare Database was utilized to identify primary THA patients from 2015 to 2021 who were aged ≤30 or >30 years. Patient demographics, hospital factors, and primary indications were compared for each cohort. Rates of complications and readmissions were assessed for each cohort by primary indication. Differences were assessed through univariate analysis. Results: Overall, 539,173 primary THA patients were identified (age ≤30: 1849; >30: 537,234). Compared to the >30 cohort, the ≤30 cohort was more likely to be male (56.5% vs 44.9%, P < .001) and non-White (34.0% vs 14.2%, P < .001). The most common indications for THA in the ≤30 cohort were osteonecrosis (49.3%), osteoarthritis (17.8%), and congenital hip deformities (16.0%), and in the >30 cohort, they were osteoarthritis (77.0%), other arthritis (11.3%), and osteonecrosis (5.4%). Patients aged ≤30 years had lower rates of respiratory failure (0.16% vs 0.57%, P < .001), acute renal failure (0.32% vs 1.72%, P < .001), and urinary tract infection (0.38% vs 1.11%, P = .003) than those aged >30 years, but higher rates of wound dehiscence (0.59% vs 0.29%, P = .015) and transfusion (3.68% vs 2.21%, P < .001). There were no differences in 90-day readmission rates (P = .811) or 90-day in-hospital death (P = .173) between cohorts. Conclusions: Younger patients undergoing THA differed significantly in indication, patient characteristics, and hospital factors compared to the older population on univariate analysis. Despite differences in indications, the cohorts did not differ markedly with regard to complication rates in this study.

Risk Factors Associated with Thromboembolic Complications After total Hip Arthroplasty: An Analysis of 1,129 Pulmonary Emboli.

INTRODUCTION: Venous thromboembolism (VTE) remains a dangerous complication after total hip arthroplasty (THA), despite advances in chemoprophylactic measures. This study aimed to identify risk factors of developing pulmonary embolism (PE) and deep vein thrombosis (DVT) after THA using a modern cohort of patients reflecting contemporary practices. METHODS: The Premier Healthcare Database was queried for primary, elective THAs from January 1st, 2015, to December 31st, 2021. Patients who developed PE or DVT within 90 days of THA were compared with patients who did not develop any postoperative VTE. Differences in patient demographics, comorbidities, hospital factors, perioperative medications, chemoprophylactic agents, and allogeneic blood transfusion were compared between cohorts. Multivariable logistic regression models were used to identify independent risk factors of PE and DVT. In total, 544,298 THAs were identified, of which 1,129 (0.21%) developed a PE and 1,799 (0.33%) developed a DVT. RESULTS: Patients diagnosed with a PE had significantly higher rates of in-hospital death (2.6% vs 0.1%, P < 0.001) compared with those without a PE. Age (adjusted odds ratio: 1.02 per year, 95% confidence interval [CI]: 1.01 to 1.03) and Black race (aOR: 1.52, 95% CI: 1.24 to 1.87) were associated with an increased risk of PE. Comorbidities associated with increased risk of PE included chronic pulmonary disease (aOR: 1.58, 95% CI: 1.36 to 1.84), pulmonary hypertension (aOR: 2.06, 95% CI: 1.39 to 3.04), and history of VTE (aOR: 2.38, 95% CI: 1.98 to 2.86). Allogeneic blood transfusion (aOR: 2.40, 95% CI: 1.88 to 3.06) was also associated with an increased risk of PE while dexamethasone utilization was associated with a reduced risk (aOR: 0.83, 95% CI: 0.73 to 0.95). DISCUSSION: Increasing age; Black race; allogeneic blood transfusion; and comorbidities, including chronic pulmonary disease, pulmonary hypertension, and history of VTE, were independent risk factors of PE after THA. Given the increased mortality associated with PE, patients should be carefully evaluated for these factors and managed with an appropriate chemoprophylactic regimen.

An Updated Estimate of Total Hip and Total Knee Arthroplasty Inpatient Case Volume During the 2020 COVID-19 Pandemic in the United States.

