Significant Cost Savings and Improved Early Clinical Outcomes in Medicare Patients Utilizing a Clinician-Controlled Telerehabilitation System Following Total Knee Arthroplasty.

BACKGROUND: The costs and benefits of different rehabilitation protocols following total knee arthroplasty are unclear. The emergence of telerehabilitation has introduced the potential for enhanced patient convenience and cost reduction. The purpose of this study was to assess the cost difference between standard physical therapy (SPT) and a telerehabilitation home-based clinician-controlled therapy system (HCTS). METHODS: A prospectively enrolled, consecutive series of 109 Medicare patients who received SPT were compared to 101 Medicare patients who were treated with a HCTS. The analysis focused on total rehabilitation costs and the assessment of outcome measures: knee range of motion, visual analog scale pain levels, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement. RESULTS: The HCTS group demonstrated not only statistically significantly lower average costs but also faster and sustained knee range of motion improvements. Furthermore, in comparison to SPT, the HCTS group exhibited superior visual analog scale pain scores and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement functional scores at all assessment points postoperatively, which were statistically significant (all P < .001) and surpassed the minimal clinically important difference thresholds. CONCLUSIONS: The HCTS used in this study exhibited a remarkable cost-saving advantage of $2,460 per patient compared to standard therapy. As approximately 500,000 primary total knee arthroplasties in the United States are covered by Medicare annually, a switch to HCTS could yield total cost savings of more than $1.23 billion per year for our taxpayer-funded health care system. Furthermore, the HCTS cohort demonstrated superior functional outcomes and improved pain scores across all assessment time points, exceeding the minimal clinically important difference.

A Home-Based, Remote-Clinician-Controlled, Physical Therapy Device Leads to Superior Outcomes When Compared to Standard Physical Therapy for Rehabilitation After Total Knee Arthroplasty.

BACKGROUND: The optimal postoperative rehabilitation regimen following total knee arthroplasty (TKA) is not clearly defined. The advent of telerehabilitation offers potential for increased patient convenience and decreased cost, while maintaining similar outcomes to traditional physical therapy (PT). Therefore, we evaluated a novel, home-based, clinician-controlled, multi-modal evaluation and therapy device with telerehabilitation functionality for TKA. METHODS: A total of 135 consecutive TKA patients receiving standard therapy protocol (STP) were compared to 135 consecutive patients receiving a home-based clinician-controlled therapy system (HCTS). Outcomes were assessed at 2, 6, and 12 weeks, including visual analog scale (VAS) for pain, knee injury and osteoarthritis outcome score JR (KOOS JR), and knee range of motion (ROM) measured by the same certified physical therapists. RESULTS: Postoperative knee ROM was greater in the HCTS group at all time points throughout the study period (P < .001 at 2, 6, and 12 weeks). VAS and the KOOS JR functional scores were statistically better (P < .001) in the HCTS group at all time points and exceeded the threshold for minimal clinically important difference (MCID) for both VAS and KOOS JR. There were significantly fewer cases of arthrofibrosis requiring manipulation under anesthesia (MUA) in the HCTS group (1.48 versus 4.44%). CONCLUSION: Following TKA, a novel, home-based, clinician-controlled, multi-modal therapy device was superior to standard PTduring the first 12 weeks postoperatively for ROM, KOOS JR, and VAS (with all scores exceeding the MCID) and had substantially fewer manipulations for arthrofibrosis.

Survival in patients with carcinomas presenting with bone metastasis at diagnosis: a SEER population-based cohort study.

