No Difference in 30-day Mortality Between Patients Undergoing Bilateral Simultaneous Total Knee Arthroplasty With Technology Assistance Compared to Conventional Instrumentation.

Background: Bilateral simultaneous total knee arthroplasty (BSTKA) has decreased in frequency due to concerns about higher rates of early mortality and complications than unilateral or staged surgeries. Purpose: We sought to evaluate whether technology assistance (encompassing robotics and computer assistance) decreases early mortality following BSTKA. Methods: We conducted a retrospective cohort study using a national all-payer claims database. Patients who underwent BSTKA from October 2015 to December 2020 were identified. Univariate and multivariable analyses were conducted to compare outcomes in patients who underwent BSTKA with technology assistance compared to conventional instrumentation. The primary outcome was 30-day postoperative mortality. Secondary outcomes were respiratory failure and fat embolism. A post-hoc analysis was performed to evaluate length of stay, readmission, and other medical complications. Results: A total of 14,870 patients who underwent BSTKA were included in this study. Of these, 860 patients underwent technology-assisted BSTKA, and 14,010 patients underwent BSTKA without technology assistance. After a multivariable analysis, patients who underwent technology-assisted BSTKA had equivalent odds of 30-day mortality compared to those who underwent BSTKA without technology assistance. Technology assistance was not protective against the development of acute respiratory failure or fat embolism. Conclusion: This retrospective cohort study found no differences in the rates of 30-day mortality, respiratory failure, or fat embolism after technology-assisted BSTKA compared to conventional BSTKA. On the post-hoc analysis, technology use was associated with a decreased length of stay, lower readmission risk, and decreased rates of deep vein thrombosis, pulmonary embolism, and blood transfusion.

Increased Risk of 10-Year Revision Following Total Hip Arthroplasty for Femoral Neck Fracture.

INTRODUCTION: As the incidence of femoral neck fracture (FNF) increases with the aging population, understanding its impact on surgical outcomes is important to improving implant survival and patient satisfaction. Despite increasing use of total hip arthroplasty (THA) as management for FNF, few studies have examined long-term implant survivability. Thus, this study sought to determine the 10-year cumulative incidence of revision and indications for revision in patients undergoing THA for FNF in comparison to osteoarthritis. METHODS: Patients who underwent primary THA for FNF or osteoarthritis were identified using a national administrative claims database and propensity-score matched in a 1:2 ratio based on age, gender, the Charlson Comorbidity Index (CCI), smoking, obesity, and diabetes mellitus. Kaplan-Meier and Cox proportional hazards analyses were used to observe the cumulative incidence and risk of all-cause revision, periprosthetic joint infection (PJI), dislocation, mechanical loosening, and periprosthetic fracture (PPF) within 10 years of primary THA. In total, 19,735 patients who underwent THA for FNF and 39,383 patients who underwent THA for osteoarthritis were included. RESULTS: The 10-year cumulative incidences of all-cause revision (7.1 versus 4.9%), PJI (5.0 versus 3.3%), dislocation (6.8 versus 3.8%), mechanical loosening (3.1 versus 1.9%), and PPF (7.8 versus 4.0%) were significantly higher for those who underwent THA for FNF versus osteoarthritis. Femoral neck fractures were associated with higher risks of revision (hazard ratio [HR]: 1.6), PJI (HR: 1.7), dislocation (HR: 2.0), mechanical loosening (HR: 1.6), and PPF (HR: 2.2) (P < 0.001 for all). DISCUSSION: Despite the advantages of THA, femoral neck fractures remain a major risk factor for long-term complications. Tailored preoperative planning, surgical techniques, and postoperative bone health optimization in these patients may help minimize poor outcomes.

Routine Prescription of Proton Pump Inhibitors in the Perioperative Period is Associated with Decreased Rates of 2-Year Revision Surgery after Total Hip and Knee Arthroplasty.