Background: Inpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA) practices were dramatically affected in the United States in 2020 as elective surgeries were paused in response to the COVID-19 pandemic. This study sought to provide an updated estimate of inpatient total joint arthroplasty (TJA) case volumes in the United States in 2020. Methods: A retrospective cohort study was performed by identifying all adult patients who underwent primary, elective TJA from January 1st, 2017 to December 31st, 2020, using the National Inpatient Sample. Monthly and annual case volumes were reported with descriptive statistics. Baseline case volumes were established by taking the average number of monthly cases performed in 2017, 2018, and 2019. These monthly averages were compared to 2020 values. Results: From 2017 to 2019, the average case volume was 1,056,669 cases per year (41.0% THA, 59.0% TKA) and 88,055 cases per month. In 2020, 535,441 cases were identified (45.4% THA, 54.6% TKA), corresponding to a 49.3% reduction from the 2017-2019 annual average. Monthly cases decreased to 4515 in April during the "first wave" of COVID-19, corresponding to a 94.8% decrease from prior years. In June, cases rebounded to 55,520 before decreasing again in July to 50,100 during the "second wave" of COVID-19. During the "third wave," COVID-19 cases decreased month-over-month from October through December (56.5% decrease). Conclusions: This updated estimate identified a 49.3% decrease in inpatient TJA cases in 2020 compared to prior years. This is similar to the 46.5-47.7% decrease in case volume previously reported.

Duloxetine for Postoperative Pain Control Following Knee or Hip Replacement: A Systematic Review and Meta-Analysis.

Background: Duloxetine is a Food and Drug Administration-approved selective norepinephrine reuptake inhibitor for treating depression, anxiety, fibromyalgia, and neuropathic and chronic musculoskeletal pain. This meta-analysis aims to evaluate the efficacy of duloxetine in reducing pain and postoperative opioid use following lower extremity total joint arthroplasty. Methods: A literature search was performed, identifying randomized controlled trials investigating duloxetine for pain management after total hip and total knee arthroplasty. Data from the visual analog scale (VAS) for pain during movement and at rest were extracted for postoperative days (PODs) 1, 3, 7, and 14, as well as postoperative week 6 and postoperative month 3. Opioid use data were obtained at 24, 48 and 72 hours. All data were analyzed using inverse variance with random effects and presented as weighted mean difference. Results: Eight unique studies were identified and included, 7 of which were analyzed quantitatively. Duloxetine decreased postoperative opioid consumption at 48 and 72 hours. For VAS for pain at rest, significantly reduced pain was reported by duloxetine-treated patients at POD 3, POD 7, and postoperative week 6. For VAS for pain at movement, significantly reduced pain was reported by duloxetine-treated patients at POD1, POD 3, POD 7, POD 14, postoperative week 6, and postoperative month 3. Conclusions: Duloxetine appears to decrease postoperative pain and opioid consumption following total joint arthroplasty. However, definitive conclusions are limited by small sample size and study heterogeneity. While there is a need for follow-up studies to determine the optimal dose, duration, and patient population, strong preliminary data provide robust support for future large-scale efficacy studies.

An Analysis of a Decade of Lumbar Interbody Cage Failures in the United States: A MAUDE Database Study.

STUDY DESIGN: A retrospective case series. OBJECTIVE: This study aims to assess the rates of lumbar interbody cage failures based on their material and manufacturer. SUMMARY OF BACKGROUND DATA: Perioperative lumbar interbody cage malfunctions are underreported events in the spine literature and may result in complications. Although the Food and Drug Administration ensures the safety of these devices under physiological conditions after implantation, these devices may experience nonphysiological conditions during implantation, which may be overlooked. MATERIALS AND METHODS: The MAUDE database was examined for reports of lumbar cage device malfunctions from 2012 to 2021. Each report was categorized based on failure type and implant design. A market analysis was performed by dividing the total number of failures per year for each manufacturer by their approximate yearly revenue from spinal implants in the United States. Outlier analysis was performed to generate a threshold value above which failure rates were defined as greater than the normal index. RESULTS: Overall, 1875 lumbar cage malfunctions were identified. Of these, 1230 (65.6%) were cage breakages, 257 (13.7%) were instrument malfunctions, 177 (9.4%) were cage migrations, 143 (7.6%) were assembly failures, 70 (4.5%) were screw-related failures, and 21 (1.1%) were cage collapses. Of the breakages, 923 (74.9%) occurred during insertion or impaction and 97 entries detailed a medical complication or a retained foreign body. Of the migrations, 155 (88.6%) were identified postoperatively, of which 73 (47.1%) detailed complications and 52 (33.5%) required a revision procedure. Market analysis demonstrated that Medtronic, Zimmer Biomet, Stryker, Seaspine, and K2M exceeded the calculated threshold. CONCLUSIONS: Lumbar cages with polyether ether ketone core material failed more frequently by breakage, whereas titanium surface cages failed more frequently by migration. Failure rates varied depending on the manufacturer. Most cage breakages identified in the present study occurred intraoperatively during implantation. These findings call for a more detailed Food and Drug Administration evaluation of these intraoperative malfunctions before commercial approval. LEVEL OF EVIDENCE: Level 4.