INTRODUCTION: Carcinoma metastasis to bone is a common reason for consultation to orthopedic surgeons. The presence of bone metastases (BM) is usually associated with poor prognosis which is worsened in the presence of synchronous metastases. The purpose of this study was to: (1) identify the most common carcinomas presenting with BM at diagnosis, to (2) analyze their survival, and (3) compare this against the survival of patients with additional synchronous metastasis based on a large population analysis. MATERIALS AND METHODS: Patients diagnosed with carcinoma between January 2010 and December 2015 were identified from the Surveillance, Epidemiology and End Results (SEER) database. The most common carcinomas presenting with BM at diagnosis were identified. Survival based on the presence of BM and synchronous metastases (lung, brain, liver, lymph nodes) was evaluated with Kaplan-Meier analysis. Five-year survival (%) stratified by carcinoma type was calculated. Hazard ratio (HR) for mortality comparing isolated BM to other synchronous metastases was performed. RESULTS: A total of 4.85% of patients (98,606/2,035,204) with carcinoma presented with BM at diagnosis, most commonly from a lung primary. Five-year survival with isolated BM was lowest in patients with pancreatic carcinoma (5.8%, 95% CI 3.0-9.9%), and highest in patients with breast carcinoma (41.1%, 95% CI 38.6-43.5%). Synchronous metastases increased significantly the risk of mortality within the majority of carcinomas. CONCLUSION: BM at diagnosis has a poor prognosis which is worsened if synchronous metastases are present; a fact to consider when planning orthopedic interventions. LEVEL OF EVIDENCE: Level III, prognostic study.

Neuropathic pain-induced depressive-like behavior and hippocampal neurogenesis and plasticity are dependent on TNFR1 signaling.

Patients suffering from neuropathic pain have a higher incidence of mood disorders such as depression. Increased expression of tumor necrosis factor (TNF) has been reported in neuropathic pain and depressive-like conditions and most of the pro-inflammatory effects of TNF are mediated by the TNF receptor 1 (TNFR1). Here we sought to investigate: (1) the occurrence of depressive-like behavior in chronic neuropathic pain and the associated forms of hippocampal plasticity, and (2) the involvement of TNFR1-mediated TNF signaling as a possible regulator of such events. Neuropathic pain was induced by chronic constriction injury of the sciatic nerve in wild-type and TNFR1(-/-) mice. Anhedonia, weight loss and physical state were measured as symptoms of depression. Hippocampal neurogenesis, neuroplasticity, myelin remodeling and TNF/TNFRs expression were analyzed by immunohistochemical analysis and western blot assay. We found that neuropathic pain resulted in the development of depressive symptoms in a time dependent manner and was associated with profound hippocampal alterations such as impaired neurogenesis, reduced expression of neuroplasticity markers and myelin proteins. The onset of depressive-like behavior also coincided with increased hippocampal levels of TNF, and decreased expression of TNF receptor 2 (TNFR2), which were all fully restored after mice spontaneously recovered from pain. Notably, TNFR1(-/-) mice did not develop depressive-like symptoms after injury, nor were there changes in hippocampal neurogenesis and plasticity. Our data show that neuropathic pain induces a cluster of depressive-like symptoms and profound hippocampal plasticity that are dependent on TNF signaling through TNFR1.

Effects of Venous Insufficiency in Patients Undergoing Primary Total Knee Arthroplasty: An Analysis of 1.2 Million Patients.

Chronic venous insufficiency (CVI) is extraordinarily prevalent in our aging population with over 30 million people in the United States suffering from the disease. There is a paucity of data analyzing the effects of CVI on outcomes following total knee arthroplasty (TKA). The purpose of this study was to utilize a nationwide administrative claims database to determine whether patients with CVI undergoing TKA have higher rates of: (1) in-hospital lengths of stay (LOS); (2) readmission rates; (3) medical complications; (4) implant-related complications; and (5) costs of care compared to controls. Using a nationwide database, we matched patients with CVI undergoing TKA to controls without CVI undergoing TKA in a 1:5 ratio by age, sex, and medical comorbidities associated with CVI. Primary outcomes analyzed within the study included LOS, 90-day readmission rates, 90-day medical complications, 2-year implant-related complications, in addition to 90-day total global episode of care costs. The query yielded 1,265,534 patients with (n = 210,926) and without (n = 1,054,608) CVI undergoing primary TKA. Patients with CVI had significantly longer LOS (4 vs. 3 days, p < 0.0001), higher 90-day readmission rates (20.96 vs. 15.34%; odds ratio [OR]: 1.46, 95% confidence interval [CI]: 1.44-1.48, p < 0.0001), and higher odds of medical complications (2.27 vs. 1.30%; OR: 1.76, 95% CI: 1.70-1.83, p < 0.0001) compared to matched controls. Patients with CVI also had higher odds of periprosthetic joint infections (2.23 vs. 1.03%; OR: 2.18, p < 0.0001) and implant-related complications in general (4.27 vs. 2.17%; OR: 2.01, 95% CI: 1.96-2.06, p < 0.0001). Additionally, patients with CVI had higher total global 90-day episode of care costs ($15,583.07 vs. $14,286.95, p < 0.0001). Patients with CVI undergoing TKA have increased LOS, higher odds of medical and implant complications, and increased costs of care compared to those without CVI. The study can be utilized by orthopaedic surgeons to counsel patients on the potential complications following this procedure. This is a level III, retrospective cohort study.