INTRODUCTION: Proton Pump Inhibitors (PPIs) are often prescribed in conjunction with nonsteroidal anti-inflammatory drugs (NSAIDs) after total hip (THA) and total knee arthroplasty (TKA) due to their gastroprotective effects. In animal studies, it has been suggested that PPIs have immunosuppressive effects and impair fracture healing, however, the association between PPI use and adverse events following THA and TKA has not been well studied. METHODS: An administrative claims database was queried for patients who underwent elective THA from 2010 to 2019. The experimental group consisted of patients who did not have a prior history of gastrointestinal (GI) bleeding or gastroesophageal reflux disease (GERD) and who received a PPI prescription in the perioperative period. A 1:1 propensity score matching was used to create control cohorts of patients who did not have any PPI prescription filled, also matching for age, sex, and Charlson comorbidity index. This same cohort selection and matching procedure was then repeated for patients undergoing elective TKA. In total, 11,450 patients were studied (3,103 TKA+PPI, 2,622 THA+PPI, 3,103 TKA Controls, and 2,622 THA Controls). The mean age was 64 years (range, 38 to 94), and 57% were women. Significance was considered at P < 0.05. RESULTS: Perioperative PPI prescription in TKA patients was associated with significantly lower rates of all-cause revision (3.0 versus 4.1%, P < 0.01) and periprosthetic joint infection (1.0 versus 1.8%, P < 0.01). In THA patients, PPI prescription was associated with a lower all-cause revision rate (2.8 versus 4.0%, P = 0.02). No significant differences were found between PPI and non-PPI groups for aseptic loosening, periprosthetic fracture, gastrointestinal bleeding, or surgical site infection in either cohort. CONCLUSIONS: Patients receiving routine PPI prescriptions in the perioperative period surrounding TKA and THA have a lower risk of all-cause revision surgery, and perioperative PPI use is associated with a decreased risk of PJI in patients undergoing TKA. As these results conflict with the few previous studies performed on this topic, additional controlled studies are warranted to fully elucidate the relationship between PPI use and adverse events after THA and TKA.

Evaluating the Effect of Rotator Cuff Repair With Concomitant Distal Claviculectomy on 2 and 4 Year Reoperation Rates.

BACKGROUND: The current literature has differing views on the efficacy of concomitant distal claviculectomy (DC) during rotator cuff repair (RCR) in preventing revision surgery. Our aim was to investigate the revision surgery rate between RCR with DC and RCR without DC. METHODS: A retrospective cohort analysis was conducted using a national claims database. Patients undergoing open or arthroscopic primary RCR with or without concomitant DC were identified. The primary outcome was 4-year revision surgery rates. Univariate analysis was conducted using chi-square or Student t tests. Multivariable analysis was conducted using logistic regression, and an adjusted number needed to harm was calculated. RESULTS: A total of 131,232 patients met inclusion criteria. After logistic regression, patients undergoing RCR with DC had higher odds of requiring a subsequent DC procedure [OR; 95% CI; P-value (1.49; 1.35-1.64; P < 0.001)] but lower odds of any revision surgery (0.87; 0.80-0.91; P < 0.001) within 4 years than those who underwent RCR without DC. CONCLUSION: Although associated with a lower rate of overall revision surgeries within 2 and 4 years of RCR, those who underwent RCR with DC were 85% more likely at 2 years and 49% more likely at 4 years to undergo revision surgery of the distal clavicle than those without concomitant DC.

The Effect of Varying Preoperative Hemoglobin Levels on the Risk of Major Complications and Surgical Site Infections After Single Level Lumbar Fusion.

INTRODUCTION: Blood transfusions are associated with an increased risk of complications after lumbar fusion, and current anemia hemoglobin thresholds are not surgery specific. We aimed to calculate single-level lumbar fusion-specific preoperative hemoglobin strata that observe the likelihood of 90-day transfusion and evaluate whether these strata are associated with increased risk of 90-day complications and 2-year infections. METHODS: A national database identified patients undergoing primary single-level lumbar fusion with preoperative hemoglobin values (g/dL). Stratum-specific likelihood ratio analysis calculated sex-based hemoglobin strata associated with the risk of 90-day transfusion. Incidence and risk of 90-day major complications and 2-year infections were observed between strata. RESULTS: Three female (hemoglobin strata, likelihood ratio [<10.9, 2.41; 11.0 to 12.4, 1.35; 12.5 to 17.0, 0.78]) and male (<11.9, 2.95; 12.0 to 13.4, 1.46; 13.5 to 13.9, 0.71) strata were associated with varying likelihood of 90-day blood transfusion. Increased 90-day complication risk was associated with two female strata (hemoglobin strata, relative risk [11.0 to 12.4, 1.52; <10.9, 3.40]) and one male stratum (<11.9, 2.02). Increased 2-year infection risk was associated with one female (<10.9, 3.67) and male stratum (<11.9, 2.11). CONCLUSION: Stratum-specific likelihood ratio analysis established sex-based single-level lumbar fusion-specific hemoglobin strata that observe the likelihood of 90-day transfusion and the risk of 90-day major complications and 2-year infections. These thresholds are a unique addition to the literature and can assist in counseling patients on their postoperative risk profile and in preoperative patient optimization. LEVEL OF EVIDENCE: Level III.

Identification of Data-Driven Preoperative Hemoglobin Strata That Predict the Likelihood of Blood Transfusion and the Risk of Major Complications and Prosthetic Joint Infection After Total Hip Arthroplasty.