Achilles Injury and Access to Care in South Florida.

Introduction. Despite the amount of orthopaedic research evaluating access to care based on insurance status, no study quantifies the effects of insurance status on the care of acute Achilles tendon ruptures. Methods. Using Current Procedural Terminology codes, we identified all patients who underwent surgical management of Achilles tendon rupture between December 31, 2013, and December 31, 2018, and followed-up at either a county hospital-based orthopaedic surgery clinic and/or private university-based clinic. Inclusion criteria included patients who (1) underwent surgical management of an Achilles tendon rupture during this time period and (2) were at least 18 years of age at the time of surgery. A univariate 2-tailed t test was used to compare various groups. Statistical significance was set at P < 0.05. Results. When compared to adequately insured patients (private and Medicare), underinsured patients (uninsured and Medicaid) experienced a significantly greater time from the date of injury to first clinic visit (14.5 days vs 5.2 days, P < .001), first clinic visit to surgery (34.6 days vs 4.8 days, P < .002), injury to surgery date (48.9 days vs 9.8 days, P < .001), initial presentation to when magnetic resonance imaging was obtained (48.1 days vs 1.9 days, P < .002). Conclusions. Disparities in access to care for Achilles tendon ruptures are intimately related to insurance status. Uninsured and Medicaid patients are subject to institutional delays and decreased access to care when compared to patients with private insurance.Levels of Evidence: Level III: Prognostic, retrospective.

Extended Postoperative Prophylactic Antibiotics for Primary and Aseptic Revision Total Joint Arthroplasty: A Systematic Review.

INTRODUCTION: Limited literature is available about the effects of extended (>24 hours) antibiotic use after primary and aseptic revision total joint arthroplasty (TJA) on rates of periprosthetic joint infection (PJI). The purpose of this study was to systematically review the outcomes of extended prophylactic antibiotic use. METHODS: A systematic search on PubMed and EMBASE databases was done in August 2021 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles that met inclusion criteria were screened by two separate authors. Basic patient demographics, route of delivery, type, dose, frequency of the antibiotic, rates of PJI, and length of stay were extracted. RESULTS: A total of 11 articles published from 1979 to 2021 were included in the final analysis. Two studies evaluated aseptic revisions, seven evaluated primary TJA, and two studies evaluated both. Five studies were randomized controlled trials, one multicenter nonrandomized trial, and five retrospective cohort studies. All 11 studies used a cephalosporin or a penicillin antibiotic in both the control and cohort groups. Five studies used intravenous (IV) antibiotics, one study used oral (PO) antibiotics, and the other five studies used both IV and PO antibiotics. Length of stay was reported in three studies, all using IV antibiotics. All 11 studies evaluated rates of PJI, while four studies evaluated included rates of superficial surgical site infections. Four studies showed a statistically significant decrease in PJI when compared with a control group, while seven studies showed no statistically significant difference. CONCLUSION: There is conflicting evidence regarding the benefit of extended (>24 hours) antibiotics, IV or PO, after TJA. As of now, current guidelines do not support the use of extended antibiotics; future prospective clinical trials are needed to help support these claims.

Nationwide analysis on the impact of peripheral vascular disease following primary total knee arthroplasty: A matched-control analysis.

BACKGROUND: As the prevalence of peripheral vascular disease (PVD) continues to increase nationwide, studies demonstrating its effects following primary total knee arthroplasty (TKA) are limited. Therefore, the purpose of this study was to evaluate whether patients with PVD have higher rates of: 1) in-hospital lengths of stay (LOS); 2) readmissions; 3) medical complications; 4) implant-related complications; and 5) costs of care. METHODS: Using a nationwide database, patients with PVD undergoing primary TKA were identified and matched to controls in a 1:5 ratio by age, sex, and medical comorbidities. The query yielded 1,547,092 between the cohorts. Outcomes analyzed included: in-hospital LOS, readmission rates, complications, and costs of care. A p-value less than 0.004 was considered statistically significant. RESULTS: PVD patients had significantly longer in-hospital LOS (4-days vs. 3-days, p < 0.0001). Additionally, the study cohort had a higher incidence and odds (OR) of readmissions (20.5 vs. 15.2%; OR: 1.43, 95% CI: 1.42-1.45, p < 0.0001), medical complications (2.46 vs. 1.32%; OR: 1.88, CI: 1.83-1.94, p < 0.0001), and implant-related complications (3.82 vs. 2.18%; OR: 1.78, CI: 1.26-1.58, p < 0.0001). Additionally, the study found patients with PVD had higher day of surgery (p < 0.0001) and 90-day costs of care (p < 0.0001). CONCLUSIONS: After adjusting for confounding variables the results of the study show patients with PVD undergoing primary TKA have longer in-hospital LOS; in addition to higher rates of complications, readmissions, and costs of care. The study can be utilized by orthopaedists to adequately counsel patients of the potential complications following their procedure.

Intra-operative referencing technique is non-inferior to use of fluoroscopy for acetabular component positioning in anterior hip arthroplasty.

BACKGROUND: Intra-operative fluoroscopy has been shown to improve the accuracy of acetabular component positioning when compared to no fluoroscopy in direct anterior approach (DAA) total hip arthroplasty (THA). Due to logistical reasons, our senior author has been performing DAA THA at one institution without the use of fluoroscopy and has created an intraoperative referencing technique to aid in acetabular component positioning. The purpose of this study is to evaluate the accuracy of acetabular component positioning using fluoroscopy when compared to an intra-operative referencing technique without fluoroscopy. METHODS: A total of 214 consecutive primary DAA THA were performed by one surgeon at two institutions and were retrospectively reviewed over a 3-year period. Intra-operative fluoroscopy was used with all patients at Institution A (N = 154). At institution B (N = 60), no fluoroscopy was used, and an intra-operative referencing technique was employed to assist in placement of the acetabular component. RESULTS: In the fluoroscopy group, 91% of components met our abduction target, 90% met our anteversion target, and 82.5% simultaneously met both targets. In the non-fluoroscopy group, 98% of components met our abduction target, 92% met our anteversion target, and 90% simultaneously met both targets. There was no difference between groups for placement of the component within both targets simultaneously (p = .171). CONCLUSION: Use of our intra-operative referencing technique is non-inferior in placing acetabular components within a pre-defined safe zone when compared to use of intraoperative fluoroscopy. The intra-operative reference technique can be a helpful adjunct for ensuring accurate acetabular component positioning while simultaneously reducing cost and limiting radiation exposure.

Oncological Outcomes in Patients with Appendicular Myxofibrosarcomas: A Retrospective Study.