INTRODUCTION: Preoperative anemia is an independent risk factor of complications after primary total hip arthroplasty (THA). Currently used hemoglobin thresholds are not developed for risk stratification of arthroplasty patients and do not provide surgery-specific information on postoperative complication risk. Thus, we aimed to calculate THA-specific preoperative hemoglobin strata that observe the likelihood of 90-day blood transfusion and determine whether these strata are associated with increased risk of 90-day complications and 2-year prosthetic joint infection (PJI). METHODS: A retrospective cohort analysis identified 56,101 patients who underwent primary THA from 2013 to 2022. Using the lowest hemoglobin value for each patient one month before THA, stratum-specific likelihood ratio (SSLR) analysis calculated sex-based hemoglobin strata associated with the likelihood of 90-day postoperative blood transfusion. Propensity score matching was performed. Incidence rates and risk of 90-day major complications and 2-year PJI were observed for each identified preoperative hemoglobin stratum. RESULTS: SSLR analysis identified five male (strata, likelihood ratio [<10.4 g/dL, 12.5; 10.5 to 11.4 g/dL, 8.0; 11.5 to 12.4 g/dL, 2.4; 12.5 to 13.4 g/dL, 1.3; 13.5 to 13.9 g/dL, 0.5]) and five female (<8.9 g/dL, 10.7; 9.0 to 10.9 g/dL, 4.0; 11.0 to 11.4 g/dL, 2.0; 12.0 to 12.9 g/dL, 1.0; 13.0 to 13.4 g/dL, 0.6) preoperative hemoglobin strata associated with varying likelihoods of 90-day blood transfusion after THA. After matching in both male and female cohorts, as the calculated preoperative hemoglobin strata decreased, the relative risk of overall 90-day major complications and 2-year PJI increased incrementally (all P < 0.05). CONCLUSION: SSLR analysis established THA-specific sex-based preoperative hemoglobin strata that observe the likelihood of 90-day blood transfusion and predict the risk of 90-day medical complications and 2-year PJI. These strata are a first of their kind in THA research. While preoperatively optimizing patients, we recommend using these hemoglobin thresholds to help guide decisions on presurgery anemia optimization and to reduce the need for postoperative blood transfusion. LEVEL OF EVIDENCE: Level III.

No difference in 10-year survivorship of total shoulder arthroplasty vs. hemiarthroplasty for avascular necrosis of the humeral head.

BACKGROUND: Avascular necrosis (AVN) of the humeral head is characterized by osteonecrosis secondary to disrupted blood flow to the glenohumeral joint. Following collapse of the humeral head, arthroplasty, namely, total shoulder arthroplasty (TSA) or humeral head arthroplasty (hemiarthroplasty), is recommended standard of care. The literature is limited to underpowered and small sample sizes in comparing arthroplasty modalities. Therefore, the aims of this study were (1) to compare the 10-year survivorship of TSA and hemiarthroplasty in the treatment of AVN of the humeral head and (2) to identify differences in their revision etiologies. METHODS: Patients who underwent primary TSA and hemiarthroplasty for AVN were identified using the PearlDiver database. TSA patients were matched by age, gender, and Charlson Comorbidity Index (CCI) to the hemiarthroplasty cohort in a 4:1 ratio because TSA patients were generally older, sicker, and more often female. The 10-year cumulative incidence rate of all-cause revision was determined using Kaplan-Meier survival analysis. Multivariable analysis was conducted using Cox proportional hazard modeling. χ2 analysis was conducted to compare the indications for revisions between matched cohorts including periprosthetic joint infection (PJI), dislocation, mechanical loosening, broken implants, periprosthetic fracture, and stiffness. RESULTS: In total, 4825 patients undergoing TSA and 1969 patients undergoing hemiarthroplasty for AVN were included in this study. The unmatched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 7.0% and 7.7%, respectively. The matched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 6.7% and 8.0%, respectively. When comparing the unmatched cohorts, TSA patients were at significantly higher risk of 10-year all-cause revision (HR: 1.39; P = .017) when compared to hemiarthroplasty patients. After matching, there was no significant difference in risk of 10-year all-cause revision (HR: 1.29; P = .148) and no difference in the observed etiologies for revision (P > .05 for all). CONCLUSION: After controlling for confounders, only 6.7% of TSA and 8.0% hemiarthroplasties for humeral head AVN were revised within 10 years of index surgery. The demonstrated high and comparable long-term survivorship for both modalities supports the utilization of either for the AVN induced humeral head collapse.

Trends in Venous Thromboembolism and Chemoprophylaxis Utilization in Elective Total Knee Arthroplasty From 2011 to 2020.