BACKGROUND: Myxofibrosarcoma (MFS) is notorious for its infiltrative growth pattern, making wide excisions difficult to achieve. Our objective was to assess the impact of surgical margins and other factors that affected rates of local recurrence (LR), distant metastasis (DM), and overall survival (OS) of individuals undergoing resection for MFS. METHODS: We retrospectively reviewed the medical records of 209 patients with appendicular soft tissue sarcomas between January 2012 and June 2018. Of these, 29 patients (14%) were diagnosed with myxofibrosarcoma. These patients underwent a total of 33 resections. The pathological analyses were conducted by an experienced musculoskeletal (MSK) pathologist. Demographics data, operative details, adjuvant therapy, and oncological outcomes were assessed. RESULTS: Of the 29 patients (33 resections), the overall LR rate was 24% (7/29) and the 2-year LR rate was 17% (5/29). Factors associated with negative oncological outcomes were as follows: tumor size ≤10 cm (2-year local recurrence-free rates (LRFRs), 65%; 95% CI, 44-86%; p=0.02) and positive surgical margins grouped with surgical margins ≤0.1 cm (hazard ratio (HR), 11.74; 95% CI, 1.41-97.74; p=0.02). Chemotherapy and radiotherapy together increased the 2-year LRFR (LRFR, 100%; 95% CI, 100%, p=0.001). Two-year DM and OS rates were 15% and 79%, respectively. Female gender was a predictor of distant metastasis. Local recurrence had a negative impact on overall survival. Intraoperative analysis of resection margin accuracy was 75% (12/16) when non-MSK pathologists were involved but 100% accurate (12/12) when analyzed by an MSK pathologist. CONCLUSION: Myxofibrosarcomas showed high LR rates after treatment. Close margins (≤0.1 cm) should be considered as a risk factor for LR, and LR is associated with negative overall survival. Neoadjuvant therapy in terms of combined chemotherapy and radiation therapy associates with decreased LR rates. If intraoperative assessment of margins is to be done, it should be performed by an experienced MSK pathologist.

Innovation in Orthopaedic Surgery Education: Novel Tools for Modern Times.

Orthopaedic residency training has and will continue to evolve with a wide variety of changes. Hands-on surgical simulation "boot camps," computerized simulation of surgical process, and even virtual reality simulators, all can help trainees acquire surgical experience without compromising patient care. Low-cost training modules help remedy the rising costs associated with teaching complex orthopaedic surgery skills. Motion tracking and checklists help refine standardization of assessment. As technology and healthcare systems continue to grow, we encourage training programs to keep pace by considering engagement of these tools.

Surgeon level of expertise reported in Journal of Hand Surgery (American Volume) and (European Volume) publications.

The purpose of the study was to evaluate the trend in documentation of surgeon level of expertise among the Journal of Hand Surgery (American Volume) and the Journal of Hand Surgery (European Volume) publications. A review of Journal of Hand Surgery (American Volume) and Journal of Hand Surgery (European Volume) databases for level of expertise between January 2015 and October 2019 was performed. Of 1042 articles identified, all 115 (20%) reporting level of expertise were published in Journal of Hand Surgery (European Volume). Since 2015, there has been an increase in reported level of expertise in Journal of Hand Surgery (European Volume) (2015: 8 (7%); 2016: 15 (13%); 2017: 22 (19%); 2018: 28 (24%); 2019: 42 (37%)). In the same period, no publications have reported level of expertise in Journal of Hand Surgery (American Volume). Documenting level of expertise may provide readers with additional information for incorporation of novel techniques into their practices. It may identify procedures that require a baseline level of expertise for effective performance. Further evaluation of level of expertise criteria may improve the reliability of the numeric scale, while widespread adoption of this scale will allow future outcome analysis by level of expertise.

Unifying the Orthopaedic Surgery Residency Application Process Under a Single Accreditation System: A Primer.

In 2020, the Accreditation Council for Graduate Medical Education and the American Osteopathic Association will merge creating a single accreditation system for graduate medical education in the United States under the National Residency Match Program. The goal of this merger is to ensure nationwide consistency in purpose and practice of medical care in the United States, specifically in the context of residency education and training for the next generation of physicians. The proposed impact is still speculative since we do not know what lasting effects, if any, this merger will have on subspecialties such as orthopaedic surgery. There are many considerations that medical school advisors need to take into account when guiding their students applying to residency after the match merge. The newly unified accreditation system will pose additional competition, considering that there will be more applicants than spots available in competitive specialties, including orthopaedic surgery. These are important caveats to keep in mind as the residency application process is evolving actively. It is the authors' hope that concepts discussed in this article stimulate further discussion, catalyze research, and optimize the ability for students to succeed in the match process.

Clinical and radiographic outcomes of total hip replacement with a 3-part metaphyseal osseointegrated titanium alloy stem enhanced with low plasticity burnishing: a mean 5-year follow-up study.

BACKGROUND: This study evaluates midterm results of a 3-part titanium alloy stem with metaphyseal fixation and a neck-metaphyseal taper junction strengthened with low plasticity burnishing (LPB). Our hypothesis is that this multimodular implant with LPB succeeds in offering the advantages of three-part modularity without junctional failure. METHODS: Twenty-eight of 32 complex primary (n = 9) and revision (n = 9) total hip arthroplasties were accounted for with minimum 2-year follow-up. Clinical and radiographic data were reviewed at a mean follow-up period of 60 months. One stem, removed for failure to osseointegrate, was submitted for sectioning and taper examination. RESULTS: There were no modular junction failures despite body mass indices of 20 to 40 and offsets of 34 to 47 mms. Implant survival was 96.3%, with one removal due to aseptic loosening in a patient with chronic renal failure. Taper analyses of the removed implant showed minimal damage. Preoperative and postoperative Harris Hip Scores and Oxford Hip Scores were 20 to 86 and 16 to 41, respectively. Patient satisfaction was 9.7/10. Radiographs showed stem subsidence >2 mm and radiolucencies around the metaphyseal cone only in the hip requiring implant removal. CONCLUSIONS: This 3-part titanium alloy modular stem with LPB of the neck-metaphyseal taper junction showed good functional and radiographic results at a mean 5 years without junctional failures. Although this follow-up exceeds previously published reports, longer follow-up will be important to confirm our confidence in the additional strengthening provided by LPB.

The association of mental health disease with perioperative outcomes following femoral neck fractures.

INTRODUCTION: Mental illness in the United States is a growing problem, leading to significant implications for those effected as well as direct and indirect costs to the health care system. The association between psychiatric comorbidity and increased risk of perioperative adverse events has previously been described following elective orthopedic surgery, however, there is a paucity of literature evaluating the correlation between mental health disease and outcomes in patients in an orthopedic trauma setting. METHODS: Utilizing data from the US National Hospital Discharge Survey, all patients undergoing surgery for femoral neck fracture were identified between the years 1990 and 2007. The association of depression, anxiety, dementia and schizophrenia on surgical outcomes were then analyzed using univariate regression analysis. RESULTS: A cohort of 2,432,931 patients was identified. All psychiatric comorbidities were associated with a lower rate of routine discharge home following surgery (p < 0.001). Schizophrenia was associated with increased odds of any adverse event (p < 0.001), acute post-operative mechanical complications (p < 0.001) and increased length of stay (p < 0.001). DISCUSSION: Patients undergoing surgery for femoral neck fracture with comorbid psychiatric illness are at increased risk for non-routine discharge. Schizophrenia is independently associated with an increased risk for post-operative complications. An awareness of these risks should optimize preoperative multidisciplinary patient care planning so as to maximize patient outcome and minimize resource utilization.

Proximal Tibial Reconstruction After Tumor Resection: A Systematic Review of the Literature.