BACKGROUND: Venous thromboembolism (VTE) is a feared complication of joint arthroplasty, leading to recent clinical practice guidelines aimed at VTE prevention and prophylaxis. However, limited studies have examined national changes in practice regarding chemoprophylaxis and the resultant changes in VTE rates. The purpose of this study was to identify: (1) the temporal trends in thrombotic complications; and (2) changes in chemoprophylaxis utilization in patients undergoing elective total knee arthroplasty (TKA). METHODS: A retrospective study was conducted using a large all-payer claims dataset. Patients who underwent osteoarthritis-indicated TKA between 2011 and 2020 were identified. Annual rates of VTE, including deep vein thrombosis and pulmonary embolism, within 90 days of TKA were determined. Utilization patterns for postoperative aspirin and anticoagulant medications were observed. Temporal trends were analyzed with linear regression and the calculation of the cumulative annual growth rate. Multivariable logistic regression was conducted to account for the effects of age and comorbidities. RESULTS: A total of 1,263,351 TKA patients were identified between 2011 and 2020. There were significant reductions in VTE rates (2.9% in 2011 to 1.8% in 2020), deep vein thrombosis rates (2.0% in 2011 to 1.3% in 2020), and pulmonary embolism rates (1.1% in 2011 to 0.6% in 2020). Postoperative utilization of aspirin increased from 5.9% in 2011 to 53.2% in 2020, whereas utilization of anticoagulants decreased from 94.1% in 2011 to 46.8% in 2020. Among anticoagulants, direct factor Xa inhibitors had the greatest increase in utilization (4.6 to 69.7%). The average reimbursement associated with VTE after TKA decreased from $18,061 in 2011 to $7,835 in 2020. CONCLUSIONS: The incidence rate and economic burden of VTE after TKA have significantly declined since 2011. There has been a trend toward increased aspirin and direct oral anticoagulant utilization for postoperative chemoprophylaxis. LEVEL OF EVIDENCE: Level III.

The association of alcohol use disorder with revision rates and post-operative complications in total shoulder arthroplasty.

Background: Alcohol use disorder (AUD) is the most prevalent substance use disorder in the United States. However, the current literature on AUD as a preoperative risk factor for Total Shoulder Arthroplasty (TSA) outcomes is limited. The purpose of this study was to identify the association of AUD with revision rates and 90-day postoperative complications in TSA. Methods: A retrospective study was conducted using the PearlDiver database. Patients diagnosed with AUD were identified. Patients in remission or with underlying cirrhosis were excluded. Outcomes included 2-year revision, 90-day readmission, 90-day emergency, and 90-day post-operative medical complications. Analysis was performed with univariate chi-squared tests followed by multivariable logistic regression. Results: A total of 59,261 patients who underwent TSA for osteoarthritis were identified, with 1522 patients having a diagnosis of AUD. Multivariable logistic regression showed that patients with AUD were more likely to undergo 2-year all-cause revision (OR = 1.49, p = 0.007), 2-year aseptic revision (OR = 1.47, p = 0.014), 90-day hospital readmission (OR = 1.57, p = 0.015), and 90-day transient mental disorder (OR = 2.13, p = 0.026). Conclusions: AUD is associated with increased rates of 2-year revision surgery, as well as 90-day readmission and 90-day transient mental disorder following primary TSA for osteoarthritis. These findings may assist orthopedic surgeons in counseling patients with AUD during the pre-operative course.

Evaluating the Effect of Decreasing Preoperative Hemoglobin on Blood Transfusions, Major Complications, and Periprosthetic Joint Infection After Primary Total Knee Arthroplasty.

INTRODUCTION: Preoperative anemia is associated with increased postoperative transfusion and complication rates after total knee arthroplasty (TKA). We aimed to create TKA-specific data-driven preoperative hemoglobin strata that quantify the likelihood of 90-day postoperative blood transfusion and evaluate whether these strata are associated with increased risk of 90-day major complications and 2-year prosthetic joint infection (PJI). METHODS: Primary TKA patients from 2013 to 2022 were identified using a national database. Stratum-specific likelihood ratio (SSLR) analysis defined hemoglobin strata associated with the risk of 90-day blood transfusion. Each stratum was propensity score matched to the highest identified hemoglobin strata. Unmatched incidence rates and matched risk of 90-day major complications and 2-year PJI between strata were compared. RESULTS: SSLR identified four 90-day blood transfusion hemoglobin strata for men (strata [g/dL], likelihood ratio [<11.4, 8.06; 11.5 to 11.9, 4.34; 12.0 to 12.9, 1.70; 13.0 to 17.0, 0.54]) and women (<10.4, 8.22; 10.5 to 11.4, 2.84; 11.5 to 12.4, 1.38; 12.5 to 17.0, 0.50). Increased 2-year PJI risk was associated with three male strata (<11.4, 11.5 to 11.9, 12.0 to 12.9; all P < 0.001) and three female strata (<10.4, 10.5 to 11.4, 11.5 to 12.4; all P < 0.001). Increased 90-day major complication risk was associated with three male strata (<11.4, 11.5 to 11.9, 12.0 to 12.9; all P < 0.001) and three female strata (<10.4, 10.5 to 11.4, 11.5 to 12.4; all P < 0.001). CONCLUSIONS: Using SSLR analysis, we identified unique TKA-specific data-driven hemoglobin strata for both men and women that quantify the likelihood of 90-day blood transfusions and predict the risk of both 90-day major complications and 2-year PJI. These strata are a first in the TKA literature and can assist surgeons in stratifying patients' transfusion and complication risk based on their preoperative hemoglobin value. While optimizing patients in the preoperative setting, we recommend using these TKA-specific hemoglobin thresholds to help guide decision making on the need for presurgery anemia optimization and to help reduce the need for blood transfusion.

Trend of using cementless total knee arthroplasty: a nationwide analysis from 2015 to 2021.

BACKGROUND: Modern cementless total knee arthroplasty (TKA) fixation has shown comparable long-term outcomes to cemented TKA, but the trend of using cementless TKA remains unclear. This study aimed to investigate the trend of using cementless TKA based on a national database. METHODS: The patients undergoing cementless TKA between 2015 and 2021 were retrospectively extracted from the PearlDiver (Mariner dataset) Database. The annual percentage of cementless TKA was calculated using the following formula: annual number of cementless TKA/annual number of TKA. The trend of the number of patients undergoing cementless TKA was created according to a compounded annual growth rate (CAGR) calculation of annual percentages. Patient age, comorbidity, region, insurance type, etc., were also investigated. Differences were considered statistically significant at P < 0.05. RESULTS: Of the 574,848 patients who received TKA, 546,731 (95%) underwent cemented fixation and 28,117 (5%) underwent cementless fixation. From 2015 to 2021, the use of cementless TKA significantly increased by 242% from 3 to 9% (compounded annual growth rate (CAGR): + 20%; P < 0.05). From 2015 to 2021, we observed a CAGR greater than 15% for all age groups (< 50, 50-59, 60-69, 70-74, 75 +), insurance types (cash, commercial, government, Medicare, Medicaid), regions (Midwest, Northeast, South, West), sex (male and female), and certain comorbidities (osteoporosis, diabetes mellitus, tobacco use, underweight (BMI < 18.5), rheumatoid arthritis) (P < 0.05 for all). Patients undergoing TKA with chronic kidney disease, prior fragility fractures, and dementia demonstrated a CAGR of + 9%-13% from 2015 to 2021 (P < 0.05). CONCLUSION: From 2015 to 2021, the use of cementless TKA saw a dramatic increase in all patient populations. However, there is still no consensus on when to cement and in whom. Clinical practice guidelines are needed to ensure safe and effective use of cementless fixation.

A National Database Analysis: Does Cold Weather Affect the Surgical Intervention Rate for Developmental Dysplasia of the Hip in Children Under Five Years?

Background Cold weather in the first few months of life may increase the risk of a late diagnosis of developmental dysplasia of the hip (DDH). Early detection of DDH can often be treated non-surgically. The purpose of this study is to observe whether the rates of surgical intervention for DDH differ based on average outdoor temperatures in the winter months. Methods A retrospective observational study of DDH patients diagnosed from 2010 to 2021 was conducted using a national administrative database. Five geographic regions were defined based on the average temperatures in the coldest quarter of the year. The rates of DDH-related surgeries were compared across these temperature regions. Results A total of 55,911 patients ≤5 years old with a DDH diagnosis from 2010 to 2021 were identified in the database. When compared to the warmest region (Group 5), the coldest region (Group 1) had higher rates of open reduction (4.59% vs. 2.06%, p<0.001), adductor tenotomy (6.95% vs. 2.91%, p<0.001), femoral osteotomy (5.75% vs. 2.04%, p<0.001), pelvic osteotomy (5.27% vs. 2.04%, p<0.001), and total DDH surgeries (11.42% vs. 5.03%, p<0.001). Conclusion Children living in states with an average winter temperature of -6.17°C had an increased likelihood of requiring surgical intervention for DDH within the first five years of life.

Risk of revision total knee arthroplasty for patients with prior bariatric surgery or class III obesity.