BACKGROUND: The proximal part of the tibia is a common location for primary bone tumors, and many options for reconstruction exist following resection. This anatomic location has a notoriously high complication rate, and each available reconstruction method is associated with unique risks and benefits. The most commonly utilized implants are metallic endoprostheses, osteoarticular allografts, and allograft-prosthesis composites. There is a current lack of data comparing the outcomes of these reconstructive techniques in the literature. METHODS: A systematic review of peer-reviewed observational studies evaluating outcomes after proximal tibial reconstruction was conducted, including both aggregate and pooled data sets and utilizing a Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) review for quality assessment. Henderson complications, amputation rates, implant survival, and functional outcomes were evaluated. RESULTS: A total of 1,643 patients were identified from 29 studies, including 1,402 patients who underwent reconstruction with metallic endoprostheses, 183 patients who underwent reconstruction with osteoarticular allografts, and 58 patients who underwent with reconstruction with allograft-prosthesis composites. The mean follow-up times were 83.5 months (range, 37.3 to 176 months) for the metallic endoprosthesis group, 109.4 months (range, 49 to 234 months) for the osteoarticular allograft group, and 88.8 months (range, 49 to 128 months) for the allograft-prosthesis composite reconstruction group. The mean patient age per study ranged from 13.5 to 50 years. Patients with metallic endoprostheses had the lowest rates of Henderson Type-1 complications (5.1%; p < 0.001), Type-3 complications (10.3%; p < 0.001), and Type-5 complications (5.8%; p < 0.001), whereas, on aggregate data analysis, patients with an osteoarticular allograft had the lowest rates of Type-2 complications (2.1%; p < 0.001) and patients with an allograft-prosthesis composite had the lowest rates of Type-4 complications (10.2%; p < 0.001). The Musculoskeletal Tumor Society (MSTS) scores were highest in patients with an osteoarticular allograft (26.8 points; p < 0.001). Pooled data analysis showed that patients with a metallic endoprosthesis had the lowest rates of sustaining any Henderson complication (23.1%; p = 0.009) and the highest implant survival rates (92.3%), and patients with an osteoarticular allograft had the lowest implant survival rates at 10 years (60.5%; p = 0.014). CONCLUSIONS: Osteoarticular allograft appears to lead to higher rates of Henderson complications and amputation rates when compared with metallic endoprostheses. However, functional outcomes may be higher in patients with osteoarticular allograft. Further work is needed using higher-powered randomized controlled trials to definitively determine the superiority of one reconstructive option over another. In the absence of such high-powered evidence, we encourage individual surgeons to choose reconstructive options based on personal experience and expertise. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Opioid Use Disorders Are Associated With Perioperative Morbidity and Mortality in the Hip Fracture Population.

OBJECTIVES: To determine whether opioid use disorders (OUDs) are associated with adverse perioperative outcomes in patients undergoing surgical fixation for proximal femur fractures. METHODS: The National Hospital Discharge Survey was queried to identify patients surgically treated for proximal femur fractures between 1990 and 2007. Patients were grouped into those with a diagnosis of OUD, nonopioid drug use disorder, or neither. Demographic information and comorbidities were included in univariable and multivariable analyses to identify independent risk factors for perioperative outcomes. RESULTS: A total of 8154 patients with a diagnosis of drug use disorder and 4704 patients with a diagnosis of OUD were identified from a cohort of 4,732,165 surgically treated proximal femur fractures. Patients with OUD were significantly younger (46 vs. 79), and a significantly smaller proportion of them had medical comorbidities (21.9% vs. 60.2%) when compared with the no drug misuse cohort. Patients with OUD had significantly more medical complications (51.1% vs. 26.8%), mechanical complications (3% vs. 0.3%), and adverse events (55% vs. 39.7%) when compared with the no drug misuse group. OUD had higher odds for leaving against medical advice [odds ratio (OR) 12.868, range 10.7771-15.375], for any adverse event (OR 4.107, range 3.869-4.360), and for mortality (OR 1.744, range 1.250-2.433) when compared with nondrug misusers. CONCLUSIONS: Despite being younger and with significantly less medical comorbidities, patients with OUD have higher odds for adverse events, leaving against medical advice, and mortality after surgical treatment of a hip fracture. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hepatitis C is an Independent Risk Factor for Perioperative Complications and Nonroutine Discharge in Patients Treated Surgically for Hip Fractures.