BACKGROUND: Bariatric surgery (BS) is indicated for select class III obesity patients undergoing total knee arthroplasty (TKA) to reduce obesity-related complications. This study assessed the effect of BS on TKA revision rates compared to the general population and class III obesity patients without a history of BS. METHODS: A national database identified patients who had primary TKA. They were divided into two groups: those with BS prior to TKA and those without. Patients without BS formed two control groups, a matched general population, and a matched class III obese cohort. The BS group was matched with controls based on age, Charlson Comorbidity Index (CCI), gender, and diabetes mellitus. Revision rates were analyzed using Kaplan-Meier survival analysis and hazard ratios (HR), calculated using Cox proportional hazard modeling. RESULTS: 14,292 BS patients were compared to 57,006 matched general population controls, and 19,504 BS patients were compared to 77,846 matched class III obesity control patients. BS patients had a higher risk of 5-year all-cause revision (HR: 1.13; P = 0.014) and revision due to periprosthetic fracture (HR: 1.39; P < 0.001) compared to the general population. Compared to class III obesity controls, BS patients had a lower risk of 5-year revision due to prosthetic joint infection (HR: 0.77; P = 0.001), with no difference in all-cause revision (P = 0.362). CONCLUSION: BS does not reduce all-cause TKA revision risk compared to the general or matched class III obesity population. However, it lowers the risk of revision due to prosthetic joint infection when compared to patients with class III obesity. LEVEL OF EVIDENCE: IV.

The cost-effectiveness of osteoporosis medications for preventing periprosthetic fractures following femoral neck fracture indicated hip arthroplasty: a break-even analysis.

Osteoporosis treatment following arthroplasty for femoral neck fracture (FNF) is associated with lower rates of periprosthetic fracture (PPF). Our study evaluated the economic viability of treatment in patients following arthroplasty and demonstrates that treatment with oral bisphosphonates can be cost-effective in preventing PPF. INTRODUCTION: Osteoporosis treatment following arthroplasty for femoral neck fracture (FNF) is associated with lower rates of periprosthetic fracture (PPF). Although cost-effective in reducing the rate of secondary fragility fracture, the economic viability of osteoporosis treatment in preventing PPF has not been evaluated. Therefore, the purpose of this study is to use a break-even analysis to determine whether and which current osteoporosis medications are cost-effective in preventing PPF following arthroplasty for FNFs. METHODS: Three-year average cost of osteoporosis medication (oral bisphosphonates, estrogen hormonal therapy, intravenous (IV) bisphosphonates, denosumab, teriparatide, and abaloparatide), costs of PPF care, and PPF rates in patients who underwent hip arthroplasty for FNFs without osteoporosis treatment were used to perform a break-even analysis. The absolute risk reduction (ARR) related to osteoporosis treatment and sensitivity analyses were used to evaluate the cost-effectiveness of this intervention and break-even PPF rates. RESULTS: Oral bisphosphonate therapy following arthroplasty for hip fractures would be economically justified if it prevents one out of 56 PPFs (ARR, 1.8%). Given the current cost and incidence of PPF, overall treatment can only be economically viable for PPF prophylaxis if the 3-year costs of these agents are less than $1500. CONCLUSION: The utilization of lower cost osteoporosis medications such as oral bisphosphonates and estrogen hormonal therapy as PPF prophylaxis in this patient population would be economically viable if they reduce the PPF rate by 1.8% and 1.5%, respectively. For IV bisphosphonates and newer agents to be economically viable as PPF prophylaxis in the USA, their costs need to be significantly reduced.

Reverse total shoulder arthroplasty within 6 weeks of proximal humerus fracture is associated with the lowest risk of revision.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular treatment strategy in the management of complex proximal humeral fractures (PHFs). However, no definitive consensus has been reached regarding the optimal surgical timing of RTSA following PHF, particularly considering nonoperative management is often a viable option. Therefore, the aim of this study was (1) to identify optimal timing intervals that maximize the likelihood of revision following RTSA and (2) to determine differences in revision etiologies using the identified timing intervals. METHODS: A retrospective cohort analysis of patients undergoing PHF-indicated RTSA from 2010 to 2021 was conducted using a national administrative claims database. Stratum-specific likelihood ratio (SSLR) analysis was conducted to determine data-driven timing strata between PHF and RTSA that maximized the likelihood of revision surgery within 2 years of RTSA. To control for confounders, multivariable regression analysis was conducted to confirm the identified data-driven strata's association with 2-year revision rates as well as compare the likelihood of various indications for revision including mechanical loosening, dislocation, periprosthetic joint infection (PJI), and periprosthetic fracture (PPF). RESULTS: In total, 11,707 patients undergoing TSA following PHF were included in this study. SSLR analysis identified 2 timing categories: 0-6 weeks and 7-52 weeks from the time of PHF to TSA surgery. Relative to the 0-6-week cohort, the 7-52-week cohort was more likely to undergo revision surgery within 2 years (OR 1.93, P < .001). Moreover, the 7-52-week cohort had significantly higher odds of revision indicated for dislocation (OR 2.24, P < .001), mechanical loosening (OR 1.71, P < .001), PJI (OR 1.74, P < .001), and PPF (OR 1.96, P < .001). CONCLUSIONS: Using SSLR, we were successful in identifying 2 data-driven timing strata between PHF and RTSA that maximized the likelihood of 2-year revision surgery. As it can be difficult to determine whether RTSA or nonoperative management is initially more appropriate, considering the results of this study, an early trial of 4-6 weeks of nonoperative management may be appropriate without altering the risks associated with RTSA.

Chronic Oral Corticosteroid Use and 10-Year Incidence of Major Complications Following Total Knee Arthroplasty.

BACKGROUND: Oral corticosteroids are the primary treatment for several autoimmune conditions. The risk of long-term implant, bone health, and infectious-related complications in patients taking chronic oral corticosteroids before total knee arthroplasty (TKA) is unknown. We compared the 10-year cumulative incidence of revision, periprosthetic joint infection (PJI), fragility fracture (FF), and periprosthetic fracture following TKA in patients who had and did not have preoperative chronic oral corticosteroid use. METHODS: A retrospective cohort analysis was conducted using a national database. Primary TKA patients who had chronic preoperative oral corticosteroid use were identified using Current Procedural Terminology and International Classification of Disease 9 and 10 codes. Exclusion criteria included malignancy, osteoporosis treatment, trauma, and < 2-year follow-up. Primary outcomes were 10-year cumulative incidence and hazard ratios (HRs) of all-cause revision (ACR), aseptic revision, PJI, FF, and periprosthetic fracture. A Kaplan-Meier analysis and a multivariable Cox proportional hazards model were utilized. Overall, 611,596 patients were identified, and 5,217 (0.85%) were prescribed chronic corticosteroids. There were 10,000 control patients randomly sampled for analysis. RESULTS: Corticosteroid patients had significantly higher 10-year HR of FF (HR; 95% confidence interval); P value (1.47; 1.34 to 1.62; P < .001)], ACR (1.21; 1.05 to 1.40; P = .009), and PJI (1.30; 1.01 to 1.69; P = .045) when compared to the control. CONCLUSIONS: Patients prescribed preoperative chronic oral corticosteroids had higher risks of ACR, PJI, and FF within 10 years following TKA compared to patients not taking corticosteroids. This information can be used by surgeons during preoperative counseling to educate this high-risk patient population about their increased risk of postoperative complications.

Patients Who Have Prior Solid Organ Transplants Have Increased Risk of 10-Year Periprosthetic Joint Infection Revision Following Primary Total Knee Arthroplasty: A Propensity-Matched Analysis.

BACKGROUND: Total knee arthroplasty (TKA) for solid organ transplant (SOT) patients is becoming more prominent as life expectancy in this population increases. However, data on long-term (10 year) implant survivorship in this cohort are sparse. The purpose of this study was to compare 90-day, 2-year, 5-year, and 10-year implant survivability following primary TKA in patients who did and did not have prior SOT. METHODS: The PearlDiver database was utilized to query patients who underwent unilateral elective TKA with at least 2 years of active follow-up. These patients were stratified into those who had a SOT before TKA and those who did not. The SOT cohort was propensity-matched to control patients based on age, sex, Charlson Comorbidity Index, and obesity in a 1:2 ratio. Cumulative incidence rates and hazard ratios (HRs) were compared between the SOT, matched, and unmatched cohorts. RESULTS: No difference was observed in 10-year cumulative incidence and risk of all-cause revision surgery in TKA patients with prior SOT when compared to matched and unmatched controls. Compared to the matched control, the SOT cohort had no difference in the risk of revision when stratified by indication and timing. However, when compared to the unmatched control, patients who had prior SOT had a higher risk for revision due to periprosthetic joint infection at 10 years (HR: 1.80; 95% confidence interval: 1.17 to 2.76) as well as all-cause revision within 90 days after TKA (HR: 1.93; 95% confidence interval: 1.10 to 3.36). CONCLUSIONS: Prior SOT patients have higher rates of all-cause revision within 90 days and periprosthetic joint infection within 10 years when compared to the general population, likely associated with the elevated number of comorbidities in SOT patients and not the transplant itself. Therefore, these patients should be monitored in the preoperative and early postoperative settings to optimize their known comorbidities.

The Effect of Concomitant Biceps Tenodesis on Revision Surgery Rates After Primary Rotator Cuff Repair.

INTRODUCTION: We aimed to use a national database to compare the 4-year revision surgery rates after rotator cuff repair (RCR) in patients with concomitant biceps tenodesis (BT) versus those without BT. METHODS: A retrospective cohort analysis was conducted using the PearlDiver database from 2015 to 2017. Patients undergoing primary open and arthroscopic RCR with and without BT were identified. Demographic variables, 90-day complications, and 2- and 4-year revision surgery rates were analyzed, and a multivariable logistic regression was conducted. RESULTS: Of the 131,155 patients undergoing RCR, 24,487 (18.7%) underwent concomitant BT and 106,668 (81.3%) did not. After controlling for comorbidities and demographics, patients with concomitant BT were associated with lower odds of all-cause revision (OR; P-value [0.77; P < 0.001]), revision BT (0.65; P < 0.001), revision RCR (0.72; P < 0.001), and shoulder arthroplasty (0.81; P = 0.001) within 4 years when compared with those without concomitant BT. DISCUSSION: In our analysis, patients undergoing primary RCR with concomitant BT had 35% reduced odds of revision BT and 23% reduced odds of any all-cause revision within 4 years when compared with those without concomitant BT. This suggests that tenodesis at the time of primary RCR may be associated with a reduction in the utilization of ipsilateral shoulder revision surgery rates.

The Association Between Oral Bone Mineral Density-Reducing Medications and the Risk of 2-Year Implant-Related Complications Following Total Knee Arthroplasty.

BACKGROUND: Certain medications interfere with the bone remodeling process and may potentially increase the risk of complications after total knee arthroplasty (TKA). As patients undergoing TKA may be taking these bone mineral density (BMD)-reducing medications, it is unclear as to whether and which medications impact TKA outcomes. Therefore, the purpose of this study was to observe the impact of various BMD-reducing medications on 2-year implant-related complications following TKA. METHODS: A retrospective analysis of patients undergoing primary TKA was conducted using a national administrative claims database. Patients were identified if they were taking any known BMD-reducing medication and were compared to control patients. To control for confounders associated with taking multiple agents, multivariable logistic regression analyses were conducted for each 2-year outcome (all-cause revision, loosening-indicated revision, and periprosthetic fracture--indicated revision), with the output recorded as odds ratios (ORs). RESULTS: In our study, 502,927 of 1,276,209 TKA patients (39.4%) were taking at least one BMD-reducing medication perioperatively. On multivariable analysis, medications associated with a higher likelihood of 2-year all-cause revision included first- and second-generation antipsychotics (SGAs) (OR: 1.42 and 1.26, respectively), selective serotonin reuptake inhibitors (SSRIs) (OR: 1.14), glucocorticoids (1.13), and proton pump inhibitors (PPIs) (OR: 1.23) (P < .05 for all). Medications associated with a higher likelihood of 2-year periprosthetic fracture included SGAs (OR: 1.51), SSRIs (OR: 1.27), aromatase inhibitors (OR: 1.29), and PPIs (OR: 1.42) (P < .05 for all). CONCLUSIONS: Of the drug classes observed, the utilization of perioperative PPIs, SSRIs, glucocorticoids, first-generation antipsychotics, and SGAs was associated with the highest odds of all-cause revision. Our findings suggest a relationship between these medications and BMD-related complications; however, further studies should seek to determine the causality of these relationships.

AIDS but not asymptomatic HIV is associated with lower 2-10-year implant survivorship following total knee arthroplasty.

INTRODUCTION: Prior studies have demonstrated HIV does not increase the risk of 2-year complications following TKA; however, the literature is sparse regarding the impact of HIV and AIDS on long-term implant survivorship. The purpose of this study was to compare the 10-year cumulative incidence and risk of revision TKA in patients with and without asymptomatic HIV, and with and without AIDS. METHODS: Patients with HIV who underwent elective TKA were identified using a national database and divided into subgroups of asymptomatic HIV (AHIV) and acquired immunodeficiency syndrome (AIDS). These patients with HIV were propensity matched based on age, sex, and Charlson Comorbidity Index (CCI) to a control group of elective TKA patients without HIV in a 1:2 ratio. Patients were also compared to an unmatched control group. RESULTS: The 10-year risk for all-cause revision TKA was higher in the HIV group compared to unmatched controls (HR 1.40, 95% CI 1.02-1.93, p = 0.038) but not matched controls (HR 1.13, 95% CI 0.77-1.63, p = 0.594). When compared to both control groups (unmatched; matched), the AIDS group had a higher risk of 10-year all-cause revision (HR 2.74, 95% CI 1.51-4.99, p < 0.001; HR 2.19, 95% CI 1.17-4.11, p = 0.014), dislocation/instability (HR 4.89, 95% CI 1.54-15.51, p = 0.007; HR 3.86, 95% CI 1.12-13.34, p = 0.033), and periprosthetic fracture [PPF] (HR 0.67, 95% CI 0.16-2.74, p = 0.002; HR 3.82, 95% CI 1.08-13.45, p = 0.037). However, patients with AIDS were not at increased risk of PJI or mechanical loosening compared to unmatched controls or matched controls. DISCUSSION: This study expands on current literature by following a nationwide cohort of HIV/AIDS patients for 10 years after TKA. Although a diagnosis of asymptomatic HIV was not associated with increased risk of 10-year revision rates following TKA, a diagnosis of AIDS was. Surgeons should ensure patients' serum CD4 level is sufficient, ideally in the normal range of 500-1500 cells per mm3, before undergoing TKA.