OBJECTIVE: To evaluate the relationship between noncirrhotic hepatitis C virus (HCV) infection, perioperative complications, and discharge status in patients undergoing surgical procedures for hip fractures. METHODS: A retrospective epidemiological study was performed, querying the National Hospital Discharge Survey. Patients were selected using the International Classification of Diseases-9 diagnostic codes for hip fracture and primary procedural codes for open reduction internal fixation, hemiarthroplasty, total hip arthroplasty, or internal fixation. Patients with concurrent cirrhosis, HIV, hepatitis A, B, D, or E were excluded. Pearson χ tests, independent-samples t test, and multivariable binary logistic regression were used for data analysis. RESULTS: Two cohorts surgically treated for a hip fracture were identified and compared. The first cohort included 5377 patients with a concurrent diagnosis of noncirrhotic HCV infection (HCV+) and the second included 4,712,159 patients without a diagnosis of HCV (HCV-). The HCV+ cohort was younger and had fewer medical comorbidities, yet was found to have a longer length of hospital stay, higher rates of nonroutine discharge, and higher rates of complications than the HCV- cohort. Multivariate regression analysis demonstrated that HCV+ is an independent risk factor for perioperative complications and nonroutine discharge. CONCLUSIONS: In conclusion, our study demonstrates a negative association between noncirrhotic HCV infection and hip fracture surgery outcomes. Caution and appropriate preparation should be taken when surgically treating hip fractures in HCV+ patients because of higher risk of perioperative complications and nonroutine discharge. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

CANNABIS USE INCREASES RISK FOR REVISION AFTER TOTAL KNEE ARTHROPLASTY.

As an increasing number of states begin to legalize marijuana for either medical or recreational use, it is important to determine its effects on joint arthroplasty. The purpose of this study is to determine the impact of cannabis use on total knee arthroplasty (TKA) revision incidence, revision causes, and time to revision by analyzing the Medicare database between 2005 and 2014. A retrospective review of the Medicare database for TKA, revision TKA, and causes was performed utilizing Current Procedural Terminology (CPT) and International Classification of Disease ninth revision codes (ICD-9). Patients who underwent TKA were cross-referenced for a history of cannabis use by querying ICD-9 codes 304.30-32 and 305.20-22. The resulting group was then longitudinally tracked postoperatively for revision TKA. Cause for revision, time to revision, and gender were also investigated. Our analysis returned 2,718,023 TKAs and 247,112 (9.1%) revisions between 2005 and 2014. Cannabis use was prevalent in 18,875 (0.7%) of TKA patients with 2,419 (12.8%) revisions within the cannabis cohort. Revision incidence was significantly greater in patients who use cannabis (p < 0.001). Time to revision was also significantly decreased in patients who used cannabis, with increased 30- and 90-day revision incidence compared to the noncannabis group (P < 0.001). Infection was the most common cause of revision in both groups (33.5% nonusers versus 36.6% cannabis users).Cannabis use may result in decreasing implant survivorship and increasing the risk for revision within the 90-day global period compared to noncannabis users following primary TKA.

Operative Trends in the Treatment of Hip Fractures and the Role of Arthroplasty.

INTRODUCTION: There is a projected exponential increase in the number of hip fractures in the United States. Trends in patient demographics and the role of total hip arthroplasty (THA) and its associated outcomes following hip fractures surgery have not been well studied. METHODS: Patients with proximal femur fractures between 1990 and 2007 were identified in the National Hospital Discharge Survey database. Demographics, comorbidities, perioperative complications, and discharge status for patients undergoing THA, hemiarthroplasty, or internal fixation were examined. Multivariable regression was performed to determine independent risk factors for perioperative complications. RESULTS: Between 1990 and 2007, there was a statistically significant increase in patient age, adverse events, medical comorbidities, surgical complications, medical complications, and nonroutine discharge across all surgical treatment modalities. In the same time period, the utilization of THA for all fracture types decreased significantly. DISCUSSION: Total hip arthroplasty was found to be an independent risk factor for perioperative complications. Orthopedic surgeons should be aware that the hip fracture population continues to get older, with more medical comorbidities and are at higher risk for perioperative complications. CONCLUSION: Total hip arthroplasty is associated with a higher rate of perioperative complications in the hip fracture